Proposed Rule: Medicare: Hospital Outpatient Prospective Payment System and 2008 CY Payment Rates Ambulatory Service Center Procedures

Thursday,
August 2, 2007
Book 2 of 2 Books
Pages 42627–43130
Part III
Department of
Health and Human
Services
Centers for Medicare & Medicaid Services
42 CFR Parts 410, 411, 414 et al.

Medicare and Medicaid Programs: CY
2008 Proposed Changes; Proposed Rule
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42628 Federal Register / Vol. 72, No. 148 / Thursday, August 2, 2007 / Proposed Rules
DEPARTMENT OF HEALTH AND Further, we are proposing changes to please call telephone number (410) 786–
HUMAN SERVICES several of the current conditions of 9994 in advance to schedule your
participation that hospitals must meet to arrival with one of our staff members.
Centers for Medicare & Medicaid participate in the Medicare and (Because access to the interior of the
Services Medicaid programs to require the Hubert H. Humphrey Building is not
completion and documentation in the readily available to persons without
42 CFR Parts 410, 411, 414, 416, 419, medical record of medical histories and Federal Government identification,
482, and 485 physical examinations of patients commenters are encouraged to leave
conducted after admission and prior to their comments in the CMS drop slots
[CMS–1392–P]
surgery or a procedure requiring located in the main lobby of the
RIN 0938–AO71 anesthesia services and for building. A stamp-in clock is available
postanesthesia evaluations of patients for persons wishing to retain proof of
Medicare Program: Proposed Changes before discharge or transfer from the filing by stamping in and retaining an
to the Hospital Outpatient Prospective postanesthesia recovery area. extra copy of the comments being filed.)
Payment System and CY 2008 Payment DATES: To be assured consideration, Comments mailed to the addresses
Rates; Proposed Changes to the comments on all sections of the indicated as appropriate for hand or
Ambulatory Surgical Center Payment preamble of this proposed rule must be courier delivery may be delayed and
System and CY 2008 Payment Rates; received at one of the addresses received after the comment period.
Medicare and Medicaid Programs: provided in the ADDRESSES section no For information on viewing public
Proposed Changes to Hospital later than 5 p.m. on September 14, 2007. comments, see the beginning of the
Conditions of Participation; Proposed ADDRESSES: In commenting, please refer SUPPLEMENTARY INFORMATION section.
Changes Affecting Necessary Provider to file code CMS–1392–P. Because of FOR FURTHER INFORMATION CONTACT:
Designations of Critical Access staff and resource limitations, we cannot Alberta Dwivedi, (410) 786–0378,
Hospitals accept comments by facsimile (FAX) Hospital outpatient prospective
AGENCY: Centers for Medicare & transmission. payment issues.
Medicaid Services (CMS), HHS. You may submit comments in one of Dana Burley, (410) 786–0378,
four ways (no duplicates, please): Ambulatory surgical center issues.
ACTION: Proposed rule.
1. Electronically. You may submit Suzanne Asplen, (410) 786–4558, Partial
SUMMARY: This proposed rule would electronic comments on specific issues hospitalization and community
revise the Medicare hospital outpatient in this regulation to http:// mental health centers issues.
prospective payment system to www.cms.hhs.gov/eRulemaking. Click Sheila Blackstock, (410) 786–3502,
implement applicable statutory on the link ‘‘Submit electronic Reporting of quality data issues.
requirements and changes arising from comments on CMS regulations with an Mary Collins, (410) 786–3189, and
our continuing experience with this open comment period.’’ (Attachments Jeannie Miller, (410) 786–3164,
system. In this proposed rule, we should be in Microsoft Word, Necessary provider designations for
describe the proposed changes to the WordPerfect, or Excel; however, we CAHs Issues.
amounts and factors used to determine prefer Microsoft Word.) Scott Cooper, (410) 786–9465, and
2. By regular mail. You may mail Jeannie Miller, (410) 786–3164, Hospital
the payment rates for Medicare hospital
written comments (one original and two conditions of participation Issues.
outpatient services paid under the
copies) to the following address ONLY:
prospective payment system. These SUPPLEMENTARY INFORMATION:
Centers for Medicare & Medicaid
changes would be applicable to services Services, Department of Health and Submitting Comments: We welcome
furnished on or after January 1, 2008. Human Services, Attention: CMS– comments from the public on all issues
In addition, this proposed rule would 1392–P, P.O. Box 8011, Baltimore, MD set forth in this proposed rule to assist
update the revised Medicare ambulatory 21244–1850. us in fully considering issues and
surgical center (ASC) payment system to Please allow sufficient time for mailed developing policies. You can assist us
implement certain related provisions of comments to be received before the by referencing file code CMS–1392–P
the Medicare Prescription Drug, close of the comment period. and the specific ‘‘issue identifier’’ that
Improvement, and Modernization Act of 3. By express or overnight mail. You precedes the section on which you
2003 (MMA). In this proposed rule, we may send written comments (one choose to comment.
propose the applicable relative payment original and two copies) to the following Inspection of Public Comments: All
weights and amounts for services address ONLY: Centers for Medicare & comments received before the close of
furnished in ASCs, specific HCPCS Medicaid Services, Department of the comment period are available for
codes to which the final policies of the Health and Human Services, Attention: viewing by the public, including any
ASC payment system would apply, and CMS–1392–P, Mail Stop C4–26–05, personally identifiable or confidential
other pertinent ratesetting information 7500 Security Boulevard, Baltimore, MD business information that is included in
for the CY 2008 ASC payment system. 21244–1850. a comment. We post all comments
These changes would be applicable to 4. By hand or courier. If you prefer, received before the close of the
services furnished on or after January 1, you may deliver (by hand or courier) comment period on the following Web
2008. your written comments (one original site as soon as possible after they have
In this proposed rule, we also are and two copies) before the close of the been received: http://www.cms.hhs.gov/
proposing changes to the policies comment period to one of the following eRulemaking. Click on the link
relating to the necessary provider addresses: Room 445–G, Hubert H. ‘‘Electronic Comments on CMS
designations of critical access hospitals Humphrey Building, 200 Independence Regulations’’ on that Web site to view
(CAHs) that are being recertified when Avenue, SW., Washington, DC 20201; or public comments.
a CAH enters into a new co-location 7500 Security Boulevard, Baltimore, MD Comments received timely will also
arrangement with another hospital or 21244–1850. be available for public inspection as
CAH or when the CAH creates or If you intend to deliver your they are received, generally beginning
acquires an off-campus location. comments to the Baltimore address, approximately 3 weeks after publication
Federal Register / Vol. 72, No. 148 / Thursday, August 2, 2007 / Proposed Rules 42629
of a document, at the headquarters of CORF Comprehensive outpatient NCD National Coverage Determination
the Centers for Medicare & Medicaid rehabilitation facility NTIOL New technology intraocular
Services, 7500 Security Boulevard, CPT [Physicians’] Current Procedural lens
Baltimore, MD 21244, on Monday Terminology, Fourth Edition, 2007, OCE Outpatient Code Editor
through Friday of each week from 8:30 copyrighted by the American Medical OMB Office of Management and
a.m. to 4 p.m. To schedule an Association Budget
appointment to view public comments, CRNA Certified registered nurse OPD [Hospital] Outpatient department
phone 1–800–743–3951. anesthetist OPPS [Hospital] Outpatient
CY Calendar year prospective payment system
Electronic Access DMEPOS Durable medical equipment, PHP Partial hospitalization program
This Federal Register document is prosthetics, orthotics, and supplies PM Program memorandum
also available from the Federal Register DMERC Durable medical equipment PPI Producer Price Index
PPS Prospective payment system
online database through GPO Access, a regional carrier
PPV Pneumococcal pneumonia (virus)
service of the U.S. Government Printing DRA Deficit Reduction Act of 2005, PRA Paperwork Reduction Act
Office. Free public access is available on Pub. L. 109–171 QIO Quality Improvement
a Wide Area Information Server (WAIS) DSH Disproportionate share hospital Organization
through the Internet and via EACH Essential Access Community RFA Regulatory Flexibility Act
asynchronous dial-in. Internet users can Hospital RHQDAPU Reporting Hospital Quality
access the database by using the World E/M Evaluation and management Data for Annual Payment Update
Wide Web; the Superintendent of EPO Erythropoietin [Program]
Documents’ home page address is ESRD End-stage renal disease RHHI Regional home health
http://www.gpoaccess.gov/index.html, FACA Federal Advisory Committee intermediary
by using local WAIS client software, or Act, Pub. L. 92–463 SBA Small Business Administration
by telnet to swais.access.gpo.gov, then FAR Federal Acquisition Regulations SCH Sole community hospital
login as guest (no password required). FDA Food and Drug Administration SDP Single Drug Pricer
Dial-in users should use FFS Fee-for-service SI Status indicator
communications software and modem FSS Federal Supply Schedule TEFRA Tax Equity and Fiscal
to call (202) 512–1661; type swais, then FTE Full-time equivalent Responsibility Act of 1982, Pub. L.
login as guest (no password required). FY Federal fiscal year 97–248
GAO Government Accountability TOPS Transitional outpatient
Alphabetical List of Acronyms Office payments
Appearing in the Proposed Rule HCPCS Healthcare Common Procedure USPDI United States Pharmacopoeia
ACEP American College of Emergency Coding System Drug Information
Physicians HCRIS Hospital Cost Report WAC Wholesale acquisition cost
AHA American Hospital Association Information System In this document, we address two
AHIMA American Health Information HHA Home health agency payment systems under the Medicare
Management Association HIPAA Health Insurance Portability program: the hospital outpatient
AMA American Medical Association and Accountability Act of 1996, Pub. prospective payment system (OPPS) and
APC Ambulatory payment L. 104–191 the revised ambulatory surgical center
classification HOPD Hospital outpatient department (ASC) revised payment system. The
AMP Average manufacturer price HOP QDRP Hospital Outpatient provisions relating to the OPPS are
ASC Ambulatory Surgical Center Quality Data Reporting Program included in sections I. through XV.,
ASP Average sales price ICD–9–CM International Classification XVII., and XIX. through XXII. of this
AWP Average wholesale price of Diseases, Ninth Edition, Clinical proposed rule and in Addenda A, B, C
BBA Balanced Budget Act of 1997, Modification (Addendum C is available on the
Pub. L. 105–33 IDE Investigational device exemption Internet only; see section XIX. of this
BBRA Medicare, Medicaid, and SCHIP IOL Intraocular lens proposed rule), D1, D2, E, L, and M to
[State Children’s Health Insurance IPPS [Hospital] Inpatient prospective this proposed rule. The provisions
Program] Balanced Budget payment system related to the revised ASC payment
Refinement Act of 1999, Pub. L. 106– IVIG Intravenous immune globulin system are included in sections XVI.,
113 MAC Medicare Administrative XVII., and XIX. through XXII. of this
BCA Blue Cross Association Contractors proposed rule and in Addenda AA, BB,
BCBSA Blue Cross and Blue Shield MedPAC Medicare Payment Advisory DD1, and DD2 to this proposed rule.
Association Commission
BIPA Medicare, Medicaid, and SCHIP MDH Medicare-dependent, small rural Table of Contents
Benefits Improvement and Protection hospital I. Background for the OPPS
Act of 2000, Pub. L. 106–554 MIEA–TRHCA Medicare A. Legislative and Regulatory Authority for
CAH Critical access hospital Improvements and Extension Act the Hospital Outpatient Prospective
CAP Competitive Acquisition Program under Division B, Title I of the Tax Payment System
CBSA Core-Based Statistical Area Relief Health Care Act of 2006, Pub. B. Excluded OPPS Services and Hospitals
CCR Cost-to-charge ratio L. 109–432 C. Prior Rulemaking
CERT Comprehensive Error Rate MMA Medicare Prescription Drug, D. APC Advisory Panel
Testing Improvement, and Modernization Act 1. Authority of the APC Panel

2. Establishment of the APC Panel
CMHC Community mental health of 2003, Pub. L. 108–173 3. APC Panel Meetings and Organizational
center MPFS Medicare Physician Fee Structure
CMS Centers for Medicare & Medicaid Schedule E. Provisions of the Medicare
Services MSA Metropolitan Statistical Area Improvements and Extension Act under
CoP [Hospital] Condition of NCCI National Correct Coding Division B of Title I of the Tax Relief and
participation Initiative Health Care Act of 2006
F. Summary of the Major Contents of This (a) Background 8. Implantation of Spinal Neurostimulators
Proposed Rule (b) Proposed Payment for LDR Prostate (APC 0222)
1. Proposed Updates Affecting OPPS Brachytherapy 9. Stereotactic Radiosurgery (SRS)
Payments (3) Proposed Cardiac Electrophysiologic Treatment Delivery Services (APCs 0065,
2. Proposed OPPS Ambulatory Payment Evaluation and Ablation Composite APC 0066, and 0067)
Classification (APC) Group Policies (a) Background 10. Blood Transfusion (APC 0110)
3. Proposed OPPS Payment for Devices (b) Proposed Payment for Cardiac 11. Screening Colonscopies and Screening
4. Proposed OPPS Payment for Drugs, Electrophysiologic Evaluation and Flexible Sigmoidoscopies (APCs 0158
Biologicals, and Radiopharmaceuticals Ablation and 0159)
5. Proposed Estimate of OPPS Transitional e. Service-Specific Packaging Issues IV. Proposed OPPS Payment for Devices
Pass-Through Spending for Drugs, B. Proposed Payment for Partial A. Proposed Treatment of Device-
Biologicals, and Devices Hospitalization Dependent APCs
6. Proposed OPPS Payment for 1. Background 1. Background
Brachytherapy Sources 2. Proposed PHP APC Update 2. Proposed Payment
7. Proposed OPPS Coding and Payment for 3. Proposed Separate Threshold for Outlier 3. Proposed Payment When Devices Are
Drug Administration Services Payments to CMHCs Replaced With Partial Credit to the
8. Proposed OPPS Hospital Coding and C. Proposed Conversion Factor Update Hospital
Payment for Visits D. Proposed Wage Index Changes B. Pass-Through Payments for Devices
9. Proposed OPPS Payment for Blood and E. Proposed Statewide Average Default 1. Expiration of Transitional Pass-Through
Blood Products CCRs Payments for Certain Devices
10. Proposed OPPS Payment for F. Proposed OPPS Payments to Certain a. Background
Observation Services Rural Hospitals b. Proposed Policy
11. Proposed Procedures That Will Be Paid 1. Hold Harmless Transitional Payment 2. Proposed Provisions for Reducing
Only as Inpatient Services Changes Made by Pub. L. 109–171 (DRA) Transitional Pass-Through Payments to
12. Proposed Nonrecurring Technical and 2. Proposed Adjustment for Rural SCHs Offset Costs Packaged Into APC Groups
Policy Changes Implemented in CY 2006 Related to Pub. a. Background
13. Proposed OPPS Payment Status and L. 108–173 (MMA) b. Proposed Policy
Comment Indicators G. Proposed Hospital Outpatient Outlier V. Proposed OPPS Payment Changes for
14. OPPS Policy and Payment Payments Drugs, Biologicals, and
Recommendations H. Calculation of the Proposed National Radiopharmaceuticals
15. Proposed Update of the Revised ASC Unadjusted Medicare Payment A. Proposed Transitional Pass-Through
Payment for Additional Costs of Drugs
Payment System I. Proposed Beneficiary Copayments
and Biologicals
16. Proposed Quality Data for Annual 1. Background
1. Background
Payment Updates 2. Proposed Copayment
2. Drugs and Biologicals with Expiring
17. Proposed Changes Affecting Necessary 3. Calculation of a Proposed Adjusted
Pass-Through Status in CY 2007
Provider Critical Access Hospitals Copayment Amount for an APC Group
3. Drugs and Biologicals With Proposed
(CAHs) and Hospital Conditions of III. Proposed OPPS Ambulatory Payment Pass-Through Status in CY 2008
Participation (CoPs) Classification (APC) Group Policies B. Proposed Payment for Drugs,
18. Regulatory Impact Analysis A. Proposed Treatment of New HCPCS and Biologicals, and Radiopharmaceuticals
II. Proposed Updates Affecting OPPS CPT Codes Without Pass-Through Status
Payments 1. Proposed Treatment of New HCPCS 1. Background
A. Proposed Recalibration of APC Relative Codes Included in the April and July 2. Proposed Criteria for Packaging Payment
Weights Quarterly OPPS Updates for CY 2007 for Drugs and Biologicals
1. Database Construction 2. Proposed Treatment of New Category I 3. Proposed Payment for Drugs and
a. Database Source and Methodology and III CPT Codes and Level II HCPCS Biologicals Without Pass-Through Status
b. Proposed Use of Single and Multiple Codes That Are Not Packaged
Procedure Claims B. Proposed Changes—Variations Within a. Payment for Specified Covered
(1) Proposed Use of Date of Service APCs Outpatient Drugs
Stratification and a Bypass List To 1. Background (1) Background
Increase the Amount of Data Used To 2. Application of the 2 Times Rule (2) Proposed Payment Policy
Determine Medians 3. Proposed Exceptions to the 2 Times Rule (3) Proposed Payment for Blood Clotting
(2) Exploration of Allocation of Packaged C. New Technology APCs Factors
Costs to Separately Paid Procedure 1. Introduction (4) Proposed Payment for
Codes 2. Proposed Movement of Procedures From Radiopharmaceuticals
c. Proposed Calculation of CCRs New Technology APCs to Clinical APCs (a) Background
2. Proposed Calculation of Median Costs a. Positron Emission Tomography (PET)/ (b) Proposed Payment for Diagnostic
3. Proposed Calculation of OPPS Scaled Computed Tomography (CT) Scans (New Radiopharmaceuticals
Payment Weights Technology APC 1511) (c) Proposed Payment for Therapeutic
4. Proposed Changes to Packaged Services b. IVIG Preadministration-Related Services Radiopharmaceuticals
a. Background (New Technology APC 1502) b. Proposed Payment for Nonpass-Through
b. Addressing Growth in OPPS Volume c. Other Services in New Technology APCs Drugs, Biologicals, and
and Spending D. Proposed APC-Specific Policies Radiopharmaceuticals With HCPCS
c. Proposed Packaging Approach 1. Hyperbaric Oxygen Therapy (APC 0659) Codes, But Without OPPS Hospital
(1) Guidance Services 2. Skin Repair Procedures (APCs 0024, Claims Data
(2) Image Processing Services 0025, 0027, and 0686) VI. Proposed Estimate of OPPS Transitional
(3) Intraoperative Services 3. Cardiac Computed Tomography and Pass-Through Spending for Drugs,
(4) Imaging Supervision and Interpretation Computed Tomographic Angiography Biologicals, Radiopharmaceuticals, and
Services (APCs 0282, 0376, 0377, and 0398) Devices
(5) Diagnostic Radiopharmaceuticals 4. Ultrasound Ablation of Uterine Fibroids A. Total Allowed Pass-Through Spending
(6) Contrast Agents With Magnetic Resonance Guidance B. Proposed Estimate of Pass-Through
(7) Observation Services (MRgFUS) (APCs 0195 and 0202) Spending
d. Proposed Development of Composite 5. Single Allergy Tests (APC 0381) VII. Proposed OPPS Payment for
APCs 6. Myocardial Positron Emission Brachytherapy Sources
(1) Background Tomography (PET) Scans (APC 0307) A. Background
(2) Proposed Low Dose Rate (LDR) Prostate 7. Implantation of Cardioverter- B. Proposed Payment for Brachytherapy
Brachytherapy Composite APC Defibrillators (APCs 0107 and 0108) Sources
VIII. Proposed OPPS Drug Administration b. Identification of Surgical Procedures 4. Classes of NTIOLS Approved for
Coding and Payment Eligible for Payment under the Revised Payment Adjustment
A. Background ASC Payment System 5. Payment Adjustment
B. Proposed Coding and Payment for Drug c. Payment for Covered Surgical 6. Proposed CY 2008 ASC Payment for
Administration Services Procedures under the Revised ASC Insertion of IOLs
IX. Proposed Hospital Coding and Payments Payment System J. Proposed ASC Payment and Comment
for Visits (1) General Policies Indicators
A. Background (2) Office-Based Procedures K. ASC Policy and Payment
B. Proposed Policies for Hospital (3) Device-Intensive Procedures Recommendations
Outpatient Visits (4) Multiple and Interrupted Procedure L. Proposed Calculation of the ASC
1. Clinic Visits: New and Established Discounting Conversion Factor and ASC Payment
Patient Visits and Consultations (5) Transition to Revised ASC Payment Rates
2. Emergency Department Visits Rates 1. Overview
C. Proposed Visit Reporting Guidelines 2. Covered Ancillary Services under the 2. Budget Neutrality Requirement
1. Background Revised ASC Payment System 3. Calculation of the ASC Payment Rates
2. CY 2007 Work on Visit Guidelines a. General Policies for CY 2008
3. Proposed Visit Guidelines b. Payment Policies for Specific Items and 4. Calculation of the ASC Payment Rates
X. Proposed OPPS Payment for Blood and Services for CY 2009 and FutureYears
Blood Products (1) Radiology Services XVII. Reporting Quality Data for Annual
A. Background (2) Brachytherapy Sources Payment Rate Updates
B. Proposed Payment for Blood and Blood (3) Drugs and Biologicals A. Background
Products (4) Implantable Devices with Pass-Through 1. Reporting Hospital Outpatient Quality
XI. Proposed OPPS Payment for Observation Status under the OPPS Data for Annual Payment Update
Services (5) Corneal Tissue Acquisition 2. Reporting ASC Quality Data for Annual
XII. Proposed Procedures That Will Be Paid 3. General Payment Policies Payment Increase
Only as Inpatient Procedures a. Geographic Adjustment B. Proposed Hospital Outpatient Measures
A. Background b. Beneficiary Coinsurance C. Other Proposed Hospital Outpatient
B. Proposed Changes to the Inpatient List D. Proposed Treatment of New HCPCS Measures
XIII. Proposed Nonrecurring Technical and Codes D. Proposed Implementation of the HOP
Policy Changes 1. Treatment of New CY 2008 Category I QDRP
A. Outpatient Hospital Services and and III CPT Codes and Level II HCPCS E. Proposed Requirements for HOP Quality
Supplies Incident to a Physician Service Codes Data Reporting for CY 2009 and
B. Interrupted Procedures 2. Proposed Treatment of New Mid-Year Subsequent Calendar Years
C. Transitional Adjustments Hold Category III CPT Codes 1. Administrative Requirements
Harmless Provisions 3. Proposed Treatment of Level II HCPCS 2. Data Collection and Submission
D. Reporting of Wound Care Services Codes Released on a Quarterly Basis Requirements
E. Reporting of Cardiac Rehabilitation E. Proposed Updates to Covered Surgical 3. HOP QDRP Validation Requirements
Services Procedures and Covered Ancillary F. Publication of HOP QDRP Data
F. Reporting of Bone Marrow and Stem Services Collected
Cell Processing Services 1. Identification of Covered Surgical G. Proposed Attestation Requirement for
XIV. Proposed OPPS Payment Status and Procedures Future Payment Years
Comment Indicators a. General Policies H. HOP QDRP Reconsiderations
A. Proposed Payment Status Indicator b. Proposed Changes in Designation of I. Reporting of ASC Quality Data
Definitions Covered Surgical Procedures as Office- XVIII. Proposed Changes Affecting Critical
1. Proposed Payment Status Indicators to Based Access Hospitals (CAHs) and Hospital
Designate Services That Are Paid under c. Proposed Changes in Designation of Conditions of Participation (CoPs)
the OPPS Covered Surgical Procedures as Device- A. Proposed Changes Affecting CAHs
2. Proposed Payment Status Indicators to Intensive 1. Background
Designate Services That Are Paid Under 2. Proposed Changes in Identification of 2. Co-Location of Necessary Provider CAHs
a Payment System Other Than the OPPS Covered Ancillary Services 3. Provider-Based Facilities of CAHs
3. Proposed Payment Status Indicators to F. Proposed Payment for Covered Surgical 4. Termination of Provider Agreement
Designate Services That Are Not Procedures and Covered Ancillary 5. Proposed Regulation Changes
Recognized under the OPPS But That Services B. Proposed Revisions to Hospital CoPs
May Be Recognized by Other 1. Proposed Payment for Covered Surgical 1. Background
Institutional Providers Procedures 2. Provisions of the Proposed Regulations
4. Proposed Payment Status Indicators to a. Proposed Update to Payment Rates a. Proposed Timeframes for Completion of
Designate Services That Are Not Payable b. Payment Policies When Devices Are the Medical History and Physical
by Medicare Replaced at No Cost or With Credit Examination
B. Proposed Comment Indicator (1) Policy When Devices Are Replaced at b. Proposed Requirements for
Definitions No Cost or With Full Credit Preanesthesia and Postanesthesia
XV. OPPS Policy and Payment (2) Proposed Policy When Implantable Evaluations
Recommendations Devices Are Replaced With Partial Credit c. Proposed Technical Amendment to
A. MedPAC Recommendations 2. Proposed Payment for Covered Ancillary Nursing Services CoP
B. APC Panel Recommendations Services XIX. Files Available to the Public Via the
XVI. Proposed Update of the Revised G. Physician Payment for Procedures and Internet
Ambulatory Surgical Center Payment Services Provided in ASC A. Information in Addenda Related to the
System H. Proposed Changes to Definitions of CY 2008 Hospital OPPS
A. Legislative and Regulatory Authority for ‘‘Radiology and Certain Other Imaging B. Information in Addenda Related to the
the ASC Payment System Services’’ and ‘‘Outpatient Prescription CY 2008 ASC Payment System
B. Rulemaking for the Revised ASC Drugs’’ XX. Collection of Information Requirements
Payment System I. New Technology Intraocular Lenses XXI. Response to Comments
C. Revisions to the ASC Payment System 1. Background XXII. Regulatory Impact Analysis
Effective January 1, 2008 2. Changes to the NTIOL Determination A. Overall Impact
1. Covered Surgical Procedures under the Process Finalized for CY 2008 1. Executive Order 12866
Revised ASC Payment System 3. NTIOL Application Process for CY 2008 2. Regulatory Flexibility Act (RFA)
a. Definition of Surgical Procedure Payment Adjustment 3. Small Rural Hospitals
4. Unfunded Mandates services and to encourage more efficient coinsurance, as an outpatient

5. Federalism delivery of care, the Congress mandated department service, payable under the
B. Effects of OPPS Changes in This replacement of the reasonable cost- OPPS.
Proposed Rule The OPPS rate is an unadjusted
based payment methodology with a
1. Alternatives Considered
prospective payment system (PPS). The national payment amount that includes
2. Limitation of Our Analysis
3. Estimated Impact of This Proposed Rule Balanced Budget Act (BBA) of 1997 the Medicare payment and the
on Hospitals and CMHCs (Pub. L. 105–33) added section 1833(t) beneficiary copayment. This rate is
4. Estimated Effect of This Proposed Rule to the Social Security Act (the Act) divided into a labor-related amount and
on Beneficiaries authorizing implementation of a PPS for a nonlabor-related amount. The labor-
5. Conclusion hospital outpatient services (OPPS). related amount is adjusted for area wage
6. Accounting Statement The Medicare, Medicaid, and SCHIP differences using the hospital inpatient
C. Effects of ASC Payment System Changes Balanced Budget Refinement Act wage index value for the locality in
in This Proposed Rule (BBRA) of 1999 (Pub. L. 106–113) made which the hospital or CMHC is located.
1. Alternatives Considered All services and items within an APC
major changes in the hospital OPPS.
2. Limitations on Our Analysis
3. Estimated Effects of This Proposed Rule The Medicare, Medicaid, and SCHIP group are comparable clinically and
on ASCs Benefits Improvement and Protection with respect to resource use (section
4. Estimated Effects of This Proposed Rule Act (BIPA) of 2000 (Pub. L. 106–554) 1833(t)(2)(B) of the Act). In accordance
on Beneficiaries made further changes in the OPPS. with section 1833(t)(2) of the Act,
5. Conclusion Section 1833(t) of the Act was also subject to certain exceptions, services
6. Accounting Statement amended by the Medicare Prescription and items within an APC group cannot
D. Effects of the Proposed Requirements for Drug, Improvement, and Modernization be considered comparable with respect
Reporting of Quality Data for Hospital Act (MMA) of 2003 (Pub. L. 108–173). to the use of resources if the highest
Outpatient Settings median (or mean cost, if elected by the
The Deficit Reduction Act (DRA) of
E. Effects of the Proposed Policy on CAH
2005 (Pub. L. 109–171), enacted on Secretary) for an item or service in the
Off-Campus and Co-Location
Requirements February 8, 2006, made additional APC group is more than 2 times greater
F. Effects of Proposed Policy Revisions to changes in the OPPS. In addition, the than the lowest median cost for an item
the Hospital CoPs Medicare Improvements and Extension or service within the same APC group
G. Executive Order 12866 Act under Division B of Title I of the (referred to as the ‘‘2 times rule’’). In
Tax Relief and Health Care Act (MIEA– implementing this provision, we use the
Regulation Text
TRHCA) of 2006 (Pub. L. 109–432), median cost of the item or service
Addenda enacted on December 20, 2006, made assigned to an APC group.
Addendum A—Proposed OPPS APCs for CY further changes in the OPPS. A Special payments under the OPPS
2008 discussion of these provisions is may be made for New Technology items
Addendum AA—Proposed ASC Covered included in sections I.E., VII., and XVII. and services in one of two ways. Section
Surgical Procedures for CY 2008 of this proposed rule. 1833(t)(6) of the Act provides for
(Including Surgical Procedures for The OPPS was first implemented for temporary additional payments, which
Which Payment is Packaged) services furnished on or after August 1, we refer to as ‘‘transitional pass-through
Addendum B—Proposed OPPS Payment By payments,’’ for at least 2 but not more
2000. Implementing regulations for the
HCPCS Code for CY 2008
OPPS are located at 42 CFR Part 419. than 3 years for certain drugs, biological
Addendum BB—Proposed ASC Covered
Ancillary Services Integral to Covered Under the OPPS, we pay for hospital agents, brachytherapy devices used for
Surgical Procedures for CY 2008 outpatient services on a rate-per-service the treatment of cancer, and categories
(Including Ancillary Services for Which basis that varies according to the of other medical devices. For New
Payment Is Packaged) ambulatory payment classification Technology services that are not eligible
Addendum D1—Proposed OPPS Payment (APC) group to which the service is for transitional pass-through payments,
Status Indicators assigned. We use the Healthcare and for which we lack sufficient data to
Addendum D2—Proposed OPPS Comment Common Procedure Coding System appropriately assign them to a clinical
Indicators (HCPCS) codes (which include certain APC group, we have established special
Addendum DD1—Proposed ASC Payment Current Procedural Terminology (CPT) APC groups based on costs, which we
Indicators
codes) and descriptors to identify and refer to as New Technology APCs. These
Addendum DD2—Proposed ASC Comment
Indicators group the services within each APC New Technology APCs are designated
Addendum E—Proposed HCPCS Codes That group. The OPPS includes payment for by cost bands which allow us to provide
Would Be Paid Only as Inpatient most hospital outpatient services, appropriate and consistent payment for
Procedures for CY 2008 except those identified in section I.B. of designated new procedures that are not
Addendum L—Proposed Out-Migration this proposed rule. Section yet reflected in our claims data. Similar
Adjustment 1833(t)(1)(B)(ii) of the Act provides for to pass-through payments, an
Addendum M—Proposed HCPCS Codes for Medicare payment under the OPPS for assignment to a New Technology APC is
Assignment to Composite APCs for CY hospital outpatient services designated temporary; that is, we retain a service
2008 by the Secretary (which includes partial within a New Technology APC until we
I. Background for the OPPS hospitalization services furnished by acquire sufficient data to assign it to a
community mental health centers clinically appropriate APC group.
A. Legislative and Regulatory Authority (CMHCs)) and hospital outpatient
for the Hospital Outpatient Prospective services that are furnished to inpatients B. Excluded OPPS Services and
Payment System who have exhausted their Part A Hospitals

When the Medicare statute was benefits, or who are otherwise not in a Section 1833(t)(1)(B)(i) of the Act
originally enacted, Medicare payment covered Part A stay. Section 611 of Pub. authorizes the Secretary to designate the
for hospital outpatient services was L. 108–173 added provisions for hospital outpatient services that are
based on hospital-specific costs. In an Medicare coverage of an initial paid under the OPPS. While most
effort to ensure that Medicare and its preventive physical examination, hospital outpatient services are payable
beneficiaries pay appropriately for subject to the applicable deductible and under the OPPS, section
1833(t)(1)(B)(iv) of the Act excludes published in the Federal Register on other requirements, that the APC Panel
payment for ambulance, physical and November 24, 2006 the CY 2007 OPPS/ continue to be technical in nature; be
occupational therapy, and speech- ASC final rule with comment period (71 governed by the provisions of the
language pathology services, for which FR 67960). In that final rule with FACA; may convene up to three
payment is made under a fee schedule. comment period, we revised the OPPS meetings per year; has a Designated
Section 614 of Pub. L. 108–173 to update the payment weights and Federal Officer (DFO); and is chaired by
amended section 1833(t)(1)(B)(iv) of the conversion factor for services payable a Federal official designated by the
Act to exclude OPPS payment for under the CY 2007 OPPS on the basis Secretary.
screening and diagnostic mammography of claims data from January 1, 2005, The current APC Panel membership
services. The Secretary exercised the through December 31, 2005, and to and other information pertaining to the
authority granted under the statute to implement certain provisions of Pub. L. APC Panel, including its charter,
exclude from the OPPS those services 108–173 and Pub. L. 109–171. In Federal Register notices, meeting dates,
that are paid under fee schedules or addition, we responded to public agenda topics, and meeting reports can
other payment systems. Such excluded comments received on the provisions of be viewed on the CMS Web site at:
services include, for example, the the November 10, 2005 final rule with http://www.cms.hhs.gov/FACA/
professional services of physicians and comment period (70 FR 86516) 05_AdvisoryPanelonAmbulatory
nonphysician practitioners paid under pertaining to the APC assignment of PaymentClassificationGroups.asp#
the Medicare Physician Fee Schedule HCPCS codes identified in Addendum B TopOfPage.
(MPFS); laboratory services paid under of that rule with the new interim (NI) 3. APC Panel Meetings and
the clinical diagnostic laboratory fee comment indicator; and public Organizational Structure
schedule (CLFS); services for comments received on the August 23,
beneficiaries with end-stage renal The APC Panel first met on February
2006 OPPS/ASC proposed rule for CY
disease (ESRD) that are paid under the 27, February 28, and March 1, 2001.
2007 (71 FR 49506).
ESRD composite rate; and services and Since the initial meeting, the APC Panel
procedures that require an inpatient stay D. APC Advisory Panel has held 11 subsequent meetings, with
that are paid under the hospital the last meeting taking place on March
1. Authority of the APC Panel
inpatient prospective payment system 7 and 8, 2007. Prior to each meeting, we
(IPPS). We set forth the services that are Section 1833(t)(9)(A) of the Act, as publish a notice in the Federal Register
excluded from payment under the OPPS amended by section 201(h) of the BBRA, to announce the meeting, and when
in § 419.22 of the regulations. and redesignated by section 202(a)(2) of necessary to solicit and announce
Under § 419.20(b) of the regulations, the BBRA, requires that we consult with nominations for the APC Panel’s
we specify the types of hospitals and an outside panel of experts to review the membership.
entities that are excluded from payment clinical integrity of the payment groups The APC Panel has established an
under the OPPS. These excluded and their weights under the OPPS. The operational structure that, in part,
entities include Maryland hospitals, but Act further specifies that the panel will includes the use of three subcommittees
only for services that are paid under a act in an advisory capacity. The to facilitate its required APC review
cost containment waiver in accordance Advisory Panel on Ambulatory Payment process. The three current
with section 1814(b)(3) of the Act; Classification (APC) Groups (the APC subcommittees are the Data
critical access hospitals (CAHs); Panel), discussed under section I.D.2. of Subcommittee, the Observation and
hospitals located outside of the 50 this proposed rule, fulfills these Visit Subcommittee, and the Packaging
States, the District of Columbia, and requirements. The APC Panel is not Subcommittee. The Data Subcommittee
Puerto Rico; and Indian Health Service restricted to using data compiled by is responsible for studying the data
hospitals. CMS, and may use data collected or issues confronting the APC Panel, and
developed by organizations outside the for recommending options for resolving
C. Prior Rulemaking Department in conducting its review. them. The Observation and Visit
On April 7, 2000, we published in the Subcommittee reviews and makes
2. Establishment of the APC Panel recommendations to the APC Panel on
Federal Register a final rule with
comment period (65 FR 18434) to On November 21, 2000, the Secretary all technical issues pertaining to
implement a prospective payment signed the initial charter establishing observation services and hospital
system for hospital outpatient services. the APC Panel. This expert panel, which outpatient visits paid under the OPPS
The hospital OPPS was first may be composed of up to 15 (for example, APC configurations and
implemented for services furnished on representatives of providers subject to APC payment weights). The Packaging
or after August 1, 2000. Section the OPPS (currently employed full-time, Subcommittee studies and makes
1833(t)(9) of the Act requires the not as consultants, in their respective recommendations on issues pertaining
Secretary to review certain components areas of expertise), reviews clinical data to services that are not separately
of the OPPS, no less often than and advises CMS about the clinical payable under the OPPS, but whose
annually, and to revise the groups, integrity of the APC groups and their payments are bundled or packaged into
relative payment weights, and other weights. For purposes of this Panel, APC payments. Each of these
adjustments that take into account consultants or independent contractors subcommittees was established by a
changes in medical practices, changes in are not considered to be full-time majority vote from the full APC Panel
technologies, and the addition of new employees. The APC Panel is technical during a scheduled APC Panel meeting,
services, new cost data, and other in nature, and is governed by the and their continuation as
relevant information and factors. provisions of the Federal Advisory subcommittees was approved at the
Since initially implementing the Committee Act (FACA). Since its initial March 2007 APC Panel meeting. All
OPPS, we have published final rules in chartering, the Secretary has renewed subcommittee recommendations are
the Federal Register annually to the APC Panel’s charter three times: on discussed and voted upon by the full
implement statutory requirements and November 1, 2002; on November 1, APC Panel.
changes arising from our continuing 2004; and effective November 21, 2006. Discussions of the recommendations
experience with this system. We The current charter specifies, among resulting from the APC Panel’s March
2007 meeting are included in the Secretary to establish a process for procedures from New Technology APCs
sections of this proposed rule that are making the submitted data available for to clinical APCs.
specific to each recommendation. For public review.
3. Proposed OPPS Payment for Devices
discussions of earlier APC Panel
F. Summary of the Major Contents of In section IV. of this proposed rule,
meetings and recommendations, we
This Proposed Rule we discuss proposed payment for
reference previous hospital OPPS final
rules or the Web site mentioned earlier In this proposed rule, we are setting device-dependent APCs and the pass-
in this section. forth proposed changes to the Medicare through payment for specific categories
hospital OPPS for CY 2008. These of devices.
E. Provisions of the Medicare changes would be effective for services
Improvements and Extension Act Under 4. Proposed OPPS Payment for Drugs,
furnished on or after January 1, 2008. Biologicals, and Radiopharmaceuticals
Division B of Title I of the Tax Relief
We are also setting forth proposed
and Health Care Act of 2006 In section V. of this proposed rule, we
changes to the Medicare ASC payment
The Medicare Improvements and system for CY 2008. These changes discuss the proposed CY 2008 OPPS
Extension Act under Division B of Title would be effective for services furnished payment for drugs, biologicals, and
I of the Tax Relief and Health Care Act on or after January 1, 2008. The radiopharmaceuticals, including the
(MIEA–TRHCA) of 2006, Pub. L. 109– following is a summary of the major proposed payment for drugs,
432, enacted on December 20, 2006, changes that we are proposing to make: biologicals, and radiopharmaceuticals
included the following provisions with and without pass-through status.
affecting the OPPS: 1. Proposed Updates Affecting OPPS
Payments 5. Proposed Estimate of OPPS
1. Section 107(a) of the MIEA–TRHCA
Transitional Pass-Through Spending for
amended section 1833(t)(16)(C) of the In section II. of this proposed rule, we Drugs, Biologicals, and Devices
Act to extend the period for payment of set forth—
brachytherapy devices based on the • The methodology used to In section VI. of this proposed rule,
hospital’s charges adjusted to cost for 1 recalibrate the proposed APC relative we discuss the estimate of CY 2008
additional year, through December 31, payment weights. OPPS transitional pass-through
2007. • The proposed payment for partial spending for drugs, biologicals, and
2. Section 107(b)(1) of the MIEA– hospitalization services, including the devices.
TRHCA amended section 1833(t)(2)(H) proposed separate threshold for outlier 6. Proposed OPPS Payment for
of the Act by adding stranded and non- payments for CMHCs. Brachytherapy Sources
stranded devices furnished on or after • The proposed update to the
July 1, 2007, as additional conversion factor used to determine In section VII. of this proposed rule,
classifications of brachytherapy devices payment rates under the OPPS. we discuss our proposal concerning
for which separate payment groups • The proposed retention of our coding and payment for brachytherapy
must be established for payment under current policy to use the IPPS wage sources.
the OPPS. Section 107(b)(2) of the indices to adjust, for geographic wage 7. Proposed OPPS Coding and Payment
MIEA–TRCHA provides that the differences, the portion of the OPPS for Drug Administration Services
Secretary may implement the section payment rate and the copayment
107(b)(1) amendment to section In section VIII. of this proposed rule,
standardized amount attributable to we set forth our proposed policy
1833(t)(2)(H) of the Act ‘‘by program labor-related cost.
instruction or otherwise.’’ concerning coding and payment for
• The proposed update of statewide
3. Section 109(a) of the MIEA–TRHCA drug administration services.
average default CCRs.
added new paragraph (17) to section • The proposed application of hold 8. Proposed OPPS Hospital Coding and
1833(t) of the Act which authorizes the harmless transitional outpatient Payments for Visits
Secretary, beginning in 2009 and each payments (TOPs) for certain small rural
subsequent year, to reduce the OPPS In section IX. of this proposed rule,
hospitals. we set forth our proposed changes to
full annual update by 2.0 percentage • The proposed payment adjustment
points if a hospital paid under the OPPS policies for the coding and reporting of
for rural SCHs. clinic and emergency department visits
fails to submit data as required by the • The proposed calculation of the
Secretary in the form and manner and critical care services on claims paid
hospital outpatient outlier payment. under the OPPS.
specified on selected measures of • The calculation of the proposed
quality of care, including medication national unadjusted Medicare OPPS 9. Proposed OPPS Payment for Blood
errors. In accordance with this payment. and Blood Products
provision, the selected measures are • The proposed beneficiary In section X. of this proposed rule, we
those that are appropriate for the copayments for OPPS services. discuss our proposed payment for blood
measurement of quality of care and blood products.
furnished by hospitals in the outpatient 2. Proposed OPPS Ambulatory Payment
setting, that reflect consensus among Classification (APC) Group Policies 10. Proposed OPPS Payment for
affected parties and, to the extent In section III. of this proposed rule, Observation Services
feasible and practicable, that include we discuss the proposed additions of In section XI. of this proposed rule,
measures set forth by one or more of the new procedure codes to the APCs; our we discuss the proposed payment
national consensus entities, and that proposal to establish a number of new policies for observation services
may be the same as those required for APCs; and our analyses of Medicare furnished to patients on an outpatient
reporting by hospitals paid under the claims data and certain basis.
IPPS. This provision specifies that a recommendations of the APC Panel. We
reduction for 1 year cannot be taken into also discuss the application of the 2 11. Proposed Procedures That Will Be
account when computing the OPPS times rule and proposed exceptions to Paid Only as Inpatient Services
update for a subsequent year. In it; proposed changes to specific APCs; In section XII. of this proposed rule,
addition, this provision requires the and the proposed movement of we discuss the procedures that we are
proposing to remove from the inpatient to develop quality measures for payment weights for each APC based on
list and assign to APCs. reporting by ASCs. claims and cost report data for
outpatient services. We are proposing to
12. Proposed Nonrecurring Technical 17. Proposed Changes Affecting
use the most recent available data to
and Policy Changes Necessary Provider Critical Access
construct the database for calculating
Hospitals (CAHs) and Hospital
In section XIII. of this proposed rule, APC group weights. For the purpose of
Conditions of Participation (CoPs)
we set forth our proposals for recalibrating the proposed APC relative
nonrecurring technical and policy In section XVIII. of this proposed rule, payment weights for CY 2008, we used
changes and clarifications relating to we discuss our proposed changes approximately 131 million final action
outpatient hospital services and affecting necessary provider claims for hospital OPD services
supplies incident to a physician service; designations for CAHs that are being furnished on or after January 1, 2006,
payment for interrupted procedures recertified when the CAH enters into a and before January 1, 2007. (For exact
prior to and after the administration of new co-location arrangement with counts of claims used, we refer readers
anesthesia; transitional adjustments to another hospital or CAH or when the to the claims accounting narrative under
payments for covered outpatient CAH creates or acquires an off-campus supporting documentation for this
services furnished by small rural location. We also discuss our proposed proposed rule on the CMS Web site at
hospitals and SCHs located in rural changes relating to several hospital CoPs http://www.cms.hhs.gov/
areas; and reporting requirements for to require the completion of physical HospitalOutpatientPPS/HORD/). Of the
wound care services, cardiac examinations and medical histories, and 131 million final action claims for
rehabilitation services, and bone documentation in the medical records, services provided in hospital outpatient
marrow and stem cell processing for patients after admission and prior to settings, approximately 101 million
services. surgery or a procedure requiring claims were of the type of bill
anesthesia services and for potentially appropriate for use in setting
13. Proposed OPPS Payment Status and postanesthesia evaluations of patients rates for OPPS services (but did not
Comment Indicators before discharge or transfer from the necessarily contain services payable
In section XIV. of this proposed rule, postanesthesia recovery area. under the OPPS). Of the 101 million
we discuss proposed changes to the 18. Regulatory Impact Analysis claims, approximately 46 million were
definitions of status indicators assigned not for services paid under the OPPS or
to APCs and present our proposed In section XXII. of this proposed rule, were excluded as not appropriate for
comment indicators for the OPPS/ASC we set forth an analysis of the impact use (for example, erroneous cost-to-
final rule with comment period. the proposed changes will have on charge ratios (CCRs) or no HCPCS codes
affected entities and beneficiaries. reported on the claim). We were able to
14. OPPS Policy and Payment use approximately 50 million whole
Recommendations II. Proposed Updates Affecting OPPS
Payments claims of the approximately 54 million
In section XV. of this proposed rule, claims that remained to set the OPPS
we address recommendations made by A. Proposed Recalibration of APC APC relative weights we are proposing
MedPAC and the APC Panel regarding Relative Weights for the CY 2008 OPPS. From the 50
the OPPS for CY 2008. (If you choose to comment on issues million whole claims, we created
in this section, please include the approximately 88 million single records,
15. Proposed Update of the Revised ASC caption ‘‘APC Relative Weights’’ at the of which approximately 58 million were
Payment System beginning of your comment.) ‘‘pseudo’’ single claims (created from
In section XVI. of this proposed rule, multiple procedure claims using the
1. Database Construction
we discuss the proposed update of the process we discuss in this section).
revised ASC payment system payment a. Database Source and Methodology Approximately 822,000 claims trimmed
rates for CY 2008. We also discuss our Section 1833(t)(9)(A) of the Act out on cost or units in excess of ±3
proposed changes to our regulations requires that the Secretary review and standard deviations from the geometric
§ 414.22 (b)(5)(i)(A) and (B) regarding revise the relative payment weights for mean, yielding approximately 87
physician payment for performing APCs at least annually. In the April 7, million single bills used for median
noncovered ASC surgical procedures in 2000 OPPS final rule with comment setting. Ultimately, we were able to use
ASCs. In addition, we are proposing to period (65 FR 18482), we explained in for proposed CY 2008 ratesetting some
revise the definitions of ‘‘radiology and detail how we calculated the relative portion of 92 percent of the CY 2006
certain other imaging services’’ and payment weights that were claims containing services payable
‘‘outpatient prescription drugs’’ when implemented on August 1, 2000, for under the OPPS.
provided integral to an ASC covered each APC group. Except for some The proposed APC relative weights
surgical procedure. reweighting due to a small number of and payments for CY 2008 in Addenda
APC changes, these relative payment A and B to this proposed rule were
16. Reporting Quality Data for Annual
weights continued to be in effect for CY calculated using claims from this period
Payment Rate Updates
2001. This policy is discussed in the that were processed before January 1,
In section XVII. of this proposed rule, November 13, 2000 interim final rule 2007, and continue to be based on the
we discuss the proposed quality (65 FR 67824 through 67827). median hospital costs for services in the
measures for reporting hospital We are proposing to use the same APC groups. We selected claims for
outpatient quality data for CY 2009 and basic methodology that we described in services paid under the OPPS and
subsequent years and set forth the the April 7, 2000 OPPS final rule with matched these claims to the most recent
requirements for data collection and comment period to recalibrate the APC cost report filed by the individual
submission for the annual payment relative payment weights for services hospitals represented in our claims data.
update. We also briefly discuss the furnished on or after January 1, 2008, We continue to believe that it is
legislative provisions of the MIEA– and before January 1, 2009. That is, we appropriate to use the most current full
TRHCA that give the Secretary authority are proposing to recalibrate the relative calendar year claims data and the most
recently submitted cost reports to toward the goal of using more multiple would otherwise have been considered
calculate the median costs which we are bill information by assessing the amount to be multiple procedure claims and,
proposing to convert to relative payment of packaging in the multiple bills and, absent the proposal for additional
weights for purposes of calculating the specifically, by exploring the amount of packaging, could have been used for
CY 2008 payment rates. packaging for drug administration ratesetting only if we had been able to
services in the single and multiple bill create ‘‘pseudo’’ single claims from
b. Proposed Use of Single and Multiple
claims. Moreover, in many cases, the them.
Procedure Claims For CY 2008, we are proposing to
proposed expansion of packaging also
For CY 2008, in general, we are enables the use of more claims data by bypass 425 HCPCS codes that are
proposing to continue to use single enabling us to treat claims with multiple identified in Table 1 of this proposed
procedure claims to set the medians on procedure codes as single claims. We rule. We are proposing to continue the
which the APC relative payment refer readers to section II.A.4. of this use of the codes on the CY 2007 OPPS
weights would be based, with some proposed rule for a full discussion of bypass list but to remove codes we are
exceptions as discussed below. We have this proposal for CY 2008. proposing to package for CY 2008. We
received many requests asking that we also are proposing to remove codes that
ensure that the data from claims that (1) Proposed Use of Date of Service were on the CY 2007 bypass list that
contain charges for multiple procedures Stratification and a Bypass List To ceased to meet the empirical criteria
are included in the data from which we Increase the Amount of Data Used To under the proposed packaging changes
calculate the relative payment weights. Determine Medians when clinical review confirmed that
Requesters believe that relying solely on By bypassing specified codes that we their removal would be appropriate in
single procedure claims to recalibrate believe do not have significant packaged the context of the full proposal for the
APC relative payment weights fails to costs, we are able to use more data from CY 2008 OPPS. Since the inception of
take into account data for many multiple procedure claims. In many the bypass list, we have calculated the
frequently performed procedures, cases, this enables us to create multiple percent of natural single bills that
particularly those commonly performed ‘‘pseudo’’ single claims from claims contained packaging for each code and
in combination with other procedures. that, as submitted, contained multiple the amount of packaging in each
They believe that if a service is separately paid procedures on the same ‘‘natural’’ single bill for each code. We
frequently performed in combination claim. We refer to these newly created retained the codes on the previous
with others, the individual services are single procedure claims as ‘‘pseudo’’ year’s bypass list and used the update
more complex and more resource- single claims because they were year’s data to determine whether it
intensive than if they were performed submitted by providers as multiple would be appropriate to add additional
alone. Stakeholders have suggested that procedure claims. The history of our use codes to the previous year’s bypass list.
including data from multiple procedure of a bypass list to generate ‘‘pseudo’’ The entire list (including the codes that
claims could increase the median cost single claims is well documented, most remained on the bypass list from prior
estimates for the individual services. recently in the CY 2007 OPPS/ASC final years) was open to public comment. For
They believe that depending upon rule with comment period (71 FR 67969 this CY 2008 proposed rule, we
single procedure claims alone results in through 67970). explicitly reviewed all ‘‘natural’’ single
basing relative payment weights on the The date of service stratification and bills against the empirical criteria for all
least costly services that are not bypass list process we used for the CY codes on the CY 2007 bypass list
representative of the typical services, 2007 OPPS (combined with the because of the proposal for greater
thereby introducing downward bias to packaging changes we are proposing in packaging discussed in section II.A.4. of
the medians on which the weights are section II.A.4. of this proposed rule) this proposed rule, as this effort
based. resulted in our being able to use some increased the packaging associated with
We generally use single procedure part of approximately 92 percent of the some codes. We removed 106 HCPCS
claims to set the median costs for APCs total claims that are eligible for use in codes from the CY 2007 bypass list for
because we believe that it is important the OPPS ratesetting and modeling for the CY 2008 proposal. We note also that
that the OPPS relative weights on which this proposed rule. This process enabled many of the codes we are proposing to
payment rates are based be appropriate us to create, for CY 2008 approximately newly package for CY 2008 were on the
when one and only one procedure is 58 million ‘‘pseudo’’ singles and bypass list used for setting the OPPS
furnished and because we are, so far, approximately 30 million ‘‘natural’’ payment rates for CY 2007 and are no
unable to ensure that packaged costs can single bills. For this proposed rule, longer proposed for bypass because we
be appropriately allocated across ‘‘pseudo’’ single procedure bills are proposing to package them, as
multiple procedures performed on the represented 66 percent of all single bills discussed in more detail below. We also
same date of service. We agree that, used to calculate median costs. This are proposing to add to the bypass list
optimally, it is desirable to use the data compares favorably to the CY 2007 HCPCS codes that, using the proposed
from as many claims as possible to OPPS final rule data in which ‘‘pseudo’’ rule data, meet the same previously
recalibrate the APC relative payment single bills represented 68 percent of all established empirical criteria for the
weights, including those claims for single bills used to calculate the median bypass list that are reviewed below or
multiple procedures. We engaged in costs on which the CY 2007 OPPS which our clinicians believe would
several efforts this year to improve our payment rates were based. We believe have little associated packaging if the
use of multiple procedure claims for that the reduction in the percent of services were correctly coded.
ratesetting. As we have for several years, ‘‘pseudo’’ single bills and the The CY 2008 packaging proposal
we continue to use date of service corresponding increase in the minimally reduced the percentage of
stratification and a list of codes to be proportion of ‘‘natural’’ single bills total claims that we were able to use, in
bypassed to convert multiple procedure occurred largely because of our proposal whole or in part, from 93 percent for CY
claims to ‘‘pseudo’’ single procedure to increase packaging as discussed in 2007 to 92 percent for this proposed
claims. We also continued our internal section II.A.4. of this proposed rule. In rule. The proposed packaging approach
efforts to better understand the patterns many cases, the packaging proposal for increased the number of ‘‘natural’’
of services and costs from multiple bills CY 2008 enabled us to use claims that single bills, in spite of reducing the
universe of codes requiring single bills or less than $50. This limits the amount TABLE 1.—PROPOSED CY 2008 BY-
for ratesetting, but reduced the number of error in redistributed costs. PASS CODES FOR CREATING ‘‘PSEU-
of ‘‘pseudo’’ single bills. More ‘‘natural’’ • The code is not a code for an DO’’ SINGLE CLAIMS FOR CALCU-
single procedure bills can be created by unlisted service.
LATING MEDIAN COSTS—Continued
the packaging of codes that always In addition, we are proposing to add
appear with another procedure because to the bypass list codes that our HCPCS
these dependent services are supportive clinicians believe have minimal Short descriptor
code
of and ancillary to the primary associated packaging based on their
independent procedures for which clinical assessment of the full CY 2008 70328 ... X-ray exam of jaw joint.
payment is being made. A claim OPPS proposal. We note that this list 70330 ... X-ray exam of jaw joints.
containing two independent procedure contains bypass codes that are 70336 ... Magnetic image, jaw joint.
appropriate to claims for services in CY 70355 ... Panoramic x-ray of jaws.
codes on the same date of service and
70360 ... X-ray exam of neck.
not on the bypass list previously could 2006 and, therefore, includes codes that 70370 ... Throat x-ray & fluoroscopy.
not be used for ratesetting, but have been deleted for CY 2007. 70371 ... Speech evaluation, complex.
packaging the cost of one of the codes Moreover, there are codes on the bypass 70450 ... Ct head/brain w/o dye.
on the claim frees the claim to be used list that are new for CY 2007 and which 70480 ... Ct orbit/ear/fossa w/o dye.
to calculate the median cost of the are appropriate additions to the bypass 70486 ... Ct maxillofacial w/o dye.
procedure that is not packaged. On the list in preparation for use of the CY 70490 ... Ct soft tissue neck w/o dye.
other hand, our proposed packaging 2007 claims for creation of the CY 2009 70544 ... Mr angiography head w/o dye.
approach reduced the number of codes OPPS. 70551 ... Mri brain w/o dye.
eligible for the bypass list because of the In order to keep the established 71010 ... Chest x-ray.
empirical criteria for the bypass list 71015 ... Chest x-ray.
limitation on packaging set by our
71020 ... Chest x-ray.
previously established empirical constant, we are seeking public 71021 ... Chest x-ray.
criteria. A smaller bypass list and the comment on whether we should adjust 71022 ... Chest x-ray.
presence of greater packaging on claims the $50 packaging cost criterion for 71023 ... Chest x-ray and fluoroscopy.
reduced the final number of ‘‘pseudo’’ inflation each year and, if so, 71030 ... Chest x-ray.
single claims. In prior years, roughly 68 recommendations for the source of the 71034 ... Chest x-ray and fluoroscopy.
percent of single bills were ‘‘pseudo’’ adjustment. Adding an inflation 71035 ... Chest x-ray.
single bills, but based on the CY 2008 adjustment factor would ensure that the 71100 ... X-ray exam of ribs.
proposed rule data, 66 percent of single same amount of packaging associated 71101 ... X-ray exam of ribs/chest.
bills were ‘‘pseudo’’ singles. Moreover, with candidate codes for the bypass list 71110 ... X-ray exam of ribs.
71111 ... X-ray exam of ribs/chest.
the number of ‘‘natural’’ single bills and is reviewed each year relative to 71120 ... X-ray exam of breastbone.
‘‘pseudo’’ single bills are reduced by the nominal costs. 71130 ... X-ray exam of breastbone.
volume of services that we are 71250 ... Ct thorax w/o dye.
proposing to package. Hence, our CY TABLE 1.—PROPOSED CY 2008 BY- 72010 ... X-ray exam of spine.
2008 proposal to package payment for PASS CODES FOR CREATING ‘‘PSEU- 72020 ... X-ray exam of spine.
some HCPCS codes with relatively high DO’’ SINGLE CLAIMS FOR CALCU- 72040 ... X-ray exam of neck spine.
frequencies would eliminate for LATING MEDIAN COSTS
72050 ... X-ray exam of neck spine.
ratesetting the number of available 72052 ... X-ray exam of neck spine.
‘‘natural’’ and ‘‘pseudo’’ single bills 72069 ... X-ray exam of trunk spine.
HCPCS 72070 ... X-ray exam of thoracic spine.
attributable to the codes that we are Short descriptor
code
72072 ... X-ray exam of thoracic spine.
proposing to package.
72074 ... X-ray exam of thoracic spine.
As in prior years, we are proposing to 11056 ... Trim skin lesions, 2 to 4.
72080 ... X-ray exam of trunk spine.
use the following empirical criteria to 11057 ... Trim skin lesions, over 4.
11300 ... Shave skin lesion. 72090 ... X-ray exam of trunk spine.
determine the additional codes to add to 72100 ... X-ray exam of lower spine.
11301 ... Shave skin lesion.
the CY 2007 bypass list to create the CY 72110 ... X-ray exam of lower spine.
11719 ... Trim nail(s).
2008 bypass list. We assume that the 11720 ... Debride nail, 1–5. 72114 ... X-ray exam of lower spine.
representation of packaging on the 11721 ... Debride nail, 6 or more. 72120 ... X-ray exam of lower spine.
single claims for any given code is 11954 ... Therapy for contour defects. 72125 ... Ct neck spine w/o dye.
comparable to packaging for that code in 17003 ... Destruct premalg les, 2–14. 72128 ... Ct chest spine w/o dye.
the multiple claims: 31231 ... Nasal endoscopy, dx. 72131 ... Ct lumbar spine w/o dye.
• There are 100 or more single claims 31579 ... Diagnostic laryngoscopy. 72141 ... Mri neck spine w/o dye.
for the code. This number of single 51798 ... Us urine capacity measure. 72146 ... Mri chest spine w/o dye.
54240 ... Penis study. 72148 ... Mri lumbar spine w/o dye.
claims ensures that observed outcomes 72170 ... X-ray exam of pelvis.
56820 ... Exam of vulva w/scope.
are sufficiently representative of 72190 ... X-ray exam of pelvis.
67820 ... Revise eyelashes.
packaging that might occur in the 69210 ... Remove impacted ear wax. 72192 ... Ct pelvis w/o dye.
multiple claims. 69220 ... Clean out mastoid cavity. 72202 ... X-ray exam sacroiliac joints.
• Five percent or fewer of the single 70030 ... X-ray eye for foreign body. 72220 ... X-ray exam of tailbone.
claims for the code have packaged costs 70100 ... X-ray exam of jaw. 73000 ... X-ray exam of collar bone.
on that single claim for the code. This 70110 ... X-ray exam of jaw. 73010 ... X-ray exam of shoulder blade.
criterion results in limiting the amount 70120 ... X-ray exam of mastoids. 73020 ... X-ray exam of shoulder.
of packaging being redistributed to the 70130 ... X-ray exam of mastoids. 73030 ... X-ray exam of shoulder.
70140 ... X-ray exam of facial bones. 73050 ... X-ray exam of shoulders.
payable procedure remaining on the
70150 ... X-ray exam of facial bones. 73060 ... X-ray exam of humerus.
claim after the bypass code is removed 70160 ... X-ray exam of nasal bones. 73070 ... X-ray exam of elbow.
and ensures that the costs associated 70200 ... X-ray exam of eye sockets. 73080 ... X-ray exam of elbow.
with the bypass code represent the cost 70210 ... X-ray exam of sinuses. 73090 ... X-ray exam of forearm.
of the bypassed service. 70220 ... X-ray exam of sinuses. 73100 ... X-ray exam of wrist.
• The median cost of packaging 70250 ... X-ray exam of skull. 73110 ... X-ray exam of wrist.
observed in the single claims is equal to 70260 ... X-ray exam of skull. 73120 ... X-ray exam of hand.
TABLE 1.—PROPOSED CY 2008 BY- TABLE 1.—PROPOSED CY 2008 BY- TABLE 1.—PROPOSED CY 2008 BY-
PASS CODES FOR CREATING ‘‘PSEU- PASS CODES FOR CREATING ‘‘PSEU- PASS CODES FOR CREATING ‘‘PSEU-
DO’’ SINGLE CLAIMS FOR CALCU- DO’’ SINGLE CLAIMS FOR CALCU- DO’’ SINGLE CLAIMS FOR CALCU-
LATING MEDIAN COSTS—Continued LATING MEDIAN COSTS—Continued LATING MEDIAN COSTS—Continued
HCPCS HCPCS HCPCS

Short descriptor Short descriptor Short descriptor
code code code
73130 ... X-ray exam of hand. 76830 ... Transvaginal us, non-ob. 88305 ... Tissue exam by pathologist.
73140 ... X-ray exam of finger(s). 76856 ... Us exam, pelvic, complete. 88307 ... Tissue exam by pathologist.
73200 ... Ct upper extremity w/o dye. 76857 ... Us exam, pelvic, limited. 88311 ... Decalcify tissue.
73218 ... Mri upper extremity w/o dye. 76870 ... Us exam, scrotum. 88312 ... Special stains.
73221 ... Mri joint upr extrem w/o dye. 76880 ... Us exam, extremity. 88313 ... Special stains.
73510 ... X-ray exam of hip. 76970 ... Ultrasound exam follow-up. 88321 ... Microslide consultation.
73520 ... X-ray exam of hips. 76977 ... Us bone density measure. 88323 ... Microslide consultation.
73540 ... X-ray exam of pelvis & hips. 76999 ... Echo examination procedure. 88325 ... Comprehensive review of data.
73550 ... X-ray exam of thigh. 77300 ... Radiation therapy dose plan. 88331 ... Path consult intraop, 1 bloc.
73560 ... X-ray exam of knee, 1 or 2. 77301 ... Radiotherapy dose plan, imrt. 88342 ... Immunohistochemistry.
73562 ... X-ray exam of knee, 3. 77315 ... Teletx isodose plan complex. 88346 ... Immunofluorescent study.
73564 ... X-ray exam, knee, 4 or more. 77326 ... Brachytx isodose calc simp. 88347 ... Immunofluorescent study.
73565 ... X-ray exam of knees. 77327 ... Brachytx isodose calc interm. 88348 ... Electron microscopy.
73590 ... X-ray exam of lower leg. 77328 ... Brachytx isodose plan compl. 88358 ... Analysis, tumor.
73600 ... X-ray exam of ankle. 77331 ... Special radiation dosimetry. 88360 ... Tumor immunohistochem/manual.
73610 ... X-ray exam of ankle. 77336 ... Radiation physics consult. 88365 ... Insitu hybridization (fish).
73620 ... X-ray exam of foot. 77370 ... Radiation physics consult. 88368 ... Insitu hybridization, manual.
73630 ... X-ray exam of foot. 77401 ... Radiation treatment delivery. 88399 ... Surgical pathology procedure.
73650 ... X-ray exam of heel. 77402 ... Radiation treatment delivery. 89049 ... Chct for mal hyperthermia.
73660 ... X-ray exam of toe(s). 77403 ... Radiation treatment delivery. 89230 ... Collect sweat for test.
73700 ... Ct lower extremity w/o dye. 77404 ... Radiation treatment delivery. 89240 ... Pathology lab procedure.
73718 ... Mri lower extremity w/o dye. 77407 ... Radiation treatment delivery. 90761 ... Hydrate iv infusion, add-on.
73721 ... Mri jnt of lwr extre w/o dye. 77408 ... Radiation treatment delivery. 90766 ... Ther/proph/dg iv inf, add-on.
74000 ... X-ray exam of abdomen. 77409 ... Radiation treatment delivery. 90801 ... Psy dx interview.
74010 ... X-ray exam of abdomen. 77411 ... Radiation treatment delivery. 90802 ... Intac psy dx interview.
74020 ... X-ray exam of abdomen. 77412 ... Radiation treatment delivery. 90804 ... Psytx, office, 20–30 min.
74022 ... X-ray exam series, abdomen. 77413 ... Radiation treatment delivery. 90805 ... Psytx, off, 20–30 min w/e&m.
74150 ... Ct abdomen w/o dye. 77414 ... Radiation treatment delivery. 90806 ... Psytx, off, 45–50 min.
74210 ... Contrst x-ray exam of throat. 77416 ... Radiation treatment delivery. 90807 ... Psytx, off, 45–50 min w/e&m.
74220 ... Contrast x-ray, esophagus. 77418 ... Radiation tx delivery, imrt. 90808 ... Psytx, office, 75–80 min.
74230 ... Cine/vid x-ray, throat/esoph. 77470 ... Special radiation treatment. 90809 ... Psytx, off, 75–80, w/e&m.
74246 ... Contrst x-ray uppr gi tract. 77520 ... Proton trmt, simple w/o comp. 90810 ... Intac psytx, off, 20–30 min.
74247 ... Contrst x-ray uppr gi tract. 77523 ... Proton trmt, intermediate. 90812 ... Intac psytx, off, 45–50 min.
74249 ... Contrst x-ray uppr gi tract. 80500 ... Lab pathology consultation. 90816 ... Psytx, hosp, 20–30 min.
76020 ... X-rays for bone age. 80502 ... Lab pathology consultation. 90818 ... Psytx, hosp, 45–50 min.
76040 ... X-rays, bone evaluation. 85097 ... Bone marrow interpretation. 90826 ... Intac psytx, hosp, 45–50 min.
76061 ... X-rays, bone survey. 86510 ... Histoplasmosis skin test. 90845 ... Psychoanalysis.
76062 ... X-rays, bone survey. 86850 ... RBC antibody screen. 90846 ... Family psytx w/o patient.
76065 ... X-rays, bone evaluation. 86870 ... RBC antibody identification. 90847 ... Family psytx w/patient.
76066 ... Joint survey, single view. 86880 ... Coombs test, direct. 90853 ... Group psychotherapy.
76070 ... Ct bone density, axial. 86885 ... Coombs test, indirect, qual. 90857 ... Intac group psytx.
76071 ... Ct bone density, peripheral. 86886 ... Coombs test, indirect, titer. 90862 ... Medication management.
76075 ... Dxa bone density, axial. 86890 ... Autologous blood process. 92002 ... Eye exam, new patient.
76076 ... Dxa bone density/peripheral 86900 ... Blood typing, ABO. 92004 ... Eye exam, new patient.
76077 ... Dxa bone density/v-fracture. 86901 ... Blood typing, Rh (D). 92012 ... Eye exam established pat.
76078 ... Radiographic absorptiometry. 86903 ... Blood typing, antigen screen. 92014 ... Eye exam & treatment.
76100 ... X-ray exam of body section. 86904 ... Blood typing, patient serum. 92020 ... Special eye evaluation.
76400 ... Magnetic image, bone marrow. 86905 ... Blood typing, RBC antigens. 92081 ... Visual field examination(s).
76510 ... Ophth us, b & quant a. 86906 ... Blood typing, Rh phenotype. 92082 ... Visual field examination(s).
76511 ... Ophth us, quant a only. 86930 ... Frozen blood prep. 92083 ... Visual field examination(s).
76512 ... Ophth us, b w/non-quant a. 86970 ... RBC pretreatment. 92135 ... Opthalmic dx imaging.
76513 ... Echo exam of eye, water bath. 88104 ... Cytopath fl nongyn, smears. 92136 ... Ophthalmic biometry.
76514 ... Echo exam of eye, thickness. 88106 ... Cytopath fl nongyn, filter. 92225 ... Special eye exam, initial.
76516 ... Echo exam of eye. 88107 ... Cytopath fl nongyn, sm/fltr. 92226 ... Special eye exam, subsequent.
76519 ... Echo exam of eye. 88108 ... Cytopath, concentrate tech. 92230 ... Eye exam with photos.
76536 ... Us exam of head and neck. 88112 ... Cytopath, cell enhance tech. 92240 ... Icg angiography.
76645 ... Us exam, breast(s). 88160 ... Cytopath smear, other source. 92250 ... Eye exam with photos.
76700 ... Us exam, abdom, complete. 88161 ... Cytopath smear, other source. 92275 ... Electroretinography.
76705 ... Echo exam of abdomen. 88162 ... Cytopath smear, other source. 92285 ... Eye photography.
76770 ... Us exam abdo back wall, comp. 88172 ... Cytopathology eval of fna. 92286 ... Internal eye photography.
76775 ... Us exam abdo back wall, lim. 88173 ... Cytopath eval, fna, report. 92520 ... Laryngeal function studies.
76778 ... Us exam kidney transplant. 88182 ... Cell marker study. 92541 ... Spontaneous nystagmus test.
76801 ... Ob us < 14 wks, single fetus. 88184 ... Flowcytometry/tc, 1 marker. 92546 ... Sinusoidal rotational test.
76805 ... Ob us >/= 14 wks, sngl fetus. 88185 ... Flowcytometry/tc, add-on. 92548 ... Posturography.
76811 ... Ob us, detailed, sngl fetus. 88300 ... Surgical path, gross. 92552 ... Pure tone audiometry, air.
76816 ... Ob us, follow-up, per fetus. 88302 ... Tissue exam by pathologist. 92553 ... Audiometry, air & bone.
76817 ... Transvaginal us, obstetric. 88304 ... Tissue exam by pathologist. 92555 ... Speech threshold audiometry.
TABLE 1.—PROPOSED CY 2008 BY- TABLE 1.—PROPOSED CY 2008 BY- contributions of packaged costs
PASS CODES FOR CREATING ‘‘PSEU- PASS CODES FOR CREATING ‘‘PSEU- (including packaged revenue code
DO’’ SINGLE CLAIMS FOR CALCU- DO’’ SINGLE CLAIMS FOR CALCU- charges and charges for packaged
LATING MEDIAN COSTS—Continued LATING MEDIAN COSTS—Continued
HCPCS codes) to the median cost of
each drug administration service. (We
HCPCS HCPCS refer readers to Recommendation #28 in
Short descriptor Short descriptor the August 23–24, 2006 meeting
code code
recommendation summary on the CMS
92556 ... Speech audiometry, complete. 95900 ... Motor nerve conduction test. Web site at: http://www.cms.hhs.gov/
92557 ... Comprehensive hearing test. 95921 ... Autonomic nerv function test. FACA/05_AdvisoryPanelonAmbulatory
92567 ... Tympanometry. 95925 ... Somatosensory testing. PaymentClassificationGroups.asp#
92582 ... Conditioning play audiometry. 95930 ... Visual evoked potential test.
TopOfPage.) In our continued effort to
92585 ... Auditor evoke potent, compre. 95950 ... Ambulatory eeg monitoring.
92603 ... Cochlear implt f/up exam 7 >. 95953 ... EEG monitoring/computer. better understand the multiple claims in
92604 ... Reprogram cochlear implt 7 >. 95970 ... Analyze neurostim, no prog. order to extract single bill information
92626 ... Eval aud rehab status. 95972 ... Analyze neurostim, complex. from them, we examined the extent to
93005 ... Electrocardiogram, tracing. 95974 ... Cranial neurostim, complex. which the packaging in multiple
93225 ... ECG monitor/record, 24 hrs. 95978 ... Analyze neurostim brain/1h. procedure claims differs from the
93226 ... ECG monitor/report, 24 hrs. 96000 ... Motion analysis, video/3d. packaging in the single procedure
93231 ... Ecg monitor/record, 24 hrs. 96101 ... Psycho testing by psych/phys. claims on which we base the median
93232 ... ECG monitor/report, 24 hrs. 96111 ... Developmental test, extend. costs both in general and more
93236 ... ECG monitor/report, 24 hrs. 96116 ... Neurobehavioral status exam.
specifically for drug administration
93270 ... ECG recording. 96118 ... Neuropsych tst by psych/phys.
96119 ... Neuropsych testing by tec. services. We performed this analysis
93271 ... Ecg/monitoring and analysis.
93278 ... ECG/signal-averaged. 96150 ... Assess hlth/behave, init. using the claims data on which we
93727 ... Analyze ilr system. 96151 ... Assess hlth/behave, subseq. based the CY 2007 OPPS/ASC final rule
93731 ... Analyze pacemaker system. 96152 ... Intervene hlth/behave, indiv. with comment period. We examined the
93732 ... Analyze pacemaker system. 96153 ... Intervene hlth/behave, group. amount of packaging in multiple
93733 ... Telephone analy, pacemaker. 96415 ... Chemo, iv infusion, addl hr. procedure versus single procedure
93734 ... Analyze pacemaker system. 96423 ... Chemo ia infuse each addl hr. claims in general and in claims for drug
93735 ... Analyze pacemaker system. 96900 ... Ultraviolet light therapy. administration services in particular.
93736 ... Telephonic analy, pacemaker. 96910 ... Photochemotherapy with UV-B.
We conducted this analysis without
93741 ... Analyze ht pace device sngl. 96912 ... Photochemotherapy with UV-A.
96913 ... Photochemotherapy, UV-A or B. taking into account the proposed
93742 ... Analyze ht pace device sngl.
96920 ... Laser tx, skin < 250 sq cm. packaging approach presented in this
93743 ... Analyze ht pace device dual.
93744 ... Analyze ht pace device dual. 98925 ... Osteopathic manipulation. proposed rule. However, we do not
93786 ... Ambulatory BP recording. 98926 ... Osteopathic manipulation. expect the services newly proposed for
93788 ... Ambulatory BP analysis. 98927 ... Osteopathic manipulation. packaged payment to commonly appear
93797 ... Cardiac rehab. 98940 ... Chiropractic manipulation. with a drug administration service.
93798 ... Cardiac rehab/monitor. 98941 ... Chiropractic manipulation. Therefore, we believe that the analysis
93875 ... Extracranial study. 98942 ... Chiropractic manipulation. conducted on the CY 2007 final rule
93880 ... Extracranial study. 99204 ... Office/outpatient visit, new. with comment period data is sufficient
93882 ... Extracranial study. 99212 ... Office/outpatient visit, est.
to inform our development of this
93886 ... Intracranial study. 99213 ... Office/outpatient visit, est.
99214 ... Office/outpatient visit, est. proposed rule.
93888 ... Intracranial study. In general, we do not believe that the
93922 ... Extremity study. 99241 ... Office consultation.
99242 ... Office consultation. proportionate amount of packaged costs
93923 ... Extremity study.
93924 ... Extremity study. 99243 ... Office consultation. in the multiple bills relative to the
93925 ... Lower extremity study. 99244 ... Office consultation. number of primary services is greater
93926 ... Lower extremity study. 99245 ... Office consultation. than that in the single bills. The costs
93930 ... Upper extremity study. 0144T ... CT heart wo dye; qual calc. in uncoded revenue codes and HCPCS
93931 ... Upper extremity study. C8951 .. IV inf, tx/dx, each addl hr. codes with a packaged status indicator
93965 ... Extremity study. C8955 .. Chemotx adm, IV inf, addl hr. account for 22 percent of observed costs
93970 ... Extremity study. G0008 .. Admin influenza virus vac. in the universe of all CY 2005 claims
93971 ... Extremity study. G0101 .. CA screen;pelvic/breast exam.
that we used to model the CY 2007
93975 ... Vascular study. G0127 .. Trim nail(s).
G0130 .. Single energy x-ray study. OPPS (including both the single and
93976 ... Vascular study.
G0166 .. Extrnl counterpulse, per tx. multiple procedure bills). Similarly, the
93978 ... Vascular study.
93979 ... Vascular study. G0175 .. OPPS Service,sched team conf. costs in uncoded revenue codes and
93990 ... Doppler flow testing. G0332 .. Preadmin IV immunoglobulin. HCPCS codes with a packaged status
94015 ... Patient recorded spirometry. G0340 .. Robt lin-radsurg fractx 2–5. indicator account for 18 percent of the
94690 ... Exhaled air analysis. G0344 .. Initial preventive exam. total cost in the subset of CY 2005 single
95115 ... Immunotherapy, one injection. G0365 .. Vessel mapping hemo access. bills that we used to calculate the
95117 ... Immunotherapy injections. G0367 .. EKG tracing for initial prev. median costs on which the relative
95165 ... Antigen therapy services. G0376 .. Smoke/tobacco counseling >10. weights are based.
95805 ... Multiple sleep latency test. M0064 .. Visit for drug monitoring. However, the bypass methodology
95806 ... Sleep study, unattended. Q0091 .. Obtaining screen pap smear.
creates a ‘‘pseudo’’ single bill for all
95807 ... Sleep study, attended. claims for services or items on the
95808 ... Polysomnography, 1–3. (2) Exploration of Allocation of bypass list, and these ‘‘pseudo’’ single
95812 ... Eeg, 41–60 minutes. Packaged Costs to Separately Paid
95813 ... Eeg, over 1 hour. bills have no associated packaging, by
Procedure Codes definition of the application of the
95816 ... Eeg, awake and drowsy.
95819 ... Eeg, awake and asleep. During its August 23–24, 2006 bypass list. Excluding the total cost
95822 ... Eeg, coma or sleep only. meeting, the APC Panel recommended associated with bypass codes, 28
95869 ... Muscle test, thor paraspinal. that CMS provide claims analysis of the percent of observed costs in the single
bills are attributable to packaged descriptors, status indicators, deleted series (Pharmacy), 0260 series (IV
services, and 29 percent of observed code status, and CY 2007 APC Therapy), and 0630 series (Pharmacy—
costs across all claims are attributable to assignments in columns 1, 2, 3, and 4, Extension). These columns demonstrate
packaged services. Therefore, we respectively. HCPCS codes for that packaged costs substantially
conclude that, in general, the extent of additional hours of infusion services are contribute to median cost estimates for
packaging in all bills is similar to the not presented because these codes were the majority of drug administration
amount of packaging in the single included on the CY 2007 bypass list HCPCS codes.
procedure bills we use to set median and, therefore, we explicitly associated For all single bills for CPT code 90780
costs for most APCs. no packaged costs with them, as (Intravenous infusion for therapy/
We recognize that aggregate numbers discussed in the CY 2007 OPPS/ASC
do not address the packaging associated diagnosis, administered by physician or
final rule with comment period (71 FR under direct supervision of physician;
with single and multiple procedure 68117 through 68118). Column 6 of the
claims for specific services. We have up to one hour), on average, packaged
table contains the number of single bills costs were 31 percent of total cost
received comments stating that the
relative to total occurrences of the code (median 27 percent). For the same code,
amount of packaging in the single bills
in the CY 2005 claims, and column 8 packaged drug and pharmacy costs
for drug administration services is not
shows the percentage of single bills comprised, on average, 23 percent of
representative of the typical packaged
costs of these drug administration used to set payment rates. Drug total costs (median 15 percent). Single
services, which are usually performed administration services demonstrate bills make up 34 percent of all line-item
in combination with one another, reasonable single bill representation in occurrences of the service, suggesting
because the single bills represent less comparison with other OPPS services. that this single bill median cost was
complex and less resource-intensive Single bills for drug administration fairly robust and probably captured
services than the usual cases. constitute, roughly, 30 percent of all packaging adequately. On the other
We published a study in the CY 2007 observed occurrences of drug hand, CPT code 90784 (Therapeutic,
OPPS/ASC final rule with comment administration services, varying by code prophylactic or diagnostic injection
period (71 FR 68120 through 68121) that from 7 to 55 percent. Columns 10 (specify material injected);
discussed the amount of packaging on through 13 of the table show measures subcutaneous or intramuscular)
the single bills for drug administration of central tendency for packaged costs demonstrates limited packaging (median
procedure codes, and we promised to as a percentage of total cost on each 0 percent and mean 17 percent), and the
replicate that study for the APC Panel. single claim. Columns 10 and 11 show median cost for the code is derived from
We discussed the results of this study the mean and median of all packaged only 7 percent of all occurrences of the
with the APC Panel at its March 2007 costs as a percentage of total costs, and code. Across all drug administration
meeting, in accordance with the APC columns 12 and 13 break out the costs codes, over half show significant
Panel’s August 2006 recommendation. of packaged drug HCPCS codes and median packaged costs largely
Table 2 below shows the drug uncoded pharmacy revenue code attributable to packaged drug and
administration HCPCS codes and their charges for revenue codes in the 0250 pharmacy costs.
TABLE 2.—PACKAGED COST DATA FOR CY 2005 SINGLE CLAIMS FOR DRUG ADMINISTRATION SERVICES
All packaged costs as Packaged drug and
De- Percent a percent of total cost pharmacy costs as a
HCPCS Total fre- Median
Short descriptor SI leted APC Single bills single percent of total cost
code quency cost ($)
code bills Median Mean Median Mean
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13)
90780 .. IV infusion therapy, 1 hour S ... X .... 0440 1,008,055 2,974,785 33.9 110.43 27.1 30.8 15.3 22.6
90782 .. Injection, sc/im .................... S ... X .... 0437 1,326,094 2,894,231 45.8 24.77 0.0 10.1 0.0 8.7
90783 .. Injection, ia .......................... S ... X .... 0438 427 3,012 14.2 51.35 0.0 10.9 0.0 6.8
90784 .. Injection, iv .......................... S ... X .... 0438 183,096 2,812,204 6.5 49.54 0.0 16.7 0.0 9.7
90788 .. Injection of antibiotic ........... S ... X .... 0437 19,400 141,293 13.7 45.96 24.6 32.3 20.7 30.4
96400 .. Chemotherapy, sc/im .......... S ... ........ 0438 57,472 81,546 70.5 51.98 0.0 6.3 0.0 4.5
96405 .. Chemo intralesional, up to 7 S ... ........ 0438 142 181 78.5 193.65 0.0 12.0 0.0 10.5
96406 .. Chemo intralesional over 7 S ... ........ 0438 2 7 28.6 46.42 0.0 0.0 0.0 0.0
96408 .. Chemotherapy, push tech- S ... ........ 0439 21,113 134,447 15.7 96.85 10.6 21.3 2.4 13.6
nique.
96410 .. Chemotherapy, infusion S ... ........ 0441 161,872 555,170 29.2 151.55 21.4 27.0 12.4 19.6
method.
96414 .. Chemo, infuse method add- S ... ........ 0441 2,370 14,561 16.3 182.89 15.4 23.0 8.6 15.6
on.
96420 .. Chemo, ia, push tecnique ... S ... ........ 0439 170 933 18.2 99.86 9.6 27.6 4.2 15.4
96422 .. Chemo ia infusion up to 1 S ... ........ 0441 556 1,814 30.7 162.94 45.9 46.5 31.0 35.1
hr.
96425 .. Chemotherapy, infusion S ... ........ 0441 149 557 26.8 216.68 29.4 33.5 14.7 24.4
method.
96440 .. Chemotherapy, intracavitary S ... ........ 0439 38 104 36.5 37.12 0.0 2.1 0.0 1.5
96445 .. Chemotherapy, intracavitary S ... ........ 0439 43 137 31.4 61.98 23.8 25.0 23.7 21.1
96450 .. Chemotherapy, into CNS .... S ... ........ 0441 394 869 45.3 160.03 25.8 28.7 2.0 8.3
96520 .. Port pump refill & main ....... S ... ........ 0440 9,771 23,928 40.8 140.66 29.0 31.5 16.8 23.6
96530 .. Syst pump refill & main ....... S ... ........ 0440 8,334 19,283 43.2 100.00 7.4 22.2 0.7 13.7
96542 .. Chemotherapy injection ...... S ... ........ 0438 511 929 55.0 51.56 0.0 10.8 0.0 6.5
By definition, we are unable to packaging associated with drug bills. As a proxy, we estimated
precisely assess the amount of administration codes in the multiple packaging as a percent of total cost on
each claim for two subsets of claims. as procedure codes with a status drugs and pharmacy revenue codes
Both analyses suggest the presence of indicator of ‘‘S,’’ ‘‘T,’’ ‘‘V,’’ ‘‘X,’’ or ‘‘P’’), comprise 6 percent of total cost at the
moderate packaged costs, especially we estimate that packaged costs are 22 median (10 percent, on average). The
drug and pharmacy costs, associated percent of total costs (27 percent, on amount of packaging in both proxy
with drug administration services in the average), where total costs consist of measures, but especially the first subset,
multiple bills. Table 3 below shows costs for all payable codes. Costs for closely resembles the packaged costs as
measures of central tendency for packaged drug HCPCS codes and a percentage of drug administration
packaging percentages in the multiple pharmacy revenue codes comprise 13 costs observed in the single bills for
bills or portions of multiple bills percent of total cost at the median (19 drug administration services. While
remaining after ‘‘pseudo’’ singles have percent, on average). For the second
finding a way to accurately use data
been created. We refer to this group of subset of ‘‘hardcore’’ multiple bills with
from the ‘‘hardcore’’ multiple bills to
the multiple bills as the ‘‘hardcore’’ any drug administration code, that is,
estimate drug administration median
multiple bills. For the first subset of where a drug administration code
‘‘hardcore’’ multiple bills with only appears with other payable codes costs undoubtedly would impact
drug administration codes, that is, (largely radiology services and visits), medians, these comparisons suggest that
where multiple drug administration we estimate packaged costs are 13 the multiple bill data probably would
codes are the only separately paid percent of total cost at the median (19 support current median estimates.
procedure codes on the claim (defined percent, on average). Costs for packaged
TABLE 3.—PACKAGED COSTS ON MULTIPLE BILL CLAIMS FOR DRUG ADMINISTRATION SERVICES
All packaged costs as a percent Packaged drug and pharmacy
of total cost costs as a percent of total cost
Total frequency
Median Mean Median Mean
Subset 1: ‘‘Hardcore’’ Multiple Claims with Only Drug Administration Codes
693,925 ............................................................................................................ 21.6 26.8 12.7 19.3
Subset 2: ‘‘Multiple’’ Claims with At Least One Drug Administration Code
4,816,338 ......................................................................................................... 13.2 19.4 5.8 10.0
We have received several comments the OPPS payment rates. We apply the charges for low cost items to a much
over the past few years offering hospital-specific CCR to the hospital’s greater extent than they mark up high
algorithms for packaging the costs charges at the most detailed level cost items, and that these items are often
associated with specific revenue codes possible, based on a revenue code-to- combined in a single cost center on their
or packaged drugs with certain drug cost center crosswalk that contains a Medicare cost report. Commenters
administration codes. Because of the hierarchy of CCRs used to estimate costs stated that when items with widely
complexity of even routine OPPS from charges for each revenue code. varying costs are combined in a single
claims, prior research suggests that such That crosswalk is available for review cost center using that cost center’s CCR
algorithms have limited power to and continuous comment on the CMS to estimate costs from charges for those
generate additional single bill claims Web site at: http://www.cms.hhs.gov/ items, this approach will overestimate
and do little to change median cost HospitalOutpatientPPS/ the cost of low cost items and
estimates. We continue to look for 03_crosswalk.asp#TopOfPage. underestimate the cost of high cost
simple, but powerful, methodologies Comments on the proposed items. This is commonly known as
like the bypass list and packaging of configuration of the crosswalk for CY ‘‘charge compression.’’ They stated that,
HCPCS codes for additional ancillary 2008 should be included with in the case of implantable devices, the
and supportive services to assign comments on this section of this charges for both high cost devices and
packaged costs to all services within the proposed rule. We calculate CCRs for
low cost supplies typically are reported
‘‘hardcore’’ multiple bills. Ideally, these the standard and nonstandard cost
under the medical supply revenue code
methodologies should be intuitive to the centers accepted by the electronic cost
series and that the costs of both
provider community, easily integrated report database. In general, the most
into the complexity of OPPS median detailed level at which we calculate typically are reported in the medical
cost estimation, and simple to maintain CCRs is the hospital-specific supply cost center on the cost report.
from year to year. We solicit and will departmental level. Commenters stated that the application
carefully consider methodologies for Following the expiration of most of one medical supply CCR to charges
creation of single bills that meet these medical devices from pass-through for all items reported under the medical
criteria. status in CY 2003, prior to which supply revenue code underestimates the
devices were paid at charges reduced to cost of expensive medical supplies and
c. Proposed Calculation of CCRs cost using the hospital’s overall CCR, we overestimates the cost of inexpensive
We calculate hospital-specific overall received comments that our OPPS cost supplies. They indicated that when
CCRs and hospital-specific estimates for device implantation these costs are packaged into the costs
departmental CCRs for each hospital for procedures systematically of the procedures in which they are
which we have claims data in the period underestimate the cost of the devices used, the result is inaccurate median
of claims being used to calculate the included in the packaged payment for costs for the HCPCS codes and APCs,
median costs that we convert to scaled the procedures. Commenters informed and thus the standard OPPS ratesetting
relative weights for purposes of setting us that hospitals routinely mark up methodology systematically distorts
relative payment weights for procedures specifically recommends that RTI recommendation. Further, we
using devices. disaggregated CCRs be reestimated for estimate a CCR for blood that is often
In CY 2006, the device industry outpatient hospital charges. higher than that in the cost report based
commissioned a study to interpolate a Cost report CCRs combine both on a special methodology that is
device-specific CCR from the medical inpatient and outpatient services. discussed further in section X of this
supply CCR, using publicly available Ideally, RTI would be able to examine proposed rule. Therefore, the OPPS is
hospital claim and Medicare cost report the correlation between CCRs for already meeting, and in several cases
data rather than proprietary data on Medicare inpatient services and exceeding, the RTI recommendation for
device costs. After reviewing the device inpatient claim charges and the specificity with regard to estimating the
industry’s data analysis and study correlation between CCRs for Medicare costs associated with emergency
model, CMS contracted with RTI outpatient services and outpatient claim department and blood product services.
International (RTI) to study the impact charges. However, the comprehensive (3) RTI recommends reclassification
of charge compression on the cost-based nature of the cost report CCR (which of intermediate care charges from the
weight methodology adopted in the FY combines inpatient and outpatient intensive care unit to the routine cost
2007 IPPS final rule, to evaluate this services) argues for an analysis of the center (RTI study, pages 10 and 85).
model and to propose solutions. For correlation between CCRs and combined This recommendation is not relevant to
more information, interested inpatient and outpatient claim charges. the OPPS because our methodology for
individuals can view RTI’s report on the As noted, the RTI study accepted some calculating costs under the OPPS relies
CMS Web site at: http:// measurement error in its analysis by solely on ancillary cost centers and does
www.cms.hhs.gov/reports/downloads/ matching an ‘‘all charges’’ CCR to not use either cost center included in
Dalton.pdf. inpatient estimates of charges for groups the recommendation to estimate costs
Any study of cost estimation in of similar services represented by for hospital outpatient services.
general, and charge compression revenue codes because of short (4) RTI recommends establishment of
specifically, has obvious importance for timelines and because inpatient costs regression-based estimates as a
both the OPPS and the IPPS. RTI’s dominate outpatient costs in many temporary or permanent method for
research explicitly focused on the IPPS ancillary cost centers. We believe that disaggregating national average CCRs for
for several reasons, which include CCR adjustments used to calculate medical supplies, drugs, and radiology
greater Medicare expenditure under the payment should be based on the services under the IPPS (RTI study,
IPPS, a desire to evaluate the model comparison of cost report CCRs to pages 11 and 86). With regard to
quickly given IPPS regulation deadlines, combined inpatient and outpatient radiology services, RTI estimated
and a focus on other components of the charges. An ‘‘all charges’’ model would significantly lower CCRs for the cost
new FY 2007 IPPS cost-based weight reduce measurement error and estimate centers for computed tomography (CT)
methodology (CMS Contract No. 500– adjustments to disaggregated CCRs that scans and magnetic resonance imaging
00–0024–T012, ‘‘A Study of Charge could be used in both hospital inpatient (MRI) services. RTI triangulated its
Compression in Calculating DRG and outpatient payment systems. findings with lower observed CCRs for
Relative Weights,’’ page 5). The study RTI made several short-term the one-third of providers reporting
first addressed the possibility of cross- recommendations for improving the nonstandard cost centers, specifically
aggregation bias in the CCRs used to accuracy of DRG weight estimates from MRI Scan and CT Scan. However, in
estimate costs under the IPPS created by a cost-based methodology to address using CCRs for nonstandard cost
the IPPS methodology of aggregating bias in combining cost centers and centers, including MRI Scan and CT
cost centers into larger departments charge compression that could be Scan, the OPPS already has partially
before calculating CCRs. The report also considered in the context of OPPS implemented RTI’s recommendation to
addressed potential bias created by policy. We discuss each use lower CCRs to estimate costs for
estimating costs using a CCR that recommendation within the context of those OPPS services allocated to these
reflects the combined costs and charges the OPPS and provide our assessment of two imaging cost centers.
of services with wide variation in the its application to the OPPS. We do not For reasons discussed in more detail
amount of hospital markup. In its discuss RTI’s recommendations to below, we are proposing to develop an
assessment of the latter, RTI targeted its change cost report policy, which, by all-charges model that would compare
attempt to identify the presence of definition, would not have an effect on variation in CCRs with variation in
charge compression to those cost centers payment weight estimates until several combined inpatient and outpatient
presumably associated with revenue years in the future. charges for sets of similar services and
codes demonstrating significant IPPS (1) RTI recommends expansion of the establish disaggregated CCRs that could
expenditures and utilization. RTI number of CCRs used under the IPPS be applied to both inpatient and
assessed the correlation between cost (RTI study, pages 11 and 85). Our OPPS outpatient charges. We are proposing to
report CCRs and the percent of charges methodology is already more specific evaluate the results of that methodology
in a cost center attributable to a set of than the RTI recommendation. To the for purposes of determining whether the
similar services represented by a group extent possible, the OPPS uses hospital- resulting disaggregated CCRs should be
of revenue codes. RTI did not examine specific cost centers, both standard and proposed for use in developing the CY
the correlation between CCRs and nonstandard, to reduce charges to 2009 OPPS payment rates. The revised
revenue codes without significant IPPS estimated costs and, therefore, the OPPS all-charges model and resulting
expenditures or a demonstrated ratesetting methodology is already more disaggregated CCRs will not be available
concentration in a specific Diagnosis specific than the RTI recommendation. in time for use in the CY 2008 OPPS/
Related Group (DRG). For example, RTI (2) RTI recommends disaggregation of ASC final rule with comment period.
did not examine revenue code groups emergency department and blood There are several reasons that we are
within the pharmacy cost center with products from the ‘‘other services’’ CCR not proposing to use the
low proportionate inpatient charges that used in the IPPS (RTI study, pages 11 intradepartmental CCRs that RTI
might be important to the OPPS, such as and 85). Because we use standard and estimated using IPPS charges for the CY
‘‘Pharmacy Incident to Radiology.’’ RTI nonstandard cost center data, our OPPS 2008 OPPS estimation of median costs.
states this limitation in its study and methodology already comports with this We agree with RTI that the
intradepartmental CCRs it calculated for 2. Proposed Calculation of Median Costs that contain hospital bill types paid
the IPPS would not always be under the OPPS.
In this section of this proposed rule, 1. Claims that were not bill types 12X,
appropriate for application to the OPPS
we discuss the use of claims to calculate 13X, 14X (hospital bill types), or 76X
(RTI study, pages 34 and 35). While RTI
the proposed OPPS payment rates for (CMHC bill types). Other bill types are
recommends that the model be
CY 2008. The hospital OPPS page on the not paid under the OPPS and, therefore,
recalibrated for outpatient charges
CMS Web site on which this proposed these claims were not used to set OPPS
before it is applied to the OPPS, we
rule is posted provides an accounting of payment.
believe that the combined nature of the
claims used in the development of the 2. Claims that were bill types 12X,
CCRs available from the cost report
proposed rates on the CMS Web site at: 13X, or 14X (hospital bill types). These
prevents an accurate outpatient
http://www.cms.hhs.gov/ claims are hospital outpatient claims.
recalibration that would be appropriate
HospitalOutpatientPPS. The accounting 3. Claims that were bill type 76X
for the OPPS alone. The addition of of claims used in the development of (CMHC). (These claims are later
outpatient charges could change the this proposed rule is included on the combined with any claims in item 2
variability of combined charges for some Web site under supplemental materials above with a condition code 41 to set
groups of services. For example, if for the CY 2008 proposed rule. That the per diem partial hospitalization rate
hospitals use a high volume of less accounting provides additional detail determined through a separate process.)
complex devices with lower charges in regarding the number of claims derived For the CCR calculation process, we
the outpatient department, the inclusion at each stage of the process. In addition, used the same general approach as we
or omission of the outpatient charges for below we discuss the files of claims that used in developing the final APC rates
these high volume and lower cost comprise the data sets that are available for CY 2007, using the revised CCR
devices could change the estimated for purchase under a CMS data user calculation which excluded the costs of
disaggregated device CCR. Furthermore, contract. Our CMS Web site, http:// paramedical education programs and
RTI’s analysis excluded some revenue www.cms.hhs.gov/ weighted the outpatient charges by the
codes with extensive outpatient charges HospitalOutpatientPPS, includes volume of outpatient services furnished
because these revenue codes play a information about purchasing the by the hospital. We refer readers to the
minor role in the IPPS. Therefore, we following two OPPS data files: ‘‘OPPS CY 2007 OPPS/ASC final rule with
believe that an all-charges model Limited Data Set’’ and ‘‘OPPS comment period for more information
examining an expanded subset of Identifiable Data Set.’’ (71 FR 67983 through 67985). We first
revenue codes is most appropriate, and We used the following methodology limited the population of cost reports to
that this model must be developed to establish the relative weights we are only those for hospitals that filed
before we could apply the resulting proposing to use in calculating the outpatient claims in CY 2006 before
disaggregated CCRs to the charges for OPPS payment rates for CY 2008 shown determining whether the CCRs for such
supplies paid under the OPPS. in Addenda A and B to this proposed hospitals were valid.
Moreover, to implement the rule. This methodology is as follows: We then calculated the CCRs for each
disaggregated IPPS-based CCRs in the cost center and the overall CCR for each
We used outpatient claims for the full hospital for which we had claims data.
OPPS that RTI estimated for CY 2008 CY 2006, processed before January 1,
could result in greater instability in We did this using hospital-specific data
2007, to set the proposed relative from the Healthcare Cost Report
relative payment weights for CY 2008 weights for CY 2008. To begin the
than would otherwise occur. Significant Information System (HCRIS). We used
calculation of the relative weights for the most recent available cost report
changes in CCRs, both increases and CY 2008, we pulled all claims for
decreases, could prompt the data, in most cases, cost reports for CY
outpatient services furnished in CY 2005. We used the most recently
reassignment of services to different 2006 from the national claims history submitted cost report to calculate the
APCs due to the new estimates of file. This is not the population of claims CCRs to be used to calculate median
median costs and require modification paid under the OPPS, but all outpatient costs for the proposed CY 2008 OPPS
of the overall APC structure. Not only claims (including, for example, CAH rates. If the most recent available cost
might there be significant fluctuations claims and hospital claims for clinical report was submitted but not settled, we
in payment between the CY 2007 and laboratory services for persons who are looked at the last settled cost report to
CY 2008 OPPS, but a subsequent change neither inpatients nor outpatients of the determine the ratio of submitted to
to application of the disaggregated CCRs hospital). settled cost using the overall CCR, and
resulting from development of an all- We then excluded claims with we then adjusted the most recent
charges model might also result in condition codes 04, 20, 21, and 77. available submitted but not settled cost
significant fluctuations in median costs These are claims that providers report using that ratio. We calculated
and increased instability in payments submitted to Medicare knowing that no both an overall CCR and cost center-
from CY 2008 to CY 2009. Therefore, payment will be made. For example, specific CCRs for each hospital. We
these sequential changes could result in providers submit claims with a used the overall CCR calculation
significant increases in median costs in condition code 21 to elicit an official discussed in section II.A.1.c. of this
one year and significant declines in denial notice from Medicare and proposed rule for all purposes that
median costs in the next year. document that a service is not covered. require use of an overall CCR.
Therefore, we are not proposing to We then excluded claims for services We then flagged CAH claims, which
adopt the RTI disaggregated CCRs under furnished in Maryland, Guam, the U.S. are not paid under the OPPS, and claims
the CY 2008 OPPS. We will consider Virgin Islands, American Samoa, and from hospitals with invalid CCRs. The
whether it would be appropriate to the Northern Mariana Islands because latter included claims from hospitals
adopt disaggregated CCRs for the OPPS hospitals in those geographic areas are without a CCR; those from hospitals
after we analyze the results of the use not paid under the OPPS. paid an all-inclusive rate; those from
of both inpatient and outpatient charges We divided the remaining claims into hospitals with obviously erroneous
across all payers to recalculate the three groups shown below. Groups CCRs (greater than 90 or less than
disaggregated CCRs. 2 and 3 comprise the 101 million claims .0001); and those from hospitals with
overall CCRs that were identified as pneumonia (‘‘PPV’’) vaccines. Influenza We use status indicator ‘‘Q’’ in
outliers (3 standard deviations from the and PPV vaccines are paid at reasonable Addendum B to this proposed rule to
geometric mean after removing error cost and, therefore, these claims are not identify services that receive separate
CCRs). In addition, we trimmed the used to set OPPS rates. We note that the HCPCS code-specific payment when
CCRs at the cost center (that is, separate file containing partial specific criteria are met, and payment
departmental) level by removing the hospitalization claims is included in the for the individual service is packaged in
CCRs for each cost center as outliers if files that are available for purchase as all other circumstances. We are
they exceeded ±3 standard deviations discussed above. Unlike years past, we proposing several different sets of
from the geometric mean. We used a did not create a separate file of claims criteria to determine whether separate
four-tiered hierarchy of cost center CCRs containing observation services because payment would be made for specific
to match a cost center to every possible we are proposing to package all services. For example, HCPCS code
revenue code appearing in the observation care for the CY 2008 OPPS. G0379 (Direct admission of patient for
outpatient claims, with the top tier We next copied line-item costs for hospital observation care) is assigned to
being the most common cost center and drugs, blood, and devices (the lines stay status indicator ‘‘Q’’ in Addendum B to
the last tier being the default CCR. If a on the claim, but are copied onto this proposed rule because we are
hospital’s cost center CCR was deleted another file) to a separate file. No claims proposing that it receive separate
by trimming, we set the CCR for that were deleted when we copied these payment only if it is billed on the same
cost center to ‘‘missing,’’ so that another lines onto another file. These line-items date of service as HCPCS code G0378
cost center CCR in the revenue center are used to calculate a per unit mean (Hospital observation service, per hour),
hierarchy could apply. If no other cost and median and a per day mean and
center CCR could apply to the revenue without any services with status
median for drugs, radiopharmaceutical indicator ‘‘T’’ or ‘‘V,’’ or Critical Care
code on the claim, we used the agents, blood and blood products, and
hospital’s overall CCR for the revenue (APC 0617). Proposed payment for
devices, including, but not limited to, observation services is discussed in
code in question. For example, if a visit brachytherapy sources, as well as other
was reported under the clinic revenue section XI. of this proposed rule. The
information used to set payment rates, specific services in the proposed
code, but the hospital did not have a such as a unit-to-day ratio for drugs.
clinic cost center, we mapped the composite APCs discussed in section
We then divided the remaining claims
hospital-specific overall CCR to the II.A.4. of this proposed rule also are
into the following five groups:
clinic revenue code. The hierarchy of assigned to status indicator ‘‘Q’’ in
1. Single Major Claims: Claims with a
CCRs is available for inspection and Addendum B to this proposed rule
single separately payable procedure
comment on the CMS Web site: http:// because we are proposing that their
(that is, status indicator ‘‘S,’’ ‘‘ T,’’ ‘‘V,’’
www.cms.hhs.gov/ payment would be bundled into a single
or ‘‘X’’).
HospitalOutpatientPPS. composite payment for a combination of
2. Multiple Major Claims: Claims with
We then converted the charges to major procedures under certain
more than one separately payable
costs on each claim by applying the CCR circumstances. These services would
procedure (that is, status indicator ‘‘S,’’
that we believed was best suited to the only receive separate code-specific
‘‘T,’’ ‘‘V,’’ or ‘‘X’’), or multiple units for
revenue code indicated on the line with payment if certain criteria are met. The
the charge. Table 4 of this proposed rule one payable procedure. As discussed
below, some of these can be used in same is true for those less intensive
contains a list of the allowed revenue outpatient mental health treatment
codes. Revenue codes not included in median setting. We also included in this
set claims that contain one unit of one services for which payment is limited to
Table 4 are those not allowed under the the partial hospitalization per diem rate
OPPS because their services cannot be code when the bilateral modifier is
appended to the code and the code is and which also are assigned to status
paid under the OPPS (for example, indicator ‘‘Q’’ in Addendum B to this
inpatient room and board charges), and one that is conditionally or
independently bilateral. In these cases, proposed rule. According to
thus charges with those revenue codes longstanding OPPS payment policy (65
were not packaged for creation of the these claims represent more than one
unit of the service described by the FR 18455), payment for these individual
OPPS median costs. One exception is mental health services is bundled into a
the calculation of median blood costs, as code, notwithstanding that only one
unit is billed. single payment, APC 0034 (Mental
discussed in section X. of this proposed
3. Single Minor Claims: Claims with a Health Services Composite), when the
rule.
Thus, we applied CCRs as described single HCPCS code that is assigned to sum of the individual mental health
above to claims with bill types 12X, status indicator ‘‘F,’’ ‘‘G,’’ ‘‘H,’’ ‘‘K,’’ service payments for all of these mental
13X, or 14X, excluding all claims from ‘‘L,’’ or ‘‘N.’’ health services provided on the same
CAHs and hospitals in Maryland, Guam, 4. Multiple Minor Claims: Claims with day would exceed payment for a day of
the U.S. Virgin Islands, American multiple HCPCS codes that are assigned partial hospitalization services.
Samoa, and the Northern Mariana to status indicator ‘‘F,’’ ‘‘G,’’ ‘‘H,’’ ‘‘K,’’ However, the largest number of specific
Islands and claims from all hospitals for ‘‘L,’’ or ‘‘N.’’ HCPCS codes identified by status
which CCRs were flagged as invalid. 5. Non-OPPS Claims: Claims that indicator ‘‘Q’’ in Addendum B to this
We identified claims with condition contain no services payable under the proposed rule are those codes that we
code 41 as partial hospitalization OPPS (that is, all status indicators other identify as ‘‘special’’ packaged codes,
services of hospitals and moved them to than those listed for major or minor where we are proposing that a service
another file. These claims were status). These claims are excluded from receives separate payment when it
combined with the 76X claims the files used for the OPPS. Non-OPPS appears on the same day on a claim
identified previously to calculate the claims have codes paid under other fee without another service that is assigned
partial hospitalization per diem rate. schedules, for example, durable medical to status indicator ‘‘S,’’ ‘‘T,’’ ‘‘V,’’ or
We then excluded claims without a equipment or clinical laboratory tests, ‘‘X.’’ We are proposing to package
HCPCS code. We moved to another file and do not contain either a code for a payment for these HCPCS codes when
claims that contained nothing but separately paid service or a code for a the code appears on the same date of
influenza and pneumococcal packaged service. service with any other service that is
assigned to status indicator ‘‘S,’’ ‘‘T,’’ claims and adding them to the public proposing to define ‘‘other’’ services as
‘‘V,’’ or ‘‘X.’’ use files. HCPCS codes that have a status
This last and largest subset of At its March 2007 meeting, the APC indicator other than those defined as
conditionally packaged services have to Panel recommended that CMS edit and major or minor procedures.
be integrated into the identification of return for correction claims that contain We continue to believe that using
single and multiple bills to ensure that a HCPCS code for a separately paid drug status indicators, with the proposed
the costs for these services are or device but that also do not contain a changes, is an appropriate way to sort
appropriately packaged when they HCPCS code assigned to a procedural the claims into these groups and also to
appear with any other separately paid APC (that is, those not assigned status make our process more transparent to
service. We handle these conditionally indicator ‘‘S,’’ ‘‘T,’’ ‘‘V,’’ or ‘‘X’’). The the public. We further believe that this
packaged services in the data by APC Panel stated that this edit should proposed method of sorting claims
assigning the HCPCS code an APC and improve the claims data and may would enhance the public’s ability to
a data status indicator of ‘‘N.’’ When the increase the number of single bills derive useful information for analysis
conditionally packaged HCPCS code available for ratesetting. We note that and public comment on this proposed
appears with a HCPCS code with a such an edit would be broader than the rule.
status indicator of ‘‘S,’’ ‘‘T,’’ ‘‘V,’’ or ‘‘X’’ device-to-procedure code edits we We set aside the single minor,
on the same date of service, it is treated implemented for CY 2007 for selected multiple minor, and non-OPPS claims
as a packaged code. The costs that devices. While we encourage hospitals (numbers 3, 4, and 5 above) because we
appear on the line with the code are to code correctly in accordance with did not use these claims in calculating
packaged into the cost of the HCPCS CPT, CMS, and local contractor median costs of procedural APCs. We
code with a status indicator of ‘‘S,’’ ‘‘T,’’ guidance, in general we have then examined the multiple major
‘‘V,’’ or ‘‘X.’’ When the conditionally historically implemented claims claims for dates of service to determine
packaged HCPCS code appears by itself, processing edits under the OPPS when if we could break them into single
we change the status indicator on the we believe that these edits help ensure procedure claims using the dates of
line to the status indicator of the APC complete claims data for ratesetting. In service on all lines on the claim. If we
to which the conditionally packaged the case of such Outpatient Code Editor could create claims with single major
code is assigned, converting the service (OCE) edits for drugs and devices that procedures by using date of service, we
from a minor to a major procedure. This are separately paid, it is unclear to us created a single procedure claim record
creates single bills for these that these edits would improve our for each separately paid procedure on a
conditionally packaged services that are claims data for median cost calculation different date of service (that is, a
then used to set the median cost for the because the items receive separate ‘‘pseudo’’ single).
conditionally packaged code and for the payment and do not result in multiple We then used the bypass codes listed
APC to which it is assigned when it is procedure claims when they are in Table 1 of this proposed rule and
separately paid. reported. We also are uncertain about discussed in section II.A.1.b. of this
The claims listed in numbers 1, 2, 3, the clinical circumstances that could proposed rule to remove separately
and 4 above are included in the data result in a hospital submitting an OPPS payable procedures that we determined
files that can be purchased as described claim that only reported a separately contain limited costs or no packaged
above. paid drug or device. We are soliciting costs or were otherwise suitable for
In years prior to the CY 2007 OPPS, comments specifically on the impact of inclusion on the bypass list from a
we made a determination of whether establishing such edits on hospital multiple procedure bill. When one of
each HCPCS code was a major code or billing processes and on related the two separately payable procedures
a minor code or a code other than a potential improvements to claims data on a multiple procedure claim was on
major or minor code. We used those used for median setting. the bypass list, we split the claim into
code-specific determinations to sort Therefore, in view of the prior public two ‘‘pseudo’’ single procedure claims
claims into the five groups identified comments and our desire to ensure that records. The single procedure claim
above. For the CY 2007 OPPS, we used the public data files contain all record that contained the bypass code
status indicators to sort the claims into appropriate data, for the CY 2008 OPPS, did not retain packaged services. The
these groups. We defined major we are proposing to define major single procedure claim record that
procedures as any procedure having a procedures as HCPCS codes that have a contained the other separately payable
status indicator of ‘‘S,’’ ‘‘T,’’ ‘‘V,’’ or status indicator of ‘‘S,’’ ‘‘T,’’ ‘‘V,’’ or procedure (but no bypass code) retained
‘‘X;’’ defined minor procedures as any ‘‘X.’’ We are proposing to define minor the packaged revenue code charges and
code having a status indicator of ‘‘N;’’ procedures as HCPCS codes that have a the packaged HCPCS code charges.
and classified ‘‘other’’ procedures as any status indicator of ‘‘F,’’ ‘‘G,’’ ‘‘H,’’ ‘‘K,’’ We also removed lines that contained
code having a status indicator other ‘‘L,’’ or ‘‘N’’ but, as we discuss above, multiple units of codes on the bypass
than ‘‘S,’’ ‘‘T,’’ ‘‘V,’’ ‘‘X,’’ or ‘‘N.’’ For the to make single bills out of any claims for list and treated them as ‘‘pseudo’’ single
CY 2007 OPPS proposed rule limited single procedures with a minor code claims by dividing the cost for the
data set and identifiable data set, these that also has an APC assignment. This multiple units by the number of units
definitions excluded claims on which ensures that the claims that contain only on the line. Where one unit of a single,
hospitals billed drugs and devices codes for drugs and biologicals or separately paid procedure code
without also billing separately paid devices but that do not contain codes for remained on the claim after removal of
procedure codes and, therefore, these procedures are included in the limited the multiple units of the bypass code,
public use files did not contain all data set and the identifiable data set. It we created a ‘‘pseudo’’ single claim
claims used to calculate the drug and also ensures, as discussed above, that from that residual claim record, which
device frequencies and medians. We conditionally packaged services that retained the costs of packaged revenue
corrected this for the CY 2007 OPPS/ receive separate payment only when codes and packaged HCPCS codes. This
ASC final rule with comment period they are billed without any other enabled us to use claims that would
limited data set and identifiable data set separately payable OPPS services are otherwise be multiple procedure claims
by extracting claims containing drugs treated appropriately for purposes of and could not be used. We excluded
and devices from the set of ‘‘other’’ median cost calculations. We are those claims that we were not able to
convert to single claims even after II.A.4. of this proposed rule for a more We also excluded claims that were
applying all of the techniques for complete discussion of the packaging outside 3 standard deviations from the
creation of ‘‘pseudo’’ singles. Among changes we are proposing for CY 2008. geometric mean of units for each HCPCS
those excluded were claims that contain After removing claims for hospitals code on the bypass list (because, as
codes that are viewed as independently with error CCRs, claims without HCPCS discussed above, we used claims that
or conditionally bilateral and that codes, claims for immunizations not contain multiple units of the bypass
contain the bilateral modifier (Modifier covered under the OPPS, and claims for codes).
50, Bilateral procedure) because the services not paid under the OPPS, We used the remaining claims to
line-item cost for the code represents approximately 54 million claims were calculate the CY 2008 proposed median
the cost of two units of the procedure, left. Of these 54 million claims, we were costs for each separately payable HCPCS
notwithstanding that the code appears able to use some portion of code and each APC. The comparison of
with a unit of one. Therefore, the charge approximately 50 million whole claims HCPCS and APC medians determines
on the line represents the charge for two (92 percent of approximately 54 million the applicability of the ‘‘2 times’’ rule.
services rather than a single service and potentially usable claims) to create Section 1833(t)(2) of the Act provides
using the line as reported would approximately 88 million single and that, subject to certain exceptions, the
overstate the cost of a single procedure. ‘‘pseudo’’ single claims, of which we items and services within an APC group
We then packaged the costs of packaged used 87 million single bills (after cannot be considered comparable with
HCPCS codes (codes with status trimming out just over 822,000 claims as respect to the use of resources if the
indicator ‘‘N’’ listed in Addendum B to discussed below) in the CY 2008 highest median (or mean cost, if elected
this proposed rule) and packaged median development and for ratesetting. by the Secretary) for an item or service
revenue codes into the cost of the single We also excluded (1) claims that had in the group is more than 2 times greater
major procedure remaining on the zero costs after summing all costs on the than the lowest median cost for an item
claim. claim and (2) claims containing or service within the same group (‘‘the
The list of packaged revenue codes is packaging flag number 3. Effective for 2 times rule’’). Finally, we reviewed the
shown in Table 4 of this proposed rule. services furnished on or after July 1,
medians and reassigned HCPCS codes to
At its March 2007 meeting the APC different APCs where we believed that
2004, the OCE assigns packaging flag
Panel recommended that CMS review it was appropriate. Section III. of this
number 3 to claims on which hospitals
the final list of packaged revenue codes proposed rule includes a discussion of
submit token charges for a service with
for consistency with OPPS policy and certain proposed HCPCS code
status indicator ‘‘S’’ or ‘‘T’’ (a major
ensure that future versions of the OCE assignment changes that resulted from
separately paid service under the OPPS)
edit accordingly. We compared the examination of the medians and for
for which the fiscal intermediary is
packaged revenue codes in the OCE to other reasons. The APC medians were
required to allocate the sum of charges
the finalized list of packaged revenue recalculated after we reassigned the
for services with a status indicator
codes for the CY 2007 OPPS (71 FR affected HCPCS codes. Both the HCPCS
equaling ‘‘S’’ or ‘‘T’’ based on the weight
67989 through 67990) that we used for medians and the APC medians were
packaging costs in median calculation. for the APC to which each code is weighted to account for the inclusion of
As a result of that analysis, we are assigned. We do not believe that these multiple units of the bypass codes in the
accepting the APC Panel’s charges, which were token charges as creation of ‘‘pseudo’’ single bills.
recommendation and we are proposing submitted by the hospital, are valid In our review of median costs for
to change the list of packaged revenue reflections of hospital resources. HCPCS codes and their assigned APCs,
codes for the CY 2008 OPPS in the Therefore, we deleted these claims. We we have frequently noticed that some
following manner. First, we are also deleted claims for which the services are consistently rarely
proposing to remove revenue codes charges equal the revenue center performed in the hospital outpatient
0274 (Prosthetic/Orthotic devices) and payment (that is, the Medicare payment) setting for the Medicare population. In
0290 (Durable Medical Equipment) from on the assumption that where the charge particular, there are a number of
the list of packaged revenue codes equals the payment, to apply a CCR to services, such as several procedures
because we do not permit hospitals to the charge would not yield a valid related to the care of pregnant women,
report implantable devices in these estimate of relative provider cost. that have annual Medicare claims
revenue codes (Internet Only Manual For the remaining claims, we then volume of 100 or fewer occurrences. By
100–4, Chapter 4, section 20.5.1.1). We standardized 60 percent of the costs of definition, these services also have a
also are proposing to add revenue code the claim (which we have previously small number of single bills from which
0273 (Take Home Supplies) to the list of determined to be the labor-related to estimate median costs. In addition, in
packaged revenue codes because we portion) for geographic differences in some cases, these codes have been
believe that the charges under this labor input costs. We made this historically assigned to clinical APCs
revenue code are for the incidental adjustment by determining the wage where all the services are low volume.
supplies that hospitals sometimes index that applied to the hospital that Therefore, the median costs for these
provide for patients who are discharged furnished the service and dividing the services and APCs often fluctuate from
at a time when it is not possible to cost for the separately paid HCPCS code year to year, in part due to the
secure the supplies needed for a brief furnished by the hospital by that wage variability created by such a small
time at home. We are proposing to index. As has been our policy since the number of claims. One of the benefits of
conform the list of packaged revenue inception of the OPPS, we are proposing basing payment on the median cost of
codes in the OCE to the OPPS for CY to use the pre-reclassified wage indices many HCPCS codes with sufficient
2008. for standardization because we believe single bill representation in an APC is

We packaged the costs of the HCPCS that they better reflect the true costs of that such fluctuation is moderated by
codes that are shown with status items and services in the area in which the increased number of observations
indicator ‘‘N’’ into the cost of the the hospital is located than the post- for similar services on which the APC
independent service to which the reclassification wage indices and, median cost is also based. We
packaged service is ancillary or therefore, would result in the most considered proposing a distinct
supportive. We refer readers to section accurate unadjusted median costs. methodology for calculation of the
median cost of low total volume APCs services only because they are not often of services less than 100, and only 17
in order to provide more stability in furnished to the Medicare population. APCs have a total volume of less than
payment from year to year for these low Therefore, we are proposing to 1,000, in comparison with CY 2007
total volume services. However, after reconfigure certain clinical APCs for CY where 9 APCs (including 3 New
examination of the low total volume 2008 as a way to promote stability and Technology APCs) had a total volume of
OPPS services and their assigned APCs, appropriate payment for the services less than 100 and 36 APCs had a total
we concluded that there were other assigned to them, including low total volume of less than 1,000.
clinical APCs with higher volumes of volume services. We believe that these A detailed discussion of the medians
total claims to which these low total proposed reconfigurations maintain for blood and blood products is
volume services could be reassigned, APC clinical and resource homogeneity. included in section X. of this proposed
while ensuring the continued clinical We are proposing these changes as an rule. A discussion of the medians for
and resource homogeneity of the alternative to developing specific APCs that require one or more devices
clinical APCs to which they would be quantitative approaches to treating low when the service is performed is
newly reassigned. Therefore, we believe total volume APCs differently for included in section IV.A. of this
that it is more appropriate to reconfigure purposes of median calculation. As a proposed rule. A discussion of the
clinical APCs to eliminate most of the result of this proposal, 3 APCs proposed median for partial hospitalization is
low total volume APCs. These low for CY 2008 (all of which are New included below in section II.B. of this
volume services differ from other OPPS Technology APCs) have a total volume proposed rule.
TABLE 4.—PROPOSED CY 2008 PACKAGED REVENUE CODES

Revenue Description
code
0250 ......... PHARMACY.

0251 ......... GENERIC.
0252 ......... NONGENERIC.
0254 ......... PHARMACY INCIDENT TO OTHER DIAGNOSTIC.
0255 ......... PHARMACY INCIDENT TO RADIOLOGY.
0257 ......... NONPRESCRIPTION DRUGS.
0258 ......... IV SOLUTIONS.
0259 ......... OTHER PHARMACY.
0260 ......... IV THERAPY, GENERAL CLASS.
0262 ......... IV THERAPY/PHARMACY SERVICES.
0263 ......... SUPPLY/DELIVERY.
0264 ......... IV THERAPY/SUPPLIES.
0269 ......... OTHER IV THERAPY.
0270 ......... M&S SUPPLIES.
0271 ......... NONSTERILE SUPPLIES.
0272 ......... STERILE SUPPLIES.
0273 ......... TAKE HOME SUPPLIES.
0275 ......... PACEMAKER DRUG.
0276 ......... INTRAOCULAR LENS SOURCE DRUG.
0278 ......... OTHER IMPLANTS.
0279 ......... OTHER M&S SUPPLIES.
0280 ......... ONCOLOGY.
0289 ......... OTHER ONCOLOGY.
0343 ......... DIAGNOSTIC RADIOPHARMS.
0344 ......... THERAPEUTIC RADIOPHARMS.
0370 ......... ANESTHESIA.
0371 ......... ANESTHESIA INCIDENT TO RADIOLOGY.
0372 ......... ANESTHESIA INCIDENT TO OTHER DIAGNOSTIC.
0379 ......... OTHER ANESTHESIA.
0390 ......... BLOOD STORAGE AND PROCESSING.
0399 ......... OTHER BLOOD STORAGE AND PROCESSING.
0560 ......... MEDICAL SOCIAL SERVICES.
0569 ......... OTHER MEDICAL SOCIAL SERVICES.
0621 ......... SUPPLIES INCIDENT TO RADIOLOGY.
0622 ......... SUPPLIES INCIDENT TO OTHER DIAGNOSTIC.
0624 ......... INVESTIGATIONAL DEVICE (IDE).
0630 ......... DRUGS REQUIRING SPECIFIC IDENTIFICATION, GENERAL CLASS.
0631 ......... SINGLE SOURCE.
0632 ......... MULTIPLE.
0633 ......... RESTRICTIVE PRESCRIPTION.
0681 ......... TRAUMA RESPONSE, LEVEL I.
0682 ......... TRAUMA RESPONSE, LEVEL II.
0683 ......... TRAUMA RESPONSE, LEVEL III.

0684 ......... TRAUMA RESPONSE, LEVEL IV.
0689 ......... TRAUMA RESPONSE, OTHER.
0700 ......... CAST ROOM.
0709 ......... OTHER CAST ROOM.
0710 ......... RECOVERY ROOM.
0719 ......... OTHER RECOVERY ROOM.
0720 ......... LABOR ROOM.
TABLE 4.—PROPOSED CY 2008 PACKAGED REVENUE CODES—Continued

Revenue Description
code
0721 ......... LABOR.

0762 ......... OBSERVATION ROOM.
0810 ......... ORGAN ACQUISITION.
0819 ......... OTHER ORGAN ACQUISITION.
0942 ......... EDUCATION/TRAINING.
3. Proposed Calculation of OPPS Scaled base for the CY 2008 OPPS relative 4. Proposed Changes to Packaged
Payment Weights weights. Services
Using the median APC costs Section 1833(t)(9)(B) of the Act (If you choose to comment on the
discussed previously, we calculated the requires that APC reclassification and issues in this section, please include the
proposed relative payment weights for recalibration changes, wage index caption ‘‘OPPS: Packaged Services’’ at
each APC for CY 2008 shown in changes, and other adjustments be made the beginning of your comment.)
Addenda A and B to this proposed rule. in a manner that assures that aggregate a. Background
In years prior to CY 2007, we payments under the OPPS for CY 2008
standardized all the relative payment When the Medicare program was first
are neither greater than nor less than the
weights to APC 0601 (Mid Level Clinic implemented, it paid for hospital
aggregate payments that would have services (inpatient and outpatient) based
Visit) because it is one of the most
been made without the changes. To on hospital-specific reasonable costs
frequently performed services in the
comply with this requirement attributable to furnishing services to
hospital outpatient setting. We assigned
APC 0601 a relative payment weight of concerning the APC changes, we Medicare beneficiaries. Later the law
1.00 and divided the median cost for compared aggregate payments using the was amended to limit payment to the
each APC by the median cost for APC CY 2007 relative weights to aggregate lesser of the hospital’s reasonable cost
0601 to derive the relative payment payments using the CY 2008 proposed or customary charges for services
weight for each APC. relative weights. This year, we included furnished to Medicare beneficiaries.
Beginning with the CY 2007 OPPS, payments to CMHCs in our comparison. Specific service-based methodologies
we standardized all of the relative Based on this comparison, we adjusted were then developed for certain types of
payment weights to APC 0606 (Level 3 the relative weights for purposes of services, such as clinical laboratory tests
Clinic Visits) because we deleted APC budget neutrality. The unscaled relative and durable medical equipment, while
0601 as part of the reconfiguration of the payment weights were adjusted by a payments for outpatient surgical
visit APCs. We chose APC 0606 as the weight scaler of 1.3665 for budget procedures and other diagnostic tests
base because under our proposal to neutrality. In addition to adjusting for were based on a blend of the hospital’s
reconfigure the APCs where clinic visits increases and decreases in weight due to aggregate Medicare costs for these
are assigned for CY 2007, APC 0606 is the recalibration of APC medians, the services and Medicare’s payment for
the middle level clinic visit APC (that scaler also accounts for any change in similar services in other ambulatory
is, Level 3 of five levels). We have settings. While this mix of different
the base, other than changes in volume,
historically used the median cost of the payment methodologies was in use,
which are not a factor in the weight
middle level clinic visit APC (that is hospital outpatient services were
scaler. growing rapidly following the
APC 0601 through CY 2006) to calculate
unscaled weights because mid-level The proposed relative payment implementation of the IPPS in 1983.
clinic visits are among the most weights listed in Addenda A and B to The brisk increase in hospital outpatient
frequently performed services in the this proposed rule incorporate the services led to an interest in creating
hospital outpatient setting. Therefore, to recalibration adjustments discussed in payment incentives to promote more
maintain consistency in using a median sections II.A.1. and 2. of this proposed efficient delivery of hospital outpatient
for calculating unscaled weights rule. services through a Medicare prospective
representing the median cost of some of payment system for hospital outpatient
Section 1833(t)(14)(H) of the Act, as
the most frequently provided services, services, and the final statutory
added by section 621(a)(1) of Pub. L.
we proposed to continue to use the requirements for the OPPS were
108–173, states that ‘‘Additional established by the BBA and the BBRA.
median cost of the mid-level clinic APC,
expenditures resulting from this During the period of time when
proposed APC 0606, to calculate
unscaled weights. Following our paragraph shall not be taken into different approaches to prospective
standard methodology, but using the CY account in establishing the conversion payment for hospital outpatient services
2007 median for APC 0606, for CY 2007 factor, weighting and other adjustment were being considered, a variety of
we assigned APC 0606 a relative factors for 2004 and 2005 under reports to Congress (June 1988,
payment weight of 1.00 and divided the paragraph (9) but shall be taken into September 1990, and March 1995)
median cost of each APC by the median account for subsequent years.’’ Section discussed three major issues related to
cost for APC 0606 to derive the unscaled 1833(t)(14) of the Act provides the defining the unit of payment for the
relative payment weight for each APC. payment rates for certain ‘‘specified payment system, specifically the extent
The choice of the APC on which to base covered outpatient drugs.’’ Therefore, to which clinically similar procedures
the relative weights for all other APCs the cost of those specified covered should be grouped for payment
does not affect the payments made outpatient drugs (as discussed in section purposes and the logic that should be
under the OPPS because we scale the V. of this proposed rule) is included in used for the groupings; the extent to
weights for budget neutrality. We are the budget neutrality calculations for which payment for minor, ancillary
again proposing to use APC 0606 as the the CY 2008 OPPS. services associated with a significant
procedure should be packaged into a services, rather than the efficient services that were performed, consistent
single payment for the procedure delivery of those services. Over the past with CPT or CMS coding guidelines, but
(which we refer to as ‘‘packaging’’); and several years of the OPPS, greater packaged costs also may be uncoded
the extent to which payment for unpackaging of payment has occurred and included in specific revenue code
multiple significant procedures related simultaneously with continued charges. Hospitals include charges for
to an outpatient encounter or to an tremendous growth in OPPS packaged services on their claims, and
episode of care should be bundled into expenditures as a result of increasing the costs associated with those packaged
a single unit of payment (which we refer volumes of individual services, as services are then added into the costs of
to as ‘‘bundling’’). Both packaging and discussed in further detail below. Also separately payable procedures on the
bundling were presented as approaches discussed in further detail below, most same claims in establishing payment
to creating incentives for efficiency, recently in its comments to the CY 2007 rates for the separately payable services.
with their potential policy OPPS/ASC proposed rule and in the Packaging and bundling payment for
disadvantages including inconsistency context of this rapid spending growth, multiple interrelated services into a
with other ambulatory fee schedules, the Medicare Payment Advisory single payment creates incentives for
reduced transparency of service-specific Commission (MedPAC) encouraged providers to furnish services in the most
payment, and the potential for hospitals CMS to broaden the payment bundles efficient way by enabling hospitals to
shifting the delivery of packaged or under the OPPS to encourage providers manage their resources with maximum
bundled services to delivery settings to use resources efficiently. flexibility, thereby encouraging long-
other than the hospital outpatient As permitted under section term cost containment. For example,
department (HOPD). 1833(t)(2)(B) of the Act, the OPPS where there are a variety of supplies
establishes groups of covered HOPD that could be used to furnish a service,
The OPPS, like other prospective
services, namely APC groups, and uses some of which are more expensive than
payment systems, relies on the concept
them as the basic unit of payment. others, packaging encourages hospitals
of averaging, where the payment may be
During the evolution of the OPPS over to use the least expensive item that
more or less than the estimated costs of
the past 7 years, significant attention meets the patient’s needs, rather than to
providing a service or package of
has been concentrated on service- routinely use a more expensive item.
services for a particular patient, but
specific payment for services furnished Packaging also encourages hospitals to
with the exception of outlier cases, it is
to particular patients, rather than on negotiate carefully with manufacturers
adequate to ensure access to appropriate creating incentives for the efficient and suppliers to reduce the costs of
care. Decisions about packaging and delivery of services through encounter purchased items and services or to
bundling payment involve a balance or episode-of-care-based payment. explore alternative group purchasing
between ensuring some separate Overall packaging included in the arrangements, thereby encouraging the
payment for individual services and clinical APCs has decreased, and the most economical health care. Similarly,
establishing incentives for efficiency procedure groupings have become packaging encourages hospitals to
through larger units of payment. In smaller as the focus has shifted to establish protocols that ensure that
many situations, the final payment rate refining service-level payment. services are furnished only when they
for a package of services may do a better Specifically, in the CY 2003 OPPS, there are important and to carefully scrutinize
job of balancing variability in the were 569 APCs, but by CY 2007, the the services ordered by practitioners to
relative costs of component services number of APCs had grown to 862, a 51- maximize the efficient use of hospital
compared to individual rates covering a percent increase in 4 years. Similarly, resources. Finally, packaging payments
smaller unit of service without the percentage of CPT codes for into larger payment bundles promotes
packaging or bundling. Packaging procedural services that receive the stability of payment for services over
payments into larger payment bundles packaged payment declined by over 10 time. Packaging also may reduce the
promotes the stability of payment for percent between CY 2003 and CY 2007. importance of refining service-specific
services over time, a characteristic that Currently, the APC groups reflect a payment because there is more
reportedly is very important to modest degree of packaging, including opportunity for hospitals to average
hospitals. Unlike packaged services, the packaged payment for minor ancillary payment across higher cost cases
costs of individual services typically services, inexpensive drugs, medical requiring many ancillary services and
show greater variation because the supplies, implantable devices, capital- lower cost cases requiring fewer
higher variability for some component related costs, operating and recovery ancillary services.
items and services cannot be balanced room use, and anesthesia services.
with lower variability for others and Bundling payment for multiple b. Addressing Growth in OPPS Volume
because relative weights are typically significant services provided in the and Spending
estimated using a smaller set of claims. same hospital outpatient encounter or Creating additional incentives for
When compared to service-specific during an episode of care is not providing only necessary services in the
payment, packaging or bundling currently a common OPPS payment most efficient manner is of vital
payment for component services may practice, because the APC groups importance to Medicare today, in view
change payment at the hospital level to generally reflect only the modest of the recent explosion of growth in
the extent that there are systematic packaging associated with individual program expenditures for hospital
differences across hospitals in their procedures or services. Unconditionally outpatient services paid under the
performance of the services included in packaged services with HCPCS codes OPPS. As illustrated in Table 5 below,
that unit of payment. Hospitals are identified by the status indicator total spending has been growing at a
spending more per case than payment ‘‘N.’’ Conditionally packaged services, rate of roughly 10 percent per year
received would be encouraged to review specifically those services whose under the OPPS, and the Medicare
their service patterns to ensure that they payment is packaged unless specific Trustees project that total spending
furnish services as efficiently as criteria for separate payment are met, under the OPPS will increase by more
possible. Similarly, we believe that are assigned to status indicator ‘‘Q.’’ To than $3 billion from CY 2007 through
unpackaging services heightens the the extent possible, hospitals may use CY 2008 to nearly $35 billion.
hospital’s focus on pricing individual HCPCS codes to report any packaged Implementation of the OPPS has not
slowed outpatient spending growth over spending growth has generally been with this rate of increase in program
the past few years; in fact, double-digit occurring. We are greatly concerned expenditures under the OPPS.
TABLE 5.—GROWTH IN EXPENDITURES UNDER OPPS FROM CY 2001–CY 2008

[Projected Expenditures for CY 2006–CY 2008, in Billions]
OPPS growth CY 2001 CY 2002 CY 2003 CY 2004 CY 2005 CY 2006 CY 2007 CY 2008
Incurred Cost ................................................................... 17.702 19.561 21.156 23.866 26.572 29.338 31.641 34.960
Percent Increase .............................................................. .............. 10.5 8.2 12.8 11.3 10.4 7.8 10.5
Source: CY 2007 Medicare Trustees’ Report.
As with the other Medicare fee-for- utilization of services is the major illustrates the increases in the volume
service payment systems that are reason for the current rates of growth in and intensity of hospital outpatient
experiencing rapid spending growth, the OPPS, rather than general price or services over the past several years.
brisk growth in the intensity and enrollment changes. Table 6 below
TABLE 6.—PERCENT INCREASE IN VOLUME AND INTENSITY OF HOSPITAL OUTPATIENT SERVICES

CY CY CY
CY CY CY CY 2006 2007 2008
2002 2003 2004 2005 (Est.) (Est.) (Est.)
Percent Increase ............................................................................................................ 3.5 2.5 7.6 7.4 8.6 6.4 5.8
Source: CY 2007 Medicare Trustees’ Report.
For hospital outpatient services, the fewer basic services, which increases working closely with stakeholder
volume and intensity of services are overall service complexity. The partners.
estimated to have continued to increase MedPAC expressed concern about this We continue to believe that the
significantly in recent years, at a rate of relationship and concluded that the collection and submission of
8.6 percent between CY 2005 and CY historically large increases in outpatient performance data and the public
2006, the last two completed calendar volume and service complexity suggest reporting of comparative information
years. As we discussed in the CY 2007 a need to recalibrate the OPPS. In the are strong incentives for hospital
OPPS/ASC final rule with comment future, MedPAC plans to examine accountability in general and quality
period (71 FR 68189 through 68190), the options for recalibrating the payment improvement in particular, while
rapid growth in utilization of services system to accurately match payments to encouraging the most efficient and
under the OPPS shows that Medicare is the costs of individual services effective care. Measurement and
paying mainly for more services each (Medicare Payment Advisory reporting can focus the attention of
year, regardless of their quality or Commission Report to the Congress: hospitals and consumers on specific
impact on beneficiary health. In its Medicare Payment Policy, March 2007, goals and on hospitals’ performance
March 2007 Report to Congress (pages pages 55 and 56). relative to those goals. Development and
55 and 56), MedPAC confirmed that implementation of performance
much of the growth in service volume As proposed for the CY 2007 OPPS measurement and reporting by hospitals
from 2003 to 2005 resulted from and finalized for the CY 2009 OPPS, we can thus produce quality improvement
increases in the number of services per developed a plan to promote higher in health care delivery. Hospital
beneficiary who received care, rather quality services under the OPPS, so that performance measures may also provide
than from increases in the number of Medicare spending would be directed a foundation for performance-based
beneficiaries served. The MedPAC toward those higher quality services (71 rather than volume-based payments.
found that while the rate of growth in FR 68189 through 68197). We believe In the CY 2007 OPPS/ASC final rule
service volume declined over that time that Medicare payments should with comment period, as a first step in
period, the complexity of services, encourage physicians and other the OPPS toward value-based
defined as the sum of the relative providers in their efforts to achieve purchasing, we finalized a policy that
payment weights of all OPPS services better health outcomes for Medicare would employ our equitable adjustment
divided by the volume of all services, beneficiaries at a lower cost. In the CY authority under section 1833(t)(2)(E) of
increased, and that most of the growth 2007 OPPS/ASC final rule with the Act to establish an OPPS Reporting
was attributable to the insertion of comment period, we discussed the Hospital Quality Data for Annual
devices and the provision of complex concept of ‘‘value-based purchasing’’ in Payment Update (RHQDAPU) program
imaging services. The MedPAC further the OPPS as well as in other Medicare based on measures specifically
found that regression analysis suggested payment systems. ‘‘Value-based developed to characterize the quality of
that relatively complex hospital purchasing’’ may use a range of outpatient care (71 FR 68197). We
outpatient services may be more incentives to achieve identified quality finalized implementation of the program
profitable for hospitals than less and efficiency goals, as a means of for CY 2009, when we would implement
complex services. In addition, its promoting better quality of care and a 2.0 point reduction to the OPPS
analysis indicated that favorable more effective resource use in the conversion factor update for those
payments for complex services give Medicare payment systems. In hospitals that do not meet the specific
hospitals an incentive to provide more developing the concept of value-based requirements of the CY 2009 OPPS
of those complex services rather than purchasing for Medicare, we have been RHQDAPU program. We described the
CY 2009 program which would be based With respect to the first alternative, revised ASC payment system proposed
upon CY 2008 hospital reporting of section 1833(t)(2)(F) of the Act requires to package payment for all items and
appropriate measures of the quality of us to establish a methodology for services directly related to the provision
hospital outpatient care that have been controlling unnecessary increases in the of covered surgical procedures into the
carefully developed and evaluated, and volume of covered OPPS services, and ASC facility payment for the associated
endorsed as appropriate, with section 1833(t)(9)(C) of the Act surgical procedure (71 FR 49468). These
significant input from stakeholders. We authorizes us to adjust the update to the other items and services included all
reiterated our belief that ensuring that conversion factor if, under section drugs, biologicals, contrast agents,
Medicare beneficiaries receive the care 1833(t)(2)(F) of the Act, we determine implantable devices, and diagnostic
they need and that such services are of that there is growth in volume that services such as imaging. Because a
high quality are the necessary initial exceeds established tolerances. As we number of these items and services are
steps to incorporating value-based indicated in the September 8, 1998 separately paid under the OPPS and the
purchasing into the OPPS. We proposed rule proposing the proposal included the establishment of
explained that we are specifically establishment of the OPPS (63 FR most ASC payment weights based on
seeking to encourage care that is both 47585), we considered creating a system the procedures’ corresponding OPPS
efficient and of high quality in the that mirrors the sustainable growth rate payment weights, MedPAC encouraged
HOPD. (SGR) methodology applied to the MPFS us to align the payment bundles in the
Subsequent to the publication of the update to control unnecessary growth in two payment systems by increasing the
CY 2007 OPPS/ASC final rule with service volume. However, implementing size of the payment bundles under the
comment period, section 109(b) of the such a system could have the OPPS.
MIEA-TRHCA specifies that in the case potentially undesirable effect of Moreover, MedPAC staff indicated in
of a subsection (d) hospital (defined escalating service volume as payment testimony at the January 9, 2007
under section 1886(d)(1)(B) of the Act as rates stagnate and hospital costs rise, MedPAC public meeting that the growth
hospitals that are located in the 50 thus actually resulting in a growth in in OPPS spending and volume raises
States or the District of Columbia other volume rather than providing an questions about whether the OPPS
than those categories of hospitals or incentive to control volume. Therefore, should be changed to encourage greater
hospital units that are specifically this approach to addressing the volume efficiency (page 390 of the January 9,
excluded from the IPPS, including growth under the OPPS could 2007 MedPAC meeting transcript
psychiatric, rehabilitation, long-term inadvertently result in the exact available at http://www.medpac.gov).
care, children’s, and cancer hospitals or opposite of our desired outcome. MedPAC staff explained at that time
hospital units) that does not submit to The second alternative we considered that MedPAC intends to perform a long-
the Secretary the quality reporting data is to expand the packaging of supportive term assessment of the design of the
required for CY 2009 and each ancillary services and ultimately bundle OPPS, including considering the
subsequent year, the OPPS annual payment for multiple independent bundling of payments for procedures
update factor shall be reduced by 2.0 services into a single OPPS payment. and visits furnished over a period of
percentage points. The quality reporting We believe that this would create time into a single payment, assessing
program proposed for CY 2008 incentives for hospitals to monitor and whether there should be an expenditure
according to this provision is referred to adjust the volume and efficiency of target for hospital outpatient services,
as the Hospital Outpatient Quality Data services themselves, by enabling them evaluating whether payments for
Reporting Program (HOP QDRP) and is to manage their resources with multiple imaging services provided in
discussed in detail in section XVII. of maximum flexibility. Instead of external the same session should be discounted,
this proposed rule. controls on volume, we believe that it is and reviewing the methodology used by
As the next step in our movement preferable for the OPPS to create CMS to determine relative payment
toward value-based purchasing under payment incentives for hospitals to weights for hospital outpatient services.
the OPPS and to complement the HOP carefully scrutinize their service We welcome MedPAC’s study of these
QDRP for CY 2009, with measure patterns to ensure that they furnish only areas, particularly with regard to how
reporting beginning in CY 2008, we those services that are necessary for we might develop appropriate payment
believe it is important to initiate specific high quality care and to ensure that they rates for larger bundles of services.
payment approaches to explicitly provide care as efficiently as possible. Because we believe it is important
encourage efficiency in the hospital Specifically, we believe that increased that the OPPS create enhanced
outpatient setting that we believe will packaging and bundling are the most incentives for hospitals to provide only
control future growth in the volume of appropriate payment strategies to necessary, high quality care and to
OPPS services. While the HOP QDRP establish such incentives in a provide that care as efficiently as
will encourage the provision of higher prospective payment system, and that possible, we have given considerable
quality hospital outpatient services that this approach is clearly preferable to the thought to how we could increase
lead to improved health outcomes for establishment of an SGR or other packaging under the OPPS in a manner
Medicare beneficiaries, we believe that methodology that seeks to control that would not place hospitals at
more targeted approaches are also spending by addressing significant substantial financial risk but which
necessary to encourage increased growth in volume and program would create incentives for efficiency
hospital efficiency. Two alternatives we spending with lower payments. and volume control, while providing
have considered that would be feasible In its October 6, 2006 letter of hospitals with flexibility to provide care
under current law include establishing comment on the CY 2007 OPPS/ASC in the most appropriate way for each
a methodology to measure the growth in proposed rule, MedPAC urged us to Medicare beneficiary. We are
volume and reduce OPPS payment rates establish broader payment bundles in considering the possibility of greater
to account for unnecessary increases in both the revised ASC and hospital bundling of payment for major hospital
volume or developing payment outpatient prospective payment systems outpatient services, which could result
incentives for hospitals to ensure that to promote efficient resource use and in establishing OPPS payments for
they provide necessary services as better align the two payment systems. In episodes of care, and for this reason we
efficiently as possible. particular, our proposal for the CY 2008 particularly welcome MedPAC’s
exploration of how such an approach based payment groups, and we look defibrillator leads including
might be incorporated into the OPPS forward to the findings and defibrillation threshold evaluation
payment methodology. We are recommendations of MedPAC in this (induction of arrhythmia, evaluate of
particularly concerned about the area. This is a significant change in sensing an pacing for arrhythmia
potential for shifting higher cost direction for the OPPS, and we termination) at the time of initial
bundled services to other ambulatory specifically seek the recommendations implantation or replacement; with
settings, and we welcome ideas on of all stakeholders with regard to which testing of single chamber or dual
deterring such activity. We are currently ancillary services could be packaged chamber cardioverter defibrillator) went
considering the complex policy issues and those combinations of services from separate to packaged payment.
related to the possible development and provided in a single encounter or over This service is only performed during
implementation of a bundled payment time that could be bundled together for the course of a surgical procedure for
policy for hospital outpatient services payment. We are hopeful that expanded implantation or replacement of
that involves significant services packaging and, ultimately, greater implantable cardioverter-defibrillator
provided over a period of time which bundling under the OPPS may result in (ICD) leads, and these surgical
could be paid through an episode-based sufficient moderation of growth in implantation procedures are currently
payment methodology, but we consider volume and spending that further assigned to APC 0106 (Insertion/
this possible approach to be a long-term controls would not be needed. However, Replacement/Repair of Pacemaker and/
policy objective. We encourage public if spending were to continue to escalate or Electrodes) and APC 0108 (Insertion/
comments regarding the specific at the current rates, even after we have Replacement/Repair of Cardioverter-
hospital outpatient services, clinical and exhausted our options for increased Defibrillator Leads). We considered the
financial issues, ratesetting packaging and bundling, we are electrophysiologic evaluation service
methodologies, and operational considering multiple options under our (CPT code 93641) to be an ancillary
challenges we should consider in our authority to address these issues, supportive service that may be
exploratory work in this area. including the possibility of imposing performed only in the same operative
We also are examining how we might external controls that could link growth session as a procedure that could
possibly establish payments for same- in volume to reduced payments under otherwise be performed independently
day care encounters, building upon the the OPPS in the future. of the electrophysiologic evaluation
current use of APCs for payment service. In this particular case, the APC
through greater packaging of supportive c. Proposed Packaging Approach
Panel recommended for CY 2007 that
ancillary services. This could include With the exception of the two we package payment for this diagnostic
conditional packaging of supportive composite APCs that we are proposing test and we adopted that
ancillary services into payment for the for CY 2008 and discuss in detail in recommendation for the CY 2007 OPPS.
procedure that is the reason for the section II.A.4.d. of this proposed rule, Making this payment change in this
OPPS encounter (for example, we are not currently prepared to specific case resulted in the availability
diagnostic tests performed on the day of propose an episode-based or fully of significantly more claims data and,
a scheduled procedure). Another developed encounter-based payment therefore, establishment of more valid
approach could include creation of methodology for CY 2008 as our next and representative estimated median
composite APCs for frequently step in value-based purchasing for the costs for the lead insertion and
performed combinations of surgical OPPS. However, in reviewing our electrophysiologic evaluation services
procedures (for example, one APC approach to revising payment packages furnished in the single hospital
payment for multiple cardiac and bundles, we have examined encounter.
electrophysiologic procedures services currently provided under the In the case of much of the care
performed on the same date). Not only OPPS, looking for categories of ancillary furnished in the HOPD, we believe that
could these encounter-based payment items and services for which we believe it is appropriate to view a complete
groups create enhanced incentives for payment could be appropriately service as potentially being reported by
efficiency, but they may also enable us packaged into larger payment packages a combination of two or more HCPCS
to utilize for ratesetting many of the for the encounter. For this first step in codes, rather than a single code, and to
multiple procedure claims that are not creating larger payment groups, we establish payment policy that supports
now used in our establishment of OPPS examined the HCPCS code definitions this view. Ideally, we would consider a
rates for single procedures. (We refer (including CPT code descriptors) to see complete HOPD service to be the totality
readers to section II.A.1.b. of this whether there were categories of codes of care furnished in a hospital
proposed rule for a more detailed for which packaging would be a logical outpatient encounter or in an episode of
discussion of the treatment of multiple expansion of the longstanding care. In general, we believe that it is
procedure claims in the ratesetting packaging policy that has been a part of particularly appropriate to package
process.) For CY 2008, we are proposing the OPPS since its inception. In general, payment for those items and services
two new composite APCs for CY 2008 we have often packaged the costs of that are typically ancillary and
payment of combinations of services in selected HCPCS codes into payment for supportive into the payment for the
two clinical care areas, as discussed services reported with other HCPCS primary diagnostic or therapeutic
under section II.A.4.d. of this proposed codes where we believed that one code modalities in which they are used. As
rule. We look forward to receiving reported an item or service that was a significant first step towards creating
public comment on this proposal as we integral to the provision of care that was payment units that represent larger
explore the possibility of moving toward reported by another HCPCS code. units of service, we examined whether
basing OPPS payment on larger As an example of a previous change there are categories of HCPCS codes that
packages and bundles of services in the OPPS packaging status for a are typically ancillary and supportive to
provided in a single hospital outpatient HCPCS code that is ancillary and diagnostic and therapeutic modalities.
encounter. supportive, under the CY 2007 OPPS, Specifically, as our initial substantial
We intend to involve the APC Panel we note that CPT code 93641 step toward creating larger payment
in our future exploration of how we can (Electrophysiologic evaluation of single groups for hospital outpatient care, we
develop encounter-based and episode- or dual chamber pacing cardioverter are proposing to package payment for
items and services in the seven • Observation services. reflect small distributional changes and
categories listed below into the payment We identify the HCPCS codes we are also because changes to the packaged
for the primary diagnostic or therapeutic proposing to package for CY 2008, HCPCS codes affect both the number
modality to which we believe these explain our rationale for proposing to and composition of single bills and the
items and services are typically package the codes in these categories, mix of hospitals contributing those
ancillary and supportive. We provide examples of how HCPCS and single bills. Such a decline, no change,
specifically chose these categories of APC median costs and payments would or an increase in the median cost at the
HCPCS codes for packaging because we change under these proposals, and HCPCS code level could result from a
believe that the items and services discuss the impact of these changes in change in the number of single bills
described by the codes in these the discussion below under each used to set the median cost. With greater
categories are the HCPCS codes that are category. packaging, more ‘‘natural’’ single bills
typically ancillary and supportive to a The median costs of services at the are created for some codes but fewer
primary diagnostic or therapeutic HCPCS level for many separately paid ‘‘pseudo’’ single bills are created. Thus,
modality and, in those cases, are an procedures change as a result of this some APCs gain single bills and some
integral part of the primary service they proposal because we are proposing to lose single bills due to packaging
support. We are proposing to assign change the composition of the payment changes, as well as to the reassignment
status indicator ‘‘N’’ to those HCPCS packages associated with the HCPCS of some codes to different APCs. When
codes that we believe are always codes. Moreover, as a result of changes more claims from a different mix of
integral to the performance of the to the HCPCS median costs, we are providers are used to set the median
primary modality and to package their proposing to reassign some HCPCS cost for the HCPCS code, the median
costs into the costs of the separately codes to different clinical APCs for CY cost could move higher or lower within
paid primary services with which they 2008 to avoid 2 times violations and to the array of per claim costs.
are billed. We are proposing to assign ensure continuing clinical and resource Similarly, proposed revisions to APC
status indicator ‘‘Q’’ to those HCPCS homogeneity of the APCs. Therefore, the assignments that are necessary to
codes that we believe are typically APC median costs change not only as a resolve 2 times violations that could
integral to the performance of the result of the increased packaging itself arise as a result of changes in the
primary modality and to package but also as a result of the migration of HCPCS median cost for one or more
payment for their costs into the costs of HCPCS codes into and out of APCs codes due to additional packaging may
the separately paid primary services through APC reconfiguration. The file of also result in increases or decreases to
with which they are usually billed but HCPCS code and APC median costs APC median costs and, therefore, to
to pay them separately in those resulting from our proposal is found increases or decreases in the payments
uncommon cases in which no other under supporting documentation for for HCPCS codes that would not be
separately paid primary service is this proposed rule on the CMS Web site otherwise affected except for the CY
furnished in the hospital outpatient at http://www.cms.hhs.gov/ 2008 proposed packaging approach for
encounter. HospitalOutpatientPPS/HORD/ the seven categories of items and
For ease of reference in our list.asp#TopOfPage. services.
subsequent discussion in each of the Review of the HCPCS median costs We have examined the proposed
seven areas, we refer to the HCPCS indicates that, while the proposed aggregate impact of making these
codes for which we are proposing to median costs rise for some HCPCS codes changes on payment for CY 2008.
package (or conditionally package) as a result of increased packaging that Because the OPPS is a budget neutral
payment as dependent services. We use expands the costs included in the payment system in which the amount of
the term ‘‘independent service’’ to refer payment packages, there are also cases payment weight in the system is
to the HCPCS codes that represent the in which the proposed median costs annually adjusted for changes in
primary therapeutic or diagnostic decline as a result of these proposed expenditures created by changes in APC
modality into which we are proposing changes. While it seems intuitive to weights and codes (but is not currently
to package payment for the dependent believe that the proposed median costs adjusted based on estimated growth in
service. We note that, in future years as of the remaining separately paid service volume), the effects of the
we consider the development of larger services should rise when the costs of packaging changes we are proposing
services previously paid separately are result in changes to scaled weights and,
payment groups that more broadly
packaged into larger payment groups, it therefore, to the payment rates for all
reflect services provided in an
is more challenging to understand why separately paid procedures. These
encounter or episode of care, it is
the proposed median costs of separately changes result from both shifts in
possible that we might propose to
paid services would not change or median costs as a result of increased
bundle payment for a service that we
would decline when the costs of packaging, changes in multiple
now refer to as ‘‘independent’’ in this
previously paid services are packaged. procedure discounting patterns, and a
proposed rule. Medians are generally more stable
Specifically, we are proposing to higher weight scaler that is applied to
than means because they are less all unscaled APC weights. (We refer
package the payment for HCPCS codes
sensitive to extreme observations, but readers to section II.A.3. of this
describing the dependent items and
medians typically do not reflect subtle proposed rule for an explanation of the
services in the following seven
changes in cost distributions. The OPPS’ weight scaler.) In a budget neutral
categories into the payment for the
use of medians rather than means system, the monies previously paid for
independent services with which they
usually results in relative weight services that are now proposed to be
are furnished:
• Guidance services. estimates being less sensitive to packaged are not lost, but are
• Image processing services. packaging decisions. Specifically, the redistributed to all other services. A
• Intraoperative services. median cost for a particular higher weight scaler would increase
• Imaging supervision and independent procedure generally will payment rates relative to observed
interpretation services. be higher as a result of added packaging, median costs for independent services
• Diagnostic radiopharmaceuticals. but also could change little or be lower by redistributing the lost weight of
• Contrast media and. because median costs typically do not packaged items that historically have
been paid separately and the lost weight most general type of category. The code for the primary procedure. We also
when the median costs of independent hierarchy of categories is as follows: note that there are a number of CPT
services do not completely reflect the guidance services, image processing codes describing independent surgical
full incremental cost of the packaged services, intraoperative services, and procedures but which the code
services. The impact of this proposed imaging supervision and interpretation descriptors indicate that guidance is
change on proposed CY 2008 OPPS services. Therefore, while CPT code included in the code reported for the
payments is discussed in section XXII B. 93325 may logically be grouped with surgical procedure if it is used and,
of this proposed rule, and the impact on either imaging processing services or therefore, packaged payment is already
various classifications of hospitals is intraoperative services, it is treated as made for the associated guidance
shown in Column 2B in Table 67 in that an image processing service because service under the OPPS. For example,
section. that group is more clinically specific the independent procedure described by
We estimate that our CY 2008 and precedes intraoperative services in CPT code 55873 (Cryosurgical ablation
proposal would redistribute the hierarchy. We did not believe it was of the prostate (includes ultrasonic
approximately 1.2 percent of the necessary to include diagnostic guidance for interstitial cryosurgical
estimated CY 2007 base year radiopharmaceuticals, contrast media, probe placement)) already includes the
expenditures under the OPPS. The or observation categories in this list ultrasound guidance that may be used.
monies associated with this because those services generally map to We believe packaging payment for every
redistribution would be in addition to only one of those categories. We note guidance service under the OPPS would
any increase that would otherwise occur that there is no cost estimation or provide consistently packaged payment
due to a proposed higher median cost payment implications related to the for all these services that are used to
for the APC as a result of the expanded assignment of a HCPCS code for direct independent procedures, even if
payment package. If the relative weight purposes of discussion to any specific they are currently separately reported.
for a particular APC decreases as a category. Because these dependent guidance
result of the proposed packaging procedures support the performance of
approach, the increased weight scaler (1) Guidance Services an independent procedure and they are
may or may not result in a relative We are proposing to package payment generally provided in the same
weight that is equal to or greater than for HCPCS guidance codes for CY 2008, operative session as the independent
the relative weight that would occur specifically those codes that are procedure, we believe that it would be
without the proposed packaging reported for supportive guidance appropriate to package their payment
approach. In general, the packaging that services, such as ultrasound, into the OPPS payment for the
we are proposing would have more fluoroscopic, and stereotactic navigation independent procedure performed.
effect on payment for some services services, that aid the performance of an However, guidance services differ from
than on payment for others because the independent procedure. We performed a some of the other categories of services
dependent items and services that we broad search for such services, relying that we are proposing to package for CY
are proposing for packaging are upon the American Medical 2008. Hospitals sometimes may have the
furnished more often with some Association’s (AMA’s) CY 2007 book of option of choosing whether to perform
independent services than with others. CPT codes and the CY 2007 book of a guidance service immediately
However, because of the amount of Level II HCPCS codes, which identified preceding or during the main
payment weight that would be specific HCPCS codes as guidance independent procedure, or not at all,
redistributed by this proposal, there codes. Moreover, we performed a unlike many of the imaging supervision
would be some impact on payments for clinical review of all HCPCS codes to and interpretation services, for example,
all OPPS services whose rates are set capture additional codes that are not which are generally always reported
based on payment weights, and the necessarily identified as ‘‘guidance’’ when the independent procedure is
impact on any given hospital would services but describe services that performed. Once a hospital decides that
vary based on the mix of services provide directional information during guidance is appropriate, the hospital
furnished by the hospital. the course of performing an may have several options regarding the
The following discussion separately independent procedure. For example, type of guidance service that can be
addresses each of the seven categories of we are proposing to package CPT code performed. For example, when inserting
items and services for which we are 61795 (Stereotactic computer-assisted a central venous access device, hospitals
proposing to package payment under volumetric (navigational) procedure, have the option of using no guidance,
the CY 2008 OPPS as part of our intracranial, extracranial, or spinal (List ultrasound guidance, or fluoroscopic
packaging proposal. Many codes that we separately in addition to code for guidance, and the selection in any
are proposing to package for CY 2008 primary procedure)) because we specific case will depend upon the
could fit into more than one of those consider it to be a guidance service that specific clinical circumstances of the
seven categories. For example, CPT code provides three-dimensional information device insertion procedure. In fact, the
93325 (Doppler echocardiography color to direct the performance of intracranial historical hospital claims data
flow velocity mapping (List separately or other diagnostic or therapeutic demonstrate that various guidance
in addition to codes for procedures. We also included HCPCS services for the insertion of these
echocardiography)) could be included codes that existed in CY 2006 but were devices, which have historically
in both the intraoperative and image deleted and were replaced in CY 2007. received packaged payment under the
processing categories. Therefore, for We included the CY 2006 HCPCS codes OPPS, are used frequently for the
organizational purposes, both to ensure because we are proposing to use the CY insertion of vascular access devices.
that each code appears in only one 2006 claims data to calculate the CY Thus, we recognize hospitals have
category and to facilitate discussion of 2008 OPPS median costs on which the several options regarding the
our CY 2008 proposal, we have created CY 2008 payment rates would be based. performance and types of guidance
a hierarchy of categories that determines Many, although not all, of the CPT services they use. However, we believe
which category each code appropriately guidance codes we identified are that hospitals utilize the most
falls into. This hierarchy is organized designated by CPT as add-on codes that appropriate form of guidance for the
from the most clinically specific to the are to be reported in addition to the CPT specific procedure that is performed.
We do not want to create payment previously, the median cost for a status indicator ‘‘N.’’ We are not
incentives to use guidance for all particular independent procedure proposing status indicator changes for
independent procedures or to provide generally will be higher as a result of the five guidance procedures that were
one form of guidance instead of another. added packaging, but also could change unconditionally packaged for CY 2007.
Therefore, by proposing to package little or be lower because median costs We are proposing to change the status
payment for all forms of guidance, we typically do not reflect small indicators for 31 guidance procedures
are specifically encouraging hospitals to distributional changes and because from separately paid to unconditionally
utilize the most cost effective and changes to the packaged HCPCS codes packaged (status indicator ‘‘N’’) for the
clinically advantageous method of affect both the number and composition CY 2008 OPPS. We believe that these
guidance that is appropriate in each of single bills and the mix of hospitals services are always integral to and
situation by providing them with the contributing those single bills. In fact, dependent upon the independent
maximum flexibility associated with a the CY 2007 CPT book indicates that if services that they support and,
single payment for the independent guidance is performed with CPT code therefore, their payment would be
procedure. Similarly, hospitals may 20610, it may be appropriate to bill CPT appropriately packaged because they
appropriately not utilize guidance code 76942 (Ultrasonic guidance for would generally be performed on the
services in certain situations based on needle placement (e.g. biopsy, same date and in the same hospital as
clinical indications. aspiration, injection, localization the independent services.
Because guidance services can be device), imaging supervision and We are proposing to change the status
appropriately reported in association interpretation); 77002 (Fluoroscopic indicator for 1 guidance procedure from
with many independent procedures, guidance for needle placement (e.g. separately paid to conditionally
under our proposed packaging of biopsy, aspiration, injection, packaged (status indicator ‘‘Q’’), and we
guidance services for CY 2008, the costs localization device)); 77012 (Computed will treat it as a ‘‘special’’ packaged
associated with guidance services tomography guidance for needle code for the CY 2008 OPPS, specifically,
would be mapped to a larger number of placement (e.g. biopsy, aspiration, CPT code 76000 (Fluoroscopy (separate
independent procedures than some injection, localization device), procedure), up to 1 hour physician time,
other categories of codes that we are radiological supervision and other than 71023 or 71034 (e.g. cardiac
proposing to package. For example, CPT interpretation); or 77021 (Magnetic fluoroscopy)). This code was discussed
code 76001 (Fluoroscopy, physician resonance guidance for needle in the past with the Packaging
time more than one hour, assisting a placement (e.g., for biopsy, needle Subcommittee of the APC Panel which
non-radiologic physician (e.g., aspiration, injection, or placement of determined that, consistent with its
nephrostolithotomy, ERCP, localization device) radiological code descriptor as a separate procedure,
bronchoscopy, transbronchial biopsy)) supervision and interpretation). The CY this procedure could sometimes be
can be reported with a wide range of 2007 CPT book also implies that it is not provided alone, without any other
services. According to the CPT code always clinically necessary to use services on the claim. We believe that
descriptor, these procedures include guidance in performing an this procedure would usually be
nephrostolithotomy, which may be arthrocentesis described by CPT code provided by a hospital as guidance in
reported with CPT code 50080 20610. conjunction with another significant
(Percutaneous nephrostolithotomy or The guidance procedures that we are independent procedure on the same
pyelostolithotomy, with or without proposing to package for CY 2008 vary date of service but may occasionally be
dilation, endoscopy, lithotripsy, in their resource costs. Resource cost provided without another independent
stenting, or basket extraction; up to 2 was not a factor we considered when service. As a ‘‘special’’ packaged code,
cm), and endoscopic retrograde proposing to package guidance if the fluoroscopy service were billed
cholangiopancreatography, which may procedures. Notably, most of the without any other service assigned to
be reported with CPT code 43260 guidance procedures are relatively low status indicator ‘‘S,’’ ‘‘T,’’ ‘‘V,’’ or ‘‘X’’
(Endoscopic retrograde cost in comparison to the independent reported on the same date of service,
cholangiopancreatography (ERCP); services they frequently accompany. under our proposal we would not treat
diagnostic, with or without collection of The codes we are proposing to the fluoroscopy procedure as a
specimen(s) by brushing or washing identify as guidance codes for CY 2008 dependent service for purposes of
(separate procedure)). Therefore, the that would receive packaged payment payment. If we were to unconditionally
cost of the fluoroscopic guidance would are listed in Table 8 below. package payment for this procedure,
be reflected in the payment for each of Several of these codes, including CPT treating it as a dependent service,
these independent services, in addition code 76937 (Ultrasound guidance for hospitals would receive no payment at
to numerous other procedures, rather vascular access requiring ultrasound all when providing this service alone,
than in the payment for only one or two evaluation of potential access sites, although the procedure would not be
independent services, as is the case for documentation of selected vessel functioning as a guidance service in that
some of the other categories of codes patency, concurrent realtime ultrasound case. However, according to our
that we are proposing to package for CY visualization of vascular needle entry, proposal, its conditionally packaged
2008. with permanent recording and reporting status with its designation as a ‘‘special’’
In addition, because independent (List separately in addition to code for packaged code would allow payment to
procedures such as CPT code 20610 primary procedure)), are already be provided for this ‘‘Q’’ status
(Arthrocentesis, aspiration and/or unconditionally (that is, always) fluoroscopy procedure, in which case it
injection; major joint or bursa (e.g., packaged under the CY 2007 OPPS, would be treated as an independent
shoulder, hip, knee joint, subacromial where they have been assigned to status service under these limited
bursa)) may be reported with or without indicator ‘‘N.’’ Payment for these circumstances. On the other hand, when
guidance, the cost for the guidance will services is currently made as part of the the fluoroscopy service is furnished as
be reflected in the median cost for the payment for the separately payable, a guidance procedure on the same day
independent procedure as a function of independent services with which they and in the same hospital as
the frequency that guidance is reported are billed. No separate payment is made independent, separately paid services
with that procedure. As we stated for services that we have assigned to that are assigned to status indicator ‘‘S,’’
‘‘T,’’ ‘‘V,’’ or ‘‘X,’’ we are proposing to was billed with CPT code 47382 the budget neutrality adjustment that
package payment for it as a dependent (Ablation, one or more liver tumor(s), would result from the aggregate effects
service. In all cases, we are proposing percutaneous, radiofrequency) 148 of the CY 2008 packaging proposal
that hospitals that furnish independent times in the CY 2008 OPPS proposed (were there no further budget neutrality
services on the same date as dependent rule claims data, and 42 percent of the adjustment for other reasons)
guidance services must bill them all on claims for CPT code 76940 reported CPT significantly changes the final payment
the same claim. We believe that when code 47382 on the same date of service. rates relative to median cost estimates.
dependent guidance services and Similarly, we note that almost 19 Table 7 presents a comparison of the CY
independent services are furnished on percent of the claims for CPT code 2007 payment for CPT codes 47382 and
the same date and in the same facility, 47382 also reported the ultrasound 76940, where CPT code 76940 is paid
they are part of a single complete guidance service described by CPT code separately, to the CY 2008 payment we
hospital outpatient service that is 76940. Under our proposed policy for are proposing for CPT codes 47382 and
reported with more than one HCPCS the CY 2008 OPPS, we are proposing to 76940, where payment for CPT code
code, and no separate payment should expand the packaging associated with 76940 would be packaged. This example
be made for the guidance service which CPT code 47382 so that payment for the cannot demonstrate the overall impact
supports the independent service. ultrasound guidance, if performed, of packaging guidance services on
We have calculated the median costs would be packaged into the payment for payment to any given hospital because
on which the proposed CY 2008 the liver tumor ablation. Specifically, each individual hospital’s case-mix and
payment rates are based using the we would package payment for CPT billing patterns would be different. The
packaging status of each code as code 76940 so that under the CY 2008 overall impact of packaging payment for
provided in Table 8 below. As we OPPS, the dependent procedure, in this CPT code 76940, as well as all the other
discussed earlier in more detail, this has case ultrasound guidance, would proposed packaging changes we are
the effect of both changing the median receive packaged payment through the proposing for CY 2008, can only be
cost for the independent service into separate OPPS payment for the assessed in the aggregate for classes of
which the cost of the dependent service independent procedure, in this case, the hospitals. Section XXII.B. of this
is packaged and also of redistributing liver tumor ablation. The payment rates proposed rule displays the overall
payment that would otherwise have for this example associated with our CY impact of APC weight recalibration and
been made separately for the service we 2008 proposal are outlined in Table 7 packaging changes we are proposing by
are proposing to newly package for CY below. classes of hospitals, and the OPPS
2008. In this case, the proposed CY 2008 Hospital-Specific Impacts—Provider-
For example, CPT code 76940 median cost for APC 0423 (Level II Specific Data file presents our estimates
(Ultrasound guidance for, and Percutaneous Abdominal and Biliary of CY 2008 hospital payment for those
monitoring of, parenchymal tissue Procedures) to which CPT code 47382 is hospitals we include in our ratesetting
ablation) is assigned to APC 0268 (Level assigned is $2,775.33, while the CY and payment simulation database. The
I Ultrasound Guidance Procedures) for 2007 median cost of APC 0423 is hospital-specific impacts file can be
CY 2007. We are proposing to $2,283.08 and of APC 0268 is $72.61. found on the CMS Web site at http://
discontinue APC 0268 for CY 2008 and However, as discussed in section www.cms.hhs.gov/
to provide packaged payment for the II.A.4.c. of this proposed rule HospitalOutpatientPPS/ under
HCPCS codes that were previously concerning our general proposed supporting documentation for this
assigned to APC 0268. CPT code 76940 packaging approach, the added effect of proposed rule.
TABLE 7.—EXAMPLE OF THE EFFECTS OF THE CY 2008 PACKAGING PROPOSAL ON PAYMENT FOR CPT CODES 76940
AND 47382
Sum of CY
Sum of CY 2008 proposed
2007 payment
HCPCS code Short descriptor payment
(76940 paid (76940 pack-
separately) aged)
76940 ......................... Us guide, tissue ablation spine (dependent service) ...................................................... $73.04 $0.00
47382 ......................... Percut ablate liver rf (independent service) .................................................................... 2,296.47 2,810.08
Total Payment .... .......................................................................................................................................... 2,369.51 2,810.08
The estimated overall impact of these data would show such a change in for the guidance service to meaningfully
changes presented in section XXII.B. of practice in future years and that change contribute to the treatment of the patient
this proposed rule is based on the would be reflected in future budget in directing the performance of the
assumption that hospital behavior neutrality adjustments. However, with independent procedure. We do not
would not change with regard to when respect to guidance services in believe the clinical characteristics of the
these dependent services are performed particular, we believe that hospitals are guidance services reported with the
on the same date and by the same limited in the extent to which they guidance HCPCS codes listed in Table 8
hospital that performs the independent could change their behavior with regard below will change in the immediate
services. To the extent that hospitals to how they furnish these services. By future.
could change their behavior and their definition, these guidance services As we indicated earlier, in all cases
perform the guidance services more or generally must be furnished on the same we are proposing that hospitals that
less frequently, on subsequent dates, or date and at the same operative location furnish the guidance service on the
at settings outside of the hospital, the as the independent procedure in order same date as the independent service
must bill both services on the same basis to determine whether there is to request that Program Safeguard
claim. We expect to carefully monitor reason to request that Quality Contractors review the claims against
any changes in billing practices on a Improvement Organizations (QIOs) the medical record.
service-specific and hospital-specific review the quality of care furnished or
TABLE 8.—GUIDANCE HCPCS CODES PROPOSED FOR PACKAGED PAYMENT IN CY 2008

Inactive
HCPCS Code
effective 1/1/
Proposed Proposed
CY 2007 CY 2007 2008 or earlier Short descriptor of the inac-
HCPCS code Short descriptor CY 2008 CY 2008
SI APC (listed on the tive HCPCS code
SI APC same line as
its replace-
ment code)
19295 .......... Place breast clip, precut ........ S 0657 N n/a

61795 .......... Brain surgery using computer S 0302 N n/a
62160 .......... Neuroendoscopy add-on ....... T 0122 N n/a
76000 .......... Fluoroscope examination ....... X 0272 Q 0272
76001 .......... Fluoroscope exam, extensive N n/a N n/a
76930 .......... Echo guide, cardiocentesis .... S 0268 N n/a
76932 .......... Echo guide for heart biopsy .. S 0309 N n/a
76936 .......... Echo guide for artery repair ... S 0309 N n/a
76937 .......... Us guide, vascular access ..... N n/a N n/a
76940 .......... Us guide, tissue ablation ....... S 0268 N n/a
76941 .......... Echo guide for transfusion ..... S 0268 N n/a
76942 .......... Echo guide for biopsy ............ S 0268 N n/a
76945 .......... Echo guide, villus sampling ... S 0268 N n/a
76946 .......... Echo guide for amniocentesis S 0268 N n/a
76948 .......... Echo guide, ova aspiration .... S 0309 N n/a
76950 .......... Echo guidance radiotherapy .. S 0268 N n/a
76965 .......... Echo guidance radiotherapy .. S 0308 N n/a
76975 .......... GI endoscopic ultrasound ...... S 0266 N n/a
76998 .......... Us guide, intraop ................... S 0266 N n/a 76986 Ultrasound guide intraoper.
77001 .......... Fluoro guide for vein device .. N n/a N n/a 75998 Fluoro guide for vein device.
77002 .......... Needle localization by xray .... N n/a N n/a 76003 Needle localization by xray.
77003 .......... Fluoroguide for spine inject ... N n/a N n/a 76005 Fluoroguide for spine inject.
77011 .......... Ct scan for localization .......... S 0283 N n/a 76355 Ct scan for localization.
77012 .......... Ct scan for needle biopsy ...... S 0283 N n/a 76360 Ct scan for needle biopsy.
77013 .......... Ct guide for tissue ablation .... S 0333 N n/a 76362 Ct guide for tissue ablation.
77014 .......... Ct scan for therapy guide ...... S 0282 N n/a 76370 Ct scan for therapy guide.
77021 .......... Mr guidance for needle place S 0335 N n/a 76393 Mr guidance for needle place.
77022 .......... Mri for tissue ablation ............ S 0335 N n/a 76394 Mri for tissue ablation.
77031 .......... Stereotact guide for brst bx ... X 0264 N n/a 76095 Stereotactic breast biopsy.
77032 .......... Guidance for needle, breast .. X 0263 N n/a
77417 .......... Radiology port film(s) ............. X 0260 N n/a
77421 .......... Stereoscopic x-ray guidance S 0257 N n/a
95873 .......... Guide nerv destr, elec stim ... S 0215 N n/a
95874 .......... Guide nerv destr, needle emg S 0215 N n/a
0054T .......... Bone surgery using computer S 0302 N n/a
(2) Image Processing Services processing. For example, we are processing services that we are
proposing to package payment for CPT proposing to package for CY 2008 do not
We are proposing to package payment
code 93325 (Doppler echocardiography need to be provided face-to-face with
for ‘‘image processing’’ HCPCS codes for
color flow velocity mapping (List the patient in the same encounter as the
CY 2008, specifically those codes that
are reported as supportive dependent separately in addition to codes for independent service. While this
services to process and integrate echocardiography)) because it is an approach to service delivery may be
diagnostic test data in the development image processing procedure, even administratively advantageous from a
of images, performed concurrently or though the code descriptor does not hospital’s perspective, providing
after the independent service is specifically indicate it as such. separate payment for each image
complete. We performed a broad search An image processing service processing service whenever it is
for such services, relying upon the processes and integrates diagnostic test performed is not consistent with
AMA’s CY 2007 book of CPT codes and data that were captured during another encouraging value-based purchasing
the CY 2007 book of Level II HCPCS independent procedure, usually one under the OPPS. We believe it is
codes, which identified specific codes that is separately payable under the important to package payment for
as ‘‘processing’’ codes. In addition, we OPPS. The image processing service is supportive dependent services that
performed a clinical review of all not necessarily provided on the same accompany independent services but
HCPCS codes to capture additional date of service as the independent that may not need to be provided face-
codes that we consider to be image procedure. In fact, several of the image to-face with the patient in the same
encounter because the supportive proposed rule claims data. CPT code 0697 is $302.40. CPT code 93325 was
services utilize data that were collected 76376 was provided with CPT code billed with CPT code 93350
during the preceding independent 70450 less than 2 percent of the total (Echocardiography, transthoracic, real-
services and packaging their payment instances that CPT code 70450 was time with image documentation (2D),
encourages the most efficient use of billed. Therefore, as the frequency of with or without M-mode recording,
hospital resources. We are particularly CPT code 76376 provided in during rest and cardiovascular stress
concerned with any continuance of conjunction with CPT code 70450 test using treadmill, bicycle exercise
current OPPS payment policies that increases, the median cost for CPT code and/or pharmacologically induced
could encourage certain inefficient and 70450 would be more likely to reflect stress, with interpretation and report)
more costly service patterns. As stated that additional cost. approximately 43,000 times in the CY
above, packaging encourages hospitals The image processing services that we 2008 OPPS proposed rule data, and 5
to establish protocols that ensure that are proposing to package vary in their percent of the claims for CPT code
services are furnished only when they hospital resource costs. Resource cost 93325 reported CPT code 93350 on the
are medically necessary and to carefully was not a factor we considered when same date of service. Similarly, we note
scrutinize the services ordered by proposing to package supportive image that almost 35 percent of the claims for
practitioners to minimize unnecessary processing services. Notably, the CPT code 93350 also reported the image
use of hospital resources. Our standard majority of image processing services processing service described by CPT
methodology to calculate median costs that we are proposing to package have code 93325. Because CPT code 93350 is
packages the costs of dependent services modest median costs in relationship to designated by CPT as an add-on code to
with the costs of independent services the cost of the independent service that a stress test service, as would be
on ‘‘natural’’ single claims across they typically accompany. expected, we also observed that a CPT
different dates of service, so we are Several of these codes, including CPT code for a stress test, most commonly
confident that we would capture the code 76350 (Subtraction in conjunction CPT code 93017 (Cardiovascular stress
costs of the supportive image processing with contrast studies), are already test using maximal or submaximal
services for ratesetting when they are unconditionally (that is, always) treadmill or bicycle exercise,
packaged according to our CY 2008 packaged under the CY 2007 OPPS, continuous electrocardiographic
proposal, even if they were provided on where they have been assigned to status monitoring, and/or pharmacological
a different date than the independent indicator ‘‘N.’’ Payment for these stress; with physician supervision, with
procedure. services is made as part of the payment interpretation and report) was also
We list the image processing services for the separately payable, independent frequently reported on the same claim
that would be packaged for CY 2008 in services with which they are billed. No on the same day as both of the other two
Table 10 below. As these services separate payment is made for services CPT codes. CPT code 93017 is assigned
support the performance of an that we have assigned to status indicator
to APC 0100 (Cardiac Stress Tests) with
independent service, we believe it ‘‘N.’’ We are not proposing status
a proposed CY 2008 median cost of
would be appropriate to package their indicator changes for the four image
$180.10. Under our proposed policy for
payment into the OPPS payment for the processing services that were
the CY 2008, we are proposing to
independent service provided. unconditionally packaged for CY 2007.
We are proposing to change the status expand the packaging associated with
As many independent services may be
indicator for seven image processing the independent stress test and
reported with or without image
services from separately paid to echocardiography services so that
processing services, the cost of the
unconditionally packaged (status payment for the echocardiography color
image processing services will be
indicator ‘‘N’’) for the CY 2008 OPPS. flow velocity mapping, if performed,
reflected in the median cost for the
independent HCPCS code as a function We believe that these services are would be packaged. Specifically, we
of the frequency that image processing always integral to and dependent upon would package payment for CPT code
services are reported with that the independent service that they 93325, the echocardiography color flow
particular HCPCS code. Again, while support and, therefore, their payment velocity mapping, so that this
the median cost for a particular would be appropriately packaged. We dependent procedure would receive
independent procedure generally will have calculated the median costs on packaged payment through the separate
be higher as a result of added packaging, which the proposed CY 2008 payment OPPS payments for the independent
it could also change little or be lower rates are based using the packaging procedures, here the stress test and
because median costs typically do not status of each code as provided in Table echocardiography services. The
reflect small distributional changes and 10 below. As we discuss above in more payment rates for this example
because changes to the packaged HCPCS detail, this has the effect of both associated with our CY 2008 proposal
codes affect both the number and changing the median cost for the are outlined in Table 9 below.
composition of single bills and the mix independent service into which the cost In this case, the proposed CY 2008
of hospitals contributing those single of the dependent service is packaged median cost for APC 0100 to which CPT
bills. For example, CPT code 70450 and also of redistributing payment that code 93017 is assigned is $180.10. The
(Computed tomography, head or brain; would otherwise have been made proposed CY 2008 median cost for APC
without contrast material) may be separately for the service we are 0697, to which CPT code 93350 is
provided alone or in conjunction with proposing to newly package for CY assigned, is $302.40. The CY 2007
CPT code 76376 (3D rendering with 2008. median cost for APC 0100 is $154.83
interpretation and reporting of For example, CPT code 93325 and the median cost for APC 0697 is
computed tomography, magnetic (Doppler echocardiography color flow $97.61. However, as discussed in
resource imaging, ultrasound, or other velocity mapping (List separately in section II.A.4.c. of this proposed rule
tomographic modality; not requiring addition to codes for echocardiography)) concerning our general proposed
image postprocessing on an is assigned to APC 0697 (Level I packaging approach, the added effect of
independent workstation). In fact, CPT Echocardiogram Except the budget neutrality adjustment that
code 70450 was provided approximately Transesophageal) for CY 2007. The would result from the aggregate effects
1.5 million times based on CY 2008 proposed CY 2008 median cost of APC of the CY 2008 packaging proposal
(were there no further budget neutrality demonstrate the overall impact of packaging changes that we are
adjustment for other reasons) packaging image processing services on proposing by classes of hospitals, and
significantly changes the final payment payment to any given hospital because the OPPS Hospital-Specific Impacts—
rates relative to the median cost each individual hospital’s case-mix and Provider-Specific Data file presents our
estimates. Table 9 presents a billing patterns would be different. The estimates of CY 2008 hospital payment
comparison of payments for CPT codes overall impact of packaging payment for for those hospitals we include in our
93017, 93350, and 93325 in CY 2007, CPT code 93325, as well as the ratesetting and payment simulation
where payment for CPT code 93325 is proposed packaging changes that we are database. The hospital-specific impacts
made separately, to our CY 2008 proposing for CY 2008, can only be file can be found on the CMS Web site
proposed payments for CPT codes assessed in the aggregate for classes of at http://www.cms.hhs.gov/
93017, 93350, and 93325, where hospitals. Section XXII.B. of this HospitalOutpatientPPS/ under
payment for CPT code 93325 would be proposed rule displays the overall supporting documentation for this
packaged. This example cannot impact of APC weight recalibration and proposed rule.
TABLE 9.—EXAMPLE OF THE EFFECTS OF THE CY 2008 PACKAGING PROPOSAL ON PAYMENT FOR CPT CODES 93325,
93350, AND 93017
Sum of CY
2007 payment
(93325 paid (93325 Pack-
separately) aged)
93325 ......................... Doppler color flow add-on (dependent service) .............................................................. $98.18 $0.00
93350 ......................... Echo transthoracic (independent service) ....................................................................... 197.64 306.18
93017 ......................... Cardiovascular stress test (independent service) ........................................................... 155.74 182.36
Total Payment .... .......................................................................................................................................... 451.56 488.54
The estimated overall impact of these processing services more or less same claim. We expect to carefully
proposed changes presented in section frequently, the data would show such a monitor any changes in billing practices
XXII.B. of this proposed rule is based on change in practice in future years and on a service-specific and hospital-
the assumption that hospital behavior that change would be reflected in future specific basis to determine whether
would not change with regard to how budget neutrality adjustments. there is reason to request that QIOs
often these dependent image processing As we indicated earlier, in all cases review the quality of care furnished or
services are performed in conjunction we are proposing that hospitals that to request that Program Safeguard
with the independent services. To the furnish the image processing procedure Contractors review the claims against
extent that hospitals could change their in association with the independent the medical record.
behavior and perform the image service must bill both services on the
TABLE 10.—IMAGE PROCESSING HCPCS CODES PROPOSED FOR PACKAGED PAYMENT IN CY 2008
Inactive CPT
code effective 1/
1/08 or earlier
HCPCS CY 2007 Proposed CY Short descriptor of the inac-
Short descriptor CY 2007 SI (listed on the
code APC 2008 SI tive CPT code
same line as its
replacement
code
76125 ......... Cine/video x-rays add-on ....... X .................. 0260 ............ N

76350 ......... Special x-ray contrast study .. N ................. n/a ............... N
76376 ......... 3d render w/o postprocess .... X .................. 0340 ............ N
76377 ......... 3d rendering w/postprocess .. S .................. 0282 ............ N
93325 ......... Doppler color flow add-on ...... S .................. 0697 ............ N
93613 ......... Electrophys map 3d, add-on .. T .................. 0087 ............ N
95957 ......... EEG digital analysis ............... S .................. 0214 ............ N
0159T ......... Cad breast MRI ..................... N ................. n/a ............... N
0174T ......... Cad cxr remote ...................... N .................. n/a ............... N ................. 0152T Computer chest add-on.
0175T ......... Cad cxr with interp ................. N .................. n/a ............... N ................. 0152T Computer chest add-on.
G0288 ........ Recon, CTA for surg plan ...... S .................. 0417 ............ N
(3) Intraoperative Services independent procedures. We performed HCPCS codes to capture additional
a broad search for possible supportive diagnostic testing or other

We are proposing to package payment intraoperative HCPCS codes, relying minor intraoperative or intraprocedural
for ‘‘intraoperative’’ HCPCS codes for upon the AMA’s CY 2007 book of CPT codes that are not necessarily identified
CY 2008, specifically those codes that codes and the CY 2007 book of Level II as ‘‘intraoperative’’ codes. For example,
are reported for supportive dependent HCPCS codes, to identify specific codes we are proposing to package payment
diagnostic testing or other minor as ‘‘intraoperative’’ codes. Furthermore, for CPT code 95955
procedures performed during we performed a clinical review of all (Electroencephalogram (EEG) during
nonintracranial surgery (e.g., carotid resource costs. Resource cost was not a were billed without any other service
surgery)) because it is a minor factor we considered when determining assigned to status indicator ‘‘S,’’ ‘‘T,’’
intraoperative diagnostic testing which supportive intraoperative ‘‘V,’’ or ‘‘X’’ reported on the same date
procedure even though the code procedures to package. of service, under our proposal we would
descriptor does not indicate it as such. The codes we are proposing to not treat the IMT study as a dependent
Although we use the term identify as intraoperative services for service for purposes of payment. If we
‘‘intraoperative’’ to categorize these CY 2008 that would receive packaged were to continue to unconditionally
procedures, we also have included payment under the OPPS are listed in package payment for this procedure,
supportive dependent services in this Table 12 below. treating it as a dependent service,
group that are provided during an Several of these codes, including CPT hospitals would receive no payment at
independent procedure, although that code 93640 (Electrophysiologic all when providing this service alone,
procedure may not necessarily be a evaluation of single or dual chamber although the procedure would not be
surgical procedure. These dependent pacing cardioverter-defibrillator leads functioning as an intraoperative service
services clearly fit into this category including defibrillation threshold in that case. However, according to our
because they are provided during, and evaluation (induction of arrhythmia, proposal, its conditionally packaged
are integral to, an independent evaluation of sensing and pacing for status as a ‘‘special’’ packaged code
procedure, like all the other arrhythmia termination) at the time of would allow payment to be provided for
intraoperative codes, but the initial implantation or replacement), are this ‘‘Q’’ status IMT study when
independent procedure they accompany already unconditionally (that is, always) provided alone, in which case it would
may not necessarily be a surgical packaged under the CY 2007 OPPS, be treated as an independent service
procedure. For example, we are where they have been assigned to status under these limited circumstances. On
proposing to package HCPCS code indicator ‘‘N.’’ Payment for these the other hand, when this service is
G0268 (Removal of impacted cerumen services is made through the payment furnished as an intraoperative
(one or both ears) by physician on same for the separately payable, independent procedure on the same day and in the
date of service as audiologic function services with which they are billed. No same hospital as independent,
testing). While specific audiologic separate payment is made for services separately paid services that are
function testing procedures are not that we have assigned to status indicator assigned to status indicator ‘‘S,’’ ‘‘T,’’
surgical procedures performed in an ‘‘N.’’ We are not proposing status ‘‘V,’’ or ‘‘X,’’ we are proposing to
operating room, they are independent indicator changes for the five diagnostic package payment for it as a dependent
procedures that are separately payable intraoperative services that were service. In all cases, we are proposing
under the OPPS, and HCPCS code unconditionally packaged for CY 2007. that hospitals that furnish independent
We are proposing to change the status services on the same date as this IMT
G0268 is a supportive dependent service
indicator for 34 intraoperative services procedure must bill them all on the
always provided in association with one
from separately paid to unconditionally same claim. We believe that when
of these independent services. All packaged (status indicator ‘‘N’’) for the
references to ‘‘intraoperative’’ below dependent and independent services are
CY 2008 OPPS. We believe that these furnished on the same date and in the
refer to services that are usually or services are always integral to and
always provided during a surgical same facility, they are part of a single
dependent upon the independent complete hospital outpatient service
procedure or other independent services that they support and,
procedure. that is reported with more than one
therefore, their payment would be HCPCS code, and no separate payment
By definition, a service that is appropriately packaged because they should be made for the intraoperative
performed intraoperatively is provided would generally be performed on the procedure that supports the
during and, therefore, on the same date same date and in the same hospital as independent service.
of service as another procedure that is the independent services. We have calculated the median costs
separately payable under the OPPS. We are also proposing to change the on which the proposed CY 2008
Because these intraoperative services status indicator for one intraoperative payment rates are based using the
support the performance of an procedure from unconditionally packaging status of each code as
independent procedure and they are packaged to conditionally packaged provided in Table 12 below. As we
provided in the same operative session (status indicator ‘‘Q’’) as a ‘‘special’’ discuss above in more detail, this has
as the independent procedure, we packaged code for the CY 2008 OPPS, the effect of both changing the median
believe it would be appropriate to specifically, CPT code 0126T (Common cost for the independent service into
package their payment into the OPPS carotid intima-media thickness (IMT) which the cost of the dependent service
payment for the independent procedure study for evaluation of atherosclerotic is packaged and also of redistributing
performed. Therefore, we are not burden or coronary heart disease risk payment that would otherwise have
proposing to package payment for CY factor assessment). This code was been made separately for the service we
2008 for those diagnostic services, such discussed in the past with the Packaging are proposing to newly package for CY
as CPT code 93005 (Electrocardiogram, Subcommittee of the APC Panel which 2008.
routine ECG with at least 12 leads; determined that, consistent with its For example, CPT code 92547 (Use of
tracing only, without interpretation and code descriptor as a separate procedure, vertical electrodes (List separately in
report) that are sometimes or only rarely this procedure could sometimes be addition to code for primary procedure))
performed and reported as supportive provided alone, without any other OPPS is assigned to APC 0363 (Level I
services in association with other services on the claim. We believe that Otorhinolaryngologic Function Tests)
independent procedures. Instead, we are this procedure would usually be for CY 2007. The proposed CY 2008
proposing to include those HCPCS provided by a hospital in conjunction median cost of APC 0363 is $53.73. CPT
codes that are usually or always with another independent procedure on code 92547 was billed with CPT code
performed intraoperatively, based upon the same date of service but may 92541 (Spontaneous nystagmus test,
our review of the codes described above. occasionally be provided without including gaze and fixation nystagmus,
The intraoperative services that we are another independent service. As a with recording) 6,056 times in the CY
proposing to package vary in hospital ‘‘special’’ packaged code, if the study 2008 OPPS proposed rule data, and 97
percent of the claims for CPT code CPT code 92541 is assigned, is $53.73, any given hospital because each
92547 reported CPT code 92541 on the while the CY 2007 median cost of this individual hospital’s case-mix and
same date of service. Similarly, we note APC with status indicator ‘‘S’’ and to billing patterns would be different. The
that over half of the claims for CPT code which both CPT codes 92547 and 02541 overall impact of packaging payment for
92541 also reported the service are assigned is $52.09. However, as CPT code 92547, as well as all other
described by CPT code 92547. Under discussed in the section II.A.4. of this packaging changes we are proposing for
our proposed policy for the CY 2008 proposed rule concerning our general CY 2008, can only be assessed in the
OPPS, we are proposing to expand the proposed packaging approach, the aggregate for classes of hospitals.
packaging associated with the added effect of the budget neutrality Section XXII.B. of this proposed rule
independent nystagmus test so that adjustment that would result from the
displays the overall impact of APC
payment for the use of vertical aggregate effects of the complete CY
weight recalibration and packaging
electrodes, if used, would be packaged. 2008 packaging proposal (were there no
Specifically, we would package further budget neutrality adjustment for changes we are proposing by classes of
payment for CPT code 92547 so that other reasons) significantly changes the hospitals, and the OPPS Hospital-
under the CY 2008 OPPS the commonly final payment rates relative to median Specific Impacts—Provider-Specific
billed dependent procedure, the use of cost estimates. Table 11 presents a Data file presents our estimates of CY
vertical electrodes, would receive comparison of payment for CPT codes 2008 hospital payment for those
packaged payment through the separate 92541 and 92547 in CY 2007, where hospitals we include in our ratesetting
OPPS payment for the independent CPT code 92547 is paid separately, to and payment simulation database. The
procedure, in this case the nystagmus our CY 2008 proposed payment for CPT hospital-specific impacts file can be
test. The payment rates for this example codes 92541 and 92547, where payment found on the CMS Web site at
associated with our CY 2008 proposal for CPT code 92547 would be packaged. http://www.cms.hhs.gov/
are outlined in Table 11 below. This example cannot demonstrate the HospitalOutpatientPPS/ under
In this case, the proposed CY 2008 overall impact of packaging supporting documentation for this
median cost for APC 0363, to which intraoperative services on payment to proposed rule.
TABLE 11.— EXAMPLE OF THE EFFECTS OF THE CY 2008 PACKAGING PROPOSAL ON PAYMENT FOR CPT CODES
92541 AND 92547
Sum of CY
2007 payment
HCPCS Code Short descriptor payment
(92547 paid (92547
separately) packaged)
92541 ......................... Spontaneous nystagmus study (independent service) ................................................... $52.40 $54.41
92547 ......................... Supplemental electrical test (dependent service) ........................................................... 52.40 0.00
Total Payment .................................................................................................................................................. 104.80 54.41
The estimated overall impact of these with respect to intraoperative services As we indicated earlier, in all cases
proposed changes is based on the in particular, we believe that hospitals we are proposing that hospitals that
assumption that hospital behavior are limited in the extent to which they furnish the intraoperative procedure on
would not change with regard to when could change their behavior with regard the same date as the independent
these dependent intraoperative services to how they furnish these services. By service must bill both services on the
are performed on the same date and by their definition, these intraoperative same claim. We expect to carefully
the same hospital that performs the services generally must be furnished on monitor any changes in billing practices
independent services. To the extent that the same date and at the same operative on a service-specific and hospital-
hospitals could change their behavior location as the independent procedure specific basis to determine whether
and perform the intraoperative services in order to be considered intraoperative.
there is reason to request that QIOs
more or less frequently, on subsequent For these codes, we assume that both
review the quality of care furnished or
dates, or at settings outside of the the dependent and independent services
hospital, the data would show such a would be furnished on the same date in to request that Program Safeguard
change in practice in future years and the same hospital, and hospitals should Contractors review the claims against
that change would be reflected in future bill them on the same claim with the the medical record.
budget neutrality adjustments. However, same date of service.
TABLE 12.—INTRAOPERATIVE HCPCS CODES PROPOSED FOR PACKAGED PAYMENT IN CY 2008

HCPCS Proposed CY
Short descriptor CY 2007 SI CY 2007 APC
Code 2008 SI
20975 .......... Electrical bone stimulation ...................................................................................... X .................. 0340 N

31620 .......... Endobronchial us add-on ........................................................................................ S .................. 0670 N

37250 .......... Iv us first vessel add-on ......................................................................................... S .................. 0416 N
37251 .......... Iv us each add vessel add-on ................................................................................ S .................. 0416 N
58110 .......... Bx done w/colposcopy add-on ............................................................................... T .................. 0188 N
67299 .......... Eye surgery procedure ........................................................................................... T .................. 0235 N
73530 .......... X-ray exam of hip ................................................................................................... X .................. 0261 N
74300 .......... X-ray bile ducts/pancreas ....................................................................................... X .................. 0263 N
TABLE 12.—INTRAOPERATIVE HCPCS CODES PROPOSED FOR PACKAGED PAYMENT IN CY 2008—Continued

HCPCS Proposed CY
Short descriptor CY 2007 SI CY 2007 APC
Code 2008 SI
74301 .......... X-rays at surgery add-on ........................................................................................ X .................. 0263 N

75898 .......... Follow-up angiography ........................................................................................... X .................. 0263 N
78020 .......... Thyroid met uptake ................................................................................................. S .................. 0399 N
78478 .......... Heart wall motion add-on ....................................................................................... S .................. 0399 N
78480 .......... Heart function add-on ............................................................................................. S .................. 0399 N
78496 .......... Heart first pass add-on ........................................................................................... S .................. 0399 N
92547 .......... Supplemental electrical test .................................................................................... X .................. 0363 N
92978 .......... Intravasc us, heart add-on ...................................................................................... S .................. 0670 N
92979 .......... Intravasc us, heart add-on ...................................................................................... S .................. 0416 N
93320 .......... Doppler echo exam, heart ...................................................................................... S .................. 0697 N
93321 .......... Doppler echo exam, heart ...................................................................................... S .................. 0697 N
93571 .......... Heart flow reserve measure ................................................................................... S .................. 0670 N
93572 .......... Heart flow reserve measure ................................................................................... S .................. 0416 N
93609 .......... Map tachycardia, add-on ........................................................................................ T .................. 0087 N
93613 .......... Electrophys map 3d, add-on .................................................................................. T .................. 0087 N
93621 .......... Electrophysiology evaluation .................................................................................. T .................. 0085 N
93622 .......... Electrophysiology evaluation .................................................................................. T .................. 0085 N
93623 .......... Stimulation, pacing heart ........................................................................................ T .................. 0087 N
93631 .......... Heart pacing, mapping ........................................................................................... T .................. 0087 N
93640 .......... Evaluation heart device .......................................................................................... N ................. n/a N
93641 .......... Electrophysiology evaluation .................................................................................. N ................. n/a N
93662 .......... Intracardiac ecg (ice) .............................................................................................. S .................. 0670 N
95829 .......... Surgery electrocorticogram ..................................................................................... S .................. 0214 N
95920 .......... Intraop nerve test add-on ....................................................................................... S .................. 0216 N
95955 .......... EEG during surgery ................................................................................................ S .................. 0213 N
95999 .......... Neurological procedure ........................................................................................... S .................. 0215 N
96020 .......... Functional brain mapping ....................................................................................... X .................. 0373 N
0126T .......... Chd risk imt study ................................................................................................... N ................. n/a Q
0173T .......... Iop monit io pressure .............................................................................................. N ................. n/a N
G0268 .......... Removal of impacted wax md ................................................................................ X .................. 0340 N
G0275 .......... Renal angio, cardiac cath ....................................................................................... N .................. n/a N
G0278 .......... Iliac art angio, cardiac cath .................................................................................... N ................. n/a N
(4) Imaging Supervision and designated as ‘radiological supervision CPT codes in other series that describe
Interpretation Services and interpretation’.’’ In addition, CPT similar procedures that we are
We are proposing to change the guidance notes that, ‘‘When a physician proposing to include in the group of
packaging status of many imaging performs both the procedure and imaging supervision and interpretation
supervision and interpretation codes for provides imaging supervision and codes proposed for packaging under the
CY 2008. We define ‘‘imaging interpretation, a combination of CY 2008 OPPS. For example, CPT code
supervision and interpretation codes’’ as procedure codes outside the 70000 93555 (Imaging supervision,
HCPCS codes for services that are series and imaging supervision and interpretation and report for injection
defined as ‘‘radiological supervision and interpretation codes are to be used.’’ In procedure(s) during cardiac
interpretation’’ in the radiology series, the hospital outpatient setting, the catheterization; ventricular and/or atrial
70000 through 79999, of the AMA’s CY concept of one or more than one angiography) whose payment under the
2007 book of CPT codes, with the physician performing related OPPS is currently packaged, is
addition of some services in other code procedures does not apply to the commonly reported with an injection
ranges of CPT, Category III CPT tracking reporting of these codes, but the procedure code, such as CPT code
codes, or Level II HCPCS codes that are radiological supervision and 93543 (Injection procedure during
clinically similar or directly crosswalk interpretation codes clearly are cardiac catheterization; for selective left
to codes defined as radiological established for reporting in association ventricular or left atrial angiography),
supervision and interpretation services with other procedural services outside whose payment is also currently
in the CPT radiology range. We also the CPT 70000 series. Because these packaged under the OPPS, and a cardiac
included HCPCS codes that existed in imaging supervision and interpretation catheterization procedure code, such as
CY 2006 but were deleted and were codes are always reported for imaging CPT code 93526 (Combined right heart
replaced in CY 2007. We included the services that support the performance of catheterization and retrograde left heart
CY 2006 HCPCS codes because we are an independent procedure and they are, catheterization), that is separately paid.
proposing to use the CY 2006 claims by definition, always provided in the In the case of cardiac catheterization,
data to calculate the CY 2008 OPPS same operative session as the CPT code 93555 describes an imaging
median costs on which the CY 2008 independent procedure, we believe that supervision and interpretation service
payment rates would be based. it would be appropriate to package their in support of the cardiac catheterization
In its discussion of ‘‘radiological payment into the OPPS payment for the procedure, and this dependent service is
supervision and interpretation,’’ CPT independent procedure performed. clinically quite similar to radiological
indicates that ‘‘when a procedure is In addition to radiological supervision supervision and interpretation codes in
performed by two physicians, the and interpretation codes in the the radiology range of CPT. Payment for
radiologic portion of the procedure is radiology range of CPT codes, there are the cardiac catheterization imaging
supervision and interpretation services ‘‘special’’ packaged codes would allow For example, CPT code 72265
has been packaged since the beginning payment to be provided for these ‘‘Q’’ (Myelography, lumbosacral, radiological
of the OPPS. Therefore, in developing status imaging supervision and supervision and interpretation) is
this proposal for the CY 2008 proposed interpretation services as independent assigned to APC 0274 (Myelography) for
rule, we conducted a comprehensive services in these limited circumstances, CY 2007. The proposed CY 2008 median
clinical review of all Category I and and for which payment for the cost of APC 0274 is $245.38. CPT code
Category III CPT codes and Level II accompanying minor procedure would 72265 was billed with CPT code 72132
HCPCS codes to identify all codes that be packaged. However, when these (Computed tomography, lumbar spine;
describe imaging supervision and imaging supervision and interpretation with contrast material) 20,233 times in
interpretation services. The codes we dependent services are furnished on the the CY 2008 OPPS proposed rule data,
are proposing to identify as imaging same day and in the same hospital as and 62 percent of the claims for CPT
supervision and interpretation codes for independent separately paid services, code 72265 reported CPT code 72132 on
CY 2008 that would receive packaged specifically, any service assigned to the same date of service. Similarly, we
payment are listed in Table 14 below. status indicator ‘‘S,’’ ‘‘T,’’ ‘‘V,’’ or ‘‘X,’’ note that over half of the claims for CPT
Several of these codes, including CPT we are proposing to package payment code 72132 also reported the
code 93555 discussed above, are already for them as dependent services. In all myelography service described by CPT
unconditionally (that is, always) cases, we are proposing that hospitals code 72265. As would be expected, we
packaged under the CY 2007 OPPS, that furnish the independent services on also observed that a CPT code for the
where they have been assigned to status the same date as the dependent services clinically necessary intrathecal
indicator ‘‘N.’’ Payment for these must bill them all on the same claim. injection, specifically CPT code 62284
services is made as part of the payment We believe that when the dependent (Injection procedure for myelography
for the separately payable, independent and independent services are furnished and/or computed tomography, spinal
services with which they are billed. No on the same date and in the same (other than C1–C2 and posterior fossa))
separate payment is made for services hospital, they are part of a single was also frequently reported on the
that we have assigned to status indicator complete hospital outpatient service same claim on the same day as both of
‘‘N.’’ We are not proposing status that is reported with more than one the other two CPT codes. Payment for
indicator changes for the six imaging HCPCS code, and no separate payment CPT code 62284 is already packaged
supervision and interpretation services should be made for the imaging under the OPPS for CY 2007, as is
that were unconditionally packaged for supervision and interpretation service payment for most HCPCS codes that
CY 2007. that supports the independent service. describe dependent injection
We are proposing to change the status In the case of services for which we procedures that accompany
indicator for 33 imaging supervision are proposing conditional packaging, we independent procedures. Under our
and interpretation services from would expect that, although these proposed policy for the CY 2008 OPPS,
separately paid to unconditionally services would always be performed in we are proposing to expand the
packaged (status indicator ‘‘N’’) for the the same session as another procedure, packaging associated with the
CY 2008 OPPS. We believe that these in some cases that other procedure’s independent spinal computed
services are always integral to and payment would also be packaged. For tomography (CT) scan so that payment
dependent upon the independent example, CPT code 73525 (Radiological for both the associated injection
services that they support and, examination, hip, arthrography, procedure and the related myelography
therefore, their payment would be radiological supervision and
service, if performed, would be
appropriately packaged because they interpretation) and CPT code 27093
packaged. Specifically, we would
would generally be performed on the (Injection procedure for hip
same date and in the same hospital as package payment for CPT code 72265
arthrography; without anesthesia) could
the independent services. when it appears on the same claim with
be provided in a single hospital
We are proposing to change the status a separately paid service such as CPT
outpatient encounter and reported as
indicator for 93 imaging supervision code 72132, so that, under the CY 2008
the only two services on a claim. In the
and interpretation services from OPPS, both commonly billed dependent
case where only these two services were
separately paid to conditionally procedures, the injection procedure and
performed, the conditionally packaged
packaged (status indicator ‘‘Q’’) as the myelography service, would receive
status of CPT code 73525 would
‘‘special’’ packaged codes for the CY appropriately allow for its separate packaged payment through the separate
2008 OPPS. These services may payment as an independent imaging OPPS payment for the independent
occasionally be provided at the same supervision and interpretation procedure, the CT scan. The payment
time and at the same hospital with one arthrography service, into which rates for this example associated with
or more other procedures for which payment for the dependent injection our CY 2008 proposal are outlined in
payment is currently packaged under procedure would be packaged. Table 13 below. The proposed
the OPPS, most commonly injection We have calculated the median costs conditionally packaged status for CPT
procedures, and in these cases we on which the proposed CY 2008 code 72265 would ensure that if
would not treat the imaging supervision payment rates are based using the lumbosacral myelography was
and interpretation services as dependent packaging status of each code as performed alone, separate payment for
services for purposes of payment. If we provided in Table 14 below. As we the myelography service would be made
were to unconditionally package discuss above in more detail, this has under the OPPS as the myelography
payment for these imaging supervision the effect of both changing the median service would not be a dependent
and interpretation services as dependent cost for the independent service into service in that situation.
services, hospitals would receive no which the cost of the dependent service The proposed policy would result in
payment at all for providing the imaging is packaged and also of redistributing no separate payment for CPT code
supervision and interpretation service payment that would otherwise have 72265 when it is billed on the same day
and the other minor procedure(s). been made separately for the service we and by the same hospital as any
However, according to our proposal, are proposing to newly package for CY separately paid service, such as CPT
their conditional packaging status as 2008. code 72132. Moreover, as discussed
later in this section, the proposed policy is assigned is $156.10. However, as mix and billing patterns would be
would provide packaged payment for discussed in section II.A.4.c. of this different. The overall impact of
the contrast agent that is required to proposed rule concerning our general packaging payment CPT code 77265
perform the independent computed proposed packaging approach, the when it appears with any other
tomography service. For purposes of the added effect of the budget neutrality separately paid service, as well as all
example in Table 13 below, we include adjustment that would result from the other packaging changes that we are
the payment for HCPCS code Q9947 aggregate effects of the CY 2008 proposing for CY 2008, can only be
(Low osmolar contrast material 200–249 packaging proposal (were there no assessed in aggregate for classes of
mg/ml iodine concentration, per ml) further budget neutrality adjustment for hospitals. Section XXII.B. of this
which was reported on about one-third other reasons) significantly changes the
proposed rule displays the overall
of the CY 2008 proposed rule claims for final payment rates relative to median
impact of APC weight recalibration and
CPT code 72132. To calculate the CY cost estimates. Table 13 presents a
2007 payment for the contrast agent, we comparison of payment for CPT codes packaging changes we are proposing by
multiplied the mean number of units 72132 and 72265 and HCPCS code classes of hospitals, and the OPPS
per day from our CY 2008 proposed rule Q9947 in CY 2007, where CPT code Hospital-Specific Impacts—Provider-
data (48.3) by the April 2007 per unit 72265 and HCPCS code Q9947 are paid Specific Data file presents our estimates
payment rate for HCPCS code Q9947 separately, to our CY 2008 proposed of CY 2008 hospital payment for those
($1.33). payment for CPT codes 72132 and hospitals we include in our ratesetting
In this case, the proposed CY 2008 77265 and HCPCS code Q9947, where and payment simulation database. The
median cost for APC 0316 (Level II payment for CPT code 72265 and hospital-specific impacts file can be
Computed Tomography with Contrast) HCPCS code Q9947 would be packaged. found on the CMS Web site at http://
to which CPT code 72132 is assigned is This example cannot demonstrate the www.cms.hhs.gov/
$741.80. The CY 2007 median cost for overall impact of packaging imaging HospitalOutpatientPPS/ under
APC 0283 to which CPT code 72132 is supervision and interpretation services supporting documentation for this
assigned is $249.48 and the median cost on payment to any given hospital proposed rule.
of APC 0274 to which CPT code 72265 because each individual hospital’s case-
TABLE 13.—EXAMPLE OF THE EFFECTS OF THE CY 2008 PACKAGING PROPOSAL ON PAYMENT FOR CPT CODES 72265
AND 72132 AND HCPCS CODE Q9947
Sum of CY
2007 payment
(72265 paid (72265 pack-
separately) aged)
62284 ................................................................... Injection for myelogram (dependent service) ........................ $0.00 $0.00
Q9947* ................................................................. LOCM 200–249mg/ml iodine, 1ml (dependent service) ....... 64.24 0.00
72265 ................................................................... Contrast x-ray lower spine (dependent service) ................... 157.01 0.00
72132 ................................................................... CT lumbar spine w/dye (independent service) ..................... 250.94 751.09
Total Payment .............................................. ................................................................................................ 472.14 751.09

* Based on the mean number of units per day from our CY 2008 proposed rule data (48.3) and the April 2007 per unit payment rate for Q9947
($1.33).
The estimated overall impact of these believe that hospitals are limited in the hospital, and hospitals should bill them
changes presented in XXII.B. of this extent to which they could change their on the same claim with the same date
proposed rule is based on the behavior with regard to how they of service.
assumption that hospital behavior furnish these services. By their As we indicated earlier in this
would not change with regard to when definition, these imaging and
section, in all cases we are proposing
these dependent services are performed supervision services generally must be
that hospitals that furnish the imaging
on the same date and by the same furnished on the same date and at the
hospital that performs the independent same operative location as the supervision and interpretation service
services. To the extent that hospitals independent procedure in order for the on the same date as the independent
could change their behavior and imaging service to meaningfully service must bill both services on the
perform the imaging supervision and contribute to the diagnosis or treatment same claim. We expect to carefully
interpretation services more or less of the patient. For those radiological monitor any changes in billing practices
frequently, on subsequent dates, or at supervision and interpretation codes in on a service-specific and hospital-
settings outside of the hospital, the data the radiology range of CPT in particular, specific basis to determine whether
would show such a change in practice if the same physician is able to perform there is reason to request that QIOs
in future years and that change would both the procedure and the supervision review the quality of care furnished or
be reflected in future budget neutrality and interpretation as stated by CPT, we to request that Program Safeguard
adjustments. However, with respect to assume that both the dependent and Contractors review the claims against
the imaging supervision and independent services would be the medical record.
interpretation services in particular, we furnished on the same date in the same
TABLE 14.—IMAGING SUPERVISION AND INTERPRETATION HCPCS CODES PROPOSED FOR PACKAGED PAYMENT IN CY
2008
Inactive
CPT code
effective 1/
1/2008 or
Proposed Proposed
HCPCS CY 2007 CY 2007 earlier (list- Short descriptor of the
Short descriptor CY 2008 CY 2008
code SI APC ed on the inactive CPT code
SI APC same line
as its re-
placement
code)
70010 ....... Contrast x-ray of brain ................... S .............. 0274 Q .............. 0274
70015 ....... Contrast x-ray of brain ................... S .............. 0274 Q .............. 0274
70170 ....... X-ray exam of tear duct ................. X .............. 0264 Q .............. 0264
70332 ....... X-ray exam of jaw joint .................. S .............. 0275 Q .............. 0275
70373 ....... Contrast x-ray of larynx ................. X .............. 0263 Q .............. 0263
70390 ....... X-ray exam of salivary duct ........... X .............. 0263 Q .............. 0263
71040 ....... Contrast x-ray of bronchi ............... X .............. 0263 Q .............. 0263
71060 ....... Contrast x-ray of bronchi ............... X .............. 0263 Q .............. 0263
71090 ....... X-ray & pacemaker insertion ......... X .............. 0272 N .............. n/a
72240 ....... Contrast x-ray of neck spine .......... S .............. 0274 Q .............. 0274
72255 ....... Contrast x-ray, thorax spine .......... S .............. 0274 Q .............. 0274
72265 ....... Contrast x-ray, lower spine ............ S .............. 0274 Q .............. 0274
72270 ....... Contrast x-ray, spine ...................... S .............. 0274 Q .............. 0274
72275 ....... Epidurography ................................ S .............. 0274 N .............. n/a
72285 ....... X-ray c/t spine disk ........................ S .............. 0388 Q .............. 0388
72291 ....... Perq vertebroplasty, fluor ............... S .............. 0274 N .............. n/a 76012 Perq vertebroplasty,
fluor.
72292 ....... Perq vertebroplasty, ct ................... S .............. 0274 N .............. n/a 76013 Perq vertebroplasty,
ct.
72295 ....... X-ray of lower spine disk ............... S .............. 0388 Q .............. 0388
73040 ....... Contrast x-ray of shoulder ............. S .............. 0275 Q .............. 0275
73085 ....... Contrast x-ray of elbow .................. S .............. 0275 Q .............. 0275
73115 ....... Contrast x-ray of wrist .................... S .............. 0275 Q .............. 0275
73525 ....... Contrast x-ray of hip ...................... S .............. 0275 Q .............. 0275
73542 ....... X-ray exam, sacroiliac joint ............ S .............. 0275 Q .............. 0275
73580 ....... Contrast x-ray of knee joint ........... S .............. 0275 Q .............. 0275
73615 ....... Contrast x-ray of ankle .................. S .............. 0275 Q .............. 0275
74190 ....... X-ray exam of peritoneum ............. S .............. 0264 Q .............. 0264
74235 ....... Remove esophagus obstruction .... S .............. 0257 N .............. n/a
74305 ....... X-ray bile ducts/pancreas .............. X .............. 0263 N .............. n/a
74320 ....... Contrast x-ray of bile ducts ............ X .............. 0264 Q .............. 0264
74327 ....... X-ray bile stone removal ................ S .............. 0296 N .............. n/a
74328 ....... X-ray bile duct endoscopy ............. N .............. n/a N .............. n/a
74329 ....... X-ray for pancreas endoscopy ....... N .............. n/a N .............. ma
74330 ....... X-ray bile/panc endoscopy ............ N .............. n/a N .............. n/a
74340 ....... X-ray guide for GI tube .................. X .............. 0272 N .............. n/a
74350 ....... X-ray guide, stomach tube ............. X .............. 0263 N .............. n/a
74355 ....... X-ray guide, intestinal tube ............ X .............. 0263 N .............. n/a
74360 ....... X-ray guide, GI dilation .................. S .............. 0257 N .............. n/a
74363 ....... X-ray, bile duct dilation .................. S .............. 0297 N .............. n/a
74425 ....... Contrast x-ray, urinary tract ........... S .............. 0278 Q .............. 0278
74430 ....... Contrast x-ray, bladder .................. S .............. 0278 Q .............. 0278
74440 ....... X-ray, male genital tract ................. S .............. 0278 Q .............. 0278
74445 ....... X-ray exam of penis ....................... S .............. 0278 Q .............. 0278
74450 ....... X-ray, urethra/bladder .................... S .............. 0278 Q .............. 0278
74455 ....... X-ray, urethra/bladder .................... S .............. 0278 Q .............. 0278
74470 ....... X-ray exam of kidney lesion .......... X .............. 0263 Q .............. 0263
74475 ....... X-ray control, cath insert ................ S .............. 0297 Q .............. 0297
74480 ....... X-ray control, cath insert ................ S .............. 0296 Q .............. 0296
74485 ....... X-ray guide, GU dilation ................ S .............. 0296 Q .............. 0296
74740 ....... X-ray, female genital tract .............. X .............. 0264 Q .............. 0264
74742 ....... X-ray, fallopian tube ....................... X .............. 0264 N.
75600 ....... Contrast x-ray exam of aorta ......... S .............. 0280 Q .............. 0280
75630 ....... X-ray aorta, leg arteries ................. S .............. 0280 Q .............. 0280
75635 ....... Ct angio abdominal arteries ........... S .............. 0662 Q .............. 0662
75650 ....... Artery x-rays, head & neck ............ S .............. 0280 Q .............. 0280
75658 ....... Artery x-rays, arm .......................... S .............. 0279 Q .............. 0279
2008—Continued
Inactive
CPT code
effective 1/
1/2008 or
Proposed Proposed
SI APC same line
as its re-
placement
code)
75676 ....... Artery x-rays, neck ......................... S .............. 0280 Q .............. 0280
75680 ....... Artery x-rays, neck ......................... S .............. 0280 Q .............. 0280
75685 ....... Artery x-rays, spine ........................ S .............. 0280 Q .............. 0280
75705 ....... Artery x-rays, spine ........................ S .............. 0668 Q .............. 0668
75710 ....... Artery x-rays, arm/leg .................... S .............. 0280 Q .............. 0280
75716 ....... Artery x-rays, arms/legs ................. S .............. 0280 Q .............. 0280
75722 ....... Artery x-rays, kidney ...................... S .............. 0280 Q .............. 0280
75724 ....... Artery x-rays, kidneys .................... S .............. 0280 Q .............. 0280
75726 ....... Artery x-rays, abdomen ................. S .............. 0280 Q .............. 0280
75731 ....... Artery x-rays, adrenal gland .......... S .............. 0280 Q .............. 0280
75733 ....... Artery x-rays, adrenals ................... S .............. 0668 Q .............. 0668
75736 ....... Artery x-rays, pelvis ....................... S .............. 0280 Q .............. 0280
75741 ....... Artery x-rays, lung .......................... S .............. 0279 Q .............. 0279
75743 ....... Artery x-rays, lungs ........................ S .............. 0280 Q .............. 0280
75746 ....... Artery x-rays, lung .......................... S .............. 0279 Q .............. 0279
75756 ....... Artery x-rays, chest ........................ S .............. 0279 Q .............. 0279
75774 ....... Artery x-ray, each vessel ............... S .............. 0279 N .............. n/a
75790 ....... Visualize A–V shunt ....................... S .............. 0279 Q .............. 0279
75801 ....... Lymph vessel x-ray, arm/leg .......... X .............. 0264 Q .............. 0264
75803 ....... Lymph vessel x-ray,arms/legs ....... X .............. 0264 Q .............. 0264
75805 ....... Lymph vessel x-ray, trunk .............. X .............. 0264 Q .............. 0264
75807 ....... Lymph vessel x-ray, trunk .............. X .............. 0264 Q .............. 0264
75809 ....... Nonvascular shunt, x-ray ............... X .............. 0263 Q .............. 0263
75810 ....... Vein x-ray, spleen/liver .................. S .............. 0279 Q .............. 0279
75820 ....... Vein x-ray, arm/leg ......................... S .............. 0668 Q .............. 0668
75822 ....... Vein x-ray, arms/legs ..................... S .............. 0668 Q .............. 0668
75825 ....... Vein x-ray, trunk ............................. S .............. 0279 Q .............. 0279
75827 ....... Vein x-ray, chest ............................ S .............. 0279 Q .............. 0279
75831 ....... Vein x-ray, kidney .......................... S .............. 0279 Q .............. 0279
75833 ....... Vein x-ray, kidneys ........................ S .............. 0279 Q .............. 0279
75840 ....... Vein x-ray, adrenal gland ............... S .............. 0280 Q .............. 0280
75842 ....... Vein x-ray, adrenal glands ............. S .............. 0280 Q .............. 0280
75860 ....... Vein x-ray, neck ............................. S .............. 0668 Q .............. 0668
75870 ....... Vein x-ray, skull ............................. S .............. 0668 Q .............. 0668
75872 ....... Vein x-ray, skull ............................. S .............. 0279 Q .............. 0279
75880 ....... Vein x-ray, eye socket ................... S .............. 0668 Q .............. 0668
75885 ....... Vein x-ray, liver .............................. S .............. 0280 Q .............. 0280
75893 ....... Venous sampling by catheter ........ Q .............. 0668 Q .............. 0668
75894 ....... X-rays, transcath therapy ............... S .............. 0298 N .............. n/a
75896 ....... X-rays, transcath therapy ............... S .............. 0263 N .............. n/a
75901 ....... Remove cva device obstruct ......... X .............. 0263 N .............. n/a
75902 ....... Remove cva lumen obstruct .......... X .............. 0263 N .............. n/a
75940 ....... X-ray placement, vein filter ............ S .............. 0298 N .............. n/a
75945 ....... Intravascular us .............................. S .............. 0267 Q .............. 0267
75946 ....... Intravascular us add-on ................. S .............. 0266 N .............. n/a
75960 ....... Transcath iv stent rs&i ................... S .............. 0668 N .............. n/a
75961 ....... Retrieval, broken catheter .............. S .............. 0668 N .............. n/a
75962 ....... Repair arterial blockage ................. S .............. 0668 Q .............. 0668
75964 ....... Repair Artery blockage, each ........ S .............. 0668 N .............. n/a
75966 ....... Repair arterial blockage ................. S .............. 0668 Q .............. 0668
75968 ....... Repair Artery blockage, each ........ S .............. 0668 N .............. n/a
75970 ....... Vascular biopsy .............................. S .............. 0668 N .............. n/a
75978 ....... Repair venous blockage ................ S .............. 0668 Q .............. 0668
75980 ....... Contrast xray exam bile duct ......... S .............. 0297 N .............. n/a
75982 ....... Contrast xray exam bile duct ......... S .............. 0297 N .............. n/a
75984 ....... Xray control catheter change ......... X .............. 0263 N .............. n/a
75989 ....... Abscess drainage under x-ray ....... N .............. .................... N .............. n/a
75992 ....... Atherectomy, x-ray exam ............... S .............. 0668 N .............. n/a
2008—Continued
Inactive
CPT code
effective 1/
1/2008 or
Proposed Proposed
SI APC same line
as its re-
placement
code)
76080 ....... X-ray exam of fistula ...................... X .............. 0263 Q .............. 0263
76975 ....... GI endoscopic ultrasound .............. S .............. 0266 Q .............. 0266
77053 ....... X-ray of mammary duct ................. X .............. 0263 Q .............. 0263 76086 X-ray of mammary
duct.
77054 ....... X-ray of mammary ducts ............... X .............. 0263 Q .............. 0263 76088 X-ray of mammary
ducts.
93555 ....... Imaging, cardiac cath ..................... N .............. n/a N .............. n/a
93556 ....... Imaging, cardiac cath ..................... N .............. n/a N .............. n/a
(5) Diagnostic Radiopharmaceuticals radiopharmaceutical. At that time, we radiopharmaceuticals could provoke

believed that there could be two reasons treatment decisions that may not reflect
For CY 2008, we are proposing to for the presence of these claims in the use of the most clinically appropriate
change the packaging status of data. One reason could be that the radiopharmaceutical for a particular
diagnostic radiopharmaceuticals as part radiopharmaceutical used for the nuclear medicine procedure in any
of our overall enhanced packaging procedure was packaged under the specific case (71 FR 68094).
approach for the CY 2008 OPPS. OPPS and, therefore, some hospitals After considering this issue further
Packaging costs into a single aggregate may have decided not to include the and examining our CY 2006 claims data
payment for a service, encounter, or specific radiopharmaceutical HCPCS for the CY 2008 OPPS update, we
episode of care is a fundamental code and an associated charge on the believe that it is most appropriate to
principle that distinguishes a claim. A second reason could be that the package payment for some
prospective payment system from a fee hospitals may have incorporated the radiopharmaceuticals, specifically
schedule. In general, packaging the costs cost of the radiopharmaceutical into the diagnostic radiopharmaceuticals, into
of supportive items and services into the charges for the associated nuclear the payment for diagnostic nuclear
payment for the independent procedure medicine procedures. A third possibility medicine procedures for CY 2008. We
or service with which they are not offered in the CY 2007 OPPS/ASC expect that packaging would encourage
associated encourages hospital proposed rule is that hospitals may have hospitals to use the most cost efficient
efficiencies and also enables hospitals to included the charges for diagnostic radiopharmaceutical
manage their resources with maximum radiopharmaceuticals on an uncoded products that are clinically appropriate.
flexibility. As we stated in the CY 2007 revenue code line. We anticipate that hospitals would
OPPS/ASC final rule with comment In the CY 2007 OPPS/ASC proposed continue to provide care that is aligned
period, we believe that a policy to rule, we did not propose packaging with the best interests of the patient.
package payment for additional payment for radiopharmaceuticals with Furthermore, we believe that it would
radiopharmaceuticals (other than those per day costs above the $55 CY 2007 be the intent of most hospitals to
already packaged when their per day packaging threshold because we provide both the diagnostic
costs are below the packaging threshold indicated that we were concerned that radiopharmaceutical and the associated
for OPPS drugs, biologicals, and payments for certain nuclear medicine diagnostic nuclear medicine procedure
radiopharmaceuticals based on data for procedures could potentially be less at the time the diagnostic
the update year) is consistent with than the costs of some of the packaged radiopharmaceutical is administered
OPPS packaging principles and would radiopharmaceuticals, especially those and not to send patients to a different
provide greater administrative that are relatively expensive. At the provider for administration of the
simplicity for hospitals (71 FR 68094). same time, we also noted the GAO’s radiopharmaceutical. We do not believe
All nuclear medicine procedures comment in reference to the CY 2006 that our packaging proposal would limit
require the use of at least one OPPS proposed rule that stated a beneficiaries’ ability to receive clinically
radiopharmaceutical, and there are only methodology that includes packaging all appropriate diagnostic procedures.
a small number of radiopharmaceuticals radiopharmaceutical costs into the Again, the OPPS is a system of averages,
that may be appropriately billed with payments for the nuclear medicine and payment in the aggregate is
each diagnostic nuclear medicine procedures may result in payments that intended to be adequate, although
procedure. While examining the CY exceed hospitals’ acquisition costs for payment for any one service may be
2005 hospital claims data in preparation certain radiopharmaceuticals because higher or lower than a hospital’s actual
for the CY 2007 OPPS/ASC proposed there may be more than one costs in that case.
rule, we identified a significant number radiopharmaceutical that may be used For CY 2008, we have separated
of diagnostic nuclear medicine for a particular procedure. We also radiopharmaceuticals into two
procedure claims that were missing expressed concern that packaging groupings. The first group includes
HCPCS codes for the associated payment for additional diagnostic radiopharmaceuticals, while
the second group includes therapeutic than $60 as discussed in section V.B.3. radiopharmaceutical billed. These
radiopharmaceuticals. We identified all of this proposed rule. In that section, we statistics indicate that, in a majority of
diagnostic radiopharmaceuticals as review our reasons for treating our single bills for diagnostic nuclear
those Level II HCPCS codes that include diagnostic radiopharmaceuticals (as medicine procedures, a diagnostic
the term ‘‘diagnostic’’ along with a well as contrast media) differently from radiopharmaceutical HCPCS code is
radiopharmaceutical in their long code other types of specified covered included on the single bill. Table 15
descriptors. Therefore, we were able to outpatient drugs identified in section presents the top 20 diagnostic nuclear
distinguish therapeutic 1833(t)(B) of the Act. medicine procedures in terms of the
radiopharmaceuticals from diagnostic Diagnostic radiopharmaceuticals are overall frequency with which they are
radiopharmaceuticals as those Level II always intended to be used with a reported in the OPPS claims data.
HCPCS codes that have the term diagnostic nuclear medicine procedure.
Among these high volume diagnostic
‘‘therapeutic’’ along with a In examining our CY 2006 claims data,
nuclear medicine procedures, their
radiopharmaceutical in their long code we were able to match most diagnostic
radiopharmaceuticals to their associated single bills include a HCPCS code for a
descriptors. There currently are no
diagnostic procedures and most diagnostic radiopharmaceutical at least
HCPCS C-codes used to report
radiopharmaceuticals under the OPPS. diagnostic nuclear medicine procedures 84 percent of the time for 19 out of the
For CY 2008, we are proposing to to their associated diagnostic top 20 procedures. More specifically, 84
package payment for all diagnostic radiopharmaceuticals in the vast to 86 percent of the single bills for 4
radiopharmaceuticals that are not majority of single bills used for diagnostic nuclear medicine procedures
otherwise packaged according to the ratesetting. We estimate that less than 5 include a diagnostic
proposed CY 2008 packaging threshold percent of all claims with a diagnostic radiopharmaceutical, 87 to 89 percent of
for drugs, biologicals, and radiopharmaceutical had no the single bills for 8 diagnostic nuclear
radiopharmaceuticals. We are proposing corresponding diagnostic nuclear medicine procedures include a
this packaging approach for diagnostic medicine procedure. In addition, we diagnostic radiopharmaceutical, and 90
radiopharmaceuticals, while we are found that only about 13 percent of all percent or more of the single bills for 7
proposing to continue to pay separately single bills with a diagnostic nuclear diagnostic nuclear medicine procedures
for therapeutic radiopharmaceuticals medicine procedure code had no include a diagnostic
with an average per day cost of more corresponding diagnostic radiopharmaceutical.
TABLE 15.—TOP 20 DIAGNOSTIC NUCLEAR MEDICINE PROCEDURES SORTED BY CY 2006 OPPS TOTAL VOLUME
Single bills
with a radio- Single bills as
HCPCS Total line-item pharmaceuti- a percent of
Short descriptor SI APC
code frequency cal as a per- total line-item
cent of all sin- frequency
gle bills
78465 ....... Heart image (3d), multiple ................................... S .............. 0377 566,252 88 9
78306 ....... Bone imaging, whole body .................................. S .............. 0396 368,452 90 76
78815 ....... Tumorimage pet/ct skul-thigh .............................. S .............. 0308 122,126 100 84
78223 ....... Hepatobiliary imaging .......................................... S .............. 0394 69,066 85 90
78315 ....... Bone imaging, 3 phase ....................................... S .............. 0396 56,524 89 88
78464 ....... Heart image (3d), single ...................................... S .............. 0398 35,866 93 29
78472 ....... Gated heart, planar, single .................................. S .............. 0398 32,154 89 80
78264 ....... Gastric emptying study ........................................ S .............. 0395 31,190 88 94
78812 ....... Tumor image (pet)/skul-thigh .............................. S .............. 0308 27,345 100 86
78007 ....... Thyroid image, mult uptakes ............................... S .............. 0391 23,703 84 96
78195 ....... Lymph system imaging ........................................ S .............. 0400 20,187 89 18
78585 ....... Lung V/Q imaging ................................................ S .............. 0378 20,036 91 48
78070 ....... Parathyroid nuclear imaging ................................ S .............. 0391 18,752 94 84
78006 ....... Thyroid imaging with uptake ............................... S .............. 0390 18,613 86 95
78300 ....... Bone imaging, limited area .................................. S .............. 0396 18,333 89 90
78320 ....... Bone imaging (3D) .............................................. S .............. 0396 16,710 84 35
78588 ....... Perfusion lung image ........................................... S .............. 0378 14,323 88 48
78707 ....... K flow/funct image w/o drug ................................ S .............. 0404 13,820 89 90
78580 ....... Lung perfusion imaging ....................................... S .............. 0401 13,011 66 19
78816 ....... Tumor image pet/ct full body ............................... S .............. 0308 12,349 100 86
Among the lower volume diagnostic radiopharmaceutical HCPCS code; about procedures where less than 50 percent
nuclear medicine procedures (which are 37 percent of the low volume diagnostic of the single bills include a diagnostic
outside the top 20 in terms of volume), procedures have between 50 to 79 radiopharmaceutical HCPCS code, we
there is still good representation of percent of the single bills that include believe there could be several reasons
diagnostic radiopharmaceutical HCPCS a diagnostic radiopharmaceutical why the percentage of single bills for the
codes on the single bills for most HCPCS code; and about 23 percent of diagnostic nuclear medicine procedure
procedures. About 40 percent of the low the low volume diagnostic procedures with a diagnostic radiopharmaceutical
volume diagnostic nuclear medicine have less than 50 percent of the single HCPCS code is low.
procedures have at least 80 percent of bills that include a diagnostic As noted earlier, it is possible that
the single bills for that diagnostic radiopharmaceutical HCPCS code. For hospitals may be including the charge
procedure that include a diagnostic the few diagnostic nuclear medicine for the radiopharmaceutical in the
charge for the diagnostic nuclear above discussion on the representation diagnostic nuclear medicine procedures.
medicine procedure itself or on an of diagnostic radiopharmaceuticals in Typically, packaging more procedures
uncoded revenue code line instead of the single bills for diagnostic nuclear should improve the number of single
reporting charges for a specific medicine procedures, the presence of bill claims from which to derive median
diagnostic radiopharmaceutical HCPCS uncoded revenue code charges specific cost estimates because packaging
code. We found that 24 percent of all to diagnostic radiopharmaceuticals on reduces the number of separately paid
single bills for a diagnostic nuclear claims without a coded diagnostic procedures on a claim, thereby creating
medicine procedure but without a radiopharmaceutical, and our proposal more single procedure bills. In the case
coded diagnostic radiopharmaceutical to package payment for all diagnostic of diagnostic nuclear medicine
had uncoded costs in a revenue code radiopharmaceuticals. procedures, packaging diagnostic
that might contain diagnostic It has come to our attention that radiopharmaceuticals reduces the
radiopharmaceutical costs, specifically, several diagnostic radiopharmaceuticals overall number of single bills available
revenue codes 0254 (Drugs Incident to may be used for multiple day studies; to calculate median costs by increasing
Other Diagnostic Services), 0255 (Drugs that is, a particular diagnostic packaged costs that previously were
Incident to Radiology), 0343 (Diagnostic radiopharmaceutical may be ignored in the bypass process. In prior
Radiopharmaceuticals), 0621 (Supplies administered on one day and a related years, we did not consider the costs of
Incident to Radiology), and 0622 diagnostic nuclear medicine procedure radiopharmaceuticals when we used our
(Supplies Incident to Other Diagnostic may be performed on a subsequent day. bypass methodology to extract ‘‘pseudo’’
Services). In comparison, we found that While we understand that multiple day single claims because we assumed that
only 2 percent of diagnostic nuclear episodes for diagnostic the cost of radiopharmaceutical
medicine single bills with a nuclear radiopharmaceuticals and the related overhead and handling would be
medicine procedure and a coded diagnostic nuclear medicine procedures included in the line-item charge for the
diagnostic radiopharmaceutical had occur, we expect that this would be a radiopharmaceutical, and the diagnostic
uncoded costs in these revenue codes. It small proportion of all diagnostic radiopharmaceuticals were subject to
is also possible that some of these nuclear medicine imaging procedures. potential separate payment if their mean
procedures typically use a diagnostic We estimate that, roughly, 15 diagnostic per day cost fell above the packaging
radiopharmaceutical subject to radiopharmaceuticals have a half-life threshold. The bypass process sets
packaged payment under the CY 2006 longer than one day such that they empirical and clinical criteria for
OPPS, and hospitals may have chosen could support diagnostic nuclear minimal packaging for a specific list of
not to report a separate charge for the medicine scans on different days. We procedures and services in order to
diagnostic radiopharmaceutical. believe these diagnostic assign packaged costs to other
Payment for diagnostic radiopharmaceuticals would be procedures on a claim and is discussed
radiopharmaceuticals commonly used concentrated in a specific set of at length in section II.A.1. of this
with some diagnostic nuclear medicine diagnostic procedures. Excluding the 5 proposed rule. Generally, changing the
procedures would already be packaged percent of diagnostic status of diagnostic
because these diagnostic radiopharmaceutical claims with no radiopharmaceuticals to packaged
radiopharmaceuticals’ average per day matching diagnostic nuclear medicine increases packaging on each claim. This
cost were less than $50 in CY 2006. The scan for the same beneficiary, we found could make it both harder for nuclear
that a diagnostic nuclear medicine scan
CY 2008 proposal to package additional medicine procedures to qualify for the
was reported on the same day as a
diagnostic radiopharmaceuticals would bypass list and more difficult to assign
coded diagnostic radiopharmaceutical
have little impact on the payment for packaging to individual diagnostic
90 percent or more of the time for 10 of
those diagnostic procedures that nuclear medicine procedures, resulting
these 15 diagnostic
typically use inexpensive diagnostic in a possible reduction of the number of
radiopharmaceuticals. Further, between
radiopharmaceuticals that would be ‘‘pseudo’’ singles that are produced by
80 and 90 percent single bills for each
packaged under our proposed CY 2008 the bypass process. Notwithstanding
of the remaining 5 diagnostic
packaging threshold of $60, except to this potentiality, diagnostic nuclear
radiopharmaceuticals had a diagnostic
the extent that the budget neutrality medicine procedures continue to have
nuclear medicine scan on the same day.
adjustment due to the broader packaging In the ‘‘natural’’ single bills we use for
good representation in the single bills.
proposal leads to an increase in the ratesetting, we package payment across On average, single bills as a percent of
scaler and an increase in the payment dates of service. In light of such high total occurrences remains substantial at
for procedures in general. percentages of extended half-life 55 percent for individual procedures.
At its March 2007 meeting, the APC diagnostic radiopharmaceuticals with We discuss our process for ratesetting,
Panel recommended that CMS work same day diagnostic nuclear medicine including the construction and use of
with stakeholders on issues related to scans and the ability of ‘‘natural’’ single and multiple bills, in greater
payment for radiopharmaceuticals, singles to package costs across days, we detail in section II.A.1. of this proposed
including evaluating claims data for believe that our standard OPPS rule.
different classes of ratesetting methodology of using We believe our CY 2006 claims data
radiopharmaceuticals and ensuring that median costs calculated from claims support our CY 2008 proposal to
a nuclear medicine procedure claim data adequately captures the costs of package payment for all diagnostic
always includes at least one reported diagnostic radiopharmaceuticals radiopharmaceuticals and lead to
radiopharmaceutical agent. We are associated with diagnostic nuclear proposed payment rates for diagnostic
accepting the APC Panel’s medicine procedures that are not nuclear medicine procedures that
recommendation, and we specifically provided on the same date of service. appropriately reflect payment for the
welcome public comment on the This packaging proposal reduces the costs of the diagnostic
hospitals’ burden involved should we overall frequency of single bills for radiopharmaceuticals that are
require such precise reporting. We also diagnostic nuclear medicine procedures, administered to carry out those
are seeking comment on the importance but the percent of single bills out of total diagnostic nuclear medicine procedures.
of such a requirement in light of our claims remains robust for the majority of Among the top 20 high volume
diagnostic nuclear medicine procedures, commonly used with a particular would receive packaged payment
at least 84 percent of the single bills for diagnostic nuclear medicine procedure through the separate OPPS payment for
almost every diagnostic nuclear are already packaged, the proposal to CPT code 78815. CPT code 78815 is
medicine procedure included a package additional diagnostic assigned to APC 1511 (New
diagnostic radiopharmaceutical HCPCS radiopharmaceuticals would have little Technology—Level XI ($900–$1000)) for
code. While a diagnostic impact on the payment for these CY 2007 with a CY 2007 median cost for
radiopharmaceutical, by definition, procedures. PET/CT procedures of $850.36 and to
would be anticipated to accompany 100 We have calculated the median costs APC 0308 (Non-Myocardial Positron
percent of the diagnostic nuclear on which we are proposing to base the Emission Tomography (PET) Imaging)
medicine procedures, it is not CY 2008 payment rates using the for CY 2008 with a proposed CY 2008
unexpected that while percentages in packaging status of each diagnostic APC median cost of $1,093.52.
our claims data are high, they are less radiopharmaceutical HCPCS code as The proposed CY 2008 payment rates
than 100 percent. As noted previously, provided in Table 17 below. As we associated with this example are
we have heard anecdotal reports that discussed earlier in more detail, this has outlined in Table 16 below. The table
some hospitals may include the charges the effect of both changing the median indicates that the proposed CY 2008
for diagnostic radiopharmaceuticals in cost for the independent service (the payment rate for the skull base to mid-
their charge for the diagnostic nuclear diagnostic nuclear medicine procedure) thigh PET/CT scan would be
medicine procedure or on an uncoded into which the cost of the dependent substantially higher than the CY 2007
revenue code line, rather than reporting service (the diagnostic payment amount for that code. The
a HCPCS code for the diagnostic radiopharmaceutical) is packaged and proposed increase for the PET/CT scan
radiopharmaceutical. Thus, it is likely also of redistributing payment that is slightly more than the estimated
that the frequency of diagnostic would otherwise have been made average CY 2007 payment for the
radiopharmaceutical costs reflected in separately for the service we are separately payable FDG (paid in CY
our claims data are even higher than the proposing to newly package for CY 2007 at charges reduced to cost).
percentages indicate. Furthermore, we 2008. This example cannot demonstrate the
note that the OPPS ratesetting For example, HCPCS code A9552 overall impact of packaging diagnostic
methodology is based on medians, (Fluorodeoxyglucose F–18 FDG, radiopharmaceuticals on payment to
which are less sensitive to extremes Diagnostic, per study dose, up to 45 any given hospital because each
than means and typically do not reflect millicuries) that describes the diagnostic individual hospital’s case mix and
subtle changes in cost distributions. radiopharmaceutical commonly called billing patterns would be different. The
Therefore, to the extent that the vast FDG is frequently billed with CPT code overall impact of packaging diagnostic
majority of single bills for a particular 78815 (Tumor imaging, positron radiopharmaceuticals, as well as all
diagnostic nuclear medicine procedure emission tomography (PET) with other packaging changes proposed for
include a diagnostic concurrently acquired computed CY 2008, can only be assessed in the
radiopharmaceutical HCPCS code, the tomography (CT) for attenuation aggregate for each hospital. Section
fact that the percentage is somewhat less correction and anatomical localization; XXII.B. of this proposed rule displays
than 100 percent is likely to have skull base to mid-thigh). HCPCS code the overall impact of APC weight
minimal impact on the median cost of A9552 is assigned to APC 1651 (F18 fdg) recalibration and packaging changes
the procedure in most cases. Even in for CY 2007. HCPCS code A9552 was that we are proposing by classes of
those few instances where we have a billed with CPT code 78815 101,242 hospitals, and the OPPS Hospital-
low total number of single bills, largely times in the single bills available for this Specific Impacts—Provider-Specific
because of low overall volume, we have CY 2008 proposed rule, and 97 percent Data file presents our estimates of CY
ample representation of diagnostic of the single bills for CPT code 78815 2008 hospital payment for those
radiopharmaceutical HCPCS codes on also reported HCPCS code A9552. hospitals we include in our ratesetting
the single bills for the majority of lower Under our proposed policy for CY 2008, and payment simulation database. The
volume nuclear medicine procedures. we are proposing to package payment hospital-specific impacts file can be
We also continue to have reasonable for HCPCS code A9552 into the found on the CMS Web site at http://
representation of single bills out of total payment for separately payable www.cms.hhs.gov/
claims in general. Finally, as noted procedures that are provided in HospitalOutpatientPPS/ under
previously, to the extent that the conjunction with HCPCS code A9552. supporting documentation for this
diagnostic radiopharmaceuticals In this example, HCPCS code A9552 proposed rule.
TABLE 16.—EXAMPLE OF THE EFFECTS OF THE CY 2008 PACKAGING PROPOSAL ON PAYMENT FOR HCPCS CODE
A9552 AND CPT CODE 78815
Sum of CY Sum of CY
2007 payment 2008 proposed
HCPCS code Short descriptor (A9552 paid payment
separately at (A9552 pack-
cost) aged)
A9552 ........................ F18 fdg (dependent service) ........................................................................................... *$279.29 0.00

78815 ......................... Tumor image pet/ct skul-thigh (independent service) ..................................................... 950.00 1,107.22
Total Payment .................................................................................................................................................. 1,229.29 1,107.22

*Estimated average CY 2007 payment at charges reduced to cost.
The estimated overall impact of these believe that hospitals are limited in the As we indicate above, in all cases, we
changes that we are proposing for CY extent to which they could change their are proposing that hospitals that furnish
2008 is based on the assumption that behavior with regard to how they diagnostic radiopharmaceuticals in
hospital behavior would not change furnish these items because diagnostic association with diagnostic nuclear
with regard to when the dependent radiopharmaceuticals are typically medicine procedures bill both the item
diagnostic radiopharmaceuticals are provided on the same day as a and the procedure on the same claim so
provided by the same hospital that diagnostic nuclear medicine procedure. that the costs of the diagnostic
performs the independent services. In It would be difficult for Hospital A to radiopharmaceuticals can be
order to provide diagnostic nuclear send patients to receive diagnostic appropriately packaged into payment
medicine procedures under this radiopharmaceuticals from Hospital B
for the diagnostic nuclear medicine
proposal, hospitals would either need to and then have the patients return to
procedure. We expect to carefully
administer the necessary diagnostic Hospital A for the diagnostic nuclear
radiopharmaceuticals themselves or medicine procedure in the appropriate monitor any changes in billing practices
refer patients elsewhere for the timeframe (given the on a service-specific and hospital-
administration of the diagnostic radiopharmaceutical’s half life) to specific basis to determine whether
radiopharmaceuticals. In the latter case, perform a high quality study. We would there is reason to request that QIOs
claims data would show such a change expect that hospitals would always bill review the quality of care furnished or
in practice in future years and that the diagnostic radiopharmaceutical on to request that Program Safeguard
change would be reflected in future the same claim as the other independent Contractors review the claims against
ratesetting. However, with respect to services for which the the medical record.
diagnostic radiopharmaceuticals, we radiopharmaceutical was administered.
TABLE 17.—DIAGNOSTIC RADIOPHARMACEUTICAL HCPCS CODES PROPOSED FOR PACKAGED PAYMENT IN CY 2008
CY 2008
HCPCS code Short descriptor CY 2007 SI CY 2007 APC proposed SI
A4641 .......... Radiopharm dx agent noc ...................................................................................... N ................. n/a N

A4642 .......... In111 satumomab ................................................................................................... H .................. 0704 N
A9500 .......... Tc99m sestamibi ..................................................................................................... H ................. 1600 N
A9502 .......... Tc99m tetrofosmin .................................................................................................. H ................. 0705 N
A9503 .......... Tc99m medronate ................................................................................................... N .................. n/a N*
A9504 .......... Tc99m apcitide ....................................................................................................... N ................. n/a N*
A9505 .......... TL201 thallium ........................................................................................................ H ................. 1603 N
A9507 .......... In111 capromab ...................................................................................................... H ................. 1604 N
A9508 .......... I131 iodobenguate, dx ............................................................................................ H ................. 1045 N
A9510 .......... Tc99m disofenin ..................................................................................................... N ................. n/a N*
A9512 .......... Tc99m pertechnetate .............................................................................................. N .................. n/a N*
A9516 .......... I123 iodide cap, dx ................................................................................................. H .................. 9148 N
A9521 .......... Tc99m exametazime .............................................................................................. H ................. 1096 N
A9524 .......... I131 serum albumin, dx .......................................................................................... H ................. 9100 N
A9526 .......... Nitrogen N–13 ammonia ......................................................................................... H ................. 0737 N
A9528 .......... Iodine I–131 iodide cap, dx .................................................................................... H ................. 1088 N
A9529 .......... I131 iodide sol, dx .................................................................................................. N ................. n/a N
A9531 .......... I131 max 100uCi .................................................................................................... N .................. n/a N*
A9532 .......... I125 serum albumin, dx .......................................................................................... N ................. n/a N
A9536 .......... Tc99m depreotide ................................................................................................... H .................. 0739 N
A9537 .......... Tc99m mebrofenin .................................................................................................. N ................. n/a N*
A9538 .......... Tc99m pyrophosphate ............................................................................................ N .................. n/a N*
A9539 .......... Tc99m pentetate ..................................................................................................... H .................. 0722 N*
A9540 .......... Tc99m MAA ............................................................................................................ N ................. n/a N*
A9541 .......... Tc99m sulfur colloid ................................................................................................ N ................. n/a N*
A9542 .......... In111 ibritumomab, dx ............................................................................................ H ................. 1642 N
A9544 .......... I131 tositumomab, dx ............................................................................................. H ................. 1644 N
A9546 .......... Co57/58 .................................................................................................................. H ................. 0723 N
A9547 .......... In111 oxyquinoline .................................................................................................. H ................. 1646 N
A9548 .......... In111 pentetate ....................................................................................................... H ................. 1647 N
A9550 .......... Tc99m gluceptate ................................................................................................... H ................. 0740 N
A9551 .......... Tc99m succimer ..................................................................................................... H .................. 1650 N
A9552 .......... F18 fdg .................................................................................................................... H ................. 1651 N
A9553 .......... Cr51 chromate ........................................................................................................ H ................. 0741 N
A9554 .......... I125 iothalamate, dx ............................................................................................... N ................. n/a N
A9555 .......... Rb82 rubidium ........................................................................................................ H ................. 1654 N
A9556 .......... Ga67 gallium ........................................................................................................... H ................. 1671 N
A9557 .......... Tc99m bicisate ........................................................................................................ H .................. 1672 N
A9558 .......... Xe133 xenon 10mci ................................................................................................ N ................. n/a N*

A9559 .......... Co57 cyano ............................................................................................................. H ................. 0724 N
A9560 .......... Tc99m labeled rbc .................................................................................................. H ................. 0742 N
A9561 .......... Tc99m oxidronate ................................................................................................... N ................. n/a N*
A9562 .......... Tc99m mertiatide .................................................................................................... H .................. 0743 N
A9565 .......... In111 pentetreotide ................................................................................................. H ................. 1677 N
A9566 .......... Tc99m fanolesomab ............................................................................................... H .................. 1678 N
A9567 .......... Technetium TC–99m aerosol ................................................................................. H ................. 0829 N*
TABLE 17.—DIAGNOSTIC RADIOPHARMACEUTICAL HCPCS CODES PROPOSED FOR PACKAGED PAYMENT IN CY 2008—
Continued
CY 2008
HCPCS code Short descriptor CY 2007 SI CY 2007 APC proposed SI
A9568 .......... Tc99m arcitumomab ............................................................................................... H ................. 1648 N

* Indicates that the radiopharmaceutical would have been packaged under the $60 packaging threshold methodology in CY 2008, even in the
absence of the broader packaging proposal for radiopharmaceuticals.
(6) Contrast Agents of this proposed rule.) Seventy-five others. If the 5 agents remained
percent of contrast agents HCPCS codes separately payable, there would
For CY 2008, we are proposing to
have an estimated mean per day cost effectively be two payments for contrast
package payment for all contrast media
equal to or less than $60 based on our agents when these 5 agents were
into their associated independent
CY 2006 claims data. billed—a separate payment and a
diagnostic and therapeutic procedures Contrast agents are described by those payment for packaged contrast agents
as part of our proposed packaging Level II HCPCS codes in the range from that was part of the procedure payment.
approach for the CY 2008 OPPS. As Q9945 through Q9964. There currently This could potentially provide a
noted in section II.A.4.c. of this are no HCPCS C-codes or other Level II payment incentive to administer certain
proposed rule, packaging the costs of HCPCS codes outside the range contrast agents that might not be the
supportive items and services into the specified above used to report contrast most clinically appropriate or cost
payment for the independent procedure agents under the OPPS. As shown in effective. Moreover, as noted previously,
or service with which they are Table 19, in CY 2007, we packaged 7 out contrast agents are always provided
associated encourages hospital of 20 of these contrast agent HCPCS with independent procedures and,
efficiencies and also enables hospitals to codes based on the $55 packaging under a consistent approach to
manage their resources with maximum threshold. For CY 2008, we are packaging in keeping with our enhanced
flexibility. We believe that contrast proposing to package all drugs with a efforts to encourage hospital efficiency
agents are particularly well suited for per day mean cost of $60 or less. For CY and promote value-based purchasing
packaging because they are always 2008, the vast majority of contrast under the OPPS, their payment would
provided in support of an independent agents would be packaged under the be appropriately packaged for CY 2008.
diagnostic or therapeutic procedure that traditional OPPS packaging We have calculated the median costs
involves imaging, and thus payment for methodology using the $60 packaging on which the proposed CY 2008
contrast agents can be packaged into the threshold, based on the CY 2006 claims payment rates are based using the
payment for the associated separately data available for this proposed rule. In packaging status of each contrast agent
payable procedures. fact, of the 20 contrast agent HCPCS HCPCS code as provided in Table 19
Contrast agents are generally codes we are including in our proposed below. As we discussed earlier in more
considered to be those substances packaging approach, 15 would have detail, this has the effect of both
introduced into or around a structure been proposed to be packaged for CY changing the median cost for the
that, because of the differential 2008 under our drug packaging independent service (the diagnostic or
absorption of x-rays, alteration of methodology. These 15 codes represent therapeutic procedure requiring
magnetic fields, or other effects of the 94 percent of all occurrences of contrast imaging) into which the cost of the
contrast medium in comparison with agents billed under the OPPS. We dependent service (the contrast agent) is
surrounding tissues, permit believe that this shift in the packaging packaged and also of redistributing
visualization of the structure through an status for several of these agents payment that would otherwise have
imaging modality. The use of certain between CYs 2007 and 2008 may be been made separately for the service we
contrast agents is generally associated because, in CY 2007, a number of the are proposing to newly package for CY
with specific imaging modalities, contrast agents exceeded the $55 2008.
including x-ray, computed tomography threshold by only a small amount and, For example, HCPCS code Q9947
(CT), ultrasound, and magnetic based on our latest claims data for CY (Low osmolar contrast material, 200–
resonance imaging (MRI), for purposes 2008, a number of these products have 249 mg/ml iodine concentration, per ml)
of diagnostic testing or treatment. They now fallen below the proposed $60 is one of the contrast agents that we are
are most commonly administered threshold. Given that the vast majority proposing to package that would not
through an oral or intravascular route in of contrast agents billed would already otherwise be packaged in CY 2008
association with the performance of the be packaged under the OPPS in CY under the proposed $60 packaging
independent procedures involving 2008, we believe it would be desirable threshold. HCPCS code Q9947 is
imaging that are the basis for their to package payment for the remaining sometimes billed with CPT code 71260
administration. Even in the absence of contrast agents as it promotes efficiency (Computed tomography, thorax; with
this proposal to package payment for all and results in a consistent payment contrast material(s)). HCPCS code
contrast agents, we would propose to policy across products that may be used Q9947 is assigned to APC 9159 (LOCM
package the majority of HCPCS codes in many of the same independent 200–249 mg/ml iodine, 1ml) for CY
for contrast agents recognized under the procedures. We also note that the 2007. HCPCS code Q9947 was billed
OPPS in CY 2008. We consider contrast significant costs associated with these with CPT code 71260 8,172 times in the
agents to be drugs under the OPPS, and 15 contrast agents would already be single bills available for this CY 2008
as a result they are packaged if their reflected in the proposed median costs proposed rule, and 2 percent of the
estimated mean per day cost is equal to for those independent procedures and, single bills for CPT code 71260 also
or less than $60 for CY 2008. (For more if we were to pay for the 5 remaining reported HCPCS code Q9947. Under our
discussion of our drug packaging agents separately, we would be treating proposed policy for CY 2008, we are
criteria, we refer readers to section V.B.2 these 5 agents differently than the proposing to package payment for
HCPCS code Q9947 into the payment payment for the separately payable (Computed tomography, lumbar spine;
for separately payable procedures that HCPCS code Q9947. Notably, a number with contrast material)).
are provided in conjunction with the of low osmolar contrast agents other This example cannot demonstrate the
contrast agent. Specifically, we would than HCPCS code Q9947 that were overall impact of packaging contrast
package payment for HCPCS code separately paid in CY 2007 also are agents on any given hospital because
Q9947 so that, in this example, HCPCS proposed for packaged payment in CY each individual hospital’s case mix and
code Q9947 would receive packaged 2008 because their mean per day cost
billing pattern differs. The overall
payment through the separate OPPS falls below the $60 packaging threshold
impact of packaging contrast agents, as
payment for CPT code 71260. CPT code for drugs, biologicals, and
well as all the other proposed packaging
71260 is assigned to APC 0283 radiopharmaceuticals for CY 2008.
(Computed Tomography with Contrast) Packaging the costs of these contrast changes, can only be assessed in the
for CY 2007 with a CY 2007 median cost media also affects the proposed aggregate for classes of hospitals.
of $249.48. The procedure is assigned to payment rate for CPT code 71260. For Section XXII.B. of this proposed rule
APC 0283, with a proposed APC name another example of packaging contrast displays the overall impact of APC
change to ‘‘Level I Computed agents, we refer readers to the example weight recalibration and packaging
Tomography with Contrast’’ for CY 2008 included in Table 13 of section changes we are proposing by classes of
and a proposed CY 2008 median cost of II.A.4.c.(4) of this proposed rule on hospitals, and the OPPS Hospital-
$286.13. packaging imaging supervision and Specific Impacts—Provider-Specific
The proposed CY 2008 payment rates interpretation services. That example Data file presents our estimates of CY
associated with this example are illustrates the effect of packaging both a 2008 hospital payment for those
outlined in Table 18 below. The table supervision and interpretation service hospitals we include in our ratesetting
indicates that the CY 2008 payment that (CPT code 72265 (Myelography, and payment simulation database. The
we are proposing for CPT code 71260 is lumbosacral, radiological supervision hospital-specific impact file can be
higher than the CY 2007 payment and interpretation)) and a contrast agent found on the CMS Web site at http://
amount for that code. The proposed (HCPCS code Q9947 (low osmolar www.cms.hhs.gov/
increase in the payment rate for CPT contrast material, 200–249 mg/ml HospitalOutpatientPPS/ under
code 71260 in CY 2008 is slightly iodine, per ml)) into the payment for an supporting documentation for this
greater than the estimated CY 2007 imaging procedure (CPT code 72132 proposed rule.
TABLE 18.—EXAMPLE OF THE EFFECTS OF THE CY 2008 PACKAGING PROPOSAL ON PAYMENT FOR CPT CODE 72160
AND HCPCS CODE Q9947
Sum of CY
2007 payment
(Q9947 paid (Q9947
separately) packaged)
Q9947 ........................ LOCM 200–249 mg/ml iodine, 1 ml (dependent service) ............................................... *$64.24 $0.00
71260 ......................... Ct thorax w/dye (independent service) ............................................................................ 250.94 289.71
Total Payment .................................................................................................................................................. 315.18 289.71

*Based on the mean number of units per day from our CY 2008 proposed rule data (48.3) and the April 2007 per unit payment rate for Q9947
($1.33).
The estimated overall impact of these be reflected in future ratesetting. furnish the supportive contrast agent in
changes that we are proposing for CY However, with respect to contrast association with independent
2008 is based on the assumption that agents, we believe that hospitals are procedures involving imaging must bill
hospital behavior would not change limited in the extent to which they both services on the same claim so that
with regard to when the contrast agents could change their behavior with regard the cost of the contrast agent can be
are provided by the same hospital that to how they furnish these services appropriately packaged into payment
performs the imaging procedure. Under because contrast agents are typically for the significant independent
this proposal, in order to provide provided on the same day immediately procedure. We expect to carefully
imaging procedures requiring contrast prior to an imaging procedure being monitor any changes in billing practices
agents, hospitals would either need to performed. We would expect that on a service-specific and hospital
administer the necessary contrast agent hospitals would always bill the contrast specific basis to determine whether
themselves or refer patients elsewhere agent on the same claim as the other there is reason to request that QIOs
for the administration of the contrast independent services for which the review the quality of care furnished or
agent. In the latter case, claims data contrast agent was administered. to request that Program Safeguard
would show such a change in practice As we indicated earlier, in all cases Contractors review the claims against
in future years and that change would we are proposing that hospitals that the medical record.
TABLE 19.—CONTRAST MEDIA HCPCS CODES PROPOSED FOR PACKAGED PAYMENT IN CY 2008
Proposed CY
HCPCS code Short descriptor CY 2007 SI CY 2007 APC 2008 SI
Q9945 .......... LOCM <=149 mg/ml iodine, 1 ml ........................................................................... K .................. 9157 N*

Q9946 .......... LOCM 150–199 mg/ml iodine, 1 ml ....................................................................... K .................. 9158 N*
Q9947 .......... LOCM 200–249 mg/ml iodine, 1 ml ....................................................................... K .................. 9159 N
TABLE 19.—CONTRAST MEDIA HCPCS CODES PROPOSED FOR PACKAGED PAYMENT IN CY 2008—Continued
Proposed CY
HCPCS code Short descriptor CY 2007 SI CY 2007 APC 2008 SI

Q9951 .......... LOCM >= 400 mg/ml iodine, 1 ml .......................................................................... K .................. 9163 N*
Q9952 .......... Inj Gad-base MR contrast, 1 ml ............................................................................. K .................. 9164 N*
Q9953 .......... Inj Fe-based MR contrast, 1 ml .............................................................................. K .................. 1713 N
Q9954 .......... Oral MR contrast, 100 ml ....................................................................................... K .................. 9165 N*
Q9955 .......... Inj perflexane lip micros, ml .................................................................................... K .................. 9203 N*
Q9956 .......... Inj octafluoropropane mic, ml ................................................................................. K .................. 9202 N
Q9957 .......... Inj perflutren lip micros, ml ..................................................................................... K .................. 9112 N
Q9958 .......... HOCM <=149 mg/ml iodine, 1 ml ........................................................................... N ................. n/a N*
Q9959 .......... HOCM 150–199 mg/ml iodine, 1 ml ....................................................................... N ................. n/a N
Q9960 .......... HOCM 200–249 mg/ml iodine, 1 ml ....................................................................... N ................. n/a N*
Q9964 .......... HOCM>= 400 mg/ml iodine, 1 ml ........................................................................... N ................. n/a N*
*Indicates that the contrast agent would have been packaged under the $60 packaging threshold methodology in CY 2008, even in the ab-
sence the broader packaging proposal for contrast agents.
(7) Observation Services time, physician care, and based on criteria discussed
We are proposing to package payment documentation in the medical record subsequently. (We note that if an HOPD
for all observation care, reported under (66 FR 59856, 59879). Payment for directly admits a patient to observation,
HCPCS code G0378 (Hospital observation care that did not meet these Medicare currently pays separately for
observation services, per hour) for CY specified criteria was packaged. that direct admission reported under
2008. Payment for observation would be Between CY 2003 and CY 2006, several HCPCS code G0379 (Direct admission of
packaged as part of the payment for the more changes were made to the OPPS patient for hospital observation care) in
separately payable services with which policy regarding separate payment for situations where payment for the actual
it is billed. We have defined observation observation services, such as: observation care reported under HCPCS
care as a well-defined set of specific, Clarification that observation is not code G0378 is packaged.) For CY 2008,
clinically appropriate services that separately payable when billed with as discussed in more detail later in this
include ongoing short-term treatment, ‘‘T’’ status procedures on the day of or proposed rule (section XI.), we are
day before observation care; proposing to continue the coding and
assessment, and reassessment before a
development of specific Level II HCPCS payment methodology for direct
decision can be made regarding whether
codes for hospital observation services admission to observation status, with
patients will require further treatment as
and direct admission to observation the exception of the requirement that
hospital inpatients or if they are able to
care; and removal of the initially HCPCS code G0379 is only eligible for
be discharged from the hospital.
established diagnostic testing separate payment if observation care
Observation status is commonly
requirements for separately payable reported under HCPCS code G0378 does
assigned to patients who present to the
observation (67 FR 66794, 69 FR 65828, not qualify for separate payment. This
emergency department and who then
and 70 FR 68688). Throughout this time requirement would no longer be
require a significant period of treatment
period, we maintained separate applicable under our proposal to
or monitoring before a decision is made package all observation services
concerning their next placement or to payment for observation care only for
the three specified medical conditions, reported under HCPCS code G0378.
patients with unexpectedly prolonged Currently, separate OPPS payment
recovery after surgery. Throughout this and OPPS payment for observation for
all other clinical conditions remained may be made for observation services
proposed rule, as well as in our manuals reported under HCPCS code G0378
and guidance documents, we use both packaged.
provided to a patient when all of the
of the terms ‘‘observation services’’ and Since January 1, 2006, hospitals have following requirements are met. The
‘‘observation care’’ in reference to the reported observation services based on hospital would receive a single separate
services defined above. an hourly unit of care using HCPCS payment for an episode of observation
Payment for all observation care code G0378. This code has a status care (APC 0339) when:
under the OPPS was packaged prior to indicator of ‘‘Q’’ under the CY 2007
CY 2002. Since CY 2002, separate OPPS, meaning that the OPPS claims 1. Diagnosis Requirements
payment of a single unit of an processing logic determines whether the a. The beneficiary must have one of
observation APC for an episode of observation is packaged or separately three medical conditions: congestive
observation care has been provided in payable. The OCE’s current logic heart failure, chest pain, or asthma.
limited circumstances. Effective for determines whether observation b. Qualifying ICD–9–CM diagnosis
services furnished on or after April 1, services billed under HCPCS code codes must be reported in Form Locator
2002, separate payment for observation G0378 are separately payable through (FL) 76, Patient Reason for Visit, or FL
was made if the beneficiary had chest APC 0339 (Observation) or whether 67, principal diagnosis, or both in order
pain, asthma, or congestive heart failure payment for observation services will be for the hospital to receive separate
and met additional criteria for packaged into the payment for other payment for APC 0339. If a qualifying
diagnostic testing, minimum and separately payable services provided by ICD–9–CM diagnosis code(s) is reported
maximum limits to observation care the hospital in the same encounter in the secondary diagnosis field, but is
not reported in either the Patient Reason conjunction with other independent payment for these services over this
for Visit field (FL 76) or in the principal separately payable hospital outpatient time period, the substantial growth by
diagnosis field (FL 67), separate services such as an emergency itself is noteworthy.
payment for APC 0339 is not allowed. department visit, surgical procedure, or We are also concerned that the
another separately payable service, and current criteria for separate payment for
2. Observation Time observation services may provide
thus observation costs can logically be
a. Observation time must be packaged into OPPS payment for disincentives for efficiency. In order for
documented in the medical record. independent services. As discussed observation services to be separately
b. A beneficiary’s time in observation extensively earlier in this section, payable, they must last at least 8 hours.
(and hospital billing) begins with the packaging payment into larger payment While this criterion was put in place to
beneficiary’s admission to an bundles creates incentives for providers ensure that separate payment is made
observation bed. to furnish services in the most efficient only for observation services of a
c. A beneficiary’s time in observation way that meets the needs of the patient, substantial duration, it may create a
(and hospital billing) ends when all encouraging long-term cost financial disincentive for an HOPD to
clinical or medical interventions have containment. make a timely determination regarding
been completed, including followup As we discussed in the general a patient’s safe disposition after
care furnished by hospital staff and overview of the CY 2008 packaging observation care ends. By packaging
physicians that may take place after a approach earlier in this section (section payment for all observation services,
physician has ordered the patient be regardless of their duration, we would
II.A.4.b. of this proposed rule), there has
released or admitted as an inpatient. provide incentives for more efficient
been substantial growth in program
d. The number of units reported with delivery of services and timely decision-
expenditures for hospital outpatient
HCPCS code G0378 must equal or making. The current criterion also
services under the OPPS in recent years.
exceed 8 hours. prohibits separate payment for
The primary reason for this upsurge is
observation services when a ‘‘T’’ status
3. Additional Hospital Services growth in the intensity and utilization
procedure (generally a surgical
a. The claim for observation services of services rather than the general price
procedure) is provided on the same day
must include one of the following of services or enrollment changes. This
or the previous day by the HOPD to the
services in addition to the reported observed trend is notably reflected in
same Medicare beneficiary. Again, this
observation services. The additional the frequency and costs of separately may create a financial disincentive for
services listed below must have a line- payable observation care for the last few hospitals to provide minor surgical
item date of service on the same day or years. While median costs for an procedures during a patient’s
the day before the date reported for episode of observation care that would observation stay, unless those
observation: meet the criteria for separate payment procedures are essential to the patient’s
• An emergency department visit have remained relatively stable between care during that time period, even if the
(APC 0609, 0613, 0614, 0615, or 0616); CY 2003 and CY 2006, the frequency of most efficient and effective performance
or claims for separately payable of those procedures could be during the
• A clinic visit (APC 0604, 0605, observation services has rapidly single HOPD encounter.
0606, 0607, or 0608); or increased. Comparing claims data for Currently, the OPPS pays separately
• Critical care (APC 0617); or separately payable observation care for observation care for only the three
• Direct admission to observation available for proposed rules spanning original medical conditions designated
reported with HCPCS code G0379 (APC from CY 2005 to CY 2008 (that is, claims in CY 2002, specifically chest pain,
0604). data reflecting services furnished from asthma, and congestive heart failure. As
b. No procedure with a ‘‘T’’ status CY 2003 to CY 2006), we see substantial discussed in more detail in the
indicator can be reported on the same growth in separately payable observation section (section XI.) of this
day or day before observation care is observation care billed under the OPPS proposed rule, the APC Panel
provided. over that time. In CY 2003, the full first recommended at its March 2007
year when observation care was meeting that we consider expanding
4. Physician Evaluation separately payable, there were separate payment for observation
a. The beneficiary must be in the care approximately 56,000 claims for services to include two additional
of a physician during the period of separately payable observation care. In diagnoses, syncope and dehydration. As
observation, as documented in the CY 2004, there were approximately mentioned previously, we have defined
medical record by admission, discharge, 77,000 claims for separately payable observation care as a well-defined set of
and other appropriate progress notes observation care. In CY 2005, that specific, clinically appropriate services,
that are timed, written, and signed by number increased to approximately which include ongoing, short-term
the physician. 124,300 claims, representing about a 61 treatment, assessment, and
b. The medical record must include percent increase in one year. In reassessment, that are furnished while a
documentation that the physician addition, in the CY 2006 data available decision is being made regarding
explicitly assessed patient risk to for this proposed rule, the frequency of whether a patient will require further
determine that the beneficiary would claims for separately payable treatment as a hospital inpatient or if
benefit from observation care. observation services increased again, to the individual is able to be discharged
In the context of our proposed CY more than 271,200 claims, about a 118- from the hospital. Given the definition
2008 packaging approach, for several percent increase over CY 2005 and more of observation services, it is clear that,
reasons we believe that it is appropriate than triple the number of claims from 2 in certain circumstances, observation
to package payment for all observation years earlier. While it is not possible to care could be appropriate for patients
services reported with HCPCS code discern the specific factors responsible with a range of diagnoses. Both the APC
G0378 under the CY 2008 OPPS. for the growth in claims for separately Panel and numerous commenters to
Primarily, observation services are ideal payable observation services, as there prior OPPS proposed rules have
for packaging because they are always have been minor changes in both the confirmed their agreement with this
provided as a supportive service in process and criteria for separate perspective. In addition, the June 2006
Institute of Medicine (IOM) Report We have calculated the median costs 99285 is assigned to APC 0616 (Level 5
entitled, ‘‘Hospital-Based Emergency on which the proposed CY 2008 Emergency Visits), with a CY 2007 APC
Care: At the Breaking Point,’’ payment rates are based according to median cost of $323.36 and a proposed
encourages hospitals to apply tools to our proposed packaging approach under CY 2008 median cost of $344.50. The
improve the flow of patients through which payment for HCPCS code G0378 CY 2007 median cost of APC 0339 for
emergency departments, including would always be packaged (status separately payable observation is
developing clinical decisions units indicator ‘‘N’’). As we discussed $440.22.
where observation care is provided. The previously in more detail, in this The proposed CY 2008 payment rates
IOM’s Committee on the Future of section, this has the effect of both associated with this example are
Emergency Care in the United States changing the median costs for the outlined in Table 20 below. The table
Health System recommended that CMS independent services into which the indicates that the proposed CY 2008
remove the current limitations on the costs of the dependent and supportive payment for a Level 5 emergency
medical conditions that are eligible for observation services are packaged and department visit is higher than the CY
separate observation care payment in also of redistributing payment that 2007 payment amount for that code.
order to encourage the development of would otherwise have been made However, the proposed increase in the
such observation units. separately for the observation services Level 5 emergency department visit
As packaging payment provides we are proposing to newly package for payment rate for CY 2008 is
desirable incentives for greater CY 2008. significantly less than the CY 2007
efficiency in the delivery of health care For example, separately payable payment for separately payable
and provides hospitals with significant observation care is frequently billed observation. This is due to the fact that,
flexibility to manage their resources, we with CPT code 99285 (Emergency although observation services are
believe it is most appropriate to treat department visit for the evaluation and commonly billed with a Level 5
observation care for all diagnoses management of a patient (Level 5)). In emergency department visit, the
similarly by packaging its costs into the CY 2008 OPPS proposed rule claims proportion of all Level 5 emergency
payment for the separately payable data, CPT code 99285 was billed department visits that include
independent services with which the 157,668 times on claims with HCPCS observation (12 percent) is relatively
observation is associated. This code G0378 that meet our current small. Thus, when observation care that
consistent payment methodology would criteria for separate payment for would have met the CY 2007 criteria for
provide hospitals with the flexibility to observation care. In addition, about 57 separate payment is packaged into
assess their approaches to patient care percent of the claims for HCPCS code payment for separately payable services
and patient flow and provide G0378 that meet our current criteria for such as a Level 5 emergency department
observation care for patients with a separate payment also reported CPT visit, it raises the payment rate for that
variety of clinical conditions when code 99285. Under our proposed policy separately payable service for all
hospitals conclude that observation for CY 2008, we are proposing to occurrences of the service, even those
services would improve their treatment package payment for HCPCS code occurrences where observation care is
of those patients. Approximately 70 G0378 into the payment for separately not provided. As a result, the payment
percent of the occurrences of payable procedures that are provided in rate for the separately payable service,
observation care billed under the OPPS conjunction with HCPCS code G0378. the Level 5 emergency department visit,
are currently packaged, and this Specifically, we would package does not increase by the full amount of
proposal would extend the incentives payment for HCPCS code G0378 when the former payment rate for separately
for efficiency already present for the it is provided with a separately paid payable observation care as that amount
vast majority of observation services service such as CPT code 99285, so that is spread over many more occurrences
that are already packaged under the in this example observation would of Level 5 emergency department visits.
OPPS to the remaining 30 percent of receive packaged payment through the In addition, OPPS’ use of medians leads
observation services for which we separate OPPS payment for the Level 5 relative weight estimates to be less
currently make separate payment. emergency department visit. CPT code sensitive to packaging decisions.
TABLE 20.—EXAMPLE OF THE EFFECTS OF THE CY 2008 PACKAGING PROPOSAL ON PAYMENT FOR OBSERVATION CARE
(HCPCS CODE G0378) AND CPT CODE 99295
Sum of CY Sum of CY
2007 payment 2008 proposed
HCPCS code Short descriptor (some G0378 payment
paid sepa- (G0378 pack-
rately) aged)
G0378 (under criteria for separately paid observation Hospital observation per hr (dependent service) ......... $442.81 $0.00
care).
99285 ............................................................................ Emergency dept visit (independent service) ................ 325.26 348.81
Total Payment ....................................................... ....................................................................................... 768.07 348.81

This example cannot demonstrate the code G0378, as well as all other impact of APC weight recalibration and
overall impact of packaging observation packaging changes that we are packaging changes that we are
services on any given hospital because proposing for CY 2008, can only be proposing by classes of hospitals, and
each individual hospital’s case-mix and assessed in the aggregate for classes of the OPPS Hospital-Specific Impacts—
billing pattern would be different. The hospitals. Section XXII.B. of this Provider-Specific Data file presents our
overall impact of packaging HCPCS proposed rule displays the overall estimates of CY 2008 hospital payment
for those hospitals we include in our services reported with HCPCS code and gives hospitals some flexibility to
ratesetting and payment simulation G0378 for CY 2008. Payment for manage their resources, we believe that
database. The hospital-specific impact observation services would be made as payment for larger bundles of major
file can be found at http:// part of the payment for the separately separately paid services that are
www.cms.hhs.gov/ payable independent services with commonly performed in the same
HospitalOutpatientPPS/ under which they are billed. As part of this hospital outpatient encounter or as part
supporting documentation for this proposal, we would change the status of a multi-day episode of care would
proposed rule. indicator for HCPCS code G0378 from create even more incentives for
The estimated overall impact of these ‘‘Q’’ to ‘‘N.’’ In addition, we would no efficiency, as discussed earlier.
changes that we are proposing for CY longer require the current criteria for Moreover, defining the ‘‘service’’ paid
2008 presented in section XXII.B. of this separate payment related to hospital under the OPPS by combinations of
proposed rule is based on the visits and ‘‘T’’ status procedures, HCPCS codes for component services
assumption that hospital behavior minimum number of hours, and that are commonly performed in the
would not change with regard to when qualifying diagnoses. However, we same encounter and that result in the
the dependent observation care is would retain as general reporting provision of a complete service would
provided in the same encounter and by requirements those criteria related to enable us to use more claims data and
the same hospital that performs the physician evaluation, documentation, to establish payment rates that we
independent services. To the extent that and observation beginning and ending believe more appropriately capture the
hospitals could change their behavior time as listed in sections II.A.2.a., b., costs of services paid under the OPPS.
and cease providing observation and c., and 4.a. and b. of this proposed Section 1833(t)(1)(B) of the Act
services, refer patients elsewhere for rule. Those are more general permits us to define what constitutes a
that care, or increase the frequency of requirements that encourage hospitals to ‘‘service’’ for purposes of payment
observation services, the data would provide medically reasonable and under the OPPS and is not restricted to
show such a change in practice in future necessary care and help to ensure the defining a ‘‘service’’ as a single HCPCS
years and that change would be proper reporting of observation services code. For example, the OPPS currently
reflected in future budget neutrality on correctly coded hospital claims that packages payment for certain items and
adjustments. However, with respect to reflect the full charges associated with services reported with HCPCS codes
observation care, we believe that all hospital resources utilized to provide into the payment for other separately
hospitals are limited in the extent to the reported services. payable services on the claim.
which they could change their behavior Consistent with our statutory flexibility
with regard to how they furnish these d. Proposed Development of Composite to define what constitutes a service
services because observation care, by APCs under the OPPS, we are proposing to
definition, is short-term treatment, (1) Background view a service, in some cases, as not just
assessment, and reassessment before a the diagnostic or treatment modality
decision can be made regarding whether As we discuss above in regard to our identified by one individual HCPCS
patients will require further treatment as reasons for our proposed packaging code but as the totality of care provided
hospital inpatients or if they are able to approach for the CY 2008 OPPS, we in a hospital outpatient encounter that
be discharged from the hospital after believe that it is crucial that the would be reported with two or more
receiving the independent services. We payment approach of the OPPS create HCPCS codes for component services.
believe it is unlikely that hospitals incentives for hospitals to seek ways to In view of this statutory flexibility to
would cease providing medically provide services more efficiently than define what constitutes a ‘‘service’’ for
necessary observation care or refer exist under the current OPPS structure purposes of OPPS payment, our desire
patients elsewhere for that care if they and allow hospitals maximum to encourage efficiency in HOPD care,
were unable to reach a decision that the flexibility to manage their resources. our focus on value-based purchasing,
patient could be safely discharged from The current OPPS structure usually and our desire to use as much claims
the outpatient department. We would provides payment for individual data as possible to set payment rates
expect that hospitals would always bill services which are generally defined by under the OPPS, we examined our
the supportive observation care on the individual HCPCS codes. We currently claims data to determine how we could
same claim as the other independent package the costs of some items and best use the multiple procedure claims
services provided in the single hospital services (such as drugs and biologicals (‘‘hardcore’’ multiples) that are
encounter. with an average per day cost of less than otherwise not available for ratesetting
As we indicated earlier, in all cases $55) into the payment for separately because they include multiple
we are proposing that hospitals that payable individual services. However, separately payable procedures furnished
furnish the observation care in because the extent of packaging in the on the same date of service. As
association with independent services OPPS is currently modest, furnishing discussed in more detail in our
must bill those services on the same many individual separately payable discussion of single and multiple
claim so that the costs of the observation services increases total payment to the procedure claims in section II.A.1.b. of
care can be appropriately packaged into hospital. We believe that this aspect of this proposed rule, we have focused in
payment for the independent services. the current OPPS structure is a recent years on ways to convert multiple
We expect to carefully monitor any significant factor in the growth in procedure claims to single procedure
changes in billing practices on a service- volume and spending that we discuss in claims to maximize our use of the
specific and hospital-specific basis to our general overview and provides a claims data in setting median costs for
determine whether there is reason to primary rationale for our proposed separately payable procedures. We have
request that QIOs review the quality of packaging approach for services in the been successful in using the bypass list
care furnished or to request that CY 2008 OPPS. While packaging to generate ‘‘pseudo’’ single procedure
Program Safeguard Contractors review payment for supportive dependent claims for use in median setting, but
the claims against the medical record. services into the payment for the this approach generally does not enable
In summary, we are proposing to independent services which they us to use the hardcore multiple claims
package payment for all observation accompany promotes greater efficiency that contain multiple separately payable
procedures, all with associated under the OPPS. Where the claims data payment for specified mental health
packaging that cannot be split among show that combinations of services are services provided by one hospital to a
them. We believe that we could use the commonly furnished together, in the single beneficiary on one date of service
data from many more multiple future we will actively examine whether based on the payment rates associated
procedure claims by creating APCs for it would be more appropriate to with the APCs for the individual
payment of those services defined as establish a composite APC under which services would exceed the per diem
frequently occurring common we would pay a single rate for the partial hospitalization payment (listed
combinations of HCPCS codes for service reported with a combination of as APC 0033 (Partial Hospitalization)),
component services that we see in HCPCS codes on the same date of those specified mental health services
correctly coded multiple procedure service (or different dates of service) are assigned to APC 0034, which has the
claims. than to continue to pay for these same payment rate as APC 0033, and the
Our examination of data for multiple individual services under service- hospital is paid one unit of APC 0034.
procedure claims identified two specific specific APCs. We are proposing these This longstanding policy regarding
sets of services that we believe are good specific encounter-based composite payment of APC 0034 for combinations
candidates for payment based on the APCs for CY 2008 because we believe of independent services provided in a
naturally occurring common that this approach could move the OPPS single hospital encounter resembles the
combinations of component codes that toward possible payment based on an payment policy for composite APCs that
we see on the multiple procedure encounter or episode-of-care basis, we are proposing for LDR prostate
claims. These are low dose rate (LDR) enable us to use more valid and brachytherapy and cardiac
prostate brachytherapy and cardiac complete claims data, create hospital electrophysiologic evaluation and
electrophysiologic evaluation and incentives for efficiency, and provide ablation services for CY 2008. Similar to
ablation services. hospitals with significant flexibility to the logic for the proposed composite
Specifically, we have been told (and manage their resources that do not exist APCs, the OCE determines whether to
our data support) that claims for LDR when we pay for services on a per pay these specified mental health
prostate brachytherapy, when correctly service basis. As such, these proposed services individually or to make a single
coded, report at least two major composite APCs may serve as a payment at the same rate as the per
separately payable procedure codes the prototype for future creation of more diem rate for partial hospitalization for
majority of the time. For reasons composite APCs, through which we all of the specified mental health
discussed below, we are proposing to could provide OPPS payment for other services furnished on that date of
use these correctly coded claims that types of services in the future. We note service. However, we note this
would otherwise be unusable hardcore that while these proposed composite established policy for payment of APC
multiples as the basis for an encounter- APCs for CY 2008 are based on observed 0034 differs from the proposed policies
based composite APC that would make
combinations of component HCPCS for the new CY 2008 composite APCs
a single payment when both codes are
codes reported on the same date of because APC 0034 is only paid if the
reported with the same date of service.
service for a single encounter, we also sum of the individual payment rates for
We also are proposing to pay separately
will be exploring in the future how we the specified mental health services
for these procedure codes in cases
could set payments based on episodes of provided on one date of service exceeds
where only one of the two procedures
care involving services that extend the APC 0034 payment rate, which
is provided in a hospital encounter,
beyond the same date but which are all equals the per diem rate of APC 0033 for
through the APC associated with that
supportive of a single, related course of partial hospitalization.
component procedure code that is
treatment. While we are not proposing We are not proposing to change this
furnished.
Similarly, we have been told (and our to implement multi-day episode-of-care mental health services payment policy
data support) that multiple cardiac APCs in CY 2008, we welcome for CY 2008. However, we are proposing
electrophysiologic evaluation, mapping, comments on the concept of developing to change the status indicator from ‘‘S’’
and ablation services are typically these APCs to provide payment for such to ‘‘Q’’ for the HCPCS codes for the
furnished on the same date of service episodes in order to inform our future specified mental health services to
and that the correctly coded claims are analyses in this area. which APC 0034 applies because those
typically the multiple procedure claims While we have never previously used codes are conditionally packaged when
that include several component services the term ‘‘composite’’ APC under the the sum of the payment rates for the
and that we are unable to use in our OPPS, we do have one historical single code APCs to which they are
current claims process. The CY 2007 payment policy that resembles the CY assigned exceeds the per diem payment
CPT book introductory discussion in the 2008 proposed composite APC policy. rate for partial hospitalization. While we
section entitled ‘‘Intracardiac Since the inception of the OPPS, CMS have not published APC 0034 in
Electrophysiological Procedures/ has limited the aggregate payment for Addendum A in the past, we are
Studies’’ notes that, in many specified less intensive mental health including it in Addendum A to this
circumstances, patients with services furnished on the same date to proposed rule entitled ‘‘Mental Health
arrhythmias are evaluated and treated at the payment for a day of partial Composite,’’ consistent with our naming
the same encounter. Therefore, as hospitalization, which we considered to taxonomy and publication of the two
discussed in detail below, we are also be the most resource intensive of all other proposed composite APCs. We are
proposing to establish an encounter outpatient mental health treatment (65 also including the mental health
based composite APC for these services FR 18455). The costs associated with composite APC 0034 and its member
that would provide a single payment for administering a partial hospitalization HCPCS codes in Addendum M to this
certain common combinations of program represent the most resource proposed rule in the same way that we
component cardiac electrophysiologic intensive of all outpatient mental health show the HCPCS codes to which the
services that are reported on the same treatment, and we do not believe that LDR Prostate Brachytherapy Composite
date of service. we should pay more for a day of APC and Cardiac Electrophysiologic
These composite APCs reflect an individual mental health services under Evaluation and Ablation Composite
evolution in our approach to payment the OPPS. Through the OCE, when the APC apply.
In summary, we are not proposing a needles or catheters are inserted into the reports the placement of the needles or
change to the longstanding payment prostate, and then radioactive sources catheters for services furnished on or
policy under which the OPPS pays one are permanently implanted into the after January 1, 2007. Before this date,
unit of APC 0034 in cases in which the prostate through the hollow needles or including in the claims for services
total payments for specified mental catheters. The needles or catheters are furnished in CY 2006 that were used to
health services provided on the same then removed from the body, leaving the develop this proposed rule, CPT code
date of service would otherwise exceed radioactive sources in the prostate 55859 (Transperineal placement of
the payment rate for APC 0033. forever, where they slowly give off needles or catheters into prostate for
However, we are proposing to change radiation to destroy the cancer cells interstitial radioelement application,
the status indicator to ‘‘Q’’ for the until the sources are no longer with or without cystoscopy) reported
HCPCS codes for mental health services radioactive. At least two CPT codes are this service. All of the claims for CPT
to which this policy applies and which used to report the composite treatment code 55859 (as reported in the CY 2006
comprise this existing composite APC, service because there are separate codes claims data) are for the placement of
because payment for these services that describe placement of the needles needles or catheters for prostate
would be packaged unless the sum of or catheters and application of the brachytherapy, although not all are
the individual payments assigned to the brachytherapy sources. LDR prostate related to permanent brachytherapy
codes would be less than the payment brachytherapy cannot be furnished source application.
for APC 0034. without the services described by both
CPT code 77778 (Interstitial radiation
We look forward to public comments of these codes. Generally, the
source application; complex) reports the
on the concept of composite APCs in component services represented by both
application of brachytherapy sources
general and, specifically, the two new codes occur in the same operative
and, when billed with CPT code 55859
proposed encounter-based composite session in the same hospital on the same
date of service. However, we have been (or CPT code 55875 after January 1,
APCs for CY 2008, and we hope to
told of uncommon cases in which they 2007) for the same encounter, reports
involve the public and the APC Panel in
are furnished in different locations, with placement of the sources in the prostate.
the creation of additional composite
the patient being transported from one We have been told that application of
APCs. Our goal would be to use the
location to another for application of the brachytherapy sources to the prostate is
many naturally occurring multiple
sources. In addition, other services, estimated to be about 85 percent of all
procedure claims that cannot currently
commonly CPT code 76965 (Ultrasonic occurrences of CPT code 77778 under
be incorporated under the existing APC
guidance for interstitial radioelement the OPPS, consistent with our CY 2006
structure, regardless of whether the
application) and CPT code 77290 claims data used for CY 2008
naturally occurring pattern of multiple
(Therapeutic radiology simulation-aided ratesetting. CPT code 77778 is also used
procedure claims prevents the
field setting; complex) are often to report the application of sources of
development of single bills.
provided in the same hospital brachytherapy to body sites other than
(2) Proposed Low Dose Rate (LDR) encounter. the prostate.
Prostate Brachytherapy Composite APC CPT code 55875 (Transperineal Historical coding, APC assignments,
(a) Background placement of needles or catheters into and payment rates for CPT codes 55859
LDR prostate brachytherapy is a prostate for interstitial radioelement (CPT code 55875 beginning in CY 2007)
treatment for prostate cancer in which application, with or without cystoscopy) and 77778 are shown below in Table 21.
TABLE 21.—HISTORICAL PAYMENT RATES FOR COMPLEX INTERSTITIAL APPLICATION OF BRACHYTHERAPY SOURCES
Payment APC for Payment rate APC for Brachytherapy
OPPS CY Combination APC rate for CPT HCPCS for CPT codes HCPCS source
code 77778 code 77778 55859/55875 code 55859
2000 ..................................................... N/A ........................ $198.31 APC 0312 $848.04 APC 0162 Pass-through.
2001 ..................................................... N/A ........................ 205.49 APC 0312 878.72 APC 0162 Pass-through.
2002 ..................................................... N/A ........................ 6,344.67 APC 0312 2,068.23 APC 0163 Pass-through with
pro rata reduc-
tion.
2003 (prostate brachytherapy with io- G0261, APC 648, n/a n/a n/a n/a Packaged.
dine sources). $5,154.34.
2003 (prostate brachytherapy with pal- G0256, APC 649, n/a n/a n/a n/a Packaged.
ladium sources). $5,998.24.
2003 (not prostate brachytherapy, not N/A ........................ 2,853.58 APC 0651 1,479.60 APC 0163 Separate payment
including sources). based on scaled
median cost per
source.
2004 ..................................................... N/A ........................ 558.24 APC 0651 1,848.55 APC 0163 Cost.
2005 ..................................................... N/A ........................ 1,248.93 APC 0651 2,055.63 APC 0163 Cost.
2006 ..................................................... N/A ........................ 666.21 APC 0651 1,993.35 APC 0163 Cost.
2007 ..................................................... N/A ........................ 1,035.50 APC 0651 2,146.84 APC 0163 Cost.
Payment rates for CPT code 77778, in median costs for these services results is a multiple procedure claim.
particular, have fluctuated over the in use of only incorrectly coded claims Specifically, we have been informed
years. We have frequently been for LDR prostate brachytherapy because, that a correctly coded claim for LDR
informed by the public that reliance on for application of brachytherapy sources prostate brachytherapy should include,
single procedure claims to set the to the prostate, a correctly coded claim for the same date of service, both CPT
codes 55859 and 77778, brachytherapy as a single procedure and the supporting clinical situations where the LDR
sources reported with Level II HCPCS services were either packaged or sources were not applied in the same
codes, and typically separately coded bypassed for purposes of calculating the operative session as the insertion of the
imaging and radiation therapy planning median for the combined pair of codes. needles or catheters. These data are
services, and that we should use (We refer readers to the CY 2006 final consistent with our understanding of
correctly coded claims to set the median rule with comment period (70 FR current clinical practice for prostate
for APC 0651 (Complex Interstitial 68596) and the CY 2007 final rule with brachytherapy, and we believe that
Radiation Source Application) in comment period (71 FR 68043) for those multiple claims are correctly
particular (where CPT code 77778 is specific discussion of these findings.) coded claims for this common clinical
assigned). In presentations to the APC Hence, we concluded that the single bill scenario. Similarly, 83 percent of the
Panel in its March 2006 meeting, and in median costs were reasonable and, for claims for complex interstitial
response to the CY 2006 and CY 2007 both the CY 2006 OPPS and CY 2007 brachytherapy source application CPT
OPPS proposed rules, commenters OPPS, we based payment for CPT codes code 77778 also included the CPT code
urged us to set the payment rate for LDR 55859 and 77778 on single procedure for inserting needles or catheters into
prostate brachytherapy services using claims. the prostate, consistent with our
only multiple procedure claims. (b) Proposed Payment for LDR Prostate understanding that the vast majority of
Specifically for CY 2007, they urged us Brachytherapy cases of complex interstitial
to sum the costs on multiple procedure brachytherapy source application
claims containing CPT codes 77778 and For the CY 2008 OPPS, we are procedures are specifically for the
55859 (and no other separately payable proposing to create a composite APC treatment of prostate cancer, rather than
services not on the bypass list) and, 8001, titled ‘‘LDR Prostate other types of cancer.
excluding the costs of sources, split the Brachytherapy Composite,’’ that would
Using the proposed packaging
resulting aggregate median cost on the provide one bundled payment for LDR
approach for imaging supervision and
multiple procedure claim according to a prostate brachytherapy when the
interpretation services and guidance
preestablished attribution ratio between hospital bills both CPT codes 55875 and
services for CY 2008, we were able to
CPT codes 77778 and 55859. They 77778 as component services provided
identify 1,343 claims, 14 percent of all
indicated that any claim for a during the same hospital encounter. It is
OPPS claims that reported these two
brachytherapy service that did not also shown in Addendum A to this proposed
procedures on the same date, that
rule as APC 8001 (LDR Prostate
report a brachytherapy source should be contain both CPT codes 55859 and
Brachytherapy Composite). As
considered to be incorrectly coded and 77778 on the same date of service and
discussed in detail in section VII. of this
thus not reflective of the hospital’s no other separately paid procedure
proposed rule, we are proposing to
resources required for the interstitial code. We were not able to use more
continue to pay sources of
source application procedure. The claims to develop this composite APC
brachytherapy separately in accordance
presenters to the APC Panel believed median cost because there are several
with the requirements of the statute.
that claims that did not contain both In the CY 2006 claims used to radiation therapy planning codes that
brachytherapy source and source calculate the proposed CY 2008 median are commonly reported with CPT codes
application codes should be excluded costs, CPT code 55859 was reported 55859 and 77778 and that are both
from use in establishing the median cost 14,083 times. The proposed rule median separately paid and not on the bypass
for APC 0651. They believed that cost for CPT code 55859, calculated list because the amount of their
hospitals that reported the from 2,232 single and ‘‘pseudo’’ single associated packaging exceeds the
brachytherapy sources on their claims bills, is $2,328.56. The CY 2008 threshold for inclusion on the bypass
were more likely to report complete proposed rule median cost for APC 0163 list. A complete discussion of the
charges for the associated brachytherapy (Level IV Cystourethroscopy and other bypass list under our CY 2008
source application procedure than Genitourinary Procedures) to which packaging proposal is provided in
hospitals that did not report the CPT code 55859 was assigned for CY section II.A. of this proposed rule.
separately payable brachytherapy 2006 and to which CPT code 55875 is We packaged the costs of packaged
sources. assigned for CY 2007 is $2,322.30. In the revenue codes and packaged HCPCS
As a result of those comments, for set of claims used to calculate the codes into the sum of the costs for CPT
both CY 2006 and CY 2007, we used median cost for APC 0651, to which codes 55859 and 77778 to derive a total
multiple procedure claims containing CPT code 77778 is the only assigned proposed median cost of $3,127.35 for
both CPT codes 55859 and 77778 to service, CPT code 77778 was reported the composite LDR prostate
determine a median cost for the totality 11,850 times. The CY 2008 proposed brachytherapy service based upon the
of both services (with both packaging rule median cost for APC 0651 (and, 1,343 claims that contained both CPT
and bypassing of the other commonly therefore, for CPT code 77778) based on codes and no other separately paid
furnished services). We compared the 339 single and ‘‘pseudo’’ single procedure codes. This is reasonably
median calculated from this subset of procedure bills is $969.73. comparable to $3,298.29, the sum of the
claims reflecting the most common In examining the claims data used to CPT median costs we calculated using
clinical scenario to the single bill calculate the median costs for this the single procedure bills for CPT codes
median costs for CPT codes 55859 and proposed rule, we found 9,807 claims 55859 and 77778 (($2,328.56 plus
77778 as a method of determining on which both CPT code 55859 and CPT $969.73). We believe that the difference
whether the total payment to the code 77778 were billed on the same date between the composite APC median
hospital for both services furnished to of service. These data suggest that LDR cost based upon those claims that
provide LDR prostate brachytherapy prostate brachytherapy constituted at contain both codes and the sum of the
would be reasonable. In both years, we least 70 percent of CY 2006 claims for median costs for the APCs to which the
found that the sum of the single bill CPT code 55859, with the remainder of two individual CPT codes map is
medians was reasonably close to the claims representing the insertion of minimal and may be attributable to
median cost of both services from needles or catheters for high dose rate efficiencies in furnishing the services
multiple claims when they were treated prostate brachytherapy or unusual together during a single encounter.
We believe that creation of the insertion of needles or catheters for high importantly, this composite APC
composite APC for the payment of LDR dose rate prostate brachytherapy, and payment methodology that we are
prostate brachytherapy is consistent the low dose rate brachytherapy source proposing would contribute to our goal
with the statute and with our desire to application procedure (CPT code 77778) of providing payment under the OPPS
use more claims data for ratesetting, would not be reported. In high dose rate for a larger bundle of component
particularly data from correctly coded prostate brachytherapy, the sources are services provided in a single hospital
claims that reflect typical clinical applied temporarily several times over a outpatient encounter, creating
practice, and to make payment for larger few days while the needles or catheters additional hospital incentives for
packages and bundles of services to remain in the prostate, and the needles efficiency and cost containment, while
provide enhanced incentives for or catheters are removed only after all providing hospitals with the most
efficiency and cost containment under the treatment fractions have been flexibility to manage their resources.
the OPPS and to maximize hospital completed. We have also been told by
flexibility in managing resources. (3) Proposed Cardiac Electrophysiologic
hospitals that, even when LDR prostate
Under our proposal, hospitals that Evaluation and Ablation Composite
brachytherapy is planned, there are
furnish LDR prostate brachytherapy APC
occasions in which the needles or
would report CPT codes 55875 and catheters are inserted in one facility and (a) Background
77778 and the codes for the applicable the patient is moved to another facility During its March 2007 meeting,
brachytherapy sources in the same for the application of the sources. In members of the APC Panel indicated
manner that they currently report these those cases, we would need to be able that the reason we found so few single
items and services (in addition to to appropriately pay the hospital that bills for procedures assigned to APC
reporting any other services provided), inserted the needles or catheters before 0087 (Cardiac Electrophysiologic
using the same HCPCS codes and the patient was discharged prior to Recording/Mapping), specifically 72 of
reporting the same charges. We would source application. Moreover, there are
require that hospitals report both CPT 11,834 or 0.61 percent of all proposed
cases in which the needles or catheters rule CY 2006 claims, is that most of the
codes resulting in the composite APC are inserted but it is not possible to
payment on the same claim when they services assigned to APCs 0085 (Level II
proceed to the application of the sources Electrophysiologic Evaluation), 0086
are furnished to a single Medicare and, therefore, the hospital would
beneficiary in the same facility on the (Ablate Heart Dysrhythm Focus), and
correctly report only CPT code 55875. 0087 are performed in varying
same date of service, and we would Similarly, more than 10 brachytherapy
make any necessary conforming changes combinations with one another.
sources can be applied interstitially (as Therefore, correctly coded claims would
to the billing instructions to ensure that described by CPT code 77778) to sites
they do not present an obstacle to most often include multiple codes for
other than the prostate and it is, component services that are reported
correct reporting. We may implement therefore, necessary to have a separate
edits to ensure that hospitals do not with different CPT codes and that are
payment rate for CPT code 77778. now paid separately through different
submit two separate claims for these Hence, for CY 2008 we are proposing to
two procedures when furnished on the APCs. There would never be many
continue to pay for CPT code 55875 (the single bills and those that are reported
same date in the same facility. When successor to CPT code 55859) through
this combination of codes is reported, as single bills would likely represent
APC 0163 and to pay for CPT code atypical cases or incorrectly coded
the OCE would assign the composite 77778 through APC 0651 when the
APC 8001 and the Pricer would pay claims.
services are individually furnished We examined the combinations of
based on the payment rate for the
other than on the same date of service services observed in our claims data
composite APC. The OCE would assign
in the same facility. across these three APCs to see whether
APC 0163 or APC 0651 only when both
codes are not reported on the same In summary, we are proposing to there was the potential for handling the
claim with the same date of service, and establish a composite APC, shown in data differently so that we could use
we would expect this to be the atypical Addendum A as APC 8001, to provide more claims data to set the payment
case. The composite APC would have a payment for LDR prostate brachytherapy rates for these procedures, particularly
status indicator of ‘‘T’’ so that payment when the composite service, billed as those services assigned to APC 0087
for other procedures also assigned to CPT codes 55875 and 77778, is where we have had a persistent concern
status indicator ‘‘T’’ with lower furnished in a single hospital encounter regarding the limited and reportedly
payment rates would be reduced by 50 and to base the payment for the unrepresentative single bills available
percent when furnished on the same composite APC on the median cost for use in calculating the median cost
date of service as the composite service, derived from claims that contain both according to our standard OPPS
in order to reflect the efficiency that codes. These two CPT codes are methodology. We initially developed
occurs when multiple procedures are assigned to status indicator ‘‘Q’’ in and examined frequency distributions of
furnished to a Medicare beneficiary in a Addendum B to this proposed rule to unique combinations of codes on claims
single operative session. We would not signify their conditionally packaged which contained at least one unit of any
expect that the composite APC payment status, and their composite APC code assigned to APC 0085, 0086, or
would be commonly reduced because assignments are noted in Addendum M. 0087 and then broadened these analysis
we believe that it is unlikely that a This proposal would permit us to base to any combination of an
higher paid procedure would be payment on claims for the most electrophysiologic evaluation and
performed on the same date. common clinical scenario for interstitial ablation code.
We are proposing to continue to radiation source application to the Our initial frequency distributions
establish separate payment rates for prostate. We note that this payment supported the APC Panel members’
APC 0651 (to which only CPT code bundle would also include payment for description of their experiences. We
77778 is assigned) and for APC 0163 (to the commonly associated imaging identified and enumerated the most
which we are proposing to continue to guidance services, which would be commonly appearing unique
assign CPT code 55875). In some cases, newly packaged under our proposed CY occurrences (either single procedures or
CPT 55875 may be reported for the 2008 packaging approach. Most combinations) of codes for services
assigned to status indicator ‘‘S,’’ ‘‘T,’’ 0087. There were 7,379 claims in the occurrences from CY 2006 claims
‘‘V,’’ or ‘‘X’’ that contained at least one top 100 occurrence types. Table 22 available for this proposed rule.
code assigned to APC 0085, 0086, or shows the 10 most common unique
TABLE 22.—TEN MOST FREQUENTLY OCCURRING UNIQUE OCCURRENCES OF CARDIAC ELECTROPHYSIOLOGIC

EVALUATION, MAPPING, AND ABLATION PROCEDURES AND OTHER SEPARATELY PAYABLE SERVICES
Combination HCPCS CY 2007 CY 2007
Frequency Short descriptor
number code APC SI
1 .......................... 763 93620 Electrophysiology evaluation ...................................................................... 0085 T

2 .......................... 509 93609 Map tachycardia, add-on ........................................................................... 0087 T
93620 Electrophysiology evaluation ...................................................................... 0085 T
93623 Stimulation, pacing heart ........................................................................... 0087 T
93651 Ablate heart dysrhythm focus .................................................................... 0086 T
3 .......................... 398 93609 Map tachycardia, add-on ........................................................................... 0087 T
4 .......................... 381 93650 Ablate heart dysrhythm focus .................................................................... 0086 T
5 .......................... 376 93620 Electrophysiology evaluation ...................................................................... 0085 T
6 .......................... 248 93005 Electrocardiogram, tracing ......................................................................... 0099 S
93609 Map tachycardia, add-on ........................................................................... 0087 T
93609 Map tachycardia, add-on ........................................................................... 0087 T
8 .......................... 225 93613 Electrophys map 3d, add-on ...................................................................... 0087 T
10 ........................ 185 93613 Electrophys map 3d, add-on ...................................................................... 0087 T
Although the number of claims for occurring combinations of codes on least one code from group A for
each unique occurrence was modest, we claims that also contained at least one evaluation services and at least one code
were able to determine that there were code assigned to APC 0085, 0086 or from group B for ablation services
certain combinations of codes that 0087 and our clinical review of the reported on the same date of service on
occurred most often together. Based on codes, we proceeded to study an individual claim, as specified in
our review of the most frequently combination claims that contained at Table 23 below.
TABLE 23.—GROUPS OF CARDIAC ELECTROPHYSIOLOGIC EVALUATION AND ABLATION PROCEDURES FOR FURTHER
ANALYSIS
HCPCS CY 2007 CY 2007
Codes used in combinations: at least one in Group A and one in Group B code APC SI
Group A:
Electrophysiology evaluation .................................................................................................................. 93619 0085 T
Electrophysiology evaluation .................................................................................................................. 93620 0085 T
Group B:
Ablate heart dysrhythm focus ................................................................................................................. 93650 0086 T
When we studied claims that were 5,118 claims that met these code 93620 (Comprehensive
contained a code in group A and also a criteria, and that of these 5,118 claims, electrophysiologic evaluation including
code in group B, we found that there 4,552 (89 percent) contained both CPT insertion and repositioning of multiple
electrode catheters with induction or attempted induction of arrhythmia; with the same date of service and calculated
attempted induction of arrhythmia; with left atrial pacing and recording from a median cost from the total costs on
right atrial pacing and recording, right coronary sinus or left atrium (List these claims. Some claims had more
ventricular pacing and recording, His separately in addition to code for than one code from each group.
bundle recording) from APC 0085 and primary procedure)), 93622 Although the claim was required to
CPT code 93651 (Intracardiac catheter (Comprehensive electrophysiologic contain at least one code from each
ablation of arrhythmogenic focus; for evaluation including insertion and group to be included, the claim could
treatment of supraventricular repositioning of multiple electrode also contain any number of codes from
tachycardia by ablation of fast or slow catheters with induction or attempted either group and any number of units of
atrioventricular pathways, accessory induction of arrhythmia; with left those codes. In addition, the costs of the
atrioventricular connections or other ventricular pacing and recording (List five supportive intraoperative services
atrial foci, singly or in combination) separately in addition to code for previously assigned to APC 0087 that
from APC 0086 with the same date of primary procedure)), and 93623 we identify above were packaged, as
service. Given that CPT code 93651 had (Programmed simulation and pacing well as the costs of the other items and
a total frequency of 8,091, this means after intravenous drug infusion (List services proposed to be packaged for the
that more than 55 percent of the claims separately in addition to code for CY 2008 OPPS. This selection process
for CPT code 93651 also contained CPT primary procedure)). These codes are all yielded 5,118 claims to use for the
code 93620. CPT code 93620 had a total CPT add-on codes that CPT indicates calculation. The proposed composite
frequency of 12,624, approximately 50 are to be reported in addition to the median cost for these claims using the
percent higher than the total frequency code for the primary procedure. Our CY 2008 proposed rule data is
for CPT code 93651, which is consistent clinical review of the services described $8,528.83. We believe that this cost is
with our expectations because CPT code by these five CPT codes determined that attributable largely to the 4,552 claims
93620 describes a diagnostic service and they are supportive dependent services that contain one unit each of CPT code
CPT code 93651 is a treatment service that are provided most often as 93620 and CPT code 93651 (and some
that may be provided based upon the supplemental to procedures assigned to unknown numbers and combinations of
findings of the evaluation described by APCs 0085 and 0086. The procedures in packaged services). In comparison, the
CPT code 93620. In addition to the APCs 0085 and 0086 can be performed
sum of the CY 2008 proposed rule CPT
codes for group A and group B services, without these supportive add-on
code median costs for CPT code 93620
the combination claims also contained procedures, but these dependent
(which is $3,111.76) and CPT code
costs for packaged services that were services cannot be done except as a
93651 (which is $5,643.95) is $8,755.71.
reported under revenue codes without supplement to another
If the 50 percent multiple procedure
HCPCS codes and under packaged electrophysiologic procedure. Therefore,
discount is applied to the CPT code
HCPCS codes. As we discuss in we are proposing to unconditionally
median cost for the lower cost
considerable detail above, we lack a package all of these five CPT codes
procedure based on its assignment to an
methodology that could be used to under the grouping of intraoperative
APC with a ‘‘T’’ status, the adjusted sum
allocate these packaged costs to major services for the CY 2008 OPPS. We
discuss the packaging of intraoperative of the median costs is $7,199.83
separately paid procedures in a manner ($5,643.95 + $1,555.88). These medians
which gives us confidence that the costs services in general, including these
services, above. were calculated using only claims that
would be attributed correctly. We have contain correct devices and do not
However, packaging these supportive
explored and will continue to explore contain token charges or the ‘‘FB’’
ancillary services that are so often
an alternative strategy that would enable modifier. We believe the significant
reported with the cardiac
us to use these correctly coded multiple positive difference between the
electrophysiologic evaluation and
procedure claims for ratesetting. composite and discounted costs still
ablation services does not enable us to
In our review of these claims, not only use many more claims because, as we reflects efficiencies, as the sum of the
did we find a high number of claims on noted previously, the claims on which discounted median costs does not take
which there was one code from group A these codes most commonly appeared into account the cost of other
and one code from group B, but we also typically also contained at least one procedures also provided that are
found that claims for procedures separately paid code from APC 0085 assigned to APCs 0085 and 0086, while
assigned to APC 0087 for CY 2007 and one code from APC 0086. Although the composite median cost of $8,528.83
usually appeared on claims that the most common combination of codes does, to some extent, reflect the cost of
contained a code from APC 0085 or APC from APCs 0085 and 0086 is the pair of other multiple procedures in APCs 0085
0086, or both. The most frequently CPT codes 93620 and 93651, there are and 0086 that were also reported on the
appearing CPT codes that were assigned numerous other combinations of claims used to develop the composite
to APC 0087 for CY 2007 were, as services from APCs 0085 and 0086 that median cost. In addition, these two
shown above, 93609 (Intraventricular are performed and, while not as calculations are based upon two
and/or intra-atrial mapping of frequent, these combinations are also different sets of claims, single procedure
tachycardia site(s), with catheter reflected in the multiple claims. claims in one case (which do not
manipulation to record from multiple In order to use more claims and represent the way the service is
sites to identify origin of tachycardia adequately reflect the varied, common typically furnished) and the specified
(List separately in addition to code for combinations of electrophysiologic subset of clinically common
primary procedure)), 93613 evaluation and ablation CPT codes, we combination claims in the second case.
(Intracardiac electrophysiologic 3- calculated a composite median cost Moreover, while the 50 percent multiple
dimensional mapping (List separately in from all claims containing at least one procedure reduction is our best
addition to code for primary code from group A and at least one code aggregate estimate of the overall degree
procedure)), 93621 (Comprehensive from group B as if they were a single of efficiency applicable to multiple
electrophysiologic evaluation including service. We selected multiple procedure surgeries, it may or may not be
insertion and repositioning of multiple claims that contained at least one code specifically appropriate to this
electrode catheters with induction or in group A and one code in group B on particular combination of procedures.
By selecting the multiple procedure composite configuration below in Table the medians for the composite claims
claims that contained at least one code 24 represent the sum of the frequency of containing at least one code from each
in each group, we were able to use many single bills used to set the medians for group and with packaging of the costs
more claims than were available to APCs 0085 and 0086 with packaging of of the five intraoperative services,
establish the individual APC medians. the five intraoperative services and the divided by the total frequency of each
The percents by CPT code for the frequency of multiple bills used to set CPT code.
TABLE 24.—PERCENTAGE OF CLAIMS USED TO CALCULATE MEDIAN COSTS FOR CARDIAC ELECTROPHYSIOLOGIC
EVALUATION AND ABLATION PROCEDURES
Standard configuration Composite
(with packaging of configura-
intraoperative services) tion (with
packaging
of intra-
Proposed operative
Codes used in combinations: at least one in group A and one HCPCS CY 2008 SI services)
in Group B code CPT per- Overall APC
APC centage of percentage CPT per-
single of single centage of
claims claims single and
combination
claims
Group A:
Electrophysiology evaluation ............................................... 93619 0085 T ..... 38.99 25.47 63.96
Electrophysiology evaluation ............................................... 93620 0085 T ..... 22.30 25.47 61.77
Group B:
Ablate heart dysrhythm focus .............................................. 93650 0085 T ..... 39.58 25.47 52.50
Moreover, by packaging CPT codes the composite median cost of $8,528.83 procedure would be performed on the
93609, 93613, 93621, 93622, and 93623, as the basis for establishing the relative same date. We are proposing to continue
we use many more of the claims for weight for this newly created APC for to pay separately for other separately
these codes from the most common the composite electrophysiologic paid services that are not reported under
clinical scenarios than would otherwise evaluation and ablation service. Under the codes in groups A and B (such as
be possible if the supportive this composite APC, unlike most other chest x-rays and electrocardiograms).
intraoperative services were separately APCs, we would make a single payment Moreover, where a service in group A
paid. Wherever any of these codes for all services reported in groups A and is furnished on a date of service that is
appears on a claim that can be used for B. We are proposing that hospitals different from the date of service for a
median setting, the cost data for these would continue to code using CPT code in group B for the same
codes are packaged in the calculation of codes to report these services and that beneficiary, we are proposing that
the median cost for the separately paid the OCE would recognize when the payments would be made under the
services on the claim. criteria for payment of the composite single procedure APCs and the
APC are met and would assign the composite APC would not apply. Given
(b) Proposed Payment for Cardiac
composite APC instead of the single our CY 2008 proposal to
Electrophysiologic Evaluation and
procedure APCs as currently occurs. unconditionally package payment for
Ablation
The Pricer would make a single five cardiac electrophysiologic CPT
In view of our findings with regard to payment for the composite APC that codes as members of the category of
how often the codes in groups A and B would encompass the program payment intraoperative services that were
appear together on the same claim, we for the code in group A, the code in previously assigned to APCs 0085 and
are proposing to establish one group B, and any other codes reported 0087, we are also proposing to
composite APC, shown in Addendum A in groups A or B, as well as the reconfigure APCs 0084 through 0087,
as APC 8000 (Cardiac packaged services furnished on the where many of the cardiac
Electrophysiologic Evaluation and same date of service. The proposed electrophysiologic procedures that will
Ablation Composite), for CY 2008 that composite APC would have a status be separately paid when they are not
would pay for a composite service made indicator of ‘‘T’’ so that payment for paid according to the composite APC
up of any number of services in groups other procedures also assigned to status are assigned. Specifically, we are
A and B when at least one code from indicator ‘‘T’’ with lower payment rates proposing to discontinue APC 0087, and
group A and at least one code from would be reduced by 50 percent when reconfigure APCs 0084, 0085, and 0086,
group B appear on the same claim with furnished on the same date of service as with proposed titles and median costs of
the same date of service. The five CPT the composite service, in order to reflect Level I Electrophysiologic Procedures
codes involved in this composite APC the efficiency that occurs when multiple (APC 0084) at $647.41; Level II
are assigned to status indicator ‘‘Q’’ in procedures are furnished to a Medicare Electrophysiologic Procedures (APC
Addendum B to this proposed rule to beneficiary in a single operative session. 0085) at $3,059.46; and Level III
identify their conditionally packaged We would not expect that the proposed Electrophysiologic Procedures (APC
status, and their composite APC composite APC payment would be 0086) at $5,709.52, respectively. We
assignments are identified in commonly reduced because we believe refer readers to section IV.A.2. of this
Addendum M. We are proposing to use that it is unlikely that a higher paid proposed rule for a discussion of
calculation of median costs for device- prior to development of the proposed status indicator ‘‘Q’’ is billed on a date
dependent APCs. We believe this packaging approach discussed above, of service without a code that is
reconfiguration improves the clinical and we have summarized and assigned to any of the four status
and resource homogeneity of these responded to the APC Panel’s indicators noted above, the ‘‘special’’
APCs which would provide payment for packaging-related recommendations packaged code assigned to status
cardiac electrophysiologic procedures below. Three of the codes reviewed by indicator ‘‘Q’’ would be separately
that would be individually paid when the Packaging Subcommittee at the payable.
they do not meet the criteria for March 2007 APC Panel meeting are The Packaging Subcommittee
payment of the composite APC. included in the seven categories of identified areas for change for some
We believe that creation of the services identified for packaging under currently packaged CPT codes that it
proposed composite APC for cardiac the CY 2008 OPPS. For those three believed could frequently be provided
electrophysiologic evaluation and codes, we specifically applied the to patients as the sole service on a given
ablation services is the most efficient proposed CY 2008 criteria for date and that required significant
and effective way to use the claims data determining whether a code should be hospital resources as determined from
for the majority of these services and proposed as packaged or separately hospital claims data. Based on the
best represents the hospital resources payable for CY 2008. Specifically, we comments received, additional issues,
associated with performing the common determined whether the service is a and new data that we shared with the
combinations of these services that are dependent service falling into one of the Packaging Subcommittee concerning the
clinically typical. We believe that this seven specified categories that is always packaging status of codes for CY 2008,
proposed ratesetting methodology or almost always provided integral to an the Packaging Subcommittee reviewed
results in an appropriate median cost for independent service. For those four the packaging status of numerous
the composite service when at least one codes that were reviewed during the HCPCS codes and reported its findings
evaluation service in group A is March 2007 APC Panel meeting but that to the APC Panel at its March 2007
furnished on the same date as at least do not fit into any of the seven meeting. The APC Panel accepted the
one ablation service in group B. This categories of codes that are part of our report of the Packaging Subcommittee,
approach creates incentives for CY 2008 proposed packaging approach, heard several presentations on certain
efficiency by providing a single we applied the packaging criteria packaged services, discussed the
payment for a larger bundle of major described above that were historically deliberations of the Packaging
procedures when they are performed used under the OPPS. Moreover, we Subcommittee, and recommended
together, in contrast to continued took into consideration our interest in that—
separate payment for each of the expanding the size of payment groups 1. CMS place CPT code 76937
individual procedures. We expect to (Ultrasound guidance for vascular
for component services to provide
develop additional composite APCs in access requiring ultrasound evaluation
encounter-based and episode-of-care-
the future as we learn more about major of potential access sites, documentation
based payment in the future in order to
currently separately paid services that of selected vessel patency, concurrent
encourage hospital efficiency and
are commonly furnished together during realtime ultrasound visualization of
provide hospitals with maximal
the same hospital outpatient encounter. vascular needle entry, with permanent
flexibility to manage their resources.
recording and reporting (list separately
e. Service-Specific Packaging Issues In accordance with a recommendation in addition to code for primary
As a result of requests from the of the APC Panel, for the CY 2007 OPPS, procedure)) on the list of ‘‘special’’
public, a Packaging Subcommittee to the we implemented a new policy that packaged codes (status indicator ‘‘Q’’).
APC Panel was established to review all designates certain codes as ‘‘special’’ (Recommendation 1)
the procedural CPT codes with a status packaged codes, assigned to status 2. CMS evaluate providing separate
indicator of ‘‘N.’’ Commenters to past indicator ‘‘Q’’ under the OPPS, where payment for trauma activation when it
rules have suggested that certain separate payment is provided if the code is reported on a claim for an ED visit,
packaged services could be provided is reported without any other services regardless of the level of the emergency
alone, without any other separately that are separately payable under the department visit. (Recommendation 2)
payable services on the claim, and OPPS on the same date of service. 3. CMS place CPT code 0175T
requested that these codes not be Otherwise, payment for the ‘‘special’’ (Computer aided detection (CAD)
assigned status indicator ‘‘N.’’ In packaged code is packaged into (computer algorithm analysis of digital
deciding whether to package a service or payment for the separately payable image data for lesion detection) with
pay for a code separately, we have services provided by the hospital on the further physician review for
historically considered a variety of same date. We note that these ‘‘special’’ interpretation and report, with or
factors, including whether the service is packaged codes are a subset of those without digitization of film radiographic
normally provided separately or in HCPCS codes that are assigned to status images, chest radiograph(s), performed
conjunction with other services; how indicator ‘‘Q,’’ which means that their remote from primary interpretation) on
likely it is for the costs of the packaged payment is conditionally packaged the list of ‘‘special’’ packaged codes
code to be appropriately mapped to the under the OPPS. We are proposing to (status indicator ‘‘Q’’).
separately payable codes with which it update our criteria to determine (Recommendation 3)
was performed; and whether the packaged versus separate payment for 4. CMS place CPT code 0126T
expected cost of the service is relatively ‘‘special’’ packaged HCPCS codes (Common carotid intima-media
low. As discussed above regarding our assigned to status indicator ‘‘Q’’ for CY thickness (IMT) study for evaluation of
proposed packaging approach for CY 2008. For CY 2008, payment for atherosclerotic burden or coronary heart
2008, we have modified the historical ‘‘special’’ packaged codes would be disease risk factor assessment) on the
considerations outlined above in packaged when these HCPCS codes are list of ‘‘special’’ packaged codes (status
developing our proposal for the CY 2008 billed on the same date of service as a indicator ‘‘Q’’) and that CMS consider
OPPS. The Packaging Subcommittee code assigned to status indicator ‘‘S,’’ mapping the code to APC 340 (Minor
discussed many HCPCS codes during ‘‘T,’’ ‘‘V,’’ or ‘‘X.’’ When one of the Ancillary Procedures).
the March 2007 APC Panel meeting, ‘‘special’’ packaged codes assigned to (Recommendation 4)
5. CMS place CPT code 0069T procedure that we would expect to be encouraged CMS to pay differentially
(Acoustic heart sound recording and generally provided only in association for critical care services provided with
computer analysis only) on the list of with other independent services. We and without trauma activation. For CY
‘‘special’’ packaged codes (status applied the updated criteria for 2007, as a result of the APC Panel’s
indicator ‘‘Q’’) and that CMS exclude determining whether this service should August 2006 discussion and our own
APC 0096 (Non-Invasive Vascular receive packaged or separately payment data analysis, we finalized a policy to
Studies) as a potential placement for under the CY 2008 OPPS. Specifically, pay differentially for critical care
this CPT code. (Recommendation 5) we determined that this service is a provided with and without trauma
6. CMS maintain the packaged status supportive ancillary service that is activation. The CY 2007 payment rate
of HCPCS code A4306 (Disposable drug integral to an independent service, for critical care unassociated with
delivery system, flow rate of less than resulting in our CY 2008 proposal to trauma activation is $405.04 (APC 0617,
50 ml per hour) and that CMS present packaged payment for the service. Critical Care), while the payment rate
additional data on this system to the We discussed this code extensively in for critical care associated with trauma
APC Panel when available. both the CY 2006 and CY 2007 final activation is $899.58 (APC 0617 and
(Recommendation 6) rules with comment period (70 FR APC 0618 (Trauma Response with
7. CMS reevaluate the packaged OPPS 68544 through 68545; 71 FR 67996 Critical Care)). During the March 2007
payment for CPT code 99186 through 67997). Our hospital claims APC Panel meeting, a presenter
(Hypothermia; total body) based on data demonstrate that guidance services requested that CMS also pay
current research and availability of new are used frequently for the insertion of differentially for emergency department
therapeutic modalities. vascular access devices, and we have no visits provided with and without trauma
(Recommendation 7) evidence that patients lack appropriate activation. Two organizations that
8. The Packaging Subcommittee access to guidance services necessary submitted comment letters for the APC
remains active until the next APC Panel for the safe insertion of vascular access Panel’s review specifically requested
meeting. (Recommendation 8) devices in the hospital outpatient separate payment for revenue code 068x
We address each of these setting. Because we believe that every time it appears on a claim,
recommendations in turn in the ultrasound guidance would almost regardless of the other services that were
discussion that follows. always be provided with one or more billed on that claim. The APC Panel
Recommendation 1 separately payable independent recommended that CMS evaluate
procedures, its costs would be providing separate payment for trauma
For CY 2008, we are proposing to appropriately bundled with the handful
maintain CPT code 76937 as a packaged activation when it is reported on a claim
of vascular access device insertion for an emergency department visit,
service. We are not adopting the APC procedures with which it is most
Panel’s recommendation to pay regardless of the level of the emergency
commonly performed. We further department visit.
separately for this code in some believe that hospital staff chooses
circumstances as a ‘‘special’’ packaged whether to use no guidance or After accepting the APC Panel’s
code. In the CY 2006 OPPS final rule fluoroscopic guidance or ultrasound recommendation and evaluating this
with comment period (70 FR 68544 guidance on an individual basis, issue, we continue to believe that, while
through 68545), in response to several depending on the clinical circumstances it is currently appropriate to pay
public comments, we reviewed in detail of the vascular access device insertion separately for trauma activation when
the claims data related to CPT code procedure. billed in association with critical care
76937. During its March 2006 APC Therefore, we do not believe that CPT services, it is also currently appropriate
Panel meeting, after reviewing data code 76937 is an appropriate candidate to maintain the packaged payment
pertinent to CPT code 76937, the APC for designation as a ‘‘special’’ packaged status of revenue code 068x when
Panel recommended that CMS maintain code. The CY 2007 CPT book indicates trauma response services are provided
the packaged status of this code for CY that this code is an add-on code and in association with both clinic and
2007, and we accepted that should be reported in addition to the emergency department visits under the
recommendation. During the March code reported for the primary CY 2008 OPPS. As mentioned above, it
2007 APC Panel meeting, after procedure. According to our CY 2006 is our general objective to expand the
reviewing current data and listening to claims data available for this proposed size of the payment groups under the
a public presentation, the Panel rule, this code was billed over 60,000 OPPS to move toward encounter-based
recommended that we treat this code as times, yet less than one-tenth of 1 and episode-of-care-based payments in
a ‘‘special’’ packaged code for CY 2008, percent of all claims for the procedure order to encourage maximum hospital
noting that certain uncommon clinical were billed without any separately efficiency with a focus on value-based
scenarios could occur where it would be payable OPPS service on the claim. purchasing. Because trauma activation
possible to bill this service alone on a Because this code is provided alone in association with emergency
claim, without any other separately only extremely rarely, we believe this department or clinic visits would
payable OPPS services. code would not be appropriately treated always be provided in the same hospital
We are proposing to maintain CPT as a ‘‘special’’ packaged code. Therefore, outpatient encounter as the visit for care
code 76937 as an unconditionally we are proposing to continue to of the injured Medicare beneficiary,
packaged service for CY 2008, fully unconditionally package CPT code packaging payment for trauma
consistent with the proposed packaging 76937 for CY 2008. activation when billed in association
approach for the CY 2008 OPPS, as with both clinic and emergency
discussed above. Because CPT code Recommendation 2 department visits is most consistent
76937 is a guidance procedure and we For CY 2008, we are proposing to with our proposed packaging approach.
are proposing to package payment for all maintain the packaged status of revenue We are also concerned that unpackaging
guidance procedures for CY 2008, we code 068x, trauma response, when the payment for trauma activation in those
believe it is appropriate to maintain the trauma response is provided without circumstances where the trauma
unconditionally packaged status of this critical care services. During the August response would be less likely to be
code, which is a CPT designated add-on 2006 APC Panel meeting, the APC Panel essential to appropriately treating a
Medicare beneficiary would reduce the classification technologies to chest x-ray CPT codes, 0174T and 0175T, for CY
incentive for hospitals to provide the images to acquire and display 2007.
most efficient and cost-effective care. information regarding chest x-ray In its March 2007 presentation to the
We note that, while we are proposing regions that may contain indications of APC Panel, the same presenter
for CY 2008 to continue to provide cancer. CPT code 0152T (Computer requested that we pay separately for
separate payment for trauma activation aided detection (computer algorithm CPT codes 0174T and 0175T, mapping
in association with critical care services, analysis of digital image data for lesion them to New Technology APC 1492,
we may reconsider this payment policy detection) with further physician review with a payment rate of $15. The
for future OPPS updates as we further for interpretation, with or without presenter indicated that chest x-ray CAD
develop encounter-based and episode- digitization of film radiographic images; is not a screening tool and should only
of-care-based payment approaches. chest radiograph(s) (List separately in be billed to Medicare when applied to
Furthermore, continued packaged addition to code for primary chest x-rays suspicious for lung cancer.
payment for trauma activation when procedure)), the predecessor code to The presenter also explained that
unassociated with critical care is CPT codes 0174T and 0175T, was additional and distinct hospital
consistent with the principles of a indicated as an add-on code to chest x- resources are required for chest x-ray
prospective payment system, where ray CPT codes for CY 2006, according to CAD that are not required for a standard
hospitals receive payment based on the the AMA’s CY 2006 CPT book. chest x-ray. In addition, remote chest x-
median cost related to all of the hospital However, on July 1, 2006, the AMA ray CAD described by CPT code 0175T
resources associated with the main released to the public an update that can be performed at a different time or
service provided. In various situations, deleted CPT codes 0152T and replaced location or by a different provider than
each hospital’s costs may be higher or it with the two new Category III CPT the chest x-ray service. The presenter
lower than the median cost used to set codes 0174T and 0175T. expressed concern that if hospitals were
payment rates. In light of our proposed In its March 2006 presentation to the not paid separately for this technology,
packaging approach for the CY 2008 APC Panel, before the AMA had hospitals would not be able to provide
OPPS, we believe it is particularly released the CY 2007 changes to CPT it, thereby limiting beneficiary access to
important not to make any changes in code 0152T, a presenter requested that chest x-ray CAD. The APC Panel
our payment policies for other services we pay separately for this service and recommended conditional packaging as
that are not fully aligned with assign it to a New Technology APC with a ‘‘special’’ packaged code for CPT code
promoting efficient, judicious, and a payment rate of $15, based on its 0175T, but did not recommend a change
deliberate care decisions by hospitals estimated cost, clinical considerations, to the unconditionally packaged status
that allow them maximum flexibility to and similarity to other image post of CPT code 0174T. We are not adopting
manage their resources through processing services that are paid the APC Panel’s recommendation for
encouraging the most cost-effective use separately. We proposed to accept the designation of CPT code 0175T as a
of hospital resources in providing the APC Panel’s recommendation to ‘‘special’’ packaged code under the CY
care necessary for the treatment of package CPT code 0152T for CY 2007. 2008 OPPS.
Medicare beneficiaries. Packaging In its August 2006 presentation to the We believe that packaged payment for
payment encourages hospitals to APC Panel, after the AMA had released diagnostic chest x-ray CAD under a
establish protocols that ensure that the CY 2007 code changes, the same prospective payment methodology for
services are furnished only when they presenter requested that we assign both outpatient hospital services is most
are medically necessary and to carefully of the two new codes to a New appropriate. We are proposing to
scrutinize the services ordered by Technology APC with a payment rate of maintain CPT codes 0174T and 0175T
practitioners to minimize unnecessary $15. The APC Panel members discussed as unconditionally packaged services for
use of hospital resources. these codes extensively. They CY 2008, fully consistent with the
Therefore, we are adopting the APC considered the possibility of treating proposed packaging approach for the CY
Panel’s recommendation that we CPT code 0175T as a ‘‘special’’ 2008 OPPS, as discussed above. Because
evaluate providing separate payment for packaged code, thereby assigning CPT codes 0174T and 0175T are
revenue code 068x when provided in payment to the code only when it was supportive ancillary services that fit into
association with emergency department performed by a hospital without any the ‘‘image processing’’ category, and
visits. For CY 2008, after our thorough other separately payable OPPS service we are proposing to package payment
assessment, we are proposing to also provided on the same day. They for all image processing services for CY
maintain the packaged status of revenue questioned the meaning of the word 2008, we believe it is appropriate to
code 068x, except when revenue code ‘‘remote’’ in the code descriptor for CPT maintain the packaged status of these
068x is billed in association with code 0175T, noting that was unclear as codes. We applied the updated criteria
critical care services. to whether remote referred to time, for determining whether these two CAD
geography, or a specific provider. They services should receive packaged or
Recommendation 3 believed it was likely that a hospital separate payment. Specifically, we
For CY 2008, we are proposing to without a CAD system that performed a determined that this service is a
maintain the unconditionally packaged chest x-ray and sent the x-ray to another dependent service that is integral to an
status of CPT codes 0174T (Computer hospital for performance of the CAD independent service, in this case, the
aided detection (CAD) (computer would be providing the CAD service chest x-ray or other OPPS service that
algorithm analysis of digital image data under arrangement and, therefore, we would expect to be provided in
for lesion detection) with further would be providing at least one other addition to the CAD service.
physician review for interpretation and service (chest x-ray) that would be After hearing many public
report, with or without digitization of separately paid. Thus, even in these presentations and discussions regarding
film radiographic images, chest cases, payment for the CAD service the use of chest x-ray CAD, we continue
radiograph(s), performed concurrent could be appropriately packaged. After to believe that even the remote service
with primary interpretation) and 0175T. significant and lengthy deliberation, the would almost always be provided by a
These services involve the application APC Panel recommended that we hospital either in conjunction with
of computer algorithms and package payment for both of the new other separately payable services or
under arrangement. For example, if a image processing services that are not separately payable services on the same
physician orders a chest x-ray and CAD always performed face-to-face, day. For circumstances when this code
service to be performed at hospital A, including HCPCS code G0288 is paid separately, the APC Panel
and hospital A, which does not have the (Reconstruction, computer tomographic recommended that we consider
CAD technology, sends the chest-ray to angiography of aorta for surgical assigning this code to APC 0340.
hospital B for the performance of chest planning for vascular surgery) and CPT While we continue to believe that this
x-ray CAD, hospital B could only code 76377 (3D rendering with procedure would not commonly be
provide the CAD service if it were interpretation and reporting of provided alone, we are adopting the
provided under arrangement, to avoid computed tomography, magnetic APC Panel recommendation and are
the OPPS unbundling prohibition. resource imaging, ultrasound, or other proposing to treat this code as a
Assuming that the CAD service was tomographic modality; requiring image ‘‘special’’ packaged code subject to
provided under arrangement, hospital A postprocessing on an independent conditional packaging, mapping to APC
would bill for the chest x-ray CAD that workstation). 0340 for CY 2008 when it would be
was performed by hospital B and would The proposed unconditionally separately paid. This is fully consistent
pay hospital B for the service provided. packaged treatment of the two CPT with the proposed packaging approach
In that case, hospital A would also bill codes for chest x-ray CAD is fully for the CY 2008 OPPS, as discussed
the chest x-ray service that it provided. consistent with the proposed packaging above. Because CPT code 0126T is
In another scenario that has been approach for the CY 2008 OPPS, as almost always performed during another
described to us, if a physician were to discussed above, and the principles and procedure, and we are proposing to
send a patient to a hospital clinic with incentives for efficiency inherent in a package payment for all intraoperative
the patient’s chest x-ray for prospective payment system based on procedures for CY 2008, we believe it is
consultation, we believe that the patient groups of services. Packaging these appropriate to designate this CPT code
would likely receive a visit service, in services creates incentives for providers as a ‘‘special’’ packaged code. We
addition to the chest x-ray CAD. to furnish services in the most cost- applied the updated criteria for
Therefore, in both of these effective way and provides them with determining whether this service should
circumstances, payment for the chest x- the most flexibility to manage their receive packaged or separate payment.
ray CAD would be appropriately resources. As stated above, packaging Specifically, we determined that this
packaged into payment for the encourages hospitals to establish service is usually a dependent service
separately payable services with which protocols that ensure that services are that is integral to an independent
it was provided. furnished only when they are medically service, but that it could sometimes be
necessary and to carefully scrutinize the provided without an independent
We also do not believe that CPT code services ordered by practitioners to service.
0175T should be treated as a ‘‘special’’ minimize unnecessary use of hospital As with all ‘‘special’’ packaged codes,
packaged code. As discussed earlier in resources. Therefore, we are proposing we will closely monitor cost data and
this section with regard to our to continue to unconditionally package frequency of separate payment for this
packaging proposal for image processing payment for CPT codes 0174T and procedure as soon as we have more
services for CY 2008, we are concerned 0175T for CY 2008. claims data available.
with establishing payment policies that
could encourage certain inefficient and Recommendation 4 Recommendation 5
more costly service patterns, For CY 2008, we are adopting the APC For CY 2008, we are proposing to
particularly for those services that do Panel’s recommendation and proposing maintain the packaged status of CPT
not need to be provided as a face-to-face to add CPT code 0126T to the list of code 0069T, and we are not adopting
encounter with the patient. If we were ‘‘special’’ packaged codes and assign the APC Panel’s recommendation to
to assign CPT code 0175T to ‘‘special’’ this code to APC 0340 (Minor Ancillary designate this service as a ‘‘special’’
packaged status, we would likely create Procedures). packaged code. This service uses signal
an incentive for hospitals to perform This service describes an ultrasound processing technology to detect,
chest x-ray CAD remotely, for example, procedure that measures common interpret, and document acoustical
several days after performance of the carotid intima-media thickness to activities of the heart through special
initial chest x-ray, rather than evaluate a patient’s degree of sensors applied to a patient’s chest. This
immediately following the chest x-ray atherosclerosis. This code became code was a new Category III CPT code
on the same day, to enable the hospital effective January 1, 2006. We received a implemented in the CY 2005 OPPS. CPT
to receive separate payment for the comment to the CY 2007 proposed rule code 0069T was an add-on code to an
service. In CY 2005, there were requesting that this code become electrocardiography (EKG) service for
approximately 7.3 million claims for all separately payable for CY 2007. At that CYs 2005 and 2006. However, effective
chest x-ray services in the HOPD, so a point, we had no cost data for the January 1, 2007, the AMA changed the
payment policy that could induce such service and, as discussed in the CY 2007 code descriptor to remove the add-on
changes in service delivery would be OPPS/ASC final rule with comment code designation for CPT code 0069T.
problematic in light of our commitment period (71 FR 67998), we reviewed this This code has been packaged under the
to encouraging the most efficient and code with the Packaging Subcommittee, OPPS since CY 2005.
cost-effective care for Medicare as is our standard procedure for codes During the August 2005 APC Panel
beneficiaries. Creating such perverse that we are asked to review during the meeting, the APC Panel recommended
payment incentives through conditional comment period. The APC Panel noted packaging CPT code 0069T for CY 2005.
packaging is a particular problem for that this service could sometimes be In its March 2006 presentation to the
those services that do not need a face- provided to a patient without any other APC Panel, a presenter requested that
to-face encounter with the patient. In separately payable services. Therefore, we pay separately for CPT code 0069T
fact, as part of our proposed CY 2008 the APC Panel recommended that we and assign it to APC 0099
packaging approach, we are also add this code to the list of ‘‘special’’ (Electrocardiograms) based on its
proposing to unconditionally package packaged codes and pay for it separately estimated cost and clinical
payment in CY 2008 for several other when it is provided without any other characteristics. The presenter stated that
the acoustic heart sound recording and packaged because it would usually be time that this supply was reported. The
analysis service may be provided with closely linked to the performance of an APC Panel speculated that this code
or without a separately reportable EKG or other separately payable cardiac may be currently reported when other
electrocardiogram. Members of the APC service, would rarely, if ever, be the types of drug delivery devices are
Panel engaged in extensive discussion only OPPS service provided to a patient utilized for nonsurgical procedures or
of clinical scenarios as they considered in an encounter, and has a low for purposes other than the treatment of
whether CPT code 0069T could or could estimated resource cost. The proposed postoperative pain. Therefore, the APC
not be appropriately reported alone or packaged treatment of this code is Panel requested that we share additional
in conjunction with several different consistent with the principles and data when available.
procedure codes. Ultimately, the APC incentives for efficiency inherent in a In summary, because HCPCS code
Panel recommended assigning this prospective payment system based on A4306 represents a supply and payment
service to a separately payable status groups of services. Therefore, we are of supplies is packaged under the OPPS
indicator. However, during the August proposing to continue to package according to longstanding policy, we are
2006 meeting, the APC Panel further payment for CPT code 0069T for CY proposing to maintain the packaged
discussed CMS’ proposal to package 2008. status of HCPCS code A4306 for CY
payment for CPT code 0069T for CY 2008.
Recommendation 6
2007 and considered the CY 2007 code
descriptor change, finally For CY 2008, we are proposing to Recommendation 7
recommending that CMS continue to adopt the APC Panel’s recommendation For CY 2008, we are proposing to
package this code for CY 2007. and maintain the packaged status of maintain the packaged status of CPT
During the March 2007 APC Panel HCPCS code A4306. As requested by the code 99186, consistent with the APC
meeting, the same presenter requested APC Panel, we will also present to the Panel’s recommendation that we
that we pay separately for this service APC Panel additional data on this reevaluate the packaged OPPS payment
and assign it to APC 0096 (Non-Invasive system when available.
for CPT code 99186 based on current
Vascular Studies) or to APC 0097 HCPCS code A4306 describes a
research and the availability of new
(Cardiac and Ambulatory Blood disposable drug delivery system with a
flow rate of less than 50 ml per hour. As therapeutic modalities.
Pressure Monitoring), with CY 2007
discussed in a presentation at the March This service describes induced total
payment rates of $94.06 and $62.85,
2007 APC Panel meeting, there is a body hypothermia that is performed on
respectively. The presenter stated that
particular disposable drug delivery some post-cardiac arrest patients to
the estimated true cost of this service
system that is specifically used to treat avoid or lessen brain damage. The
lies between $62 and $94. The presenter
postoperative pain. Since the service has been packaged since the
clarified that this service is usually
implementation of the OPPS, this code implementation of the OPPS. One
provided with an EKG, but noted that
was assigned to status indicator ‘‘A,’’ presenter to the APC Panel at the March
the test is sometimes provided without
indicating that it was payable according 2007 meeting requested that this code
an EKG, according to its revised code
to another fee schedule, in this case, the be assigned a separately payable status
descriptor for CY 2007. The presenter
agreed that it would be rare for the Durable Medical Equipment (DME) fee indicator under the OPPS. The presenter
acoustic heart sound procedure to be schedule. There were discussions expressed concern that hospitals that
performed alone without any other during CYs 2005 and 2006 between provide this service and subsequently
separately payable OPPS services. The CMS and a manufacturer, and it was transfer the patient to another hospital
APC Panel recommended that we place determined that this code should be prior to admission are not adequately
CPT code on the list of ‘‘special’’ removed from the DME fee schedule as paid for their services.
packaged codes and that we exclude this code does not describe DME. For Because this service does not fit into
APC 0096 as a potential placement for CY 2007, HCPCS code A4306 is payable one of the seven identified categories of
this CPT code. under the OPPS, with status indicator packaged codes proposed for the CY
Because this service does not fit into ‘‘N’’ indicating that its payment is 2008 OPPS, we followed our historical
one of the seven identified categories of unconditionally packaged. packaging guidelines to determine
packaged codes proposed for the CY One presenter to the APC Panel whether to maintain the packaged status
2008 OPPS, we followed our historical requested that we pay separately for this of this code or to pay for it separately.
packaging guidelines to determine supply under the OPPS. For CY 2007, Claims data indicate that this code was
whether to maintain the packaged status we packaged payment for this code billed 39 times under the OPPS in CY
of this code or to pay for it separately. because it is considered to be a supply, 2006 and was never billed without
Based on the clinical uses that were and since the inception of the OPPS the another separately payable service on
described during the March 2007 and established payment policy packages the same date. The proposed CY 2008
earlier APC Panel meetings, APC Panel payment for supplies because they are median cost for this code is $35, with
discussions, and our claims data review, directly related and integral to an individual costs ranging from $17 to
we continue to believe that it is highly independent service furnished under $69, likely reflecting the costs
unlikely that CPT code 0069T would be the OPPS. associated with traditional methods of
performed in the HOPD as a sole service Our CY 2006 claims data indicate that inducing total body hypothermia, such
without other separately payable OPPS HCPCS code A4306 was billed on OPPS as ice packs applied to the body. In fact,
services. In addition, our data indicate claims 1,773 times, yielding a line-item the presenter noted that a
that this service is estimated to require median cost of approximately $3. The technologically advanced total body
only minimal hospital resources. Based APC Panel and a presenter believe that hypothermia system costs $30,000, with
on CY 2006 claims, we had only 8 single this code may not always be an additional cost of $1,600 per
claims for CPT code 0069T, with a appropriately billed by hospitals as the disposable body suit. As expected, our
median line-item cost of $5.21, data also show that this code was billed claims data show that this service was
consistent with its low expected cost. together with computed tomography provided most frequently with high
Therefore, we believe that payment for (CT) scans of the thorax, abdomen, and level emergency department visits and
CPT code 0069T is appropriately pelvis approximately 40 percent of the critical care services.
We believe that the circumstances in 1. Background providing partial hospitalization

which total body hypothermia would be Partial hospitalization is an intensive services. We used CCRs from the most
provided to a Medicare beneficiary and outpatient program of psychiatric recently available hospital and CMHC
billed under the OPPS are extremely services provided to patients as an cost reports to convert each provider’s
rare, as patients requiring this therapy alternative to inpatient psychiatric care line-item charges as reported on bills to
would almost always be admitted as for beneficiaries who have an acute estimate the provider’s cost for a day of
inpatients if they survive. We believe mental illness. A partial hospitalization PHP services. Per diem costs were then
that, in the uncommon situation where program (PHP) may be provided by a computed by summing the line-item
a patient presents to one hospital and hospital to its outpatients or by a costs on each bill and dividing by the
then is cooled and transported to Medicare-certified community mental number of days on the bill.
In the CY 2005 OPPS update, the
another hospital without admission to health center (CMHC). Section
CMHC median per diem cost was $310,
the first hospital, payment for the 1833(t)(1)(B)(i) of the Act provides the
the hospital-based PHP median per
hypothermia service would be most Secretary with the authority to designate
diem cost was $215, and the combined
appropriately packaged into payment the hospital outpatient services to be
CMHC and hospital-based median per
for the many other separately payable covered under the OPPS. The Medicare diem cost was $289. We believed that
services that it most likely accompanied regulations at 42 CFR 419.21 that the reduction in the CY 2005 CMHC
and that would be paid to the first implement this provision specify that median per diem cost compared to prior
hospital under the OPPS. payments under the OPPS will be made years indicated that the use of updated
for partial hospitalization services CCRs had accounted for the previous
In addition, consistent with the
furnished by CMHCs as well as those increase in CMHC charges and
principles and incentives for efficiency
furnished to hospital outpatients. represented a more accurate estimate of
inherent in a prospective payment
Section 1833(t)(2)(C) of the Act requires CMHC per diem costs for PHP.
system based on groups of services,
that we establish relative payment For the CY 2006 OPPS final rule with
packaging payment for this procedure
weights based on median (or mean, at comment period, we analyzed 12
that is highly integrated with other the election of the Secretary) hospital
services provided in the hospital months of the most current claims data
costs determined by 1996 claims data available for hospital and CMHC PHP
outpatient encounter creates incentives and data from the most recent available
for providers to furnish services in the services furnished between January 1,
cost reports. Payment to providers 2004, and December 31, 2004. We also
most cost-effective way. In situations under the OPPS for PHPs represents the
where there are a variety of supplies used the most currently available CCRs
provider’s overhead costs associated to estimate costs. The median per diem
that could be used to furnish a service, with the program. Because a day of care cost for CMHCs dropped to $154, while
some of which are more expensive than is the unit that defines the structure and the median per diem cost for hospital-
others, packaging encourages hospitals scheduling of partial hospitalization based PHPs was $201. Based on the CY
to use the most cost-effective item that services, we established a per diem 2004 claims data, the average charge per
meets the patient’s needs. payment methodology for the PHP APC, day for CMHCs was $760, considerably
Recommendation 8 effective for services furnished on or greater than hospital-based per day costs
after August 1, 2000. For a detailed but significantly lower than what it was
In response to the APC Panel’s discussion, we refer readers to the April in CY 2003 ($1,184). We believed that
recommendation for the Packaging 7, 2000 OPPS final rule with comment a combination of reduced charges and
Subcommittee to remain active until the period (65 FR 18452). slightly lower CCRs for CMHCs resulted
next APC meeting, we note that the APC Historically, the median per diem cost in a significant decline in the CMHC
Panel Packaging Subcommittee remains for CMHCs greatly exceeded the median median per diem cost between CY 2003
active, and additional issues and new per diem cost for hospital-based PHPs and CY 2004.
data concerning the packaging status of and has fluctuated significantly from Following the methodology used for
codes will be shared for its year to year, while the median per diem the CY 2005 OPPS update, the CY 2006
consideration as information becomes cost for hospital-based PHPs has OPPS updated combined hospital-based
available. We continue to encourage remained relatively constant ($200– and CMHC median per diem cost was
submission of common clinical $225). We believe that CMHCs may have $161, a decrease of 44 percent compared
scenarios involving currently packaged increased and decreased their charges in to the CY 2005 combined median per
HCPCS codes to the Packaging response to Medicare payment policies. diem amount.
Subcommittee for its ongoing review, As discussed in more detail in section As we were concerned that this
II.B.2. of this proposed rule and in the amount may not cover the cost for PHPs,
and we also encourage
CY 2004 OPPS final rule with comment as stated in the CY 2006 OPPS final rule
recommendations of specific services or
period (68 FR 63470), we also believe with comment period (70 FR 68548 and
procedures whose payment would be
that some CMHCs manipulated their 68549), we applied a 15-percent
most appropriately packaged under the
charges in order to inappropriately reduction to the combined hospital-
OPPS. Additional detailed suggestions
receive outlier payments. based and CMHC median per diem cost
for the Packaging Subcommittee should For CY 2005, the PHP per diem to establish the CY 2005 PHP APC. (We
be submitted to APCPanel@cms.hhs.gov, amount was based on 12 months of refer readers to the CY 2006 OPPS final
with ‘‘Packaging Subcommittee’’ in the hospital and CMHC PHP claims data rule with comment period for a full
subject line. (for services furnished from January 1, discussion of how we established the
B. Proposed Payment for Partial 2003, through December 31, 2003). We CY 2006 PHP rate (70 FR 68548).) We
Hospitalization used data from all hospital bills stated our belief that a reduction in the
reporting condition code 41, which CY 2005 median per diem cost would
(If you choose to comment on issues identifies the claim as partial strike an appropriate balance between
in this section, please include the hospitalization, and all bills from using the best available data and
caption ‘‘OPPS: Partial Hospitalization’’ CMHCs because CMHCs are Medicare providing adequate payment for a
at the beginning of your comment.) providers only for the purpose of program that often spans 5–6 hours a
day. We stated that 15 percent was an provide a transitional path to the per However, if the hospital does not have
appropriate reduction because it diem cost indicated by the data. We a CCR for any of the listed cost centers,
recognized decreases in median per believed that this approach accounted we consider the overall hospital CCR as
diem costs in both the hospital data and for the downward direction of the data the default. For partial hospitalization,
the CMHC data, and also reduced the and addressed concerns raised by the revenue center codes billed by PHPs
risk of any adverse impact on access to commenters about the magnitude of are mapped to Primary Cost Center 3550
these services that might result from a another 15 percent reduction in 1 year. ‘‘Psychiatric/Psychological Services’’. If
large single-year rate reduction. Thus, to calculate the CY 2007 APC PHP that cost center is not available, they are
However, we adopted this policy as a per diem cost, we reduced $245.65 (the mapped to the Secondary Cost Center
transitional measure, and stated in the CY 2005 combined hospital-based and 6000 ‘‘Clinic.’’ We use the overall
CY 2006 OPPS final rule with comment CMHC median per diem cost of $289 facility CCR for CMHCs because PHPs
period that we would continue to reduced by 15 percent) by 5 percent, are CMHCs’ only Medicare cost, and
monitor CMHC costs and charges for which resulted in a combined per diem CMHCs do not have the same cost
these services and work with CMHCs to cost of $233.37. structure as hospitals. Therefore, for
improve their reporting so that CMHCs, we use the CCR from the
2. Proposed PHP APC Update
payments can be calculated based on outpatient provider-specific file.
better empirical data, consistent with For the past 2 years, we were Closer examination of the revenue-
the approach we have used to calculate concerned that we did not have code-to-cost-center crosswalk revealed
payments in other areas of the OPPS (70 sufficient evidence to support using the that 10 of the revenue center codes
FR 68548). median per diem cost produced by the (shown in the table below) that are
To apply this methodology for CY most current year’s PHP data. After common among hospital based PHP
2006, we reduced the CY 2005 extensive analysis, we now believe we claims did not map to a Primary Cost
combined unscaled hospital-based and have determined the appropriate level Center 3550 ‘‘Psychiatric/Psychological
CMHC median per diem cost of $289 by of cost for the type of day services that Services’’ or a Secondary Cost Center of
15 percent, resulting in a combined is being provided. This analysis 6000 ‘‘Clinic.’’
median per diem cost of $245.65 for CY included an examination of revenue-to-
2006. cost center mapping, refinements to the Revenue
For the CY 2007 final rule with per diem methodology, and an in-depth center Revenue center description
comment period, we analyzed 12 analysis of the number of units of code
months of more current data for hospital service per day.
In the CY 2006 and CY 2007 OPPS 0430 ..... Occupational Therapy.
and CMHC PHP claims for services 0431 ..... Occupational Therapy: Visit
furnished between January 1, 2005, and updates, the data have produced median charge.
December 31, 2005. We also used the costs that we believe were too low to 0432 ..... Occupational Therapy: Hourly
most currently available CCRs to cover the cost of a program that charge.
estimate costs. Using these updated typically spans 5 to 6 hours per day. 0433 ..... Occupational Therapy: Group rate.
data, we recreated the analysis However, we continued to observe a 0434 ..... Occupational Therapy: Evaluation/
performed for the CY 2007 proposed clear downward trend in the data. We re-evaluation.
rule to determine if the significant stated that if the data continue to reflect 0439 ..... Occupational Therapy: Other occu-
factors we used in determining the a low PHP per diem cost in CY 2008, we pational therapy.
expect to continue the transition of 0904 ..... Psychiatric/Psychological Treat-
proposed PHP rate had changed. The ment: Activity therapy.
median per diem cost for CMHCs decreasing the PHP median per diem 0940 ..... Other Therapeutic Services.
increased $8 to $173, while the median cost to an amount that is more reflective 0941 ..... Other Therapeutic Services:
per diem cost for hospital-based PHPs of the data. Recreation Rx.
decreased $19 to $190. The CY 2005 We received a comment on the CY 0942 ..... Other Therapeutic Services: Edu-
average charge per day for CMHCs was 2007 proposed rates that CMS cation/training.
$675, similar to the figure noted in the understated the PHP median cost by not
CY 2007 proposed rule ($673) but still using a hospital-specific CCR for partial We believe these 10 revenue center
significantly lower than what was noted hospitalization. In our response to this codes did not map to either a Primary
as the average charge for CY 2003 comment in the CY 2007 OPPS/ASC Cost Center 3550 ‘‘Psychiatric/
($1,184). final rule with comment period (71 FR Psychological Services’’ or a Secondary
The combined hospital-based and 68000), we noted that, although most Cost Center 6000 ‘‘Clinic’’ because these
CMHC median per diem cost would hospitals do not have a cost center for codes may be used for services that are
have been $175 for CY 2007. Rather partial hospitalization, we used the CCR not PHP or psychiatric related. For
than allowing the PHP median per diem as specific to PHP as possible. The example, many Occupational Therapy
cost to drop to this level, we proposed following CMS Web site contains the claims are not furnished to PHP patients
to reduce the PHP median cost by 15 revenue-code-to-cost-center crosswalk: and, therefore, should be appropriately
percent, similar to the methodology http://www.cms.hhs.gov/ mapped to a Primary Cost Center 5100
used for the CY 2006 update. However, HospitalOutpatientPPS/ ‘‘Occupation Therapy’’ (the general
after considering all public comments 03_crosswalk.asp#TopOfPage. Occupational Therapy Cost Center).
received concerning the proposed CY This crosswalk indicates how charges Another example would be claims for
2007 PHP per diem rate and results on a claim are mapped to a cost center Diabetes Education, which is also not
obtained using the more current data, for the purpose of converting charges to furnished to PHP patients.
we modified our proposal to continue cost. One or more cost centers are listed In order to more accurately estimate
using the 15 percent reduction for most revenue codes that are used in costs for PHP claims, for purposes of our
methodology as the basis for calculating the OPPS median calculations, starting analysis, we remapped these 10 revenue
the combined hospital based and CMHC with the most specific, and ending with center codes to a Primary Cost Center
median per diem cost for CY 2007. the most general. Typically, we map the 3550 ‘‘Psychiatric/Psychological
Instead, we made a 5 percent reduction revenue code to the most specific cost Services’’ or a Secondary Cost Center
to the CY 2006 median per diem rate to center with a provider-specific CCR. 6000 ‘‘Clinic’’. Once we remapped the
codes, we computed an alternate cost each day of care. All of these costs are As expected, excluding the low unit
for each line item of the CY 2006 then arrayed from lowest to highest and days resulted in a higher median per
hospital-based PHP claims. There are a the middle value of the array would be diem cost estimate. However, if the
total of 638,652 line items in the CY the median per diem cost. programs have many ‘‘low unit days,’’
2006 hospital-based PHP claims. Prior We believe this alternative method of their cost and Medicare payment should
to remapping, there were 282,871 line computing a per diem median cost reflect this level of service. It would not
items where a default CCR was used to produces a more accurate estimate be appropriate to set the PHP rate to
estimate costs. After the remapping, because each day gets an equal weight exclude the ‘‘low unit days’’ because
there were 141,682 line items left towards computing the median. We these days are covered PHP days. We
defaulting to the hospitals’ overall CCR. have considered this alternative method believe the analysis of the number of
While this remapping creates a more for several years, but in light of the units of service per day supports a lower
accurate estimate of PHP per diem costs volatility of the data, we have not per diem cost. Therefore, including all
for a significant number of claims, there believed it would provide a reasonable days supports the data trend towards a
was not a large change in the resulting and appropriate median per diem cost. lower per diem cost and we believe
median per diem cost. The median per In light of the stabilizing trend in the more accurately reflects the costs of
diem costs for hospital-based PHPs data, and in light of the robustness of providing these PHP services.
increased by $5.20 (from $191.80 to recent data analysis, we now believe it Although the minimum number of
$197). is appropriate to propose the adoption PHP services required in a PHP day is
As part of our effort to produce the of this method. We believe this method three, it was never our intention that
most accurate per diem cost estimate, for computing a PHP per diem median this represented the typical number of
we have reexamined our methodology cost more accurately reflects the costs of services to be provided in a typical PHP
for computing the PHP per diem cost. a PHP and uses all available PHP data. day. Our intention was to cover days
Section 1833(t)(2)(C) of the Act requires Therefore, for CY 2008, we are that consisted of only three services,
that we establish relative payment proposing to adopt this alternate generally because a patient was
weights based on median (or mean, at method for computing PHP median per transitioning towards discharge. Rather
the election of the Secretary) hospital diem costs. than set separate rates for half-days and
costs determined by 1996 claims data full-days, we believed it was
As noted previously, for the past 2
and data from the most recent available appropriate to set one rate that would be
years, the data have produced median
cost reports. As explained in section paid for all PHP days, including those
costs that we believe were too low to
II.B.1 of this proposed rule, payment to for patients transitioning towards
cover the cost of a program that
providers under OPPS for PHP services discharge. We intend that the PHP
typically spans 5 to 6 hours per day.
represents the provider’s overhead costs benefit is for a full day, with shorter
This length of day would include 5 or
associated with the program. Because a days only occurring while a patient
6 services with a break for lunch. We
day of care is the unit that defines the transitions out of the PHP.
looked at the number of units of service However, as indicated in the data,
structure and scheduling of partial
hospitalization services, we established being provided in a day of care, as a many programs have these ‘‘low unit
a per diem payment methodology for possible explanation for the low per days,’’ and we believe their cost and
the PHP APC. Other than being a per diem cost for PHP. Our analysis Medicare payment should reflect this
diem payment, we use the general OPPS revealed that both hospital-based and level of service. It would not be
ratesetting methodology for determining CMHC PHPs have a significant number appropriate to set the PHP rate
median cost. of days where less than 4 units of excluding the low unit days because
As we have described in prior Federal service were provided. these days are covered. Again, we
Register notices, our current method for Specifically, 64 percent of the days believe the data support the estimated
computing per diem costs is as follows: that CMHCs were paid were for days per diem cost under $200 that we have
we use data from all hospital bills where 3 or less units of services were observed in the data.
reporting condition code 41, which provided, and 34 percent of the days At this time, we believe the most
identifies the claim as partial that hospital-based PHPs were paid appropriate payment rate for PHPs is
hospitalization, and all bills from were for days where 3 or less units of computed using both hospital-based and
CMHCs. We use CCRs from the most service were provided. We believe these CMHC PHP data, including the
recently available hospital and CMHC findings are significant because they remapped data for all days, resulting in
cost reports to convert each provider’s may explain a lower per diem cost. a median per diem cost of $178.
line-item charges as reported on bills to Therefore, based on these findings, we Therefore, we are proposing a CY 2008
estimate the provider’s cost for a day of computed median per diem costs in two APC PHP per diem cost of $178.
PHP services. Per diem costs are then categories:
computed by summing the line-item (a) All days. 3. Proposed Separate Threshold for
costs on each bill and dividing by the (b) Days with 4 units of service or Outlier Payments to CMHCs
number of days of PHP care provided on more (removing days with 3 services or In the November 7, 2003 final rule
the bill. These computed per diem costs less). with comment period (68 FR 63469), we
are arrayed from lowest to highest and These median per diem costs were indicated that, given the difference in
the middle value of the array is the computed separately for CMHCs and PHP charges between hospitals and
median per diem cost. hospital based PHPs and are shown in CMHCs, we did not believe it was
We have developed an alternate way the table below: appropriate to make outlier payments to
to determine median cost by computing CMHCs using the outlier percentage

a separate per diem cost for each day Hospital- target amount and threshold established
CMHCs
rather than for each bill. Under this based PHPs for hospitals. There was a significant
method, a cost is computed separately difference in the amount of outlier
for each day of PHP care. When there All Days ............ $178 $186 payments made to hospitals and CMHCs
Days with 4
are multiple days of care entered on a units or more $191 $218
for PHP. In addition, further analysis
claim, a unique cost is computed for indicated that using the same OPPS
outlier threshold for both hospitals and payments by imposing a dollar conversion factor by the proportional
CMHCs did not limit outlier payments threshold. Therefore, we are not amount of the rural floor budget
to high cost cases and resulted in proposing to set a dollar threshold for neutrality adjustment to accommodate
excessive outlier payments to CMHCs. CMHC outliers. As noted above, we are this proposed change.
Therefore, beginning in CY 2004, we proposing to set the outlier threshold for We estimated the rural adjustment for
established a separate outlier threshold CMHCs for CY 2008 at 3.40 times the CY 2008 to reflect the proposed
for CMHCs. For CYs 2004 and 2005, we APC payment amount and the CY 2008 extension of the adjustment to payment
designated a portion of the estimated 2.0 outlier payment percentage applicable for brachytherapy sources as discussed
percent outlier target amount to costs in excess of the threshold at 50 in section II.F.2. of this proposed rule,
specifically for CMHCs, consistent with percent. but as the impact of the proposed
the percentage of projected payments to extension was negligible, we did not
C. Proposed Conversion Factor Update change the proposed rural adjustment.
CMHCs under the OPPS in each of those
years, excluding outlier payments. For (If you choose to comment on issues Therefore, we calculated a budget
CY 2006, we set the estimated outlier in this section, please include the neutrality factor of 1.000 for the rural
target at 1.0 percent and allocated a caption ‘‘OPPS: Conversion Factor’’ at adjustment. For CY 2008, we estimate
portion of that 1.0 percent, 0.6 percent the beginning of your comment.) that allowed pass through spending for
(or 0.006 percent of total OPPS Section 1833(t)(3)(C)(ii) of the Act both drugs and devices would equal
payments), to CMHCs for PHP services. requires us to update the conversion approximately $54 million, which
For CY 2007, we set the estimated factor used to determine payment rates represents 0.15 percent of total OPPS
outlier target at 1.0 percent and under the OPPS on an annual basis. projected spending for CY 2008. The
allocated a portion of that 1.0 percent, Section 1833(t)(3)(C)(iv) of the Act proposed conversion factor also is
an amount equal to 0.15 percent of provides that, for CY 2008, the update adjusted by the difference between the
outlier payments and 0.0015 percent of is equal to the hospital inpatient market 0.21 percent pass through dollars set
total OPPS payments to CMHCS for PHP basket percentage increase applicable to aside in CY 2007 and the 0.15 percent
service outliers. The CY 2007 CMHC hospital discharges under section estimate for CY 2008 pass through
outlier threshold is met when the cost 1886(b)(3)(B)(iii) of the Act. spending. Finally, proposed payments
of furnishing services by a CMHC The proposed hospital market basket for outliers remain at 1.0 percent of total
exceeds 3.40 times the PHP APC increase for FY 2008 published in the payments for CY 2008.
payment amount. The CY 2007 OPPS IPPS proposed rule on May 3, 2007, is The proposed market basket increase
outlier payment percentage is 50 3.3 percent (72 FR 24835). To set the update factor of 3.3 percent for CY 2008,
percent of the amount of costs in excess OPPS proposed conversion factor for CY the required wage index and rural
of the threshold. 2008, we increased the CY 2007 budget neutrality adjustment of
The separate outlier threshold for conversion factor of $61.468, as approximately 1.0025, and the proposed
CMHCs became effective January 1, specified in the CY 2007 OPPS/ASC adjustment of 0.06 percent for the
2004, and has resulted in more final rule with comment period (71 FR difference in the pass-through set aside
commensurate outlier payments. In CY 68003), by 3.3 percent. result in a proposed standard OPPS
2004, the separate outlier threshold for In accordance with section conversion factor for CY 2008 of
CMHCs resulted in $1.8 million in 1833(t)(9)(B) of the Act, we further $63.693.
outlier payments to CMHCs. In CY 2005, adjusted the conversion factor for CY
2007 to ensure that the revisions that we D. Proposed Wage Index Changes
the separate outlier threshold for
CMHCs resulted in $0.5 million in are proposing to make to our updates for (If you choose to comment on issues
outlier payments to CMHCs. In contrast, a revised wage index and rural in this section, please include the
in CY 2003, more than $30 million was adjustment are made on a budget caption ‘‘OPPS: Wage Index’’ at the
paid to CMHCs in outlier payments. We neutral basis. We calculated an overall beginning of your comment.)
believe this difference in outlier budget neutrality factor of 1.0025 for Section 1833(t)(2)(D) of the Act
payments indicates that the separate wage index changes by comparing total requires the Secretary to determine a
outlier threshold for CMHCs has been payments from our simulation model wage adjustment factor to adjust, for
successful in keeping outlier payments using the FY 2008 IPPS proposed wage geographic wage differences, the portion
to CMHCs in line with the percentage of index values to those payments using of the OPPS payment rate and the
OPPS payments made to CMHCs. the current (FY 2007) IPPS wage index copayment standardized amount
As noted in section II.G. of this values. This adjustment reflects an attributable to labor and labor related
proposed rule, for CY 2008, we are adjustment of 1.0009 for changes to the cost. Since the inception of the OPPS,
proposing to continue our policy of wage index and an additional 1.0016 to CMS policy has been to wage adjust 60
setting aside 1.0 percent of the aggregate accommodate the IPPS budget neutrality percent of the OPPS payment, based on
total payments under the OPPS for adjustment for inclusion of the rural a regression analysis that determined
outlier payments. We are proposing that floor. As discussed further in section that approximately 60 percent of the
a portion of that 1.0 percent, an amount II.D. of this proposed rule, for the first costs of services paid under the OPPS
equal to 0.03 percent of outlier time, the proposed FY 2008 IPPS wage were attributable to wage costs. We
payments and 0.0003 percent of total indices include a blanket budget confirmed that this labor related share
OPPS payments, would be allocated to neutrality adjustment for including the for outpatient services is still
CMHCs for PHP service outliers. As rural floor provision, which previously appropriate during our regression
discussed in section II.G. of this had been applied to the IPPS analysis for the payment adjustment for
proposed rule, we again are proposing standardized amount. For further rural hospitals in the CY 2006 OPPS
to set a dollar threshold in addition to discussion of this proposed policy in its final rule with comment period (70 FR
an APC multiplier threshold for OPPS entirety, we refer readers to the FY 2008 68553). We are not proposing to revise
outlier payments. However, because the IPPS proposed rule (72 FR 24787 this policy for the CY 2008 OPPS. We
PHP is the only APC for which CMHCs through 24792). This proposed refer readers to section II.H. of this
may receive payment under the OPPS, adjustment is specific to the IPPS. For proposed rule for a description and
we would not expect to redirect outlier the OPPS, we have increased the example of how the wage index for a
particular hospital is used to determine of the changes to the wage indices and geographic differences in labor costs in
the payment for the hospital. This to the correction notice to the FY 2008 this proposed rule, we have used the
adjustment must be made in a budget IPPS proposed rule published in the wage indices identified in the FY 2008
neutral manner. (As we have done in Federal Register on June 7, 2007 (72 FR IPPS proposed rule and as corrected in
prior years, we are proposing to adopt 31507). In this proposed rule, we are not the June 7, 2007 correction notice to the
the final IPPS wage indices for the OPPS reprinting the proposed FY 2008 IPPS FY 2008 IPPS proposed rule, that are
and to extend these wage indices to wage indices referenced in the fully adjusted for differences in
hospitals that participate in the OPPS discussion below, with the exception of occupational mix using the entire 6-
but not the IPPS (referred to in this the out-migration wage adjustment table month survey data collected in 2006.
section as ‘‘non IPPS’’ hospitals).) (Addendum L to this proposed rule). We 2. The reclassifications of hospitals to
As discussed in section II.A. of this also refer readers to the CMS Web site geographic areas for purposes of the
proposed rule, we standardize 60 for the OPPS at http:// wage index. For purposes of the OPPS
percent of estimated costs (labor-related www.cms.hhs.gov/providers/hopps. At wage index, we are proposing to adopt
costs) for geographic area wage variation this Web site, the reader will find a link all of the IPPS reclassifications for FY
using the IPPS pre-reclassified wage to the proposed FY 2008 IPPS wage 2008, including reclassifications that the
indices in order to remove the effects of indices tables and to those tables as Medicare Geographic Classification
differences in area wage levels in corrected in the correction notice to the Review Board (MGCRB) approved. We
determining the national unadjusted FY 2008 IPPS proposed rule published note that reclassifications under section
OPPS payment rate and the copayment in the Federal Register on June 7, 2007. 508 of Pub. L. 108–173 were set to
amount. 1. The proposed continued use of the terminate March 31, 2007. However,
As published in the original OPPS Core Based Statistical Areas (CBSAs) section 106(a) of the MIEA-TRHCA
April 7, 2000 final rule with comment issued by the OMB as revised standards extended any geographic
period (65 FR 18545), OPPS has for designating geographical statistical reclassifications of hospitals that were
consistently adopted the final IPPS areas based on the 2000 Census data, to made under section 508 and that would
wage indices as the wage indices for define labor market areas for hospitals expire on March 31, 2007 until
adjusting the OPPS standard payment for purposes of the IPPS wage index. September 30, 2007. On March 23, 2007,
amounts for labor market differences. The OMB revised standards were we published a notice in the Federal
Thus, the wage index that applies to a published in the Federal Register on Register (72 FR 13799) that indicated
particular hospital under the IPPS will December 27, 2000 (65 FR 82235), and how we are implementing section 106 of
also apply to that hospital under the OMB announced the new CBSAs on the MIEA-TRHCA through September
OPPS. As initially explained in the June 6, 2003, through an OMB bulletin. 30, 2007. Because the section 508
September 8, 1998 OPPS proposed rule, In the FY 2005 IPPS final rule, CMS provision will expire on September 30,
we believed and continue to believe that adopted the new OMB definitions for 2007, the OPPS wage index will not
using the IPPS wage index as the source wage index purposes. In the FY 2008 include any reclassifications under
of an adjustment factor for OPPS is IPPS proposed rule, we again stated that section 508 for CY 2008.
reasonable and logical, given the hospitals located in Metropolitan 3. The out-migration wage adjustment
inseparable, subordinate status of the Statistical Areas (MSAs) will be urban to the wage index. In the FY 2008 IPPS
hospital outpatient within the hospital and hospitals that are located in proposed rule (72 FR 24798 through
overall. In accordance with section Micropolitan Areas or outside CBSAs 24799), we discussed the out-migration
1886(d)(3)(E) of the Act, the IPPS wage will be rural. We also reiterated our adjustment under section 505 of Pub. L.
index is updated annually. In policy that when an MSA is divided 108–173 for counties under this
accordance with our established policy, into one or more Metropolitan adjustment. Hospitals paid under the
we are proposing to use the final FY Divisions, we use the Metropolitan IPPS located in the qualifying section
2008 final version of these wage indices Division for purposes of defining the 505 ‘‘out-migration’’ counties receive a
to determine the wage adjustments for boundaries of a particular labor market wage index increase unless they have
the OPPS payment rate and copayment area. To help alleviate the decreased already been otherwise reclassified. We
standardized amount that would be payments for previously urban hospitals note that in the FY 2008 IPPS proposed
published in our final rule with that became rural under the new rule, we propose using the post-
comment period for CY 2008. geographical definitions, we allowed reclassified, rather than the pre-
We note that the proposed FY 2008 these hospitals to maintain for the 3- reclassified wage indices, in calculating
IPPS wage indices continue to reflect a year period from FY 2005 through FY the out-migration adjustment. (See the
number of changes implemented over 2007, the wage index of the MSA where FY 2008 IPPS proposed rule for further
the past few years as a result of the they previously had been located. This information on the out-migration
revised Office of Management and hold harmless provision expires after adjustment.) For OPPS purposes, we are
Budget (OMB) standards for defining FY 2007. We adopted the same policy proposing to continue our policy in CY
geographic statistical areas, the for OPPS, but because the OPPS 2008 to allow non IPPS hospitals paid
implementation of an occupational mix operates on a calendar year, wage index under the OPPS to qualify for the out-
adjustment as part of the wage index, policies are in effect through December migration adjustment if they are located
wage adjustments provided for under 31, 2007. To be consistent with the in a section 505 out-migration county.
Pub. L. 105–33 and Pub. L. 108–173, IPPS, as proposed in the FY 2008 IPPS Because non-IPPS hospitals cannot
and clarification of our policy for proposed rule, beginning in CY 2008 reclassify, they are eligible for the out
multicampus hospitals. The following is (January 1, 2008) under the OPPS, these migration wage adjustment. Table 4J
a brief summary of the components of hospitals will receive their statewide published in the addendum to the FY
the proposed FY 2008 IPPS wage rural wage index. Hospitals paid under 2008 IPPS proposed rule and as
indices and any adjustments that we are the IPPS are eligible to apply for corrected in the June 7, 2007 correction
proposing to apply to the OPPS for CY reclassification in FY 2008. notice to the FY 2008 IPPS proposed
2008. We refer the reader to the FY 2008 As noted above, for purposes of rule identifies counties eligible for the
IPPS proposed rule (72 FR 24776 estimating an adjustment for the OPPS out-migration adjustment. As stated
through 24802) for a detailed discussion payment rates to accommodate earlier, we are reprinting the corrected
version of Table 4J in this proposed rule including the rural floor provision, cost report, for those cost centers
as Addendum L. which previously had been applied to relevant to outpatient services weighted
4. Wage Index for Multicampus the IPPS standardized amount. For by Medicare Part B charges. We also
Hospitals. We also wish to clarify that further discussion of this proposed adjusted these ratios to reflect final
the IPPS policy for multicampus wage policy in its entirety, we refer readers to settled status by applying the
index payments also applies to OPPS. the FY 2008 IPPS proposed rule (72 FR differential between settled to submitted
As a result of the new labor market areas 24787 through 24792). costs and charges from the most recent
introduced in FY 2005, there are We note that all changes to the wage pair of settled to submitted cost reports.
hospitals with multiple campuses index resulting from geographic labor For this proposed rule, 78.17 percent
previously located in a single MSA that market area reclassifications or other of the submitted cost reports
are now in more than one CBSA. A adjustments must be incorporated in a represented data for CY 2005. We only
multicampus hospital is an integrated budget neutral manner. Accordingly, in used valid CCRs to calculate these
institution. For this reason, the calculating the OPPS budget neutrality default ratios. That is, we removed the
multicampus hospital has one provider estimates for CY 2008, in this proposed CCRs for all-inclusive hospitals, CAHs,
number and submits a single cost report rule, we have included the wage index and hospitals in Guam, and the U.S.
that combines the total wages and hours changes that would result from the Virgin Islands, American Samoa, and
of each of its campuses in the manner MGCRB reclassifications, the Northern Mariana Islands because
described in the FY 2008 IPPS proposed implementation of sections 4410 of Pub. these entities are not paid under the
rule (72 FR 24783). L. 105–33 and 505 of Pub. L. 108–173, OPPS, or in the case of all-inclusive
In the FY 2008 IPPS proposed rule, and other refinements proposed in the hospitals, because their CCRs are
we proposed to apportion wages and FY 2008 IPPS proposed rule. For the CY suspect. We further identified and
hours across multiple campuses using 2008 OPPS final rule, we are proposing removed any obvious error CCRs and
full-time equivalent (FTE) staff data in to use the final FY 2008 IPPS wage trimmed any outliers. We limited the
order to include wage data for the indices, including the budget neutrality hospitals used in the calculation of the
individual campuses of a multicampus adjustment for the rural floor for default CCRs to those hospitals that
hospital in its local wage index calculating OPPS payment in CY 2008. billed for services under the OPPS
calculation. To the extent that a We discuss how the proposed OPPS during CY 2006.
multicampus hospital system has conversion factor compensates for the
associated outpatient facilities, we Finally, we calculated an overall
inclusion of this budget neutrality
would expect the FTEs for those average CCR, weighted by a measure of
adjustment in the wage indices in the
outpatient facilities to be included in volume for CY 2006, for each state
budget neutrality section (II.C.) of this
the FTE estimate for the closest except Maryland. This measure of
proposed rule.
inpatient facility. As part of this policy, volume is the total lines on claims and
we would fully expect that an OPD that E. Proposed Statewide Average Default is the same one that we use in our
is part of a multicampus hospital system CCRs impact tables. For Maryland, we used an
would receive a wage index based on (If you choose to comment on issues overall weighted average CCR for all
the geographic location of the inpatient in this section, please include the hospitals in the nation as a substitute for
campus with which it is associated. caption ‘‘OPPS: Statewide Cost-to Maryland CCRs. Few providers in
This would include cases where one Charge Ratios’’ at the beginning of your Maryland are eligible to receive
inpatient campus reclassified. Affiliated comment.) payment under the OPPS, which limits
outpatient facilities would receive the CMS uses CCRs to determine outlier the data available to calculate an
reclassified wage index of the inpatient payments, payments for pass-through accurate and representative CCR. The
campus. For further discussion of the devices, and monthly interim observed differences between last year’s
FY 2008 IPPS proposed multicampus transitional corridor payments under and this year’s default statewide CCRs
hospital policy in its entirety, we refer the OPPS. Some hospitals do not have largely reflect a general decline in the
readers to the FY 2008 IPPS proposed a valid CCR. These hospitals include, ratio between costs and charges widely
rule (72 FR 24783 through 24784). but are not limited to, hospitals that are observed in the cost report data.
5. Rural Floor Provision. Section 4410 new and have not yet submitted a cost However, observed increases in some
of Pub. L. 105–33 provides that the area report, hospitals that have a CCR that areas suggest that the decline in CCRs is
wage index applicable to any hospital falls outside predetermined floor and moderating. Further, the addition of
that is located in an urban area of a State ceiling thresholds for a valid CCR, or weighting by Part B charges to the
may not be less than the area wage hospitals that have recently given up overall CCR in CY 2007 slightly
index applicable to hospitals located in their all-inclusive rate status. Last year, increases the variability of the overall
rural areas of the State (‘‘the rural we updated the default urban and rural CCR calculation.
floor’’). Table 4A in the FY 2008 IPPS CCRs for CY 2007 in our final rule with As stated above, CMS uses default
proposed rule (72 FR 24924), as comment period (71 FR 68006 through statewide CCRs for several groups of
corrected in the June 7, 2007 correction 68009). In this proposed rule, we are hospitals, including, but not limited to,
notice (72 FR 31507), identifies urban proposing to update the default ratios hospitals that are new and have not yet
areas where hospitals located in those for CY 2008 using the most recent cost submitted a cost report, hospitals that
areas are assigned the rural floor (noted report data. have a CCR that falls outside
by a superscript ‘‘2’’). For CY 2008 We calculated the statewide default predetermined floor and ceiling
under the OPPS, we are proposing to CCRs using the same overall CCRs that thresholds for a valid CCR, and
continue our policy to allow non-IPPS we use to adjust charges to costs on hospitals that have recently given up
hospitals paid under the OPPS to claims data. Table 25 lists the proposed their all-inclusive rate status. Current
receive the rural floor wage index when CY 2008 default urban and rural CCRs OPPS policy also requires hospitals that
applicable under the IPPS for FY 2008. by State and compares them to last experience a change of ownership, but
For the first time, the proposed FY 2008 year’s default CCRs. These CCRs are the that do not accept assignment of the
IPPS wage indices include a blanket ratio of total costs to total charges from previous hospital’s provider agreement,
budget neutrality adjustment for each provider’s most recently submitted to use the previous provider’s CCR.
For CY 2008, we are proposing to or after January 1, 2007. As stated in the costs and charges than the existing
continue to apply this treatment of CY 2007 OPPS/ASC final rule with hospital. Furthermore, we believe that
using the default statewide CCR, to comment period (71 FR 68006), we the hospital should be provided time to
include an entity that has not accepted believe that a hospital that has not establish its own costs and charges.
assignment of an existing hospital’s accepted assignment of an existing Therefore, we are proposing to use the
provider agreement in accordance with hospital’s provider agreement is similar default statewide CCR to determine
§ 489.18, and that has not yet submitted to a new hospital that will establish its cost-based payments until the hospital
its first Medicare cost report. This own costs and charges. We also believe has submitted its first Medicare cost
policy is effective for hospitals that the hospital that has chosen not to report.
experiencing a change of ownership on accept assignment may have different
TABLE 25.—PROPOSED CY 2008 STATEWIDE AVERAGE CCRS

Previous
Proposed CY default CCR
State Rural/urban 2008 default (CY 2007
CCR OPPS final
rule)
ALASKA .................................................................................................................................... RURAL ............. 0.5389 0.5337

ALASKA .................................................................................................................................... URBAN ............. 0.3851 0.3830
ALABAMA ................................................................................................................................. RURAL ............. 0.2317 0.2321
ALABAMA ................................................................................................................................. URBAN ............. 0.2198 0.2228
ARKANSAS .............................................................................................................................. RURAL ............. 0.2660 0.2645
ARKANSAS .............................................................................................................................. URBAN ............. 0.2776 0.2749
ARIZONA .................................................................................................................................. RURAL ............. 0.2770 0.2823
ARIZONA .................................................................................................................................. URBAN ............. 0.2360 0.2323
CALIFORNIA ............................................................................................................................ RURAL ............. 0.2305 0.2463
CALIFORNIA ............................................................................................................................ URBAN ............. 0.2260 0.2324
COLORADO ............................................................................................................................. RURAL ............. 0.3677 0.3704
COLORADO ............................................................................................................................. URBAN ............. 0.2578 0.2672
CONNECTICUT ........................................................................................................................ RURAL ............. 0.3888 0.3886
CONNECTICUT ........................................................................................................................ URBAN ............. 0.3481 0.3491
DISTRICT OF COLUMBIA ....................................................................................................... URBAN ............. 0.3364 0.3392
DELAWARE .............................................................................................................................. RURAL ............. 0.3192 0.3230
DELAWARE .............................................................................................................................. URBAN ............. 0.3952 0.3953
FLORIDA .................................................................................................................................. RURAL ............. 0.2175 0.2191
FLORIDA .................................................................................................................................. URBAN ............. 0.1985 0.1990
GEORGIA ................................................................................................................................. RURAL ............. 0.2842 0.2846
GEORGIA ................................................................................................................................. URBAN ............. 0.2786 0.2888
HAWAII ..................................................................................................................................... RURAL ............. 0.3781 0.3574
HAWAII ..................................................................................................................................... URBAN ............. 0.3171 0.3199
IOWA ........................................................................................................................................ RURAL ............. 0.3499 0.3489
IOWA ........................................................................................................................................ URBAN ............. 0.3379 0.3428
IDAHO ....................................................................................................................................... RURAL ............. 0.4369 0.4360
IDAHO ....................................................................................................................................... URBAN ............. 0.4097 0.4159
ILLINOIS ................................................................................................................................... RURAL ............. 0.2910 0.3082
ILLINOIS ................................................................................................................................... URBAN ............. 0.2812 0.2878
INDIANA ................................................................................................................................... RURAL ............. 0.3207 0.3160
INDIANA ................................................................................................................................... URBAN ............. 0.3155 0.3204
KANSAS ................................................................................................................................... RURAL ............. 0.3201 0.3200
KANSAS ................................................................................................................................... URBAN ............. 0.2466 0.2523
KENTUCKY .............................................................................................................................. RURAL ............. 0.2480 0.2508
KENTUCKY .............................................................................................................................. URBAN ............. 0.2666 0.2698
LOUISIANA ............................................................................................................................... RURAL ............. 0.2727 0.2808
LOUISIANA ............................................................................................................................... URBAN ............. 0.2842 0.2730
MARYLAND .............................................................................................................................. RURAL ............. 0.2924 0.3181
MARYLAND .............................................................................................................................. URBAN ............. 0.3140 0.2978
MASSACHUSETTS .................................................................................................................. URBAN ............. 0.3466 0.3487
MAINE ....................................................................................................................................... RURAL ............. 0.4580 0.4568
MAINE ....................................................................................................................................... URBAN ............. 0.4261 0.4294
MICHIGAN ................................................................................................................................ RURAL ............. 0.3354 0.3461
MICHIGAN ................................................................................................................................ URBAN ............. 0.3272 0.3286
MINNESOTA ............................................................................................................................. RURAL ............. 0.5094 0.5085
MINNESOTA ............................................................................................................................. URBAN ............. 0.3452 0.3383
MISSOURI ................................................................................................................................ RURAL ............. 0.2916 0.2944
MISSOURI ................................................................................................................................ URBAN ............. 0.2977 0.3034
MISSISSIPPI ............................................................................................................................. RURAL ............. 0.2820 0.2841
MISSISSIPPI ............................................................................................................................. URBAN ............. 0.2300 0.2312

MONTANA ................................................................................................................................ RURAL ............. 0.4664 0.4392
MONTANA ................................................................................................................................ URBAN ............. 0.4646 0.4628
NORTH CAROLINA .................................................................................................................. RURAL ............. 0.3007 0.3048
NORTH CAROLINA .................................................................................................................. URBAN ............. 0.3580 0.3700
NORTH DAKOTA ..................................................................................................................... RURAL ............. 0.3831 0.3668
NORTH DAKOTA ..................................................................................................................... URBAN ............. 0.3842 0.3945
NEBRASKA .............................................................................................................................. RURAL ............. 0.3561 0.3756
TABLE 25.—PROPOSED CY 2008 STATEWIDE AVERAGE CCRS—Continued

Previous
Proposed CY default CCR
State Rural/urban 2008 default (CY 2007
CCR OPPS final
rule)
NEBRASKA .............................................................................................................................. URBAN ............. 0.2832 0.2899

NEW HAMPSHIRE ................................................................................................................... RURAL ............. 0.3646 0.3700
NEW HAMPSHIRE ................................................................................................................... URBAN ............. 0.3217 0.3249
NEW JERSEY .......................................................................................................................... URBAN ............. 0.2908 0.2972
NEW MEXICO .......................................................................................................................... RURAL ............. 0.2759 0.2741
NEW MEXICO .......................................................................................................................... URBAN ............. 0.3691 0.3978
NEVADA ................................................................................................................................... RURAL ............. 0.3370 0.3348
NEVADA ................................................................................................................................... URBAN ............. 0.1949 0.2141
NEW YORK .............................................................................................................................. RURAL ............. 0.4210 0.4446
NEW YORK .............................................................................................................................. URBAN ............. 0.4177 0.4275
OHIO ......................................................................................................................................... RURAL ............. 0.3629 0.3689
OHIO ......................................................................................................................................... URBAN ............. 0.2760 0.2834
OKLAHOMA .............................................................................................................................. RURAL ............. 0.2874 0.2949
OKLAHOMA .............................................................................................................................. URBAN ............. 0.2517 0.2608
OREGON .................................................................................................................................. RURAL ............. 0.3344 0.3438
OREGON .................................................................................................................................. URBAN ............. 0.3899 0.4054
PENNSYLVANIA ...................................................................................................................... RURAL ............. 0.2980 0.3052
PENNSYLVANIA ...................................................................................................................... URBAN ............. 0.2448 0.2524
PUERTO RICO ......................................................................................................................... URBAN ............. 0.4718 0.4689
RHODE ISLAND ....................................................................................................................... URBAN ............. 0.3085 0.3087
SOUTH CAROLINA .................................................................................................................. RURAL ............. 0.2589 0.2546
SOUTH CAROLINA .................................................................................................................. URBAN ............. 0.2563 0.2479
SOUTH DAKOTA ..................................................................................................................... RURAL ............. 0.3517 0.3479
SOUTH DAKOTA ..................................................................................................................... URBAN ............. 0.2918 0.3035
TENNESSEE ............................................................................................................................ RURAL ............. 0.2607 0.2648
TENNESSEE ............................................................................................................................ URBAN ............. 0.2514 0.2491
TEXAS ...................................................................................................................................... RURAL ............. 0.2823 0.2891
TEXAS ...................................................................................................................................... URBAN ............. 0.2495 0.2580
UTAH ........................................................................................................................................ RURAL ............. 0.4320 0.4410
UTAH ........................................................................................................................................ URBAN ............. 0.4218 0.4161
VIRGINIA .................................................................................................................................. RURAL ............. 0.2788 0.2821
VIRGINIA .................................................................................................................................. URBAN ............. 0.2789 0.2805
VERMONT ................................................................................................................................ RURAL ............. 0.4329 0.4325
VERMONT ................................................................................................................................ URBAN ............. 0.3401 0.3376
WASHINGTON ......................................................................................................................... RURAL ............. 0.3796 0.3742
WASHINGTON ......................................................................................................................... URBAN ............. 0.3574 0.3717
WISCONSIN ............................................................................................................................. RURAL ............. 0.3633 0.3670
WISCONSIN ............................................................................................................................. URBAN ............. 0.3648 0.3638
WEST VIRGINIA ....................................................................................................................... RURAL ............. 0.3134 0.3162
WEST VIRGINIA ....................................................................................................................... URBAN ............. 0.3677 0.3691
WYOMING ................................................................................................................................ RURAL ............. 0.4655 0.4714
WYOMING ................................................................................................................................ URBAN ............. 0.3592 0.3520
F. Proposed OPPS Payments to Certain transitional corridor payments are furnished during the period that begins
Rural Hospitals temporary payments for most providers, with the provider’s first cost reporting
with two exceptions, to ease their period beginning on or after January 1,
1. Hold Harmless Transitional Payment
transition from the prior reasonable 2004, and ends on December 31, 2005.
Changes Made by Pub. L. 109–171
cost-based payment system to the OPPS Accordingly, the authority for making
(DRA)
system. Cancer hospitals and children’s transitional corridor payments under
(If you choose to comment on issues hospitals receive the transitional section 1833(t)(7)(D)(i) of the Act, as
in this section, please include the corridor payments on a permanent amended by section 411 of Pub. L. 108–
caption ‘‘Rural Hospital Hold Harmless basis. Section 1833(t)(7)(D)(i) of the Act 173, expired for rural hospitals having
Transitional Payments’’ at the beginning originally provided for transitional 100 or fewer beds and SCHs located in
of your comment.) corridor payments to rural hospitals rural areas on December 31, 2005.
When the OPPS was implemented, with 100 or fewer beds for covered OPD Section 5105 of Pub. L. 109–171
every provider was eligible to receive an services furnished before January 1, reinstituted the hold harmless
additional payment adjustment 2004. However, section 411 of Pub. L. transitional outpatient payments (TOPs)
(transitional corridor payment) if the 108–173 amended section for covered OPD services furnished on
payments it received for covered OPD 1833(t)(7)(D)(i) of the Act to extend or after January 1, 2006, and before
services under the OPPS were less than these payments through December 31, January 1, 2009, for rural hospitals
the payments it would have received for 2005, for rural hospitals with 100 or having 100 or fewer beds that are not
the same services under the prior fewer beds. Section 411 also extended SCHs. When the OPPS payment is less
reasonable cost-based system. Section the transitional corridor payments to than the payment the provider would
1833(t)(7) of the Act provides that the SCHs located in rural areas for services have received under the previous
reasonable cost-based system, the clarify that EACHs are also eligible to the amount by which the cost of
amount of payment is increased by 95 receive the rural SCH adjustment, furnishing the service exceeds 1.75
percent of the amount of the difference assuming these entities otherwise meet times the APC payment rate.
between those two payment systems for the rural adjustment criteria (71 FR As explained in the CY 2007 OPPS/
CY 2006, by 90 percent of the amount 68010 and 68227). ASC final rule with comment period (71
of that difference for CY 2007, and by This adjustment is budget neutral and FR 68011 through 68012), we set our
85 percent of the amount of that applied before calculating outliers and projected target for aggregate outlier
difference for CY 2008. coinsurance. As stated in the CY 2006 payments at 1.0 percent of aggregate
For CY 2006, we implemented section OPPS final rule with comment period total payments under the OPPS for CY
5105 of Pub. L. 109–171 through (70 FR 68560), we would not reestablish 2007. The outlier thresholds were set so
Transmittal 877, issued on February 24, the adjustment amount on an annual that estimated CY 2007 aggregate outlier
2006. We did not specifically address basis, but we might review the payments would equal 1.0 percent of
whether TOPs payments apply to adjustment in the future and, if aggregate total payments under the
essential access community hospitals appropriate, would revise the OPPS. In that final rule with comment
(EACHs), which are considered to be adjustment. period (71 FR 68010), we also published
SCHs under section For CY 2008, we are proposing to total outlier payments as a percent of
1886(d)(5)(D)(iii)(III) of the Act. continue our current policy of a budget total expenditures for CY 2005. In the
Accordingly, under the statute, EACHs neutral 7.1 percent payment increase for past, we have received comments asking
are treated as SCHs. Therefore, we rural SCHs, including EACHs, for all us to publish estimated outlier
believe that EACHs are not currently services and procedures paid under the payments to provide a context for the
eligible for TOPs payment under Pub. L. OPPS, excluding drugs, biologicals, and proposed outlier thresholds for the
109–171. In the CY 2007 OPPS/ASC services paid under the pass-through update year. Our current estimate, using
final rule with comment period, we payment policy in accordance with available CY 2006 claims, is that outlier
updated § 419.70(d) to reflect the section 1833(t)(13)(B) of the Act. For CY payments for CY 2006 would be
requirements of Pub. L. 109 171 (71 FR 2008, we are proposing to include approximately 1.1 percent of total CY
68010 and 68228). brachytherapy sources in the group of 2006 OPPS payment. Using the same set
2. Proposed Adjustment for Rural services eligible for the 7.1 percent of claims and CY 2007 payment rates,
SCHs Implemented in CY 2006 Related payment increase because we are we currently estimate that outlier
to Public Law 108–173 (MMA) proposing to pay them at prospective payments for CY 2007 would be
(If you choose to comment on issues rates based on their median costs as approximately 1.0 percent of total CY
in this section, please include the calculated from historical claims data. 2007 OPPS payments. We note that we
caption ‘‘OPPS: Rural SCH Payments’’ at Consequently, we are proposing to provide estimated CY 2008 outlier
the beginning of your comment.) revise § 419.43 to reflect our proposal to payments by hospital for hospitals with
In the CY 2006 OPPS final rule with make brachytherapy sources eligible for claims included in the claims data that
comment period (70 FR 68556), we the 7.1 percent payment increase for we used to model impacts on the CMS
finalized a payment increase for rural rural SCHs. We plan to reassess the 7.1 Web site in the Hospital Specific
SCHs of 7.1 percent for all services and percent adjustment in the near future by Impacts—Provider-Specific Data file on
procedures paid under the OPPS, examining differences between urban the CMS Web site at: http://
excluding drugs, biologicals, and rural costs using updated claims, www.cms.hhs.gov/
brachytherapy seeds, and services paid cost, and provider information. In that HospitalOutpatientPPS/.
under pass-through payment policy in process, we will include brachytherapy For CY 2008, we are proposing to
accordance with section 1833(t)(13)(B) sources in each hospital’s mix of continue our policy of setting aside 1.0
of the Act, as added by section 411 of services. percent of aggregate total payments
Pub. L. 108 173. Section 411 gave the under the OPPS for outlier payments.
Secretary the authority to make an G. Proposed Hospital Outpatient Outlier
We are proposing that a portion of that
adjustment to OPPS payments for rural Payments 1.0 percent, 0.03 percent, would be
hospitals, effective January 1, 2006, if (If you choose to comment on issues allocated to CMHCs for partial
justified by a study of the difference in in this section, please include the hospitalization program service outliers.
costs by APC between hospitals in rural caption ‘‘OPPS: Outlier Payments’’ at This amount is the amount of estimated
and urban areas. Our analysis showed a the beginning of your comment.) outlier payments resulting from the
difference in costs only for rural SCHs Currently, the OPPS pays outlier proposed CMHC outlier threshold of 3.4
and we implemented a payment payments on a service-by-service basis. times the APC payment rate, as a
adjustment for those hospitals beginning For CY 2007, the outlier threshold is proportion of all payments dedicated to
January 1, 2006. met when the cost of furnishing a outlier payments. For further discussion
Last year, we became aware that we service or procedure by a hospital of CMHC outliers, we refer readers to
did not specifically address whether the exceeds 1.75 times the APC payment section II.B.3. of this proposed rule.
adjustment applies to EACHs, which are amount and exceeds the APC payment In order to ensure that estimated CY
considered to be SCHs under section rate plus a $1,825 fixed-dollar 2008 aggregate outlier payments would
1886(d)(5)(D)(iii)(III) of the Act. Thus, threshold. We introduced a fixed-dollar equal 1.0 percent of estimated aggregate
under the statute, EACHs are treated as threshold in CY 2005 in addition to the total payments under the OPPS, we are
SCHs. Currently, fewer than 10 traditional multiple threshold in order proposing that the outlier threshold be
hospitals are classified as EACHs. As of to better target outliers to those high set so that outlier payments would be
CY 1998, under section 4201(c) of Pub. cost and complex procedures where a triggered when the cost of furnishing a
L. 105–33, a hospital can no longer very costly service could present a service or procedure by a hospital
become newly classified as an EACH. hospital with significant financial loss. exceeds 1.75 times the APC payment
Therefore, in the CY 2007 OPPS/ASC If a provider meets both of these amount and exceeds the APC payment
final rule with comment period for conditions, the multiple threshold and rate plus a $2,000 fixed-dollar
purposes of receiving this rural the fixed-dollar threshold, the outlier threshold. This proposed threshold
adjustment, we revised § 419.43(g) to payment is calculated as 50 percent of reflects minor changes to the
methodology discussed below as well as appropriate for the OPPS because, with on CY 2006 claims that were adjusted to
APC recalibration, including changes the exception of the routine service cost approximate CY 2008 charges (using the
due in part to the CY 2008 packaging centers, hospitals use the same cost proposed charge inflation factor of
proposal discussed in section II.A.4. of centers to capture costs and charges 1.1504). We simulated aggregated CY
this proposed rule. across inpatient and outpatient services 2008 outlier payments using these costs
We calculated the fixed-dollar (69 FR 65845). for several different fixed-dollar
threshold for this CY 2008 proposed In comments on the CY 2007 OPPS/ thresholds, holding the 1.75 multiple
rule using largely the same methodology ASC proposed rule, a commenter asked constant and assuming that outlier
as we did in CY 2007, except that we that CMS modify the charge payment would continue to be made at
are proposing to adjust the overall CCRs methodology used to set the OPPS 50 percent of the amount by which the
to reflect the anticipated annual decline outlier threshold to account for the cost of furnishing the service would
in overall CCRs, discussed below, and to change in CCRs over time in a manner exceed 1.75 times the APC payment
use CCRs from the most recent update similar to that used for the FY 2007 amount, until the total outlier payments
to the Outpatient Provider-Specific File IPPS. The commenter indicated that it equaled 1.0 percent of aggregated
(OPSF), rather than CCRs we calculate would be appropriate to apply an estimated total CY 2008 OPPS
internally for ratesetting. In November inflation adjustment factor so that the payments. We estimate that a proposed
2006, we issued Transmittal 1030, CCRs that CMS uses to simulate OPPS fixed dollar threshold of $2,000,
‘‘Policy Changes to the Fiscal outlier payments would more closely combined with the proposed multiple
Intermediary (FI) Calculation of reflect the CCRs that would be used in threshold of 1.75 times the APC
Hospital Outpatient Payment System CY 2007 to determine actual outlier payment rate, would allocate 1.0
(OPPS) and Community Mental Health payment. In the CY 2007 OPPS/ASC percent of aggregated total OPPS
Center (CMHC) Cost-to-Charge Ratios final rule with comment period, we payments to outlier payments. We are
(CCRs),’’ instructing fiscal expressed concern that cost increases proposing to continue to make an
intermediaries (or, if applicable, the between inpatient and outpatient outlier payment that equals 50 percent
MAC) to update the overall CCR departments could be different and of the amount by which the cost of
calculation for outlier and other cost- indicated that we would study the issue furnishing the service exceeds 1.75
based payments using the CCR and address any changes to the outlier times the APC payment amount when
calculation methodology that we methodology through future rulemaking both the 1.75 multiple threshold and the
finalized for CY 2007. As discussed in (71 FR 68012). fixed dollar $2,000 threshold are met.
the CY 2007 proposed and final rules, In assessing the possibility of utilizing For CMHCs, if a CMHC provider’s cost
this methodology aligned the fiscal a cost inflation adjustment for the OPPS, for partial hospitalization exceeds 3.4
intermediary’s CCR calculation and the we determined that we could not times the payment rate for APC 0033,
CCR calculation we previously used to calculate an OPPS-specific reliable cost the outlier payment is calculated as 50
model outlier thresholds by removing per unit, comparable to the cost per percent of the amount by which the cost
allied and nursing health costs for those discharge component of the IPPS exceeds 3.4 times the APC payment rate.
hospitals with paramedical education calculation, because of variability in
programs from the fiscal intermediary’s definition of an OPPS unit of service H. Calculation of the Proposed National
CCR calculation and weighting our across calendar years. However, we also Unadjusted Medicare Payment
‘‘traditional’’ CCR calculation by total believe that the costs and charges (If you choose to comment on issues
Medicare Part B charges. We believe reported under the applicable cost in this section, please include the
that the OPSF best estimates the CCRs centers largely are commingled caption ‘‘OPPS: National Unadjusted
that fiscal intermediaries (or, if inpatient and outpatient costs and Medicare Payment’’ at the beginning of
applicable, MAC) would use to charges. Notwithstanding fairly accurate your comment.)
determine outlier payments in CY 2008. estimates of outlier payments as a The basic methodology for
For this proposed rule, we used the percent of total payments over the past determining prospective payment rates
April update to the OPSF. We few years, as discussed above, we do not for OPD services under the OPPS is set
supplemented a CCR calculated want to systematically overestimate the forth in existing regulations at § 419.31
internally for the handful of providers OPPS outlier threshold as could occur if and § 419.32. The payment rate for
with claims in our claims dataset that we did not apply a CCR inflation services and procedures for which
were not listed in the April update to adjustment factor. Therefore, we are payment is made under the OPPS is the
the OPSF. proposing to apply the CCR inflation product of the conversion factor
The claims that we use to model each adjustment factor that is proposed to be calculated in accordance with section
OPPS update lag by 2 years. For this applied for IPPS outlier calculation to II.C. of this proposed rule and the
proposed rule, we used CY 2006 claims the CCRs used to simulate the CY 2008 relative weight determined under
to model the CY 2008 OPPS. In order to OPPS outlier payments that determine section II.A. of this proposed rule.
estimate CY 2008 outlier payments for the fixed dollar threshold. Specifically, Therefore, the national unadjusted
this proposed rule, we inflated the for CY 2008, we are proposing to apply payment rate for each APC contained in
charges on the CY 2006 claims using the an adjustment of 0.9912 to the CCRs that Addendum A to this proposed rule and
same inflation factor of 1.1504 that we are currently on the OPSF to trend them for HCPCS codes to which payment
used to estimate the IPPS fixed dollar forward from CY 2007 to CY 2008. The under the OPPS has been assigned in
outlier threshold for the FY 2008 IPPS methodology for calculating this Addendum B to this proposed rule
proposed rule. For 1 year, the inflation adjustment is discussed in the FY 2008 (Addendum B is provided as a
factor is 1.0726. The methodology for IPPS proposed rule (72 FR 24837). convenience for readers) was calculated
determining this charge inflation factor Therefore, for this CY 2008 proposed by multiplying the proposed CY 2008
was discussed in the FY 2008 IPPS rule, we applied the overall CCRs from scaled weight for the APC by the
proposed rule (72 FR 24837). As we the April 2007 OPSF file after proposed CY 2008 conversion factor.
stated in the CY 2005 OPPS final rule adjustment to approximate CY 2008 However, to determine the payment
with comment period, we believe that CCRs (using the proposed CCR inflation that will be made in a calendar year
the use of this charge inflation factor is adjustment factor of 0.9912) to charges under the OPPS to a specific hospital for
an APC for a service that has a status by the amount determined under Step 1 CY 2004. (We refer readers to the
indicator of ‘‘S,’’ ‘‘T,’’ ‘‘V,’’ or ‘‘X’’ in a that represents the labor-related portion November 7, 2003 OPPS final rule with
circumstance in which the multiple of the national unadjusted payment rate. comment period (68 FR 63458).) The
procedure discount does not apply, we Step 5. Calculate 40 percent (the proposed unadjusted copayment
take the following steps: nonlabor-related portion) of the national amounts for services payable under the
Step 1. Calculate 60 percent (the unadjusted payment rate and add that OPPS that would be effective January 1,
labor-related portion) of the national amount to the resulting product of Step 2008, are shown in Addendum A and
unadjusted payment rate. Since the 4. The result is the wage index adjusted Addendum B to this proposed rule.
initial implementation of the OPPS, we payment rate for the relevant wage We note that we have historically
have used 60 percent to represent our index area. used standard rounding principles to
estimate of that portion of costs Step 6. If a provider is a SCH, as establish a 20 percent copayment for
attributable, on average, to labor. (We defined in § 412.92, or an EACH, which those few circumstances where the
refer readers to the April 7, 2000 final is considered to be a SCH under section copayment rate was between 19.5 and
rule with comment period (65 FR 18496 1886(d)(5)(D)(iii)(III) of the Act, and 20 percent using our established
through 18497) for a detailed discussion located in a rural area, as defined in copayment rules. For example, the CY
of how we derived this percentage.) We § 412.63(b), or is treated as being located 2008 proposed payment and copayment
confirmed that this labor-related share in a rural area under § 412.103, multiply amounts for APC 9228 (Tigecycline
for hospital outpatient services is still the wage index adjusted payment rate injection) are $0.91 and $0.18,
appropriate during our regression by 1.071 to calculate the total payment. respectively. Twenty percent of $0.91 is
analysis for the payment adjustment for $0.182. Because it would be impossible
I. Proposed Beneficiary Copayments
rural hospitals in the CY 2006 OPPS to set a copayment rate at exactly 20
final rule with comment period (70 FR (If you choose to comment on issues percent in this case, that is, $0.182, we
68553). in this section, please include the rounded the amount, using standard
Step 2. Determine the wage index area caption ‘‘OPPS: Beneficiary rounding principles, to $0.18. Also
in which the hospital is located and Copayments’’ at the beginning of your using standard rounding principles,
identify the wage index level that comment.) 19.78 percent ($0.18 as a percentage of
applies to the specific hospital. The $0.91) rounds to 20 percent and meets
1. Background
wage index values assigned to each area the statutory requirement of a
reflect the new geographic statistical Section 1833(t)(3)(B) of the Act copayment amount of at least 20
areas as a result of revised OMB requires the Secretary to set rules for percent. For CY 2008, APC 9046 (Iron
standards (urban and rural) to which determining copayment amounts to be Sucrose Injection) has a proposed
hospitals are assigned for FY 2008 paid by beneficiaries for covered OPD payment amount and copayment
under the IPPS, reclassifications services. Section 1833(t)(8)(C)(ii) of the amount of $0.37 and $0.08, respectively.
through the MCGRB, section Act specifies that the Secretary must Using our established copayment rules,
1886(d)(8)(B) ‘‘Lugar’’ hospitals, and reduce the national unadjusted 20 percent of $0.37 is $0.074. Normally,
section 401 of Pub. L. 108–173. We note copayment amount for a covered OPD we would apply standard rounding
that the reclassifications of hospitals service (or group of such services) principles to achieve an amount that is
under the one-time appeals process furnished in a year in a manner so that payable, here $0.07 rather than $0.074.
under section 508 of Pub. L. 108–173 the effective copayment rate However, if we were to set a copayment
expires on September 30, 2007, and is (determined on a national unadjusted amount of $0.07, which is 18.9 percent
no longer applicable in this basis) for that service in the year does of $0.37, we would not be setting a
determination of appropriate wage not exceed specified percentages. For all copayment rate that is at least 20
values for CY 2008 OPPS. The wage services paid under the OPPS in CY percent of the OPPS payment rate. We
index values include the occupational 2008, and in calendar years thereafter, believe that section 1833(t)(3)(B) of the
mix adjustment described in section the specified percentage is 40 percent of Act requires us to set a copayment
II.D. of this proposed rule that was the APC payment rate (section amount that is at least 20 percent of the
developed for the proposed FY 2008 1833(t)(8)(C)(ii)(V) of the Act). Section OPPS payment amount, not less than 20
IPPS payment rates published in the 1833(t)(3)(B)(ii) of the Act provides that, percent. Therefore, we are proposing to
Federal Register on May 3, 2007 (72 FR for a covered OPD service (or group of set the copayment rate for APC 9046 at
24777 through 27782). such services) furnished in a year, the $0.08. Eight cents represents the lowest
Step 3. Adjust the wage index of national unadjusted coinsurance amount that we could set that would
hospitals located in certain qualifying amount cannot be less than 20 percent bring the copayment rate to 20 percent
counties that have a relatively high of the OPD fee schedule amount. or, in this case, just above 20 percent.
percentage of hospital employees who Sections 1834(d)(2)(C)(ii) and We are proposing to apply this same
reside in the county, but who work in (d)(3)(C)(ii) of the Act further requires methodology in the future to instances
a different county with a higher wage that the coinsurance for screening where the application of our standard
index, in accordance with section 505 of flexible sigmoidoscopies and screening copayment methodology would result in
Pub. L. 108–173. Addendum L to this colonoscopies be equal to 25 percent of a copayment amount that is under 20
proposed rule contains the qualifying the payment amount. We have applied percent and cannot be rounded, under
counties and the proposed wage index the 25-percent coinsurance to screening standard rounding principles, to 20
increase developed for the FY 2008 IPPS flexible sigmoidoscopies and screening percent.
as corrected in the June 7, 2007 colonoscopies since the beginning of the
correction notice to the FY 2008 IPPS OPPS. 3. Calculation of a Proposed Adjusted

proposed rule (72 FR 31507). This step Copayment Amount for an APC Group
is to be followed only if the hospital has 2. Proposed Copayment To calculate the OPPS adjusted
chosen not to accept reclassification For CY 2008, we are proposing to copayment amount for an APC group,
under Step 2 above. determine copayment amounts for new take the following steps:
Step 4. Multiply the applicable wage and revised APCs using the same Step 1. Calculate the beneficiary
index determined under Steps 2 and 3 methodology that we implemented for payment percentage for the APC by
dividing the APC’s national unadjusted III. Proposed OPPS Ambulatory We designated the payment status of
copayment by its payment rate. For Payment Classification (APC) Group these codes and added them through the
example, using APC 0001, $7.00 is 21 Policies July 2007 update (Change Request 5623,
percent of $33.15. A. Proposed Treatment of New HCPCS Transmittal 1259, dated June 1, 2007).
Step 2. Calculate the wage adjusted and CPT Codes There were no new Level II HCPCS
payment rate for the APC, for the codes for the April 2007 update. In this
(If you choose to comment on issues CY 2008 OPPS/ASC proposed rule, we
provider in question, as indicated in in this section, please include the
section II.H. of this proposed rule. are soliciting public comment on the
caption ‘‘OPPS: New HCPCS and CPT status indicators, APC assignments, and
Calculate the rural adjustment for Codes’’ at the beginning of your payment rates of these codes, which are
eligible providers as indicated in section comment.)
listed in Table 26A and Table 26B of
II.H. of this proposed rule.
1. Proposed Treatment of New HCPCS this proposed rule. Because of the
Step 3. Multiply the percentage Codes Included in the April and July timing of this proposed rule, the codes
calculated in Step 1 by the payment rate Quarterly OPPS Updates for CY 2007 implemented through the July 2007
calculated in Step 2. The result is the For the July quarter of CY 2007, we OPPS update are not included in
wage-adjusted copayment amount for created a total of 16 new Level II HCPCS Addendum B to this proposed rule. We
the APC. codes, specifically C2638, C2639, are proposing to assign the new HCPCS
The proposed unadjusted copayments C2640, C2641, C2642, C2643, C2698, codes for CY 2008 to the appropriate
for services payable under the OPPS C2699, C9728, Q4087, Q4088, Q4089, APCs with the proposed rates as
that would be effective January 1, 2008, Q4090, Q4091, Q4092, and Q4095 that displayed in the tables and incorporate
are shown in Addendum A and were not addressed in the CY 2007 them into our final rule with comment
Addendum B to this proposed rule. OPPS/ASC final rule with comment period for CY 2008, which is consistent
period that updated the CY 2007 OPPS. with our annual APC updating policy.
TABLE 26A.—NEW NON-DRUG HCPCS CODES IMPLEMENTED IN JULY 2007

Proposed Proposed
Proposed
HCPCS CY 2008 CY 2008 Implementation
Long descriptor CY 2008
code status payment date
APC
indicator rate
C2638 ...... Brachytherapy source, stranded, iodine-125, per source .................... K .............. 2638 $ 42.86 July 1, 2007.
C2639 ...... Brachytherapy source, non-stranded, iodine-125, per source ............. K .............. 2639 31.91 July 1, 2007.
C2640 ...... Brachytherapy source, stranded, palladium-103, per source .............. K .............. 2640 62.24 July 1, 2007.
C2641 ...... Brachytherapy source, non-stranded, palladium-103, per source ....... K .............. 2641 45.29 July 1, 2007.
C2642 ...... Brachytherapy source, stranded, cesium-131, per source .................. K .............. 2642 97.72 July 1, 2007.
C2643 ...... Brachytherapy source, non stranded, cesium-131, per source ........... K .............. 2643 51.35 July 1, 2007.
C2698 ...... Brachytherapy source, stranded, not otherwise specified, per source K .............. 2698 42.86 July 1, 2007.
C2699 ...... Brachytherapy source, non-stranded, not otherwise specified, per K .............. 2699 29.93 July 1, 2007.
source.
C9728 ...... Placement of interstitial device(s) for radiation therapy/surgery guid- T .............. 0156 194.91 July 1, 2007.
ance (eg, fiducial markers, dosimeter), other than prostate (any
approach) single or multiple.
TABLE 26B.—NEW DRUG HCPCS CODES IMPLEMENTED IN JULY 2007

Proposed Proposed
Proposed
HCPCS CY 2008 CY 2008 Implementation
Long descriptor CY 2008
code status payment date
APC
indicator rate
Q4087 ...... Injection, immune globulin, (Octogam), intravenous, non-lyophilized, K .............. 0943 $ 33.48 July 1, 2007.
(e.g. liquid), 500 mg.
Q4088 ...... Injection, immune globulin, (Gammagard), intravenous, non- K .............. 0944 31.20 July 1, 2007.
lyophilized, (e.g. liquid), 500 mg.
Q4089 ...... Injection, rho(d) immune globulin (human), (Rhophylac), intravenous, K .............. 0945 80.00 July 1, 2007.
100 iu.
Q4090 ...... Injection, hepatitis b immune globulin (Hepagam B), intramuscular, K .............. 0946 64.74 July 1, 2007.
0.5 ml.
Q4091 ...... Injection, immune globulin, (Flebogamma), intravenous, non- K .............. 0947 32.61 July 1, 2007.
lyophilized, (e.g. liquid), 500 mg.
Q4092 ...... Injection, immune globulin, (Gamunex), intravenous, non-lyophilized, K .............. 0948 31.86 July 1, 2007.
(e.g. liquid), 500 mg.
Q4095 ...... Injection, zoledronic acid (Reclast), 1 mg ............................................ K .............. 0951 220.81 July 1, 2007.
2. Proposed Treatment of New Category CPT codes and new Level II HCPCS following calendar year. These codes are
I and III CPT Codes and Level II HCPCS codes, which are released in the flagged with comment indicator ‘‘NI’’ in
Codes summer through the fall of each year for Addendum B to the OPPS/ASC final
As has been our practice in the past, annual updating, effective January 1, in rule with comment period to indicate
we implement new Category I and III the final rule updating the OPPS for the that we are assigning them an interim
payment status which is subject to will be open to public comment. We process) and the new Category III codes
public comment following publication will respond to all comments received released in July 2007 for
of the final rule that implements the concerning these codes in a subsequent implementation on January 1, 2008.
annual OPPS update. (We refer readers final rule. However, only those new Category III
to the discussion immediately below In addition, we are proposing to CPT codes implemented effective
concerning our policy for implementing continue our policy of the last 2 years January 1, 2008, will be flagged with
new Category I and III mid-year CPT of recognizing new mid-year CPT codes, comment indicator ‘‘NI’’ in Addendum
codes.) We are proposing to continue generally Category III CPT codes, that B to the CY 2008 OPPS/ASC final rule
this recognition and process for CY the AMA releases in January for with comment period, to indicate that
2008. New Category I and III CPT codes implementation the following July we have assigned them an interim
and new Level II HCPCS codes, effective through the OPPS quarterly update payment status which is subject to
January 1, 2008, will be listed in process. Therefore, for CY 2008, we are public comment. Category III CPT codes
Addendum B to the CY 2008 OPPS/ASC proposing to include in Addendum B to implemented in July 2007, which
final rule with comment period and the CY 2008 OPPS/ASC final rule with appear in Table 27 below, are subject to
designated using comment indicator comment period the new Category III comment through this proposed rule,
‘‘NI.’’ The status indicator, the APC CPT codes released in January 2007 for and their status will be finalized in the
assignment, or both, for all such codes implementation on July 1, 2007 CY 2008 OPPS/ASC final rule with
flagged with comment indicator ‘‘NI’’ (through the OPPS quarterly update comment period.
TABLE 27.—CATEGORY III CPT CODES IMPLEMENTED IN JULY 2007

Proposed
HCPCS CY 2008 Proposed CY
Long descriptor
code status 2008 APC
indicator
0178T ....... Electrocardiogram, 64 leads or greater, with graphic presentation and analysis; with interpretation B .............. Not applicable.
and report.
0179T ....... Electrocardiogram, 64 leads or greater, with graphic presentation and analysis; tracing and X .............. 0100.
graphics only, without interpretation and report.
0180T ....... Electrocardiogram, 64 leads or greater, with graphic presentation and analysis; interpretation and B .............. Not applicable.
report only.
0181T ....... Corneal hysteresis determination, by air impulse stimulation, bilateral, with interpretation and re- S .............. 0230.
port.
0182T ....... High dose rate electronic brachytherapy, per fraction ....................................................................... S .............. 1519.
B. Proposed Changes—Variations radiopharmaceuticals, and relative to the hospital median cost of

Within APCs brachytherapy devices. the services included in APC 0606. The
(If you choose to comment on issues We have packaged into payment for APC weights are scaled to APC 0606
in this section, please include the each procedure or service within an because it is the middle level clinic visit
caption ‘‘OPPS: 2 Times Rule’’ at the APC group the costs associated with APC (that is, where the Level 3 Clinic
beginning of your comment.) those items or services that are directly Visit HCPCS code of five levels of clinic
related to and supportive of performing visits is assigned), and because middle
1. Background the main procedures or furnishing level clinic visits are among the most
Section 1833(t)(2)(A) of the Act services. Therefore, we do not make frequently furnished services in the
requires the Secretary to develop a separate payment for packaged items or hospital outpatient setting.
classification system for covered services. For example, packaged items
and services include: (1) Use of an Section 1833(t)(9)(A) of the Act
hospital outpatient services. Section
operating, treatment, or procedure room; requires the Secretary to review the
1833(t)(2)(B) of the Act provides that
(2) use of a recovery room; (3) most components of the OPPS not less than
this classification system may be
observation services; (4) anesthesia; (5) annually and to revise the groups and
composed of groups of services, so that
services within each group are medical/surgical supplies; (6) relative payment weights and make
comparable clinically and with respect pharmaceuticals (other than those for other adjustments to take into account
to the use of resources. In accordance which separate payment may be changes in medical practice, changes in
with these provisions, we developed a allowed under the provisions discussed technology, and the addition of new
grouping classification system, referred in section V. of this proposed rule); and services, new cost data, and other
to as APCs, as set forth in § 419.31 of the (7) incidental services such as relevant information and factors.
regulations. We use Level I and Level II venipuncture. Our proposed packaging Section 1833(t)(9)(A) of the Act, as
HCPCS codes and descriptors to identify approach for CY 2008 is discussed in amended by section 201(h) of the BBRA
and group the services within each APC. section II.A.4. of this proposed rule. of 1999, also requires the Secretary,
The APCs are organized such that each Under the OPPS, we pay for hospital beginning in CY 2001, to consult with
group is homogeneous both clinically outpatient services on a rate-per-service an outside panel of experts to review the
and in terms of resource use. Using this or, as proposed for CY 2008, on a rate- APC groups and the relative payment
classification system, we have per-encounter basis that varies weights (the APC Panel
established distinct groups of similar according to the APC group to which recommendations for specific services
services, as well as medical visits. We the independent service or combination for the CY 2008 OPPS and our responses
also have developed separate APC of services is assigned. Each APC weight to them are discussed in the relevant
groups for certain medical devices, represents the hospital median cost of specific sections throughout this
drugs, biologicals, the services included in that APC proposed rule).
Finally, as discussed earlier, section many cases, the proposed HCPCS code recommendations were based on
1833(t)(2) of the Act provides that, reassignments and associated APC explicit consideration of resource use,
subject to certain exceptions, the items reconfigurations for CY 2008 included clinical homogeneity, hospital
and services within an APC group in this proposed rule are related to specialization, and the quality of the
cannot be considered comparable with changes in median costs of services and data used to determine the APC
respect to the use of resources if the APCs resulting from our proposed payment rates that we are proposing for
highest median (or mean cost, if elected packaging approach for CY 2008, as CY 2008. The median costs for hospital
by the Secretary) for an item or service discussed in section II.A.4. of this outpatient services for these and all
in the group is more than 2 times greater proposed rule. We also are proposing other APCs that were used in the
than the lowest median cost for an item changes to the status indicators for some development of this proposed rule can
or service within the same group codes that are not specifically and be found on the CMS Web site at:
(referred to as the ‘‘2 times rule’’). We separately discussed in this proposed http://www.cms.hhs.gov.
use the median cost of the item or rule. In these cases, we are proposing to
service in implementing this provision. change the status indicators for some TABLE 28.—PROPOSED APC EXCEP-
The statute authorizes the Secretary to codes because we believe that another TIONS TO THE 2 TIMES RULE FOR
make exceptions to the 2 times rule in status indicator more accurately CY 2008
unusual cases, such as low-volume describes their payment status from an
items and services. OPPS perspective based on the policies APC APC title
2. Application of the 2 Times Rule that we are proposing for CY 2008.
Addendum B to this proposed rule 0033 ..... Partial Hospitalization.
In accordance with section 1833(t)(2) identifies with a comment indicator 0043 ..... Closed Treatment Fracture Finger/
of the Act and § 419.31 of the ‘‘CH’’ those HCPCS codes for which we Toe/Trunk.
regulations, we annually review the 0060 ..... Manipulation Therapy.
are proposing a change to the APC 0080 ..... Diagnostic Cardiac Catheterization.
items and services within an APC group assignment or status indicator as
to determine, with respect to 0093 ..... Vascular Reconstruction/Fistula
assigned in the April 2007 Addendum Repair without Device.
comparability of the use of resources, if B update. 0105 ..... Repair/Revision/Removal of Pace-
the median of the highest cost item or makers, AICDs, or Vascular De-
service within an APC group is more 3. Proposed Exceptions to the 2 Times vices.
than 2 times greater than the median of Rule 0106 ..... Insertion/Replacement of Pace-
the lowest cost item or service within As discussed earlier, we may make maker Leads and/or Electrodes.
that same group (‘‘2 times rule’’). We exceptions to the 2 times limit on the 0109 ..... Removal/Repair of Implanted De-
make exceptions to this limit on the variation of costs within each APC vices.
variation of costs within each APC 0235 ..... Level I Posterior Segment Eye
group in unusual cases such as low
group in unusual cases such as low Procedures.
volume items and services. Taking into 0251 ..... Level I ENT Procedures.
volume items and services. account the APC changes that we are 0260 ..... Level I Plain Film Except Teeth.
During the APC Panel’s March 2007 proposing for CY 2008 based on the 0278 ..... Diagnostic Urography.
meeting, we presented median cost and APC Panel recommendations discussed 0282 ..... Miscellaneous Computed Axial To-
utilization data for services furnished mainly in sections III.C. and III.D. of this mography.
during the period of January 1, 2006, proposed rule, the proposed changes to 0303 ..... Treatment Device Construction.
through September 30, 2006, about status indicators and APC assignments 0323 ..... Extended Individual Psycho-
which we had concerns or about which as identified in Addendum B to this therapy.
the public had raised concerns 0330 ..... Dental Procedures.
proposed rule, and the use of CY 2006 0340 ..... Minor Ancillary Procedures.
regarding their APC assignments, status claims data to calculate the median
indicator assignments, or payment rates. 0368 ..... Level II Pulmonary Tests.
costs of procedures classified in the 0381 ..... Single Allergy Tests.
The discussions of most service-specific APCs, we reviewed all the APCs to 0409 ..... Red Blood Cell Tests.
issues, the APC Panel recommendations determine which APCs would not 0432 ..... Health and Behavior Services.
if any, and our proposals for CY 2008 satisfy the 2 times rule. We used the 0438 ..... Level III Drug Administration.
are contained principally in sections following criteria to decide whether to 0604 ..... Level 1 Hospital Clinic Visits.
III.C. and III.D. of this proposed rule. 0664 ..... Level I Proton Beam Radiation
propose exceptions to the 2 times rule
In addition to the assignment of Therapy.
for affected APCs:
specific services to APCs that we 0688 ..... Revision/Removal of
• Resource homogeneity. Neurostimulator Pulse Generator
discussed with the APC Panel, we also • Clinical homogeneity.
identified APCs with 2 times violations Receiver.
• Hospital concentration.
that were not specifically discussed • Frequency of service (volume).
with the APC Panel but for which we • Opportunity for upcoding and code C. New Technology APCs
are proposing changes to their HCPCS fragments. (If you choose to comment on issues
codes’ APC assignments in Addendum For a detailed discussion of these in this section, please include the
B to this proposed rule. In these cases, criteria, we refer readers to the April 7, caption ‘‘New Technology APCs’’ at the
to eliminate a 2 times violation or to 2000 OPPS final rule with comment beginning of your comment.)
improve clinical and resource period (65 FR 18457).
homogeneity, we are proposing to Table 28 lists the APCs that we are 1. Introduction
reassign the codes to APCs that proposing to exempt from the 2 times In the November 30, 2001 final rule
contained services that were similar rule for CY 2008 based on the criteria (66 FR 59903), we finalized changes to
with regard to both their clinical and cited above. For cases in which a the time period a service was eligible for
resource characteristics. We also are recommendation by the APC Panel payment under a New Technology APC.
proposing to rename existing APCs, appeared to result in or allow a Beginning in CY 2002, we retain
discontinue existing APCs, or create violation of the 2 times rule, we services within New Technology APC
new clinical APCs to complement generally accepted the APC Panel’s groups until we gather sufficient claims
proposed HCPCS code reassignments. In recommendation because those data to enable us to assign the service
to a clinically appropriate APC. This clinical APC for CY 2008. While we caption ‘‘PET/CT Scans’’ at the
policy allows us to move a service from might have sufficient claims data from beginning of your comment.)
a New Technology APC in less than 2 6 months of CY 2006 to support a From August 2000 through April
years if sufficient data are available. It proposal for such a reassignment for CY 2005, we paid separately for PET and
also allows us to retain a service in a 2008, we are not confident that this CT scans. In CY 2004, the payment rate
New Technology APC for more than 3 would always be the case for all new for nonmyocardial PET scans was
years if sufficient data upon which to services, given our understanding of the $1,450, while it was $193 for typical
base a decision for reassignment have dissemination of new technology diagnostic CT scans. Prior to CY 2005,
not been collected. procedures into medical practice and nonmyocardial PET and the PET portion
We note that the cost bands for New the diverse characteristics of new of PET/CT scans were described by G-
Technology APCs range from $0 to $50 technology services that treat different codes for billing to Medicare. Several
in increments of $10, from $50 to $100 clinical conditions. Therefore, we are commenters to the November 15, 2004
in increments of $50, from $100 through not accepting the APC Panel’s final rule with comment period (69 FR
$2,000 in increments of $100, and from recommendation because we believe 65682) urged that we replace the G-
$2,000 through $10,000 in increments of that accepting the recommendation codes for nonmyocardial PET and PET/
$500. These increments, which are in would limit our ability to individually CT scan procedures with the established
two parallel sets of New Technology assess the OPPS treatment of each new CPT codes. These commenters stated
APCs, one with status indicator ‘‘S’’ and technology service in the context of that movement to the established CPT
the other with status indicator ‘‘T,’’ available hospital claims data. We are codes would greatly reduce the burden
allow us to price new technology particularly concerned about continuing on hospitals of tracking and billing the
services more appropriately and to provide appropriate payment for low G-codes which are not recognized by
consistently. volume new technology services that other payers and would allow for more
may be expected to continue to be low uniform hospital billing of these scans.
2. Proposed Movement of Procedures
volume under the OPPS due to the We agreed with the commenters that
From New Technology APCs to Clinical
prevalence of the target conditions in movement from the G-codes to the
APCs
the Medicare population. We appreciate established CPT codes for
As we explained in the November 30, nonmyocardial PET and PET/CT scans
the APC Panel’s thoughtful discussion
2001 final rule (66 FR 59897), we would allow for more uniform billing of
of new technology services, and we
generally keep a procedure in the New these scans. As a result of a Medicare
agree with the APC Panel that it should
Technology APC to which it is initially national coverage determination
be our priority to regularly reassign
assigned until we have collected data (Publication 100–3, Medicare Claims
services from New Technology APCs to
sufficient to enable us to move the Processing Manual section 220.6) that
procedure to a clinically appropriate clinical APCs under the OPPS, so that
they are treated like most other OPPS was made effective January 28, 2005, we
APC. However, in cases where we find discontinued numerous G-codes that
that our original New Technology APC services for purposes of ratesetting once
hospitals have had sufficient experience described myocardial PET and
assignment was based on inaccurate or nonmyocardial PET procedures and
inadequate information, or where the with providing and reporting the new
services. Rather, consistent with our replaced them with the established CPT
New Technology APCs are restructured, codes. The CY 2005 payment rate for
we may, based on more recent resource current policy, for CY 2008 we are
concurrent PET/CT scans using the CPT
utilization information (including proposing to retain services within New
codes 78814 (Tumor imaging, positron
claims data) or the availability of refined Technology APC groups until we gather
emission tomography (PET) with
New Technology APC cost bands, sufficient claims data to enable us to
concurrently acquired computed
reassign the procedure or service to a assign the service to a clinically
tomography (CT) for attenuation
different New Technology APC that appropriate APC. The flexibility
correction and anatomical localization;
most appropriately reflects its cost. associated with this policy allows us to
limited area (eg, chest, head/neck);
At its March 2007 meeting, the APC move a service from a New Technology
78815 (Tumor imaging, positron
Panel recommended that CMS keep APC in less than 2 years if sufficient
emission tomography (PET) with
services in New Technology APCs until data are available. It also allows us to
concurrently acquired computed
sufficient data are available to assign retain a service in a New Technology tomography (CT) for attenuation
them to clinical APCs, but for no longer APC for more than 2 years if sufficient correction and anatomical localization;
than 2 years. We note that because of hospital claims data upon which to base skull base to mid-thigh); and 78816
the potential for quarterly assignment of a decision for reassignment have not Tumor imaging, positron emission
new services to New Technology APCs been collected. tomography (PET) with concurrently
and the 2 year time lag in claims data The procedures presented below acquired computed tomography (CT) for
for an OPPS update (that is, CY 2006 represent services assigned to New attenuation correction and anatomical
data are utilized for this CY 2008 OPPS Technology APCs for CY 2007 for which localization; whole body) was $1,250,
rulemaking cycle), if we were to accept we believe we have sufficient data to which was $100 higher than the
the APC Panel’s recommendation, we reassign them to clinically appropriate payment rate for PET scans alone. These
would always reassign services from APCs for CY 2008. Therefore, we are PET/CT CPT codes were placed in New
New Technology to clinical APCs based proposing to reassign them to clinically Technology APC 1514 (New
on 1 year or less of claims data. For appropriate APCs as indicated Technology—Level XIV, $1,200–$1,300)
example, if a new service was first specifically in our discussion and in for CY 2005.
assigned to a New Technology APC in Table 29 of this proposed rule. We continued with these coding and
July 2006, we would have 6 months of a. Positron Emission Tomography payment methodologies in CY 2006. For
data for purposes of CY 2008 (PET)/Computed Tomography (CT) CY 2007, while we proposed to reassign
rulemaking but, in order to ensure that Scans (New Technology APC 1511) both PET and PET/CT Scans to the same
the service was in a New Technology new clinical APC, we finalized a policy
APC for no longer than 2 years, we (If you choose to comment on issues that reassigned conventional PET
would need to move the service to a in this section, please include the procedures to APC 0308 (Non-
Myocardial Positron Emission clinical APC where nonmyocardial PET estimates of their costs until we gather
Tomography (PET) Imaging) with a final scans are also assigned, specifically APC sufficient claims data to enable us to
median cost of about $850. We also 0308, with a proposed median cost of assign the services to clinically
reassigned PET/CT services to a $1,093.52. appropriate APCs based on hospital
different New Technology APC for CY We note that we have been paying resource costs as calculated from claims.
2007, specifically New Technology APC separately for fluorodeoxyglucose According to our analysis of the hospital
1511 (New Technology—Level XI, (FDG), the radiopharmaceutical outpatient claims data, we believe we
$900–$1000), thereby maintaining the described by HCPCS code A9552 (F18 have adequate claims data from CY 2006
historical payment differential of about fdg), that is commonly administered upon which to determine the median
$100 between PET and PET/CT during nonmyocardial PET and PET/CT cost of performing IVIG
procedures. Furthermore, we stated in procedures. For CY 2008, consistent preadministration related services and
the CY 2007 OPPS/ASC final rule with with our proposed packaging approach to reassign HCPCS code G0332 to an
comment period (71 FR 68022) that we as discussed in section II.A.4. of this appropriate clinical APC for CY 2008.
would wait for a full year of CPT coded proposed rule, we are proposing to Our claims data for this high volume
claims data prior to assigning the PET/ package payment for the diagnostic service show a total of over 49,000
CT services to a clinical APC and that radiopharmaceutical FDG into payment services performed, with about 48,000
maintaining a modest payment for the associated PET and PET/CT single claims available for ratesetting.
differential between PET and PET/CT procedures. Because FDG is the most The median cost of this service
procedures was warranted for CY 2007. commonly used radiopharmaceutical for according to our claims data is $38.52.
both PET and PET/CT scans and our Therefore, we are proposing to reassign
For CY 2008, we are proposing the
single claims for these procedures HCPCS code G0332 to new clinical APC
reassignment of concurrent PET/CT
include FDG more than 80 percent of 0430 (Drug Preadministration-Related
scans, specifically CPT codes 78814,
the time, the packaging of this Services) with a median cost of $38.52
78815, and 78816, to a clinical APC
radiopharmaceutical fully maintains the for CY 2008, where it would be the only
because we believe we have adequate
clinical and resource homogeneity of service assigned to the APC at this time.
claims data from CY 2006 upon which
the reconfigured APC 0308 that we are We note that IVIG preadministration-
to determine the median cost of
proposing. related services are always provided in
performing these procedures. Based on
conjunction with other separately
our analysis of approximately 117,000 b. IVIG Preadministration-Related
payable services such as drug
CY 2006 single claims, the median cost Services (New Technology APC 1502)
administration services, and thus are
of PET/CT scans is $1,093.52. In (If you choose to comment on issues well suited for packaging into the
comparison, the median cost of the in this section, please include the payment for the separately payable
nonmyocardial PET scans, as described caption ‘‘IVIG Preadministration- services. While at this time we have not
by CPT codes 78608, 78811, 78812, and Related Services’’ at the beginning of made a determination about the
78813, is $1,093.51 based on our your comment.) appropriateness of continuing separate
analysis of approximately 34,000 single In CY 2006, we created the temporary OPPS payment for HCPCS code G0332
claims from CY 2006. We note that a HCPCS G-code G0332 (Services for after CY 2008, we would consider
comparison of the median cost of PET/ intravenous infusion of packaging payment for HCPCS code
CT scans with the median cost of immunoglobulin prior to administration G0332 in future years if we determine
nonmyocardial PET scans, as derived (this service is to be billed in separate payment is no longer
from CY 2006 claims data, demonstrates conjunction with administration of warranted. We intend to reevaluate the
that these costs are almost the same, immunoglobulin)). Based on our appropriateness of separate payment for
thereby reflecting significant hospital estimate of the costs of this service in preadministration-related services for
resource equivalency between the two comparison with other services, HCPCS the CY 2009 OPPS rulemaking cycle,
types of services. This result is not code G0332 was assigned to New especially as we explore the potential
unexpected because many newer PET Technology APC 1502 (New for greater packaging and possible
scanners also have the capability of Technology—Level II, $50–$100), with a encounter-based or episode-based OPPS
rapidly acquiring CT images for payment rate of $75 effective January 1, payment approaches.
attenuation correction and anatomical 2006. In the CY 2007 OPPS/APC final
localization, sometimes with rule with comment period, we indicated c. Other Services in New Technology
simultaneous image acquisition. The our belief that it was appropriate to APCs
median costs for both PET and PET/CT continue the temporary IVIG (If you choose to comment on issues
scans are significantly higher for CY preadministration-related services in this section, please include the
2008 than for CY 2007 due to our CY payment through HCPCS code G0332 caption ‘‘Other Services in New
2008 proposal to package payment for and its continued assignment to New Technology APCs’’ at the beginning of
all diagnostic radiopharmaceuticals as Technology APC 1502 for CY 2007, in your comment.)
described in section II.A.4. of this order to help ensure continued patient Other than the concurrent PET/CT
proposed rule that would package access to IVIG (71 FR 68092). and IVIG preadministration-related new
payment for the costs of the For CY 2008, we are proposing to technology services discussed in
radiopharmaceuticals utilized similarly continue to provide separate payment sections III.C.2.a. and III.C.2.b. of this
into the payment for both PET and PET/ for IVIG preadministration-related proposed rule, there are five procedures
CT scans. We believe that our claims services through the assignment of currently assigned to New Technology
data accurately reflect the comparable HCPCS code G0332 to a clinical APC. APCs for CY 2007 for which we believe
hospital resources required to provide This service has been assigned to a New we also have data that are adequate to
nonmyocardial PET and PET/CT Technology APC under the OPPS for 2 support their reassignment to clinical
procedures, and the scans have obvious full years. As noted previously, under APCs. For CY 2008, we are proposing to
clinical similarity as well. Therefore, for the OPPS, we retain services within reassign these procedures to clinically
CY 2008 we are proposing to reassign New Technology APC groups where appropriate APCs, applying their CY
the CPT codes for PET/CT scans to the they are assigned according to our 2006 claims data to develop their
clinical APC median costs upon which assignments are displayed in Table 29
payments would be based. These below.
procedures and their proposed APC
TABLE 29.—PROPOSED CY 2008 APC REASSIGNMENTS OF OTHER NEW TECHNOLOGY PROCEDURES TO CLINICAL APCS
Pro- Proposed
CY CY 2007 Proposed
HCPCS CY 2007 posed CY 2008
Short descriptor 2007 APC pay- CY 2008
code APC CY 2008 APC me-
SI ment rate APC
SI dian cost
19298 ....... Place breast rad tube/caths ..................................... S ....... 1524 $3,250 T ........... 0648 $3,416.66
G0302 ...... Pre-op service LVRS complete ................................ S ....... 1509 750 S ........... 0209 727.48
G0303 ...... Pre-op service LVRS 10–15dos ............................... S ....... 1507 550 S ........... 0209 727.48
G0304 ...... Pre-op service LVRS 1–9 dos .................................. S ....... 1504 250 S ........... 0213 147.68
G0305 ...... Post op service LVRS min 6 .................................... S ....... 1504 250 S ........... 0213 147.68
D. Proposed APC-Specific Policies charges rather than the CCR for the 2. Skin Repair Procedures (APCs 0024,
respiratory therapy cost center. 0025, 0027, and 0686)
1. Hyperbaric Oxygen Therapy (APC
0659) Comments on the CY 2005 proposed For CY 2006, the AMA made
rule effectively demonstrated that comprehensive changes, including code
(If you choose to comment on issues hospitals report the costs and charges
in this section, please include the additions, deletions, and revisions,
for HBOT in a wide variety of cost accompanied by new and revised
caption ‘‘Hyperbaric Oxygen Therapy’’
centers. We used this methodology to introductory language, parenthetical
at the beginning of your comment.)
When hyperbaric oxygen therapy estimate payment for HBOT in CYs notes, subheadings and cross-references,
(HBOT) is prescribed for promoting the 2005, 2006, and 2007. For CY 2008, we to the Integumentary, Repair (Closure)
healing of chronic wounds, it typically are proposing to continue using the subsection of surgery in the CPT book
is prescribed for 90 minutes and billed same methodology to estimate a ‘‘per to facilitate more accurate reporting of
using multiple units of HBOT on a unit’’ median cost for HCPCS code skin grafts, skin replacements, skin
single line or multiple occurrences of C1300 of $98.63 using 60,774 claims substitutes, and local wound care. In
HBOT on a claim. In addition to the with multiple units or multiple particular, the section of the CPT book
therapeutic time spent at full hyperbaric occurrences. previously titled ‘‘Free Skin Grafts’’ and
oxygen pressure, treatment involves containing codes for skin replacement
CY 2008 is the fourth year in which
additional time for achieving full and skin substitute procedures was
we would have a special methodology
pressure (descent), providing air breaks renamed, reorganized, and expanded.
to develop the median cost for HBOT
to prevent neurological and other New and existing CPT codes related to
services that removed obviously skin replacement surgery and skin
complications from occurring during the
erroneous claims and deviated from our substitutes were organized into five
course of treatment, and returning the
standard methodology of using subsections: Surgical Preparation,
patient to atmospheric pressure (ascent).
The OPPS recognizes HCPCS code departmental CCRs, when available, to Autograft/Tissue Cultured Autograft,
C1300 (Hyperbaric oxygen under convert hospitals’ charges to costs. Prior Acellular Dermal Replacement,
pressure, full body chamber, per 30 to CY 2005, our inclusion of significant Allograft/Tissue Cultured Allogeneic
minute interval) for HBOT provided in numbers of miscoded claims in the Skin Substitute, and Xenograft.
the hospital outpatient setting. median calculation for HBOT and our As part of the CY 2006 CPT code
In the CY 2005 final rule with exclusion of the claims for multiple update in the newly named ‘‘Skin
comment period (69 FR 65758 through units of treatment, the typical scenario, Replacement Surgery and Skin
65759), we finalized a ‘‘per unit’’ resulted in payment rates that were Substitutes’’ section, certain codes were
median cost calculation for APC 0659 artificially elevated. As explained deleted that previously described skin
(Hyperbaric Oxygen) using only claims earlier, beginning in CY 2005 and allograft and tissue cultured and
with multiple units or multiple continuing through the present, we have acellular skin substitute procedures,
occurrences of HCPCS code C1300 adjusted the CCR used in the conversion including CPT code 15342 (Application
because delivery of a typical HBOT of charges to costs for these services so of bilaminate skin substitute/neodermis;
service requires more than 30 minutes. that claims data would more accurately 25 sq cm), CPT code 15343 (Application
We observed that claims with only a reflect the relative costs of the services. of bilaminate skin substitute/neodermis;
single occurrence of the code were The median costs of HBOT calculated each additional 25 sq cm), CPT code
anomalies, either because they reflected using this methodology have been 15350 (Application of allograft, skin;
terminated sessions or because they reasonably stable for the last 4 years. We 100 sq cm or less), and CPT code 15351
were incorrectly coded with a single believe that this adjustment through use (Application of allograft, skin; each
unit. In the same rule, we also of the hospitals’ overall CCRs is all that additional 100 sq cm). Thirty-seven new
established that HBOT would not CPT codes were created in the ‘‘Skin
is necessary to yield a valid median cost
generally be furnished with additional Replacement Surgery and Skin
for establishing a scaled weight for
services that might be packaged under Substitutes’’ section, and these codes
HBOT services. Therefore, for CY 2008,
the standard OPPS APC median cost received interim final status indicators
methodology. This enabled us to use we are proposing to continue to use the and APC assignments in the CY 2006
claims with multiple units or multiple same methodology that we have used OPPS final rule with comment period
occurrences. Finally, we also used each since CY 2005 to estimate payment for and were subject to comment.
hospital’s overall CCR to estimate costs HBOT. In considering the final CY 2007 APC
for HCPCS code C1300 from billed assignments of these 37 ‘‘Skin
Replacement Surgery and Skin Repair’’ well as some new CY 2007 CPT codes treatment of an additional body area and
codes, we reviewed the without CY 2006 claims data. There is that are reported along with a primary
recommendations made by the APC also some variation in the median costs procedure for treatment of the first body
Panel at its March 2006 meeting; of the HCPCS codes assigned to APCs area. We are accepting the APC Panel’s
presentations made to the APC Panel; 0686 and 0027, but no 2 times violations recommendation through this CY 2008
comments received on the CY 2007 in these two APCs. proposal to reconfigure the skin APCs
proposed rule; the CPT code At the March 2007 APC Panel into five levels, and we have
descriptors, introductory explanations, meeting, we discussed with the APC reexamined the placement of each of the
cross-references, and parenthetical Panel one possible reconfiguration of add-on codes within the framework of
notes; the clinical characteristics of the the skin repair APCs in order to address the five APCs. We agree with the APC
procedures; and the code-specific the 2 times violations in APCs 0024 and Panel that, because these skin repair
median costs for all related CPT codes 0025 for CY 2008 by improving the APCs are assigned to status indicator
available from our CY 2005 claims data. resource homogeneity of the APCs, as ‘‘T’’ so that add-on codes would
A discussion of the final CY 2007 APC well as ensuring their clinical typically be paid at 50 percent of their
assignments of these procedures can be homogeneity. We reviewed with the APC payment rate, these add-on codes
found in the CY 2007 OPPS/ASC final APC Panel the potential results bear special examination with respect to
rule with comment period (71 FR 68054 associated with adding an additional their median costs and their appropriate
through 68057). level in this APC series and reallocating APC assignments. As a result, several
We now have CY 2006 data for the all of the procedures in the original four CPT code placements from the draft
surgical procedures assigned to the 4 CY APCs among five new APCs, taking into configuration discussed with the Panel
2007 skin repair APCs, including the 37 account the frequency, resource were changed for this proposal.
codes considered last year that were utilization, and clinical characteristics In summary, for CY 2008 we are
new for CY 2006. These APCs are: APC of each procedure. We also gave proposing to eliminate the four current
0024 (Level I Skin Repair); APC 0025 particular attention to CPT code families skin repair APCs and replace them with
(Level II Skin Repair); APC 0686 (Level in considering the clinical and resource five new APCs titled: APC 0133 (Level
III Skin Repair); and APC 0027 (Level IV homogeneity of each APC in the I Skin Repair); APC 0134 (Level II Skin
Skin Repair). Based on CY 2006 data reconfigured series. The new Repair); APC 0135 (Level III Skin
available for this proposed rule, the configuration of APCs eliminates the 2 Repair); APC 0136 (Level IV Skin
median costs for the APCs as configured times violations that would otherwise Repair); and APC 0137 (Level V Skin
for CY 2007 are approximately: $93 for exist in APCs 0024 and 0025. It also Repair). We are proposing to
APC 0024; $251 for APC 0025; $1,027 more accurately attributes higher cost redistribute each of the procedures
for APC 0686; and $1,340 for APC 0027. procedures to the Levels IV and V APCs, assigned to the current four levels of
Both APCs 0024 and 0025 have 2 times which contain the surgical procedures skin repair APCs into the five proposed
violations based on CY 2006 claims of the greatest intensity and resource APCs, with one exception. Specifically,
data. The HCPCS median costs of requirements, leading to a more we are proposing to reassign CPT code
significant procedures in APC 0024 balanced distribution of APC median 15835 (Excision, excessive skin and
range from approximately $83 to $255. costs across the five new APC levels. subcutaneous tissue (including
We note that a number of the The APC Panel made a lipectomy); buttock) to APC 0022 (Level
procedures currently assigned to APC recommendation at its March 2007 IV, Excision/Biopsy), where other CPT
0024 are very low volume, with few meeting supporting CMS’ reorganization codes in its code family reside. The
single claims available for ratesetting. of the skin repair APCs into five levels. median costs of the five proposed APCs
Similarly, the median costs of the This recommendation also asked CMS are $83.91 (APC 0133), $132.82 (APC
significant procedures in APC 0025 to give special consideration to the APC 0134), $294.50 (APC 0135), $971.25
range from a low of $119 to a high of assignments of ‘‘add-on’’ codes; in the (APC 0136), and $1,316.85 (APC 0137).
about $399. This APC also contains a context of skin procedures, these are The proposed configurations of these
number of low volume procedures, as generally those CPT codes that report new APCs are listed in Table 30 below.
TABLE 30—PROPOSED CY 2008 SKIN REPAIR APC CONFIGURATIONS

Proposed
Proposed
HCPCS CY 2008
Short descriptor CY 2008
code APC
APC median cost
11950 Therapy for contour defects ........................................................................................................................... 0133 $83.91

11951 Therapy for contour defects.
12001 Repair superficial wound(s).

TABLE 30—PROPOSED CY 2008 SKIN REPAIR APC CONFIGURATIONS—Continued

Proposed
Proposed
HCPCS CY 2008
code APC
APC median cost
12031 Layer closure of wound(s).

15775 Hair transplant punch grafts.
15776 Hair transplant punch grafts.
11760 Repair of nail bed ........................................................................................................................................... 0134 $132.82
11920 Correct skin color defects.
13120 Repair of wound or lesion.
13122 Repair wound/lesion add-on.
15040 Harvest cultured skin graft.
15170 Acell graft trunk/arms/legs.
15171 Acell graft t/arm/leg add-on.
15340 Apply cult skin substitute.
15341 Apply cult skin sub add-on.
15360 Apply cult derm sub, t/a/l.
15361 Aply cult derm sub t/a/l add.
15365 Apply cult derm sub f/n/hf/g.
15366 Apply cult derm f/hf/g add.
15819 Plastic surgery, neck.
12020 Closure of split wound .................................................................................................................................... 0135 $294.50
12021 Closure of split wound.
15000 Wound prep, 1st 100 sq cm.
15001 Wound prep, addl 100 sq cm.
15002 Wnd prep, ch/inf, trk/arm/lg.
15003 Wnd prep, ch/inf addl 100 cm.
15004 Wnd prep ch/inf, f/n/hf/g.
15005 Wnd prep, f/n/hf/g, addl cm.
15050 Skin pinch graft.
15110 Epidrm autogrft trnk/arm/leg.
15111 Epidrm autogrft t/a/l add-on.
15115 Epidrm a-grft face/nck/hf/g.
15116 Epidrm a-grft f/n/hf/g addl.
15150 Cult epiderm grft t/arm/leg.

15151 Cult epiderm grft t/a/l addl.
15152 Cult epiderm graft t/a/l +%.
15155 Cult epiderm graft, f/n/hf/g.
15156 Cult epidrm grft f/n/hfg add.
15157 Cult epiderm grft f/n/hfg +%.
15175 Acellular graft, f/n/hf/g.
15176 Acell graft, f/n/hf/g add-on.

Proposed
Proposed
HCPCS CY 2008
code APC
APC median cost
15221 Skin full graft add-on.

15300 Apply skinallogrft, t/arm/lg.
15301 Apply sknallogrft t/a/l addl.
15320 Apply skin allogrft f/n/hf/g.
15321 Apply sknallogrft f/n/hfg add.
15330 Aply acell alogrft t/arm/leg.
15331 Aply acell grft t/a/l add-on.
15335 Apply acell graft, f/n/hf/g.
15336 Apply acell grft f/n/hf/g add.
15350 Skin homograft.
15351 Skin homograft add-on.
15400 Apply skin xenograft, t/a/l.
15401 Apply skn xenogrft t/a/l add.
15420 Apply skin xgraft, f/n/hf/g.
15421 Apply skn xgrft f/n/hf/g add.
15430 Apply acellular xenograft.
15431 Apply acellular xgraft add.
20926 Removal of tissue for graft.
43887 Remove gastric port, open.
11762 Reconstruction of nail bed ............................................................................................................................. 0136 $971.25
14000 Skin tissue rearrangement.
15130 Derm autograft, trnk/arm/leg.
15131 Derm autograft t/a/l add-on.
15135 Derm autograft face/nck/hf/g.
15136 Derm autograft, f/n/hf/g add.
15200 Skin full graft, trunk.
15201 Skin full graft trunk add-on.
15220 Skin full graft sclp/arm/leg.
15240 Skin full grft face/genit/hf.
15260 Skin full graft een & lips.
15740 Island pedicle flap graft.
15936 Remove sacrum pressure sore.
15952 Remove thigh pressure sore.
20920 Removal of fascia for graft.
20922 Removal of fascia for graft.
23921 Amputation follow-up surgery.
25929 Amputation follow-up surgery.
33222 Revise pocket, pacemaker.
33223 Revise pocket, pacing-defib.
11960 Insert tissue expander(s) ................................................................................................................................ 0137 $1,316.85
13160 Late closure of wound.
15100 Skin splt grft, trnk/arm/leg.
15101 Skin splt grft t/a/l, add-on.
15120 Skn splt a-grft fac/nck/hf/g.
15121 Skn splt a-grft f/n/hf/g add.
15570 Form skin pedicle flap.

15600 Skin graft.
15610 Skin graft.
15620 Skin graft.
15630 Skin graft.
15650 Transfer skin pedicle flap.
15731 Forehead flap w/vasc pedicle.

Proposed
Proposed
HCPCS CY 2008
code APC
APC median cost
15732 Muscle-skin graft, head/neck.

15734 Muscle-skin graft, trunk.
15736 Muscle-skin graft, arm.
15738 Muscle-skin graft, leg .
15750 Neurovascular pedicle graft.
15760 Composite skin graft.
15770 Derma-fat-fascia graft.
15820 Revision of lower eyelid.
15821 Revision of lower eyelid.
15822 Revision of upper eyelid.
15823 Revision of upper eyelid.
15824 Removal of forehead wrinkles.
15825 Removal of neck wrinkles.
15826 Removal of brow wrinkles.
15828 Removal of face wrinkles.
15829 Removal of skin wrinkles.
15840 Graft for face nerve palsy.
15841 Graft for face nerve palsy.
15842 Flap for face nerve palsy.
15845 Skin and muscle repair, face.
15876 Suction assisted lipectomy.
15922 Removal of tail bone ulcer.
15944 Remove hip pressure sore.
20101 Explore wound, chest.
20102 Explore wound, abdomen.
20910 Remove cartilage for graft.
20912 Remove cartilage for graft.
43886 Revise gastric port, open.
43888 Change gastric port, open.
44312 Revision of ileostomy.
44340 Revision of colostomy
3. Cardiac Computed Tomography and 2006. In the CY 2006 OPPS final rule CCT and CCTA procedures to any APCs
Computed Tomographic Angiography with comment period, we assigned the or assign them to appropriate New
(APCs 0282, 0376, 0377, and 0398) CCT and CCTA procedure codes to Technology APCs. In addition, some
(If you choose to comment on issues interim APCs, which were subject to commenters were also concerned that
in this section, please include the public comment. We received no CCT and CCTA procedures were not
caption ‘‘Cardiac Computed comments on the interim APC clinically homogeneous with other
Tomography and Computed assignments. Since January 2006, the procedures assigned to APCs 0282,
Tomographic Angiography’’ at the CCT and CCTA procedure codes have 0376, 0377, and 0398, noting that the
beginning of your comment.) been assigned to four APCs, specifically, last three APCs previously contained
Cardiac computed tomography (CCT) APC 0282 (Miscellaneous Computerized only nuclear medicine cardiac imaging
and cardiac computed tomography Axial Tomography), APC 0376 (Level II procedures.
angiography (CCTA) are noninvasive Cardiac Imaging), APC 0377 (Level III In the CY 2007 OPPS/ASC final rule
diagnostic procedures that assist Cardiac Imaging), and APC 0398 (Level with comment period (71 FR 68038), we
physicians in obtaining detailed images I Cardiac Imaging). indicated our belief that the clinical
of coronary blood vessels. The data In the CY 2007 OPPS/ASC proposed characteristics and expected resource
obtained from these procedures can be rule, we proposed to retain the existing use associated with the CCT and CCTA
used for further diagnostic evaluations APC assignments for the CCT and CCTA procedures were sufficiently similar to
and/or appropriate therapy for coronary procedure codes. We received several the other procedures assigned to APCs
patients. comments on the proposed APCs 0282, 0376, 0377, and 0398 that we
Currently, there are eight Category III assignments, which we addressed in the believed those APC assignments were
CPT codes that describe CCT and CCTA CY 2007 OPPS/ASC final rule with appropriate. While several of those
procedures. The CPT codes, which are comment period (71 FR 68038 and APCs also contained nuclear medicine
shown in Table 31, are 0144T through 68039). Several of the commenters imaging procedures, we had never
0151T. These codes were new for CY requested that we either not assign the designated those APCs as specific to
nuclear medicine procedures. Therefore, with stakeholders to determine more reassigning these procedures to New
for CY 2007, we continued with the CY appropriate APC placements for CCT Technology APCs in CY 2008, when we
2006 APC assignments for CPT codes and CCTA procedures. The APC Panel have claims-based cost information
0144T through 0151T. We did not agree made no specific recommendations regarding these procedures, and they are
with the commenters that use of CT and regarding the appropriate APC clinically similar to other procedures
CTA for cardiac studies was a new assignments for these services, although paid under the OPPS.
technology for which we had no several different clinical APC
We acknowledge the concerns that
relevant OPPS cost information that configurations were discussed, along
have been expressed to us regarding the
could be used to estimate hospital with the alternative of assigning these
clinical homogeneity of APCs 0376,
resources for these procedures. We also procedures to New Technology APCs.
believed these services could be We note that we generally meet with 0377, and 0398, where some of the CCT
potentially covered hospital outpatient interested organizations concerning and CCTA are assigned for CY 2007
services, so that it would not be their views about OPPS payment policy along with nuclear medicine cardiac
appropriate for us to depart from our issues with respect to specific imaging procedures. Because we are
standard OPPS policy and not assign technologies or services. Following the proposing to package payment for
them to APCs. As we indicated in our publication of the CY 2007 OPPS/ASC diagnostic radiopharmaceuticals into
CY 2007 OPPS/ASC proposed rule (71 final rule with comment period, we payment for diagnostic nuclear
FR 49549), some Category III CPT codes received such information from medicine procedures in CY 2008 as
describe services that we have interested individuals and organizations discussed in detail in section II.A.4. of
determined to be similar in clinical regarding the clinical and facility this proposed rule, we believe that to
characteristics and resource use to resource characteristics of CCT and ensure the clinical and resource
HCPCS codes assigned to existing CCTA procedures. We will consider the homogeneity of APCs 0376, 0377, and
clinical APCs. In these instances, we input of any individual or organization 0398 in CY 2008, it would be most
may assign the Category III CPT code to to the extent allowed by Federal law, appropriate to reassign the CCT and
the appropriate clinical APC. Other including the Administrative Procedure CCTA services currently residing in
Category III CPT codes describe services Act (APA) and the FACA. We establish those APCs to other clinical APCs for
that we have determined are not the OPPS payment rates for services CY 2008.
compatible with an existing clinical through regulations, during our annual
Therefore, for CY 2008, we are
APC, yet are appropriately provided in rulemaking cycle. We are required to
proposing to assign the CCT and CCTA
the hospital outpatient setting. In these consider the timely comments of
procedures to two clinical APCs,
cases, we may assign the Category III interested organizations, establish the
payment policies for the forthcoming specifically new clinical APC 0383
CPT code to what we estimate is an
year, and respond to the timely (Cardiac Computed Tomographic
appropriately priced New Technology
comments of all public commenters in Imaging) and APC 0282, as shown in
APC. In other cases, we may assign a
Category III CPT code to one of several the final rule in which we establish the Table 31. The proposed median cost of
nonseparately payable status indicators, payments for the forthcoming year. $313.81 for APC 0383 is based entirely
including ‘‘N,’’ ‘‘C,’’ ‘‘B,’’’ or ‘‘E,’’’ Analysis of our hospital data for on claims data for CPT codes 0145T,
which we believe is appropriate for the claims submitted for CY 2006 indicate 0146T, 0147T, 0148T, 0149T, and 0150T
specific code. As we noted in the CY that CCT and CCTA procedures are that describe CCT and CCTA services, a
2007 OPPS/ASC final rule with performed relatively frequently on clinically homogeneous grouping of
comment period, we believed that CCT Medicare patients. Our claims data services. In addition, the individual
and CCTA procedures were appropriate show a total of over 16,000 procedures median costs of these services range
for separate payment under the OPPS performed, with about 11,000 single from a low of $276.50 to a high of
should local contractors provide claims available for ratesetting. Based $436.79, reflecting their hospital
coverage for these procedures, and, on our analysis of the robust hospital resource similarity as well. We are
therefore, they warranted status outpatient claims data, we believe we proposing to reassign the two other CCT
indicator and APC assignments that have adequate claims data from CY 2006 CPT codes, specifically CPT codes
would provide separate payment under upon which to determine the median 0144T and 0151T, to APC 0282. The
the OPPS (71 FR 68038). costs of performing these procedures inclusion of these two codes in APC
At its March 2007 meeting, the APC and to assign them to appropriate 0282 results in a CY 2008 proposed APC
Panel recommended that CMS work clinical APCs. We see no rationale for median cost of $105.48.
TABLE 31.—PROPOSED CY 2008 APC ASSIGNMENTS OF CCT AND CCTA PROCEDURES

Proposed
CY 2007 Proposed Proposed
HCPCS CY 2007 CY 2007 CY 2008
Short descriptor APC me- CY 2008 CY 2008
code SI APC APC me-
dian cost SI APC dian cost
0144T ....... CT heart wo dye; qual calc ................................... S ........... 0398 $252.17 S .............. 0282 $105.48
0145T ....... CT heart w/wo dye funct ....................................... S ........... 0376 304.52 S .............. 0383 313.81
0146T ....... CCTA w/wo dye .................................................... S ........... 0376 304.52 S .............. 0383 313.81
0147T ....... CCTA w/wo, quan calcium .................................... S ........... 0376 304.52 S .............. 0383 313.81
0148T ....... CCTA w/wo, strxr .................................................. S ........... 0377 397.29 S .............. 0383 313.81
0149T ....... CCTA w/wo, strxr quan calc ................................. S ........... 0377 397.29 S .............. 0383 313.81
0150T ....... CCTA w/wo, disease strxr ..................................... S ........... 0398 252.17 S .............. 0383 313.81
0151T ....... CT heart funct add-on ........................................... S ........... 0282 93.98 S .............. 0282 105.48
4. Ultrasound Ablation of Uterine Radiosurgery), based on their analyses At its March 2007 meeting, the APC
Fibroids With Magnetic Resonance of the procedures’ resource use and Panel recommended that, for CY 2008,
Guidance (MRgFUS) (APCs 0195 and clinical characteristics. CMS reassign CPT codes 0071T and
0202) As we stated in both the CY 2006 0072T from APCs 0195 and 0202 to APC
(If you choose to comment on issues OPPS final rule with comment period 0067 (Level III Stereotactic
in this section, please include the and the CY 2007 OPPS/ASC final rule Radiosurgery, MRgFUS, and MEG),
caption ‘‘Ultrasound Ablation of Uterine with comment period, we believe that which has a proposed APC median cost
Fibroids with Magnetic Resonance MRgFUS treatment bears a significant of $3,869.96 for CY 2008. The APC
Guidance (MRgFUS)’’ at the beginning relationship to technologies already in Panel discussed its general belief that
of your comment.) use in hospital outpatient departments while the MRgFUS procedures may not
Magnetic resonance guided focused (70 FR 68600 and 71 FR 68050, be performed frequently on Medicare
ultrasound (MRgFUS) is a noninvasive respectively). The use of focused patients, CMS should pay appropriately
surgical procedure that uses high ultrasound for thermal tissue ablation for the procedures to ensure access for
intensity focused ultrasound waves to has been in development for decades, Medicare beneficiaries. In addition,
destroy tissue in combination with and the recent application of MRI to following discussion of the potential for
magnetic resonance imaging (MRI). focused ultrasound therapy provides reassignment of the CPT codes to New
Currently, the two Category III CPT monitoring capabilities that may make Technology APCs, the APC Panel
codes for this procedure are 0071T the therapy more clinically useful. We specifically recommended that the
(Focused ultrasound ablation of uterine continue to believe that, although procedures be assigned to a clinical APC
leiomyomata, including MR guidance; MRgFUS therapy is relatively new, it is at this point in their adoption into
total leiomyomata volume less than 200 an integrated application of existing
clinical practice, instead of a New
cc of tissue) and 0072T (Focused technologies (MRI and ultrasound), and
ultrasound ablation of uterine Technology APC. Furthermore, since
its technology resembles other OPPS
leiomyomata, including MR guidance; publication of the CY 2007 OPPS/ASC
services that are assigned to clinical
total leiomyomata volume greater or final rule with comment period, we
APCs for which we have significant
equal to 200 cc of tissue), which were have received input from interested
OPPS claims data. In the CY 2007
implemented on January 1, 2005. individuals and organizations regarding
OPPS/ASC final rule with comment
In the CY 2006 OPPS proposed rule, the clinical and resource characteristics
period (71 FR 68050), we explained our
we proposed to continue to assign both of MRgFUS procedures. Based on our
belief that retaining MRgFUS
codes to APC 0193 (Level V Female procedures in clinical APCs with other consideration of all information
Reproductive Proc). However, at the female reproductive procedures would available to us regarding the necessary
August 2005 APC Panel meeting, the enable us both to set accurate payment hospital resources for the MRgFUS
APC Panel recommended that CMS rates and to maintain appropriate procedures in comparison with other
work with stakeholders to assign CPT clinical homogeneity of the APCs. procedures for which we have historical
codes 0071T and 0072T to appropriate Furthermore, we did not agree with hospital claims data, for CY 2008 we are
New Technology APCs. Based on our commenters that MRgFUS procedures proposing to accept the APC Panel’s
review of several factors, which shared sufficient clinical and resource recommendation to reassign these
included information presented at the characteristics with cobalt-based services to clinical APC 0067, an APC
August 2005 APC Panel meeting, the stereotactic radiosurgery (SRS) to that currently contains two linear
comments received on the CY 2006 reassign them to that particular clinical accelerator-based stereotactic
OPPS proposed rule, and our analysis of APC 0127, where only the single radiosurgery (SRS) procedures that are
OPPS claims data for different specific SRS procedure was assigned for conducted in a single or first session,
procedures, we reassigned CPT code CY 2007 and which had a CY 2007 APC rather than procedures for subsequent
0071T from APC 0193 to APC 0195 median cost of $8,460.53. Consequently, SRS treatment fractions. We agree with
(Level IX Female Reproductive Proc) in the CY 2007 OPPS/ASC final rule the APC Panel that these SRS
and CPT code 0072T from APC 0193 to with comment period (71 FR 68051), we procedures share sufficient clinical and
APC 0202 (Level X Female finalized payment for these procedures resource similarity with the MRgFUS
Reproductive Proc) effective January 1, in APCs 0195 and 0202 as proposed. services, including reliance on image
2006, to reflect the higher level of Analysis of our hospital outpatient guidance in a single treatment session to
resources we estimated were required data for claims submitted for CY 2006 ablate abnormal tissue, to justify their
when performing the MRgFUS indicates that MRgFUS procedures are assignment to the same clinical APC.
procedures. rarely performed on Medicare patients. Unlike the cobalt-based SRS service that
In the CY 2007 OPPS/ASC proposed As we stated in the CY 2006 OPPS final we concluded in the CY 2007 OPPS/
rule, we proposed to continue to assign rule with comment period and CY 2007 ASC final rule with comment period
CPT code 0071T to APC 0195 and CPT OPPS/ASC final rule with comment was not similar to MRgFUS procedures
code 0072T to APC 0202. We received period, because treatment of uterine based on clinical and resource
comments on the CY 2007 proposed fibroids is most common among women considerations, these linear accelerator-
APC assignments recommending that younger than 65 years of age, we do not based SRS procedures are not performed
we revise the APC assignments for CPT expect that there ever will be many solely on intracranial lesions and
codes 0071T and 0072T. The Medicare claims for the MRgFUS generally do not require immobilization
commenters indicated that, while procedures (70 FR 68600 and 71 FR of the patient’s head in a frame that is
MRgFUS treats anatomical sites that are 68050, respectively). For OPPS claims screwed into the skull, thereby
similar to other procedures assigned to submitted from CY 2005 through CY exhibiting characteristics more
APCs 0195 and 0202, the resources 2006, our claims data show that there consistent with MRgFUS treatments. In
utilized differ dramatically. Several were only two claims submitted for CPT addition, based on our understanding of
commenters recommended that the code 0071T in CY 2005 and one in CY the MRgFUS procedures described by
most appropriate APC assignment for 2006. We have no hospital claims for the two CPT codes which differ only in
the MRgFUS procedures would be APC CPT code 0072T from either of those the volume of uterine leiomyomata
0127 (Level IV Stereotactic years. treated, we believe it would be most
appropriate to assign both of these Therefore, for CY 2008 we are proposing median cost of $3,869.96, as reflected in
procedures to the same clinical APC, as to reassign CPT codes 0071T and 0072T Table 32.
recommended by the APC Panel. to APC 0067, with a proposed APC
TABLE 32.—PROPOSED CY 2008 APC ASSIGNMENTS OF MRGFUS PROCEDURES

Proposed
CY CY 2007 Proposed Proposed
HCPCS CY 2007 CY 2008
Short descriptor 2007 APC me- CY 2008 CY 2008
code APC APC me-
SI dian cost SI APC dian cost
0071T ....... U/s leiomyomata ablate <200 ..................................... T ....... 0195 $1,742.20 S ............ 0067 $3,869.96
0072T ....... U/s leiomyomata ablate >200 ..................................... T ....... 0202 2,534.46 S ............ 0067 3,869.96
5. Single Allergy Tests (APC 0381) code. Using this methodology, we APCs for the CY 2006 OPPS. The CPT
(If you choose to comment on issues calculated a proposed median cost of codes for the single scans, specifically
in this section, please include the $18.96 for APC 0381 for CY 2008. We 78459 and 78491, were assigned to APC
caption ‘‘Single Allergy Tests’’ at the will consider whether further 0306 (Myocardial Positron Emission
beginning of your comment.) instructions to hospitals for reporting Tomography (PET) Imaging, Single
For CY 2008, we are proposing to these procedures would be beneficial, Study, Metabolic Evaluation) with a
continue with our methodology of because we are concerned that our payment rate of $800.55, and the
differentiating single allergy tests (‘‘per claims data for CY 2006 reflect no multiple scan CPT code 78492 was
test’’) from multiple allergy tests (‘‘per apparent change in hospitals’ billing assigned to APC 0307 (Myocardial
visit’’) by assigning these services to two practices following our January 2006 Positron Emission Tomography (PET)
different APCs to provide accurate clarification. We remain hopeful that Imaging, Multiple Studies) with a
payments for these tests in CY 2008. better and more accurate hospital payment rate of $2,484.88, effective
Multiple allergy tests are currently reporting and charging practices for January 1, 2006. However, analysis of
assigned to APC 0370 (Allergy Tests) these single allergy test CPT codes in the CY 2005 claims data that were used
with a median cost calculated based on future years may allow us to calculate to set the payment rates for CY 2007
the standard OPPS methodology. We the median cost of APC 0381 using the revealed that when all the myocardial
provided billing guidance in CY 2006 in standard OPPS process for future OPPS PET scan procedure codes were
Transmittal 804 (issued on January 3, updates. combined into a single clinical APC, as
2006) specifically clarifying that they were prior to CY 2006, the APC
6. Myocardial Positron Emission
hospitals should report charges for the median cost for myocardial PET services
Tomography (PET) Scans (APC 0307)
CPT codes that describe single allergy was very similar to the median cost of
tests to reflect charges ‘‘per test’’ rather (If you choose to comment on issues their single CY 2005 clinical APC.
than ‘‘per visit’’ and should bill the in this section, please include the Further, our analysis revealed that the
appropriate number of units of these caption ‘‘Myocardial PET Scans’’ at the updated differential median costs of the
CPT codes to describe all of the tests beginning of your comment.) single and multiple study procedures no
provided. However, our CY 2006 claims From August 2000 to December 31, longer supported the two-level APC
data available for this CY 2008 proposed 2005, under the OPPS, we assigned one payment structure. Therefore, for CY
rule for APC 0381 (Single Allergy Tests) clinical APC to all myocardial positron 2007, CPT codes 78459, 78491, and
do not reflect improved and more emission tomography (PET) scan 78492, were assigned to a single clinical
consistent hospital billing practices of procedures, which were reported with APC, specifically APC 0307, which was
‘‘per test’’ for single allergy tests. Using multiple G-codes through March 31, renamed ‘‘Myocardial Positron Emission
the CY 2006 claims data, the median 2005. Under the OPPS, effective April 1, Tomography (PET) Imaging,’’ with a
cost of APC 0381 calculated according 2005, myocardial PET scans were median cost of $726.98.
to the standard single claims OPPS reported with three CPT codes, At its March 2007 meeting, the APC
methodology is $66.17, significantly specifically CPT codes 78459 Panel recommended that CMS reassign
higher than the CY 2007 median cost of (Myocardial imaging, positron emission CPT code 78492 to its own clinical APC,
$16.43 for APC 0381 calculated tomography (PET), metabolic to distinguish this multiple study
according to the ‘‘per unit’’ evaluation), 78491 (Myocardial imaging, procedure that the APC Panel believed
methodology and greater than we would positron emission tomography (PET), would require greater hospital resources
expect for these procedures that are to perfusion; single study at rest or stress), from less resource intensive single study
be reported ‘‘per test’’ with the and 78492 (Myocardial imaging, procedures. However, we are not
appropriate number of units. Some positron emission tomography (PET), accepting the APC Panel’s
claims for single allergy tests still perfusion; multiple studies at rest and/ recommendation because, consistent
appeared to include charges that or stress). From April 1, 2005 through with our observations from the CY 2005
represent a ‘‘per visit’’ charge, rather December 31, 2005, these three CPT claims data, our updated CY 2006
than a ‘‘per test’’ charge. Therefore, codes were assigned to one APC, claims data do not support the creation
consistent with our payment policy for specifically APC 0285 (Myocardial of a clinical APC for CPT code 78492
CYs 2006 and 2007, we are proposing to Positron Emission Tomography (PET), alone. Analysis of the latest CY 2006
calculate a ‘‘per unit’’ median cost for with a payment rate of $735.77. In CY claims data continues to support a
APC 0381, based upon 276 CY 2006 2006, in response to the public single level APC payment structure for
claims containing multiple units or comments received on the CY 2006 the myocardial PET scan procedures
multiple occurrences of a single CPT OPPS proposed rule, and based on our because very few single scan studies are
code, where packaging on the claims is claims information, myocardial PET performed and we believe single and
allocated equally to each unit of the CPT services were assigned to two clinical multiple scan procedures are clinically
similar. Our claims data available for to a single clinical APC for CY 2008 this proposed rule that would package
this proposed rule show a total of 2,547 remains appropriate because the CY payment for diagnostic
procedures reported with the multiple 2006 claims data do not support a radiopharmaceuticals into the payment
scan CPT code 78492. Alternatively, our resource differential among significant for their related diagnostic nuclear
claims data show only a combined total myocardial PET services that would medicine studies, such as myocardial
of 249 procedures reported with the necessitate the placement of single and PET scans. We believe that the proposed
single scan CPT codes 78459 and 78491, multiple PET scan procedures into two median cost appropriately reflects the
less than 10 percent of all studies separate clinical APCs. Therefore, we hospital resources associated with
reported. A similar distribution is are proposing to continue to assign both providing myocardial PET scans to
observed in the single bills available for the single and multiple myocardial PET Medicare beneficiaries in cost-efficient
ratesetting. scan procedure codes to APC 0307, with settings. Furthermore, we believe that
Similar to last year’s findings, our a proposed APC median cost of the proposed CY 2008 OPPS payment
claims data reveal that more hospitals $2,677.71 for CY 2008. We note that the rates are adequate to ensure appropriate
are not only providing multiple proposed CY 2008 median cost of APC access to these services for Medicare
myocardial PET scan services, but most 0307 is significantly higher than its CY beneficiaries. The myocardial PET scan
myocardial PET scans are multiple 2007 median cost, in part because of our CPT codes and their proposed CY 2008
studies. We believe that the assignment proposed CY 2008 packaging approach APC assignments are displayed in Table
of CPT codes 78459, 78491, and 78492 discussed in detail in section II.A.4. of 33.
TABLE 33.—PROPOSED CY 2008 APC ASSIGNMENTS FOR MYOCARDIAL PET SCANS

Proposed
HCPCS CY 2007 CY 2007 CY 2008
Short descriptor APC me- CY 2008 CY 2008
code SI APC APC me-
78459 ....... Heart muscle imaging (PET) ................................. S ............ 0307 $726.98 S ............ 0307 $2,677.71
78491 ....... Heart image (pet), single ....................................... S ............ 0307 726.98 S ............ 0307 2,677.71
78492 ....... Heart image (pet), multiple .................................... S ............ 0307 726.98 S ............ 0307 2,677.71
7. Implantation of Cardioverter- depending on whether or not they defibrillator pulse generators with or
Defibrillators (APCs 0107 and 0108) included the possibility of electrode without repositioning or implantation of
(If you choose to comment on issues insertion, specifically APC 0107 electrode lead(s) and authorize hospitals
in this section, please include the (Insertion of Cardioverter-Defibrillator) to report the CPT codes. The APC Panel
caption ‘‘Implantation of Cardioverter- and APC 0108 (Insertion/Replacement/ indicated that the requirement for
Defibrillators’’ at the beginning of your Repair of Cardioverter-Defibrillator reporting device codes would enable
comment.) Leads). CMS to continue to identify costs when
In CY 2003, we created four Level II In the same year, the OPPS ceased to different types of devices are implanted
HCPCS codes for implantation of single recognize for payment the two CPT if that were to be necessary.
and dual chamber cardioverter- codes for insertion of ICDs with or We analyzed the median cost data
defibrillators (ICDs) with and without without ICD leads. These CPT codes are associated with APCs 0107 and 0108 as
leads because, for the CY 2004 OPPS, 33240 (Insertion of single or dual part of our preparation for the APC
we deleted the device HCPCS codes and chamber pacing cardioverter- Panel discussion. While there is a
there was no other way of determining defibrillator pulse generator) and 33249 difference in the median cost when a
whether the device being implanted was (Insertion or repositioning of electrode single chamber versus a dual chamber
a single chamber or dual chamber lead(s) for single or dual chamber device is implanted, the difference has
device. We were concerned that the pacing cardioverter-defibrillator and never been great enough to justify
costs of inserting single versus dual insertion of pulse generator). differential APC assignments for the
chamber ICDs could be sufficiently We reinstated the device category procedures. See Table 34 below for a
different due to the two types of devices HCPCS codes on January 1, 2005. historical summary of all single claim
implanted such that separate APC Moreover, since January 1, 2005, median costs. (For purposes of this
assignments for the insertion procedures hospitals have been required to report analysis, we display the median costs
could be appropriate in the future. The devices they use or implant when there for all single claims without regard to
HCPCS codes are G0297 (Insertion of is a device code that describes the adjustment or to whether the claims
single chamber pacing cardioverter device. We began to edit to ensure that meet various selection criteria; these are
defibrillator pulse generator); G0298 hospitals are correctly billing devices not the median costs on which
(Insertion of dual chamber pacing required for certain procedures in April payments were based.)
cardioverter defibrillator pulse 2005 and implemented the second Hospitals have consistently indicated
generator); G0299 (Insertion or phase of device edits on October 1, that they would prefer to report the
repositioning of electrode lead for single 2005. Therefore, we no longer need services furnished using the CPT codes
chamber pacing cardioverter different procedural Level II HCPCS that describe them, rather than the
defibrillator and insertion of pulse codes to identify whether hospitals alphanumeric G-codes, because many
generator); and G0300 (Insertion or inserted a single or dual chamber ICD private payers require that they bill the
repositioning of electrode lead for dual device. CPT codes. We also prefer to recognize
chamber pacing cardioverter At its March 2007 meeting, the APC CPT codes for procedures under the
defibrillator and insertion of pulse Panel recommended that CMS delete OPPS, when possible, to minimize the
generator). The pairs of codes were the Level II HCPCS codes for administrative coding burden on
assigned to two different clinical APCs, implantation of cardioverter- hospitals.
We believe that the differences procedures. The required device coding burden on hospitals. Therefore, for CY
between the median costs for the two would allow us to continue to follow 2008 we are proposing to delete the
Level II HCPCS codes assigned to each the different costs over time by Level II HCPCS codes for ICD insertion
APC (that is, G0297 and G0298 for APC examining subsets of ICD implantation procedures and require hospitals to bill
0107 and G0299 and G0300 for APC procedure claims based on the type of the appropriate CPT codes, along with
0108) do not currently support device reported on the claims. the applicable device C-codes, for
differential APC assignments for single Moreover, we are sensitive to the payment under the OPPS.
and dual chamber ICD insertion benefits of minimizing the reporting
TABLE 34.—HISTORICAL UNADJUSTED MEDIAN COST DATA FROM ALL SINGLE CLAIMS FOR APCS 0107 AND 0108
CY 2002 claims
(includes 75% of Unadjusted CY 2003 Unadjusted CY 2004 Unadjusted CY 2005 Unadjusted CY 2006
HCPCS code device cost per claims claims claims claims
manufacturer data) (CY 2005 OPPS) (CY 2006 OPPS) (CY 2007 OPPS) (CY 2008 OPPS)
(CY 2004 OPPS)
APC 0107:
33240 ........ $17,025.21 $12,102.28 ..................................... ..................................... .....................................
G0297 ........ ..................................... 11,886.42 $13,392.82 $10,821.06 $18,470.82
G0298 ........ ..................................... 17,168.67 14,316.54 13,935.35 21,571.88
APC 0108:
33249 ........ $28,685.29 17,330.96 ..................................... ..................................... .....................................
G0299 ........ ..................................... 18,561.51 18,425.79 21,367.99 23,060.55
G0300 ........ ..................................... 21,006.03 19,306.96 23,680.34 26,204.89
8. Implantation of Spinal array), assigned to APC 0039 (Level I clinical APC. In addition, to pay
Neurostimulators (APC 0222) Implantation of Neurostimulator). differentially would require us to
The rechargeable neurostimulator establish one or more Level II HCPCS
(If you choose to comment on issues reported as device category code C1820 codes for reporting under the OPPS,
in this section, please include the has received pass-through payment because the three CPT codes for which
caption ‘‘Implantation of Spinal since January 1, 2006, and its pass- device category code C1820 is currently
Neurostimulators’’ at the beginning of through status will expire on January 1, an allowed device do not differentiate
your comment.) 2008, as discussed further in section among the device implantation
The CPT code for insertion of a spinal IV.B. of this proposed rule. During the procedures based on the specific device
neurostimulator (63685, Insertion or 2 years of pass-through payment when used. The creation of special Level II
replacement of spinal neurostimulator device category code C1820 has been HCPCS codes for OPPS reporting is
pulse generation or receiver, direct or paid at a hospital’s charges reduced to generally undesirable, unless absolutely
inductive coupling), which is assigned cost using the overall hospital CCR, we essential, because it increases hospital
to APC 0222 (Implantation of have applied a device offset when administrative burden as the codes may
Neurological Device), is reported for device category code C1820 is reported not be accepted by other payers.
both the insertion of a nonrechargeable with a CPT code assigned to APCs 0039 Establishing separate coding and
neurostimulator and a rechargeable or 0222 in order to remove the costs of payment would reduce the size of the
neurostimulator. The costs of a the predecessor nonrechargeable device APC payment groups in a year where we
nonrechargeable neurostimulator from from the cost-based payment of C1820. are proposing to increase packaging
CY 2005 claims are packaged into the This device offset ensures that no under the OPPS through expanded
payment for APC 0222 in CY 2007. We duplicate device payment is made. As a payment groups.
believe rechargeable neurostimulators general policy, under the OPPS we We believe that the principles of a
are currently most commonly implanted package payment for the costs of devices prospective payment system are best
for spinal neurostimulation, consistent into the payment for the procedure in served by following our standard
with the information provided during which they are used, unless those practice of retaining a single CPT code
our consideration of the device for pass devices have OPPS pass-through status, for neurostimulator implantation
through designation. However, in such as the case here. procedures that does not distinguish
response to hospital requests we have Review of our CY 2007 claims data for between rechargeable and
recently expanded our procedure-to- APC 0222 shows that the costs of the nonrechargeable neurostimulators, into
device edits to allow device category associated neurostimulator implantation which the costs of both types of devices
code C1820 (Generator, neurostimulator procedures are higher when the are packaged in relationship to their
(implantable), with rechargeable battery rechargeable neurostimulator is OPPS utilization. To the extent that the
and charging system) to be reported implanted rather than the traditional rechargeable neurostimulator may
with two other procedures. These nonrechargeable neurostimulator. We become the dominant device implanted
procedures are CPT code 64590 refer readers to Table 35 below for the over time for neurostimulation, the
(Insertion or replacement of peripheral median costs of APC 0222 under median costs of APCs 0222 and 0039
neurostimulator pulse generator or different device packaging scenarios. would reflect the change in surgical
receiver, direct or inductive coupling), However, the difference in costs is not practice in future years. In the
assigned to APC 0222, and CPT code so great that retaining the implantation meantime, with the rechargeable
61885 (Insertion or replacement of of both types of devices for spinal or neurostimulator coming off pass-
cranial neurostimulator pulse generator peripheral neurostimulation in APC through status for CY 2008, by following
or receiver, direct or inductive coupling; 0222 would cause a 2 times violation, our standard practice we would be
with connection to a single electrode and thereby, justify creating a new increasing the size of the APC 0222 and
APC 0039 payment bundles for CY for APC 0222 would be based. We how this specific device implantation
2008, thereby encouraging hospitals to believe this approach is the most situation differs from many other
use resources most efficiently. administratively simple, consistent with scenarios under the OPPS, where
Therefore, for CY 2008 we are OPPS packaging principles, and relatively general HCPCS codes describe
proposing to package the costs of supportive of encouraging hospital procedures that may utilize a variety of
rechargeable neurostimulators into the efficiency, yet it also provides devices with different costs, and
payment for the CPT codes that describe appropriate packaged payment for payment for those devices is packaged
the services furnished. Our proposed implantable neurostimulators. While we into the payment for the associated
median cost for APC 0222 is $12,161.64, welcome public comment on this issue, procedures.
upon which the CY 2008 payment rate we request that commenters address
TABLE 35.—APC 0222 CY 2006 DATA BASED ON CLAIMS REPORTING DIFFERENT NEUROSTIMULATOR DEVICES
CY 2006 pass CY 2006 pass
CY 2006 count edit, nontoken, edit, nontoken,
APC 0222 configurations of hospitals no FB single no FB median
billing bills cost
APC 0222, including claims with both rechargeable and nonrechargeable neurostimulators ... 868 2,830 $12,161.64
APC 0222A, including only claims with nonrechargeable neurostimulators ............................... 781 2,412 11,607.75
APC 0222B, including only claims with rechargeable neurostimulators ..................................... 238 422 18,088.71
9. Stereotactic Radiosurgery (SRS) a status indicator of ‘‘S.’’ Prior to CY treatment). Because HCPCS codes
Treatment Delivery Services (APCs 2007, CPT code 77435 was described G0173 and G0339 are more specific in
0065, 0066, and 0067) under CPT code 0083T (Stereotactic their descriptors than CPT code 77372,
(If you choose to comment on issues body radiation therapy, treatment we decided to continue using HCPCS
in this section, please include the management, per day), which was codes G0173 and G0339 under the OPPS
caption ‘‘SRS Treatment Delivery assigned to status indicator ‘‘N’’ in the for CY 2007. For CY 2007, we assigned
Services’’ at the beginning of your OPPS. The CPT Editorial Panel decided CPT code 77372 to status indicator ‘‘B’’
comment.) to delete CPT code 0083T on December under the OPPS. In addition, during CY
For CY 2007, the CPT Editorial Panel 31, 2006, and replaced it with CPT code 2006, CPT code 77373 was reported
created four new SRS Category I CPT 77435. Because the costs of SRS under one of three HCPCS codes
codes in the Radiation Oncology section treatment management were already depending on the circumstances and
of the 2007 CPT manual. Specifically, packaged into the OPPS payment rates technology used, specifically, G0251
the CPT Editorial Panel created CPT for SRS treatment delivery, we assigned (Linear accelerator-based stereotactic
codes 77371 (Radiation treatment CPT code 77435 to status indicator ‘‘N’’ radiosurgery, delivery including
delivery, stereotactic radiosurgery (SRS) which was the same status indicator collimator changes and custom
(complete course of treatment of that was assigned to its predecessor plugging, fractionated treatment, all
cerebral lesion(s) consisting of 1 Category III CPT code (0083T), under lesions, per session, maximum five
session); multi-source Cobalt 60 based)); the OPPS, effective January 1, 2007. We sessions per course of treatment); G0339
77372 (Radiation treatment delivery, note that the OPPS treatment of these (Image-guided robotic linear accelerator-
stereotactic radiosurgery (SRS) new CPT codes was open to comment based stereotactic radiosurgery,
(complete course of treatment of in the CY 2007 OPPS/ASC final rule complete course of therapy in one
cerebral lesion(s) consisting of 1 with comment period, and we will session or first session of fractionated
session); linear accelerator based)), specifically respond to those comments, treatment); and G0340 (Image-guided
77373 (Stereotactic body radiation according to our usual practice, in the robotic linear accelerator-based
therapy, treatment delivery, per fraction CY 2008 OPPS/ASC final rule with stereotactic radiosurgery, delivery
to 1 or more lesions, including image comment period. including collimator changes and
guidance, entire course not to exceed 5 As we explained in the CY 2007 custom plugging, fractionated treatment,
fractions); and 77435 (Stereotactic body OPPS/ASC final rule with comment all lesions, per session, second through
radiation therapy, treatment period (71 FR 68025), we did not fifth sessions, maximum five sessions
management, per treatment course, to recognize CPT codes 77372 and 77373 per course of treatment). Because
one or more lesions, including image because they do not accurately and HCPCS codes G0251, G0339, and G0340
guidance, entire course not to exceed 5 specifically describe the HPCPCS G- are more specific in their descriptors
fractions). codes that we currently use for linear than CPT code 77373 and are also
Of the four CPT codes, CPT codes accelerator (LINAC)-based SRS assigned to different clinical APCs for
77371 and 77435 were recognized under treatment delivery services under the CY 2007, we decided to continue
the OPPS effective January 1, 2007, OPPS. During CY 2006, CPT code 77372 recognizing HCPCS codes G0251,
while CPT codes 77372 and 77373 were was reported under one of two HCPCS G0339, and G0340 under the OPPS for
not. CPT code 77371 was assigned to the codes, depending on the technology CY 2007. Therefore, for CY 2007 we
same APC and status indicator as its used, specifically, G0173 (Linear assigned CPT code 77373 to status
predecessor code, HCPCS code G0243 accelerator based stereotactic indicator ‘‘B’’ under the OPPS.
(Multi-source photon stereotactic radiosurgery, complete course of While we have had requests from
radiosurgery, delivery including therapy in one session) and G0339 certain specialty societies and other
collimator changes and custom (Image-guided robotic linear accelerator- stakeholders that we recognize CPT
plugging, complete course of treatment, based stereotactic radiosurgery, codes 77372 and 77373 under the OPPS
all lesions). For CY 2007, CPT code complete course of therapy in one rather than continuing to use the current
77371 was assigned to APC 0127 with session or first session of fractionated Level II HCPCS codes for hospital
outpatient facility reporting of these complete and fractionated image-guided Radiosurgery, MRgFUS, and MEG), and
procedures, we have also heard from robotic linear accelerator-based SRS HCPCS code G0340 to APC 0066 (Level
others that continued use of the G-codes treatment. While all of these LINAC- II Stereotactic Radiosurgery, MRgFUS,
under the OPPS is the most appropriate based SRS procedures were originally and MEG) for CY 2008.
way to recognize the facility resource assigned to New Technology APCs Since we first established the full
differences between different types of under the OPPS, we reassigned them to group of SRS treatment delivery codes
LINAC-based procedures. For the past new clinical APCs for CY 2007 based on in CY 2004, we now have 3 years of
several years, we have collected 2 full years of hospital claims data hospital claims data reflecting the costs
information through our claims data reflecting stable median costs based on
of each of these services. Based on our
regarding the hospital costs associated significant volumes of single claims.
latest claims data from CY 2006, the
with the planning and delivery of SRS HCPCS codes G0173, G0251, G0339,
and G0340 are more specific in their proposed APC median cost for the
services. As new technology emerged in
descriptors than either CPT code 77372 complete course of therapy in one
the field of SRS several years ago, public
or 77373. In addition, their hospital session or first fraction of image-guided,
commenters urged CMS to recognize
claims data continue to reflect robotic LINAC-based SRS, as described
cost differences associated with the
significantly different hospital resources by HCPCS codes G0173 and G0339
various methods of SRS planning and
that would lead to violations of the 2 respectively in APC 0067, is $3,869.96
delivery. Beginning in CY 2001, we
times rule were we to reassign certain based on 1,946 single claims available
established G-codes to capture any such
cost variations associated with the procedures to the same clinical APCs in for ratesetting. The proposed CY 2008
various methods of planning and order to crosswalk the CY 2006 APC median cost for each fractionated
delivery of SRS. Based on comments historical claims data for the 4 G-codes session of LINAC-based SRS, as
received on the CY 2004 OPPS proposed to develop the median costs of the APCs described by HCPCS code G0251 in APC
rule regarding the G-codes used for SRS, to which the 2 CPT codes would be 0065, is $1,081.92 based on 1,938 single
we made some modifications to the assigned if we were to recognize them. claims. The proposed CY 2008 APC
coding for CY 2004 (68 FR 63431 and Therefore, we believe that we should median cost for the second through fifth
63432). First, we received comments continue to use the G-codes for sessions of image-guided, robotic
regarding the descriptors for HCPCS reporting LINAC-based SRS treatment LINAC-based fractionated SRS
codes G0173 and G0251, indicating that delivery services for CY 2008 under the treatment, reported by HCPCS code
these codes did not accurately OPPS to ensure appropriate payment to G0340 in APC 0066, is $2,980.24 based
distinguish image-guided robotic SRS hospitals for the different facility on 5,209 single claims.
systems from other forms of linear resources associated with providing Therefore, for CY 2008, we are
accelerator-based SRS systems to these complex services. That is, we are proposing to continue with the CY 2007
account for the cost variation in proposing to continue to assign HCPCS HCPCS coding for LINAC-based SRS
delivering these services. In response, codes G0173 and G0339 to APC 0067 treatment delivery services under the
for CY 2004 we modified the descriptor (Level III Stereotactic Radiosurgery, OPPS. The LINAC based SRS codes and
for G0173 and also created two HCPCS MRgFUS, and MEG), HCPCS code their CY 2008 proposed APC
G-codes, G0339 and G0340, to describe G0251 to APC 0065 (Level I Stereotactic assignments are displayed in Table 36.
TABLE 36.—PROPOSED CY 2008 APC ASSIGNMENTS FOR LINAC-BASED SRS TREATMENT DELIVERY SERVICES
Proposed
CY 2007 CY 2007 CY 2008
HCPCS code Short descriptor APC me- CY 2008 CY 2008
SI APC APC me-
G0173 .......... Linear acc stereo radsur com ...................... S ............ 0067 $3,872.87 S .............. 0067 $ 3,869.96
G0251 .......... Linear acc based stero radio ....................... S ............ 0065 1,241.89 S .............. 0065 1,081.92
G0339 .......... Robot lin-radsurg com, first ......................... S ............ 0067 3,872.87 S .............. 0067 3,869.96
G0340 .......... Robt lin-radsurg fractx 2–5 .......................... S ............ 0066 2,629.53 S .............. 0066 2,980.24
10. Blood Transfusion (APC 0110) (Transfusion), regardless of the number At its March 2007 meeting, the APC
of units of CPT code 36430 Panel recommended that CMS
(If you choose to comment on issues
(Transfusion, blood or blood investigate whether CPT code 36430
in this section, please include the
caption ‘‘Blood Transfusions’’ at the components) reported by the hospital on should identify when multiple units are
beginning of your comment.) a single date of service. The CPT code transfused and trigger a discounted
36430 descriptor does not include ‘‘per payment for the second and subsequent
We have a longstanding policy under
unit.’’ Hence, the median cost for CPT administration of additional units of
the OPPS that transfusion services are
code 36430, which is assigned to APC blood or blood components. The APC
billed and paid on a per encounter basis
0110, represents the costs of transfusion Panel indicated that the current
and not by the number of units of blood
of blood or blood products on the same payment for transfusion services does
products transfused (Internet Only
Manual 100–4, Chapter 4, Section date of service, regardless of how many not adequately pay hospitals for the
231.8). Under this policy, a transfusion units of products are transfused. In costs of these complex services, and that
APC payment is made to the OPPS addition, for payment of the transfusion payment on a per unit basis rather than
provider for transfusing blood products service, the OCE also requires the claim on a per encounter basis would result in
once per day, regardless of the number to contain a Level II HCPCS P-code for more accurate and appropriate payment.
of units or different types of blood a blood product on the same date of We do not agree with the APC Panel’s
products transfused. The OCE ensures service as the transfusion procedure. recommendation, and we are proposing
only one payment for APC 0110 to not accept this recommendation for
the CY 2008 OPPS. We believe that our 109–171 amended section 1833(b) of the establish adjustments, in a budget
current policy of providing a single Act to add colorectal cancer screening to neutral manner, as determined to be
payment for blood transfusion, the list of services for which the necessary to ensure equitable payments
regardless of the number of units beneficiary deductible no longer under the OPPS. Sections 1834(d)(2)
transfused, is most consistent with the applies. This provision applies to and (d)(3) of the Act regarding payment
goals of a prospective payment system services furnished on or after January 1, for screening flexible sigmoidoscopies
to encourage and create incentives for 2007. Second, sections 1834(d)(2) and and screening colonoscopies under the
efficiency in providing services. (d)(3) of the Act require Medicare to pay OPPS and ASC payment systems were
Payment for transfusion services on a the lesser of the ASC or OPPS payment established by Congress in 1997, many
per encounter basis encourages the amount for screening flexible years prior to the CY 2008 initial
transfusion of only those blood products sigmoidoscopies and screening implementation of the revised ASC
that are necessary for the beneficiary’s colonoscopies. For CY 2007, the OPPS payment system. The payment policies
treatment during the hospital outpatient payment for screening colonoscopies, of the revised ASC payment system, as
encounter. Moreover, the current HCPCS codes G0105 (Colorectal cancer summarized in section XVI. of this
median cost for the transfusion service, screening; colonoscopy on individual at proposed rule, make fundamental
associated with the transfusion of all risk) and G0121 (Colorectal cancer changes to the methodology for
blood products furnished on a date of screening; colonoscopy on individual developing ASC payment rates based on
service, has been set based on the not meeting criteria for high risk), certain principles, specifically that the
historical reporting of all charges for developed in accordance with our OPPS payment weight relativity is
transfusion on the same date of service standard OPPS ratesetting methodology, applicable to ASC procedures and that
and, therefore, represents the full cost of would have slightly exceeded the CY ASC costs are lower than HOPD costs
an episode of transfusion, rather than 2007 ASC payment of $446 for these for providing the same procedures, that
the cost of transfusion of a single unit procedures. Consistent with the contradict the original assumptions
of blood or blood product. Given our requirements set forth in sections underlying these provisions. According
proposed packaging approach for the CY 1834(d)(2) and (d)(3) of the Act, the to the findings of the GAO in its report,
2008 OPPS, it would be inconsistent for OPPS payment rates for HCPCS codes released on November 30, 2006, and
us to revise our current transfusion G0105 and G0121 were set equal to the
entitled ‘‘Medicare: Payment for
payment policy to provide separate CY 2007 ASC rate of $446 effective
Ambulatory Surgical Centers Should Be
payment for each unit of blood product January 1, 2007. This requirement did
Based on the Hospital Outpatient
transfused, thereby reducing the size of not impact the OPPS payment rate for
Payment System’’ (GAO–07–86), the
the current transfusion payment bundle. screening flexible sigmoidoscopies
Therefore, for CY 2008 we are payment groups of the OPPS accurately
(G0104, Colorectal cancer screening;
proposing to maintain our current reflect the relative costs of procedures
flexible sigmoidoscopy) because
payment policy, which bases payment performed in ASCs just as well as they
Medicare did not make payment to
for transfusion on the costs of all reflect the relative costs of the same
ASCs for screening flexible
transfusion services furnished on a procedures provided in HOPDs.
sigmoidoscopies in CY 2007, so there
single date of service and which was no payment comparison to be made Screening colonoscopies were among
examines hospital claims to ensure that for those services. the top 20 ASC procedures in terms of
payment is provided for only one unit According to the final policy for the volume whose costs were specifically
of CPT code 36430 on a date of service. revised ASC payment system as studied by the GAO in its work that led
However, we remind hospitals that a described in the final rule for the to this conclusion. We see no clinical or
claim for a single unit of CPT code revised ASC payment system published hospital resource explanation for why
36430 should include charges for all of elsewhere in this issue of the Federal the OPPS relative costs from CY 2006
the hospital resource costs associated Register, ASCs will be paid for OPPS claims data for screening flexible
with the totality of transfusion services screening colonoscopies based on their sigmoidoscopies and screening
furnished on the date of service, so that ASC payment weights derived from the colonoscopies would not provide an
the payment for one unit of APC 0110 related OPPS APC payment weights and appropriate basis for establishing their
is based on the costs of all transfusion multiplied by the final ASC conversion payment rates under both the OPPS and
services provided in a hospital factor (the product of the OPPS the revised ASC payment system,
outpatient encounter. conversion factor and the ASC budget according to the standard ratesetting
neutrality adjustment). As an office- methodologies of each payment system
11. Screening Colonoscopies and for CY 2008. If we were to pay for these
based procedure added to the ASC list
Screening Flexible Sigmoidoscopies of covered surgical procedures for CY screening procedures under the OPPS
(APCs 0158 and 0159) 2008, ASC payment for screening according to their ASC rates in CY 2008,
(If you choose to comment on issues flexible sigmoidoscopies will be capped we would significantly distort their
in this section, please include the at the CY 2008 MPFS nonfacility payment relativity in comparison with
caption ‘‘Screening Colonoscopies and practice expense amount. Sections other OPPS services. We believe it
Screening Flexible Sigmoidoscopies’’ at 1834(d)(2) and (d)(3) of the Act would would be inequitable to pay these
the beginning of your comment.) then require that the CY 2008 OPPS screening services in HOPDs at their
Since the implementation of the OPPS payment rates for these procedures be ASC rates for CY 2008, thereby ignoring
in August 2000, screening set equal to their significantly lower the relativity of their costs in
colonoscopies and screening flexible ASC payment rates. comparison with other OPPS services
sigmoidoscopies have been paid However, we are proposing to use the which have similar or different clinical
separately. In the CY 2007 OPPS/ASC equitable adjustment authority of and resource characteristics. Therefore,
final rule with comment period (71 FR section 1833(t)(2)(E) of the Act to adjust for CY 2008 when we will be paying for
68013), we implemented certain the OPPS payment rates for screening screening colonoscopies and screening
changes associated with colorectal colonoscopies and screening flexible flexible sigmoidoscopies performed in
cancer screening services provided in sigmoidoscopies. Section 1833(t)(2)E) of ASCs based upon their standard revised
HOPDs. First, section 5113 of Pub. L. the Act provides that the Secretary shall ASC payment rates, we are proposing to
adjust the payment rates under the the charges for the devices on their with comment period (70 FR 68620), we
OPPS to pay for the procedures claims, notwithstanding the absence of believed that this policy provided a
according to the standard OPPS specific codes for devices used. reasonable transition to full use of
payment rates. We believe that the In the CY 2004 OPPS, we used only claims data in CY 2007, which would
application of sections 1834(d)(2) and claims containing device codes to set include device coding and device
(d)(3) of the Act produces inequitable the medians for device-dependent APCs editing, while better moderating the
results because of the revised ASC and again used external data in a 50/50 amount of decline from the CY 2005
payment system to be implemented in blend with claims data to adjust OPPS payment rates.
CY 2008. We believe this proposal medians for a few device-dependent For CY 2007, we based the device-
would provide the most appropriate codes when it appeared that the dependent APC medians on CY 2005
payment for these procedures in the adjustments were important to ensure claims, the most current data available
context of the contemporary payment access to care. However, hospital device at that time. In CY 2005 we reinstated
policies of the OPPS and the revised code reporting was optional. hospital reporting of device codes and
ASC payment system. In the CY 2005 OPPS, which was made the reporting of device codes
based on CY 2003 claims data, there mandatory where an appropriate code
IV. Proposed OPPS Payment for Devices were no device codes on the claims and, exists to describe a device utilized. In
A. Proposed Treatment of Device- therefore, we could not use device- CY 2005, we also implemented HCPCS
Dependent APCs coded claims in median calculations as code procedure-to-device edits to
a proxy for completeness of the coding facilitate complete reporting of the
(If you choose to comment on issues and charges on the claims. For the CY charges for the devices used in the
in this section, please include the 2005 OPPS, we adjusted device- procedures assigned to the device-
caption ‘‘OPPS: Device-Dependent dependent APC medians for those dependent APCs. For CY 2007
APCs’’ at the beginning of your device-dependent APCs for which the ratesetting, we excluded claims for
comment.) CY 2005 OPPS payment median was which the charge for a device was less
1. Background less than 95 percent of the CY 2004 than $1.01, in part to recognize hospital
OPPS payment median. In these cases, charging practices due to a recall of
Device-dependent APCs are the CY 2005 OPPS payment median was cardioverter-defibrillator and pacemaker
populated by HCPCS codes that usually, adjusted to 95 percent of the CY 2004 pulse generators in CY 2005 for which
but not always, require that a device be OPPS payment median. We also the manufacturers provided
implanted or used to perform the reinstated the device codes and made replacement devices without cost to the
procedure. For the CY 2002 OPPS, we the use of the device codes mandatory beneficiary or hospital. We also found
used external data, in part, to establish where an appropriate code exists to that there were other devices for which
the device-dependent APC medians describe a device utilized in a the token charge was less than $1.01,
used for weight setting. At that time, procedure. In addition, we implemented and we removed those claims from the
many devices were eligible for pass HCPCS code edits to facilitate complete set used to calculate the median costs of
through payment. For the CY 2002 reporting of the charges for the devices device-dependent APCs. In summary,
OPPS, we estimated that the total used in the procedures assigned to the for the CY 2007 OPPS we set the median
amount of pass-through payments device-dependent APCs. costs for device-dependent APCs using
would far exceed the limit imposed by In the CY 2006 OPPS, which was only claims that passed the device edits
statute. To reduce the amount of a pro based on CY 2004 claims data, we set and did not contain token charges for
rata adjustment to all pass-through the median costs for device-dependent the devices. Therefore, the median costs
items, we packaged 75 percent of the APCs for CY 2006 at the highest of: (1) for these APCs for CY 2007 were
cost of the devices, using external data The median cost of all single bills; (2) determined from claims data that
furnished by commenters on the August the median cost calculated using only generally represented the full cost of the
24, 2001 proposed rule and information claims that contained pertinent device required device.
furnished on applications for pass- codes and for which the device cost was
through payment, into the median costs greater than $1; or (3) 90 percent of the 2. Proposed Payment
for the device-dependent APCs payment median that was used to set For this proposed rule, we calculated
associated with these pass-through the CY 2005 payment rates. We set 90 the median costs for device-dependent
devices. The remaining 25 percent of percent of the CY 2005 payment median APCs using three different sets of
the cost was considered to be pass as a floor rather than 85 percent as claims. We first calculated a median
through payment. proposed, in consideration of public cost using all single procedure claims
In the CY 2003 OPPS, we determined comments that stated that a 15-percent that contained appropriate device codes
APC medians for device-dependent reduction from the CY 2005 payment (where there are edits) for the procedure
APCs using a three-pronged approach. median was too large of a transitional codes in those APCs. We then
First, we used only claims with device step. We noted in our CY 2006 proposed calculated a second median cost using
codes on the claim to set the medians rule that we viewed our proposed 85 only claims that contain allowed device
for these APCs. Second, we used percent payment adjustment as a HCPCS codes with charges for all device
external data, in part, to set the medians transitional step from the adjusted codes that were in excess of $1.00
for selected device-dependent APCs by medians of past years to the use of (nontoken charge device claims). Third,
blending that external data with claims unadjusted medians based solely on we calculated the APC median cost
data to establish the APC medians. hospital claims data with device codes based only upon nontoken charge
Finally, we also adjusted the median for in future years (70 FR 42714). We also device claims with correct devices that
any APC (whether device-dependent or incorporated, as part of our CY 2006 did not also contain the HCPCS
not) that declined more than 15 percent. methodology, the recommendation of modifier ‘‘FB,’’ reported in CY 2005 to
In addition, in the CY 2003 OPPS we commenters to base payment on identify that a procedure was performed
deleted the device codes (‘‘C’’ codes) medians that were calculated using only using an item provided without cost to
from the HCPCS file because we claims that passed the device edits. As the provider, supplier, or practitioner,
believed that hospitals would include stated in the CY 2006 OPPS final rule or where a credit was received for a
replaced device (examples include, but Percutaneous Valvuloplasty); APC 0085 device edits for CY 2007, where we
are not limited to, devices covered (Level II Electrophysiologic Evaluation); require hospitals reporting certain
under warranty, devices replaced due to APC 0086 (Ablate Heart Dysrhythm implantable device HCPCS codes to also
defects, and free samples). Focus); APC 0115 (Cannula/Access report an appropriate procedure for the
As expected, the median costs Device Procedures); APC 0427 (Level III device’s use. We believe that these
calculated based upon single procedure Tube Changes and Repositioning); and reverse device edits should improve our
bills that met all three criteria, that is, APC 0623 (Level III Vascular Access packaging of device costs into the
correct devices, no token charges, and Procedures). We also are proposing to appropriate procedures for future OPPS
no ‘‘FB’’ modifier, were generally higher consider APC 0084 (Level I updates.
than the median costs calculated using Electrophysiologic Procedures) to be a We note that 12 of the APCs for which
all single bills. We believe that the device-dependent APC for CY 2008 it is appropriate to compare the
claims that meet these three criteria because we are proposing to reassign proposed CY 2008 APC medians to the
(appropriate device codes, nontoken many of the HCPCS codes that were CY 2007 final rule medians show
device charges, and no ‘‘FB’’ modifier) previously in APCs 0086 and 0087 to increases that are greater than 10
reflect the best estimated costs for these APC 0084. percent. We have examined the data for
device-dependent APCs when the As a result of the proposed APC these APCs and we believe that the
hospital pays the full cost of the device, reconfigurations resulting from HCPCS increases are attributable to a
and we are proposing to base our CY code migration, it is not appropriate to combination of factors. In some of these
2008 median costs on the medians compare the proposed CY 2008 OPPS cases, the single claims that were usable
calculated based upon these claims. median costs for these eight APCs to the for establishing the median costs are a
As a result of the effects of the CY 2007 final rule median costs that are small percent of the total bills for the
proposed CY 2008 packaging approach the basis for the CY 2007 OPPS payment services assigned to the APC and, as we
discussed in detail in section II.A.4. of rates. When we compare the median have stated previously, when small
this proposed rule on median costs, we costs for the other device-dependent percentages of single bills are used, the
are proposing to make some changes to APCs with stable proposed CY 2008 APC median cost is likely to show
CY 2007 device-dependent APCs for CY configurations in comparison with CY greater fluctuation from year to year. In
2008. Specifically, we are proposing to 2007, the median costs for 26 APCs addition, CY 2006 claims, which are the
delete APC 0081 (Noncoronary increase, some of them by significant basis for the CY 2008 proposed rule
Angioplasty or Atherectomy); APC 0087 amounts, and the median costs for 5 data, were the first set of claims subject
(Cardiac Electrophysiologic Recording/ APCs decrease. We believe that these to procedure-to-device edits for the
Mapping); and APC 0670 (Level II median costs represent valid estimates entire calendar year. These edits were
Intravascular and Intracardiac of the relative costs of the services in implemented to ensure that the charges
Ultrasound and Flow Reserve) due to these APCs, both with regard to the for the necessary devices were reported
the migration of HCPCS codes to other increases and the decreases that appear on the claims. While this editing was
APCs. Some of the HCPCS codes when the proposed CY 2008 median phased in during CY 2005, beginning in
assigned to these APCs in CY 2007 costs are compared to the CY 2007 April and concluding in October, CY
would be unconditionally packaged for median costs on which the payment 2006 was the first full year of procedure-
CY 2008. The median costs of the rates for these APCs are based. to-device edits and thus hospitals that
remaining HCPCS codes proposed for The only decline of more than 10 had not previously routinely reported
separate payment in CY 2008 were percent is found in APC 0418 (Insertion separate device codes and charges were
significantly different than CY 2007 due of Left Ventricular Pacing Electrode). In required by the edits to do so for all
to the proposed packaging of additional the case of APC 0418, we have been told claims submitted in CY 2006. The
services. We believe that reconfiguration that the very large increases in costs that reporting of device codes and charges
of the APCs is necessary to ensure that have occurred in the past several years for devices has historically resulted in
the HCPCS codes that would be for this APC were the result of claims increases in median costs for device-
separately paid in CY 2008 and that are where hospitals inserted an ICD at the dependent APCs. Thus, we believe that
assigned to these APCs in CY 2007 time of insertion of the left ventricular the more complete claims data available
would be assigned to APCs that are lead but failed to bill for the ICD for CY 2008 ratesetting likely contribute
homogeneous with regard to clinical implantation procedure. This incorrect to the increased proposed median costs
characteristics and resource use in CY reporting led to our attributing the costs observed for some device dependent
2008. The APCs we are proposing for of the expensive ICD device to the APCs.
deletion ceased to be appropriate as a median cost for the insertion of the left Furthermore, we believe that the
result of the reassignment of the HCPCS ventricular lead, instead of attributing proposed increases are also attributable,
codes that we are proposing for the cost of the ICD to a HCPCS code for in part, to our proposal to package the
continued separate payment in CY 2008. the implantation of the device. We costs of guidance services,
The following seven APCs remain believe that the decline in the median intraoperative services, and imaging
device-dependent APCs for CY 2008, cost for APC 0418 is the result of supervision and interpretation services
but we are proposing to reassign certain improvements in provider billing and into the payment for major independent
HCPCS codes mapped to these APCs for that the median cost we calculated from procedures, as described in section
CY 2007 either to other APCs or among the CY 2006 data is a reasonable II.A.4. of this proposed rule. For
these APCs for CY 2008 to ensure that, estimate of the cost of the insertion of example, CPT code 36870
in view of the median costs that result the left ventricular lead. Moreover, the (Thrombectomy, percutaneous,
from the proposed CY 2008 packaging relatively small number of single bills arteriovenous fistula, autogenous or
approach, the HCPCS codes would be and the small number of providers nonautogenous graft (includes
assigned to APCs that are homogeneous furnishing the service (158 hospitals) mechanical thrombus extraction and
with regard to clinical characteristics are likely to cause the median costs to intra-graft thrombolysis)) is the most
and resource use for CY 2008: APC 0082 vary more than for services furnished in commonly reported code in device-
(Coronary Atherectomy); APC 0083 greater volume by more hospitals. We dependent APC 0653 (Vascular
(Coronary Angioplasty and note that we have put into place reverse Reconstruction/Fistula Repair with
Device), representing 25,805 bills of CY 2007 median cost for the same APC. for devices, and lack the ‘‘FB’’ modifier
26,138 total bills in the APC. CPT code Based on our review of patterns of further reduces the pool of single bills
36870 appears with CPT code 75978 services observed in our claims data for that can be used to calculate the median
(Transluminal balloon angioplasty, the device-dependent APCs and our cost. However, even in the case of these
venous (e.g. subclavian stenosis), clinical review of the procedures low volume device-dependent APCs, we
radiological supervision and assigned to APCs that receive significant continue to believe that the median
interpretation) 14,679 times and with increases for CY 2008, we believe that costs calculated from the single bills
CPT code 75790 (Angiography, the increases in the proposed median that meet the three criteria represent the
arteriovenous shunt (e.g. dialysis costs for certain device-dependent APCs most valid estimated relative costs of
patient), radiological supervision and for CY 2008 are consistent with our these services to hospitals when they
interpretation) 15,623 times in the CY general expectations in the context of incur the full cost of the devices
2006 claims data. We are proposing to the comprehensive proposal for the CY required to perform the procedures.
2008 OPPS.
package payment for both CPT codes As we have stated in the past, some Therefore, we are proposing to base
75978 and 75790 for CY 2008. variation in relative costs from year to the payment rates for CY 2008 for all
Moreover, 9 other CPT codes that we are year is to be expected in a prospective device dependent APCs on their median
proposing to package for CY 2008 payment system. We believe that this is costs calculated using only single bills
appear with the independent CPT code particularly true for low volume device- that meet the three selection criteria
36870 more than 100 times each. dependent APCs because relatively discussed in detail above. Table 37
Therefore, many of the claims for CPT small numbers of providers furnish the below contains the proposed CY 2008
code 36870 proposed to be used for CY services; the total frequencies of services median costs for these APCs. We do not
2008 ratesetting include charges for both furnished are low (compared to believe that any special payment
CPT codes 75790 and 75978 and also commonly furnished services like policies are needed, as we believe that
contain charges for other CPT codes we visits); the number of single bills that the claims data we are proposing to use
are proposing to package, as well as are available for use in calculating the for ratesetting will ensure that the costs
uncoded revenue code charges that are full median cost of a single unit of a of the implantable devices are
packaged. Therefore, it is not surprising service is also relatively small; and the adequately and appropriately reflected
that our proposed median cost for APC selection of claims that contain in the median costs for these device-
0653 is about 30 percent higher than the appropriate devices, lack token charges dependent APCs.
TABLE 37.—PROPOSED CY 2008 MEDIAN COSTS FOR DEVICE-DEPENDENT APCS

[Note that N/A indicates APCs for which the CY 2007 OPPS medians are not comparable to the CY 2008 medians, due to proposed HCPCS
code migration for CY 2008.]
Difference
Proposed Proposed between CY Count of
CY 2007 CY 2007 Proposed CY 2008 CY 2008 2007 final providers
final rule final rule CY 2008 pass edit, pass edit, rule median billing in the
APC SI APC title pass edit, pass edit, post cost nontoken, nontoken, and pro- proposed
nontoken nontoken total no FB no FB posed CY CY 2008
frequency median cost frequency frequency median cost 2008 me- data
dian cost
0039 .... S .......... Level I Implantation 680 $11,450.84 2893 1035 $12,421.82 8.48 262
of
Neurostimulator.
0040 .... S .......... Percutaneous Im- 1402 3,457.00 12769 4663 4,010.44 16.01 994
plantation of
Neurostimulator
Electrodes, Ex-
cluding Cranial
Nerve.
0061 .... S .......... Laminectomy or In- 265 5,145.22 2938 1268 5,115.78 ¥0.57 440
cision for Implan-
tation of
Neurostimulator
Electrodes, Ex-
cluding Cranial
Nerve.
0082 .... T .......... Coronary or Non N/A N/A 16464 4374 5,584.20 N/A 925
Coronary
Atherectomy.
0083 .... T .......... Coronary or Non N/A N/A 140944 37879 2,897.95 N/A 1706
Coronary
Angioplasty and
Percutaneous
Valvuloplasty.
0084 .... S .......... Level I N/A N/A 9703 6973 647.41 N/A 600
Electrophysiolog-
ic Procedures.
0085 .... T .......... Level II N/A N/A 15791 3957 3,059.06 N/A 711
Electrophysiolog-
ic Evaluation.
TABLE 37.—PROPOSED CY 2008 MEDIAN COSTS FOR DEVICE-DEPENDENT APCS—Continued

Difference
dian cost
0086 .... T .......... Level III N/A N/A 8370 384 5,709.52 N/A 157
Electrophysiolog-
ic Procedures.
0089 .... T .......... Insertion/Replace- 388 7,557.38 3722 570 7,710.05 N/A 765
ment of Perma-
nent Pacemaker
and Electrodes.
0090 .... T .......... Insertion/Replace- 505 6,007.21 7426 524 6,279.63 4.53 314
ment of Pace-
maker Pulse
Generator.
0104 .... T .......... Transcatheter 396 5,360.43 4638 565 5,599.90 4.47 200
Placement of
Intracoronary
Stents.
ment of Pace-
maker Leads
and/or Elec-
trodes.
0107 .... T .......... Insertion of 584 18,607.21 9772 448 22,213.36 19.38 230
Cardioverter-
Defibrillator.
ment/Repair of
Cardioverter-
Defibrillator
Leads.
0115 .... T .......... Cannula/Access N/A N/A 2489 1259 1,920.99 N/A 669
Device Proce-
dures.
0202 .... T .......... Level VII Female 4451 2,627.08 17800 10043 2,719.11 3.50 1863
Reproductive
Proc.
0222 .... T .......... Implantation of 2007 11,099.02 7957 2830 12,161.64 9.57 868
Neurological De-
vice.
0225 .... S .......... Implantation of 83 13,514.45 1544 239 13,928.36 3.06 159
Neurostimulator
Electrodes, Cra-
nial Nerve.
0227 .... T .......... Implantation of 319 10,657.85 3350 1001 11,242.60 5.49 460
Drug Infusion
Device.
0229 .... T .......... Transcatherter 882 4,184.15 53470 7225 5,642.77 34.86 1226
Placement of
Intravascular
Shunts.
0259 .... T .......... Level VI ENT Pro- 472 25,351.03 1311 783 25,434.97 0.33 166
cedures.
0315 .... T .......... Level II Implanta- 516 14,845.73 807 648 16,532.22 11.36 195
tion of
Neurostimulator.
0384 .... T .......... GI Procedures with 6574 1,402.31 21958 6895 1,587.03 13.17 1428
Stents.
0385 .... S .......... Level I Prosthetic 267 4,840.44 881 581 5,368.16 10.90 319
Urological Proce-
dures.
0386 .... S .......... Level II Prosthetic 1788 8,395.82 4990 3346 9,045.78 7.74 862
Urological Proce-
dures.
TABLE 37.—PROPOSED CY 2008 MEDIAN COSTS FOR DEVICE-DEPENDENT APCS—Continued

Difference
dian cost
0418 .... T .......... Insertion of Left 169 18,777.92 4436 185 15,760.17 ¥16.07 158
Ventricular Pac-
ing Elect.
0425 .... T .......... Level II 410 6,550.59 1104 489 7,150.52 9.16 330
Arthroplasty with
Prosthesis.
0427 .... T .......... Level III Tube N/A N/A 21092 11368 936.73 N/A 1255
Changes and
Repositioning.
0622 .... T .......... Level II Vascular 25264 1,385.14 55118 33637 1,542.90 11.39 2380
Access Proce-
dures.
0623 .... T .......... Level III Vascular N/A N/A 66747 49861 1844.44 N/A 2701
Access Proce-
dures.
0625 .... T .......... Level IV Vascular 20 5,100.26 479 8 5,492.89 7.70 154
Access Proce-
dures.
0648 .... T .......... Level IV Breast 286 3,130.45 2895 382 3,330.44 6.39 388
Surgery.
0652 .... T .......... Insertion of 3676 1,805.28 5407 3138 1,997.86 10.67 996
Intraperitoneal
and Pleural
Catheters.
0653 .... T .......... Vascular Recon- 702 1,978.84 26138 1573 2,584.62 30.61 682
struction/Fistula
Repair with De-
vice.
0654 .... T .......... Insertion/Replace- 1179 6,891.44 29645 1735 6,724.90 ¥2.42 625
ment of a perma-
nent dual cham-
ber pacemaker.
0655 .... T .......... Insertion/Replace- 876 9,327.71 12769 1896 9,075.74 ¥2.70 1247
ment/Conversion
of a permanent
dual chamber
pacemaker.
0656 .... T .......... Transcatheter 2700 6,618.18 24346 3148 7,478.29 13.00 378
Placement of
Intracoronary
Drug-Eluting
Stents.
0674 .... T .......... Prostate 1737 6,646.07 3182 1997 7,782.75 17.10 366
Cryoablation.
0680 .... S .......... Insertion of Patient 972 4,436.69 2234 1465 4,506.93 1.58 689
Activated Event
Recorders.
0681 .... T .......... Knee Arthroplasty 301 12,569.11 391 286 12,029.91 ¥4.29 57
3. Proposed Payment When Devices Are hospital or credit for the device being charges for these expensive devices or
Replaced with Partial Credit to the replaced if the patient required a more that contain the ‘‘FB’’ modifier, which
Hospital expensive device. In order to ensure that would signify that the device was
As we discuss above in the context of the payment we are proposing for CY replaced without cost or with a full
the calculation of median costs for 2008 pays hospitals appropriately when credit for the cost of the device being
device dependent APCs, in recent years they incur the full cost of the device, we replaced. Similarly, to ensure equitable
there have been several field actions and have calculated the proposed median payment when the hospital receives a
recalls with regard to failure of costs for device dependent APCs using device without cost or receives a full
implantable devices. In many of these only claims that contain the correct credit for the cost of the device being
cases, the manufacturers have offered device code for the procedure. We are replaced, for CY 2007 we implemented
replacement devices without cost to the not using claims that contain token a payment policy that reduces the
payment for selected device-dependent problems through claims analysis and even in cases in which the credit is for
APCs when the hospital receives certain so that we can make appropriate as much as 50 percent of the cost of an
replacement devices without cost or payment adjustments in these cases. expensive device.
receives a full credit for the device being Collecting data on a wider set of device Under the OPPS, we calculate the
replaced (71 FR 68077). replacements under full and partial estimated costs on which the APC
Subsequent to the issuance of the CY credit situations would assist in payment weights are based by applying
2007 OPPS/ASC final rule with developing comprehensive summary a CCR to the charges for the device.
comment period, we had many inquiries data, not just a subset of data related to When hospitals charge the full amount
from hospitals that asked whether the devices replaced without cost or with a for the device, although they may have
reduction would also apply in cases in full credit to the hospital. We are received a substantial credit towards its
which there was a partial credit for the mindful of the need to use our claims cost, our methodology may result in
cost of a device that failed or was history where possible to promote early median costs that reflect the full costs
otherwise covered under a manufacturer awareness of problems with implantable of these devices in all cases, including
warranty. Those inquiring explained medical devices and to promote high those cases in which the hospital incurs
that cases of partial credit are the vast quality medical care with regard to the much less than the full cost of the
majority of cases involving devices that devices and the services in which they device. It is likely that the reduced
have failed or otherwise must be are used. hospital costs associated with steady,
replaced under warranty. They We also are concerned with the issue low volume warranty replacements of
indicated that in some cases the devices of the increased Medicare and implantable devices may never be
failed, and in other situations the beneficiary liability for the monitoring reflected in the CCRs used to adjust
patient’s energy needs exceeded the costs that are required as a result of the charges to costs for devices, because
capacity of the device and thus the recall of these 73,000 devices those CCRs are overwhelmed by the
device ceased to be useful before the (worldwide, with an unknown portion volume of other items attributed to the
end of the warranty period. They told us being applicable to Medicare cost centers. Therefore, our median
that a typical industry practice for some beneficiaries). Specifically, the costs for device-dependent APCs would
types of devices was to provide a 50 manufacturer of the devices that have not reflect the reduced hospital costs
percent credit in cases of device failure been most recently recalled associated with partial credit
(including battery depletion) under recommends that patients with the replacement procedures and would
warranty if a device failed at 3 years of recalled device consult with their result in overpayment for the
use (failure during the first 3 years physician in each case and, in some implantation procedures under the
would result in a full device credit) and cases, begin a routine of monthly OPPS. Moreover, in these cases either
to prorate the credit further over time evaluations. We would expect that not the beneficiary or a secondary insurer
between 3 and 5 years after the initial only could extra visits to physicians’ also would pay a copayment that
device implantation, as the useful life of offices or HOPDs be necessary, but reflects the full cost of the device,
the device declined. As promulgated in additional diagnostic tests may also be although the hospital may have received
the CY 2007 OPPS/ASC final rule with needed to care for the beneficiaries who a substantial credit under the warranty.
comment period and codified at have the recalled devices. Thus, even We believe that both Medicare and the
§ 419.45, the CY 2007 reduction policy when the device does not immediately beneficiary should share in the savings
does not apply to cases in which there require replacement, we are concerned that result from the partial credit that
is a partial credit toward the that the potential greater costs to the hospital receives.
replacement of the device. Medicare and to the beneficiary or his We have considered how we might
In addition to our concern over the or her secondary payor for these ensure that these cases of device failure
replacement of implantable devices at unforeseen extra services may be or premature replacement are reported
no cost to hospitals due to device substantial and burdensome. We will be and appropriately taken into account in
recalls, device failure, or other clinical actively assessing how we can identify setting OPPS payment rates and
situations, we believe that it is equally additional health care costs and beneficiary copayments. We are
as important that timely information be Medicare expenditures associated with proposing to create a HCPCS modifier
reported and analyzed regarding the device recall actions and exploring what for CY 2008 that would be reported in
performance and longevity of devices actions could be appropriate in the case all cases in which the hospital receives
replaced in partial credit situations. of these additional monitoring and a partial credit toward the replacement
This issue is particularly timely due to related expenses. We welcome public of a medical device listed in Table 39
the recent recall of 73,000 ICDs and comment on this issue to inform our of this proposed rule. These devices are
cardiac resynchronization therapy future review and analyses. the same devices to which our policy
defibrillators (CRT–Ds) because of a Moreover, the payment rates for the governing payment when the device is
faulty capacitor that can cause the APCs into which the costs of the most furnished to the provider without cost
batteries to deplete sooner than expensive devices are packaged are set or with full credit applies for CY 2008.
expected. In some cases, patients will based on the assumption that the As we discussed in the CY 2007 OPPS/
require more frequent monitoring of hospital incurs the full cost of the ASC final rule with comment period (71
their device function and early device device. To continue to pay the full APC FR 68071), we selected these devices
replacement. (We refer readers to the rate when the hospital receives a partial because they have substantial device
Web site: http://www.fda.gov/cdrh/news credit toward the cost of a very costs and because the device is
for Questions and Answers posted April expensive device would result in implanted in the beneficiary at least
20, 2007 on this recall.) Therefore, we excessive and inappropriate payment temporarily and, therefore, can be
believe that hospitals should report for the procedure and its packaged associated with an individual
occurrences of devices being replaced costs. Some hospitals have told us that beneficiary. This proposed policy would
under warranty or otherwise with a they do not reduce their charges for the enhance our ability to track the
partial credit granted to the hospital so device being implanted or used in the replacement of these implantable
that we may be able to identify procedure in cases in which they medical devices and may permit us to
systematic failures of devices or device receive a partial credit for the device, identify trends in device failure or
limited longevity. Moreover, it would APCs by half of the reduction that For example, using the proposed CY
enable us to reduce the APC payment in applies when the hospital receives a 2008 offset percents in Table 38 below
cases in which the hospital receives a device without cost or receives a full for illustration only, if a cochlear
partial credit toward the cost of the credit for a device being replaced. That implant fails under warranty and must
replacement device being implanted. is, we are proposing to reduce the be replaced and the manufacturer
We believe that this is a logical payment for the APC by half of the provides the hospital a 45-percent credit
extension of our policy regarding offset amount that represents the cost of of the cost of the new device used in the
reduction of the APC payment in cases the device packaged into the APC implantation procedure, the hospital
in which the provider furnishes the payment. In the absence of claims data would bill CPT code 69930 (Cochlear
device without cost or with a full credit on which to base a reduction factor, but device implantation, with or without
to the hospital. taking into consideration what we have mastoidectomy) with the new modifier
Specifically, as discussed in more been told is common industry practice, for partial credit devices, and Medicare
detail below, we are proposing to reduce we believe that reducing the amount of would reduce the payment to the
the payment for the APC into which the payment for the device-dependent APC hospital by 41.52 percent of the APC
device cost is packaged by one half of by half of the estimated cost of the payment rate (50 percent of the
the amount of the offset amount that device packaging represents a proposed full offset rate of 83.03 percent
would apply if the device were being reasonable and equitable reduction in that would apply if the device were
replaced without cost or with full credit, these cases. replaced with no cost to the provider or
but only where the amount of the device We considered whether to propose to at full credit for the device being
credit is greater than or equal to 20 require hospitals to reduce their charges replaced).
percent of the cost of the new in proportion to the partial credit they Even in the absence of specific
replacement device being implanted. receive for the device so that, in future instructions from us to reduce the
We also are proposing to base the years, we would have cost data reported device charges in partial credit cases,
beneficiary’s copayment on the reduced consistently on which we could we could monitor the charges that are
APC payment rate so that the consider basing the amount of reduction submitted for devices reported with the
beneficiary shares in the hospital’s to the payment for the procedure in proposed partial credit modifier to see
reduced costs. We believe that it is cases of a partial device credit. if hospitals appear to be reflecting
inequitable to set the payment rates for However, we are concerned that such a partial device credits in their charges for
the procedures into which payment for requirement could impose an these implantable devices. We believe
these devices is packaged on the administrative burden on hospitals that that we could use pattern analysis to
assumption that the hospital always would outweigh the potential benefit of determine if a hospital that is reporting
incurs the full cost for these expensive a more accurate reduction to payment in the device with the partial credit
devices but to not adjust the payment these cases. We are requesting modifier is charging at a lower rate for
when the hospital receives a partial comments on the extent to which any the same device when the modifier
credit for a failed or otherwise replaced administrative burden would be appears with the procedure in which
device. Accordingly, we believe that it balanced or compensated for by the the device is used than in cases without
is appropriate to make an equitable potential payment accuracy benefit of reporting of the modifier. If we find that
adjustment to the APC payment to an empirically based reduction to hospitals are adjusting their charges to
ensure that the Medicare program payment in these cases. reflect the reduced costs of these
payment made for the service and the In addition, we are proposing to take devices, we will explore whether
beneficiary’s liability are appropriate in this reduction only when the credit is revising the amount of the reduction
these cases in which the hospital’s for 20 percent or more of the cost of the could be appropriate.
device costs are significantly reduced. new replacement device, so that the In the course of exploring whether the
We are proposing changes to reduction is not taken in cases in which current regulations apply to partial
§§ 419.45(a) and (b) to reflect our more than 80 percent of the cost of the credit situations, inquirers have told us
proposed policy of reducing the OPPS replacement device has been incurred that they are concerned that hospitals
payment when partial credit for the by the hospital. We believe that the may refrain from returning devices that
device cost is received by the hospital burden to hospitals of requiring that fail under the warranty period to
for a failed or otherwise replaced they report cases in which the partial manufacturers if hospitals would then
device. credit for the device being replaced is be required to report the partial credit
Due to the absence of current less than 20 percent of the cost of the to Medicare and would receive a
reporting of the cases in which hospitals new replacement device is greater than reduced Medicare payment as a result.
receive a partial credit for replaced the benefit to the Medicare program and They told us that this hospital practice
devices and to our belief, based on the beneficiary. In addition, if the could delay manufacturers’ learning
conversations with hospital staff, that partial credit is less than 20 percent of vital information about device failures,
hospitals do not reduce their device the cost of the new replacement device, longevity, and overall performance.
charges to reflect the credits, we have no then we believe that reducing the APC Currently, many device manufacturers
data for use to empirically determine by payment for the device implantation encourage the return to them of all
how much we should reduce the procedure by 50 percent of the packaged implantable devices, once they are taken
payment for the procedural APC into device cost would provide too low a out of a patient’s body for any reason,
which the costs of these devices are payment to hospitals providing the for evaluation of device performance
packaged. However, device necessary device replacement and survival analysis, which estimates
manufacturers and hospitals have told procedures. Therefore, we are proposing the probability that a device will not
us that a common scenario is that, if a that the new HCPCS partial credit malfunction during a specified period of
device fails 3 years after implantation, modifier would be reported and the time. We do not believe that hospitals
the hospital would receive a 50 percent partial credit reduction would be taken would refrain from returning a device
credit towards a replacement device. only in cases in which the credit is removed from a patient to a
Therefore, we are proposing to reduce equal to or greater than 20 percent of the manufacturer in order to justify not
the payment for these device-dependent cost of the new replacement device. reporting the partial credit modifier to
Medicare. We believe that hospitals cost to increase and, therefore, could APCs to which the policy does not
have a strong interest in ensuring that result in a decline in the device portion apply in CY 2007 would meet the
manufacturers know as soon as possible as a percent of total cost. Increases in criteria for CY 2008. We concluded that
when there are problems with the the offset amounts may be caused by the one additional APC meets the criteria
devices provided to their patients, increases observed in the CCRs, changes for inclusion under this policy and that
whether the result would be a full or in the population of hospitals whose one APC currently on the list ceases to
partial credit for the failed device. In claims were used due to additional meet the criteria. Specifically, we are
addition, we believe that hospitals, key packaging, increased packaging of proposing to add APC 0625 (Level IV
participants in the broader health care services that have significant device Vascular Access Procedures) to the list
system, are concerned with device costs, higher costs of new devices, or of APCs to be adjusted in cases of full
performance, patient health, and health greater efficiency in the implantation of or partial credit for replaced devices and
care quality from the broader public devices, any of which could result in to add the device described by device
health perspective and are committed to the device portion of the APC’s median code C1881 (Dialysis access system
appropriate reporting to improve the cost increasing as a percent of the total (implantable)) that is implanted in a
quality of future health care that leads cost for the APC as compared to CY procedure assigned to APC 0625 to the
to better health outcomes for patients. 2007. As with APC median costs, the list of devices to which this policy
Moreover, we do not believe that offset amounts are expected to vary from applies. We are proposing to add APC
hospitals would intentionally fail to year to year, and we do not see undue 0625 and device code C1881 for CY
report to Medicare the service furnished variation in the proposed CY 2008 offset 2008 because they meet the criteria for
correctly and completely with the amounts compared with the final CY inclusion in this policy. In particular,
partial credit modifier when the 2007 offset amounts. the single surgical procedure (CPT code
modifier applies, because the hospital The CY 2007 final payment policy 36566 (Insertion of tunneled centrally
would then knowingly submit incorrect when devices are replaced without cost inserted central venous access device,
information on the claim. or when a full credit for a replaced requiring two catheters via two separate
In summary, we are proposing to device is furnished to the hospital venous access sites; with subcutaneous
create a HCPCS modifier to be reported applies to those APCs that met three port(s)) assigned to APC 0625 always
on a procedure code in Table 38 below criteria as described in the CY 2007 requires an implantable device that is
if a device listed in Table 39 below is OPPS/ASC final rule with comment reported, the proposed CY 2008 APC
replaced with partial credit from the period (71 FR 68072 through 68077). device offset percent is greater than 40
manufacturer that is greater than or Specifically, all procedures assigned to percent, and the device is of a type that
equal to 20 percent of the cost of the the selected APCs must require is surgically implanted in the patient,
replacement device and to reduce the implantable devices that would be where it remains at least temporarily.
payment for the procedure by 50 reported if device replacement Furthermore, costly devices described
percent of the amount of the estimated procedures were performed, the by device code C1881 are implanted in
packaged cost of the device being required devices must be surgically the procedure assigned to APC 0625. We
replaced when the modifier is reported inserted or implanted devices that also found that APC 0229 (Transcatheter
with a procedure code that is assigned remain in the patient’s body after the Placement of Intravascular Shunts)
to an APC in Table 38. We believe that conclusion of the procedures (at least ceases to meet the criteria because the
this policy is necessary to pay equitably temporarily), and the device offset device offset percent for this APC, when
for these services when the hospital amount must be significant, defined as calculated from proposed rule data, is
receives a partial credit for the cost of exceeding 40 percent of the APC cost. less than 40 percent. Moreover, we
the device being implanted. We also restricted the devices to which believe that the devices that would be
We note that, of the proposed CY the APC payment adjustment would implanted in the procedures assigned to
2008 offset amounts shown in Table 38 apply to a specific set of costly devices this APC are not of a type that would
that were in effect for CY 2007, 13 to ensure that the adjustment would not be amenable to removal and
decline slightly compared to the CY be triggered by the replacement of an replacement in a device recall or
2007 final rule offset amounts. inexpensive device whose cost would warranty situation. Therefore, we are
Similarly, the proposed CY 2008 offset not constitute a significant proportion of proposing to remove APC 0229 from the
amounts for eight of these APCs the total payment rate for an APC. list of APCs to which the no cost or full
increase somewhat. As with changes in We examined the offset amounts credit and proposed partial credit
median costs, there may be several calculated from the CY 2008 proposed reduction policies are applicable for CY
different factors that are responsible for rule data and the clinical characteristics 2008.
the observed changes. With regard to the of APCs to determine whether the APCs Table 38 presents the device offset
declines, we believe that it is possible to which the no cost or full credit amounts that we are proposing to apply
that the increased packaging we are replacement policy applies in CY 2007 to the specified APCs in cases of no cost
proposing for CY 2008 may cause the continue to meet the criteria for CY or full or partial credit for replaced
nondevice portion of an APC’s median 2008 and to determine whether other devices for the CY 2008 OPPS.
TABLE 38.—PROPOSED ADJUSTMENTS TO APCS IN CASES OF NO COST OR FULL OR PARTIAL CREDIT FOR REPLACED
DEVICES
Proposed CY Proposed CY
CY 2007 re- 2008 reduction 2008 reduction
duction for full
APC SI APC title for full credit for partial
credit case case credit case
(percent) (percent) (percent)
0039 ..... S .......... Level I Implantation of Neurostimulator ................................................... 78.85 82.15 41.07
TABLE 38.—PROPOSED ADJUSTMENTS TO APCS IN CASES OF NO COST OR FULL OR PARTIAL CREDIT FOR REPLACED
DEVICES—Continued
Proposed CY Proposed CY
CY 2007 re- 2008 reduction 2008 reduction
duction for full
APC SI APC title for full credit for partial
credit case case credit case
(percent) (percent) (percent)
0040 ..... S .......... Percutaneous Implantation of Neurostimulator Electrodes, Excluding 54.06 55.93 27.97
Cranial Nerve.
0061 ..... S .......... Laminectomy or Incision for Implantation of Neurostimulator Electrodes, 60.06 59.32 29.66
Excluding Cranial Nerve.
0089 ..... T .......... Insertion/Replacement of Permanent Pacemaker and Electrodes .......... 77.11 74.02 37.01
0090 ..... T .......... Insertion/Replacement of Pacemaker Pulse Generator .......................... 74.74 75.54 37.77
0106 ..... T .......... Insertion/Replacement/Repair of Pacemaker and/or Electrodes ............. 41.88 57.20 28.60
0107 ..... T .......... Insertion of Cardioverter-Defibrillator ....................................................... 90.44 89.43 44.72
0108 ..... T .......... Insertion/Replacement/Repair of Cardioverter-Defibrillator Leads .......... 89.40 89.26 44.63
0222 ..... T .......... Implantation of Neurological Device ........................................................ 77.65 83.29 41.64
0225 ..... S .......... Implantation of Neurostimulator Electrodes, Cranial Nerve ..................... 79.04 80.84 40.42
0227 ..... T .......... Implantation of Drug Infusion Device ....................................................... 80.27 79.69 39.85
0259 ..... T .......... Level VI ENT Procedures ........................................................................ 84.61 83.03 41.52
0315 ..... T .......... Level II Implantation of Neurostimulator .................................................. 76.03 86.23 43.12
0385 ..... S .......... Level I Prosthetic Urological Procedures ................................................. 83.19 51.67 25.83
0386 ..... S .......... Level II Prosthetic Urological Procedures ................................................ 61.16 61.98 30.99
0418 ..... T .......... Insertion of Left Ventricular Pacing Elect ................................................. 87.32 81.38 40.69
0625 ..... T .......... Level IV Vascular Access Procedures ..................................................... N/A 62.63 32.32
0654 ..... T .......... Insertion/Replacement of a permanent dual chamber pacemaker .......... 77.35 75.86 37.93
0655 ..... T .......... Insertion/Replacement/Conversion of a permanent dual chamber pace- 76.59 74.59 37.30
maker.
0680 ..... S .......... Insertion of Patient Activated Event Recorders ....................................... 76.40 72.14 36.07
0681 ..... T .......... Knee Arthroplasty ..................................................................................... 73.37 73.27 36.64
TABLE 39.—PROPOSED DEVICES FOR TABLE 39.—PROPOSED DEVICES FOR the BIPA. Prior to pass-through device
WHICH THE ‘‘FB MODIFIER’’ OR NEW WHICH THE ‘‘FB MODIFIER’’ OR NEW categories, Medicare payments for pass-
PARTIAL CREDIT MODIFIER MUST BE PARTIAL CREDIT MODIFIER MUST BE through devices under the OPPS were
REPORTED WITH THE PROCEDURE REPORTED WITH THE PROCEDURE made on a brand-specific basis. All of
the initial 97 category codes that were
CODE WHEN FURNISHED WITHOUT CODE WHEN FURNISHED WITHOUT established as of April 1, 2001, have
COST/FULL CREDIT OR PARTIAL COST/FULL CREDIT OR PARTIAL expired; 95 categories expired after CY
CREDIT FOR A REPLACED DEVICE CREDIT FOR A REPLACED DEVICE— 2002, and 2 categories expired after CY
Continued 2003. In addition, nine new categories
Device
HCPCS Short descriptor have expired since their creation. The
Device three categories listed in Table 40, along
code HCPCS Short descriptor
code with their expected expiration dates,
C1721 ...... AICD, dual chamber. were established for pass-through
C1722 ...... AICD, single chamber. C2631 ...... Rep dev, urinary, w/o sling. payment in CY 2006 or CY 2007, as
C1764 ...... Event recorder, cardiac. L8614 ....... Cochlear device/system. noted. Under our established policy, we
C1767 ...... Generator, neurostim, imp.
base the expiration dates for the
C1771 ...... Rep dev, urinary, w/sling.
C1772 ...... Infusion pump, programmable. B. Pass-Through Payments for Devices category codes on the date on which a
C1776 ...... Joint device (implantable). category was first eligible for pass-
1. Expiration of Transitional Pass-
C1777 ...... Lead, AICD, endo single coil. through payment.
Through Payments for Certain Devices
C1778 ...... Lead, neurostimulator. Of these 3 device categories, there is
C1779 ...... Lead, pmkr, transvenous VDD. (If you choose to comment on issues 1 that would be eligible for pass-through
C1785 ...... Pmkr, dual, rate-resp. in this section, please include the payment for at least 2 years as of
C1786 ...... Pmkr, single, rate-resp. caption ‘‘OPPS: Expiring Device Pass- December 31, 2007; that is, device
C1813 ...... Prosthesis, penile, inflatab. Through Payments’’ at the beginning of category code C1820 (Generator,
C1815 ...... Pros, urinary sph, imp.
C1820 ...... Generator, neuro rechg bat sys.
your comment.) neurostimulator (implantable), with
C1881 ...... Dialysis access system. rechargeable battery and charging
a. Background
C1882 ...... AICD, other than sing/dual. system). In the CY 2007 OPPS/ASC final
C1891 ...... Infusion pump, non-prog, perm. Section 1833(t)(6)(B)(iii) of the Act rule with comment period (71 FR
C1895 ...... Lead, AICD, endo dual coil. requires that, under the OPPS, a 68078), we finalized our proposal to
C1896 ...... Lead, AICD, non sing/dual. category of devices be eligible for expire device category C1820 from pass-
C1897 ...... Lead, neurostim, test kit. transitional pass-through payments for through device payment after December
C1898 ...... Lead, pmkr, other than trans. at least 2, but not more than 3, years. 31, 2007.
C1899 ...... Lead, pmkr/AICD combination. This period begins with the first date on In the November 1, 2002 OPPS final
C1900 ...... Lead coronary venous.
C2619 ...... Pmkr, dual, non rate-resp.
which a transitional pass-through rule, we established a policy for
C2620 ...... Pmkr, single, non rate-resp. payment is made for any medical device payment of devices included in pass-
C2621 ...... Pmkr, other than sing/dual. that is described by the category. The through categories that are due to expire
C2622 ...... Prosthesis, penile, non-inf. device category codes became effective (67 FR 66763). For CY 2003 through CY
C2626 ...... Infusion pump, non-prog, temp. April 1, 2001, under the provisions of 2007, we packaged the costs of the
devices no longer eligible for pass- b. Proposed Policy hospital claims data used for this
through payments into the costs of the For CY 2008, we are implementing proposed OPPS update.
procedures with which the devices were the final decision we discussed in the In addition, the 2 device categories
billed in the claims data used to set the CY 2007 OPPS/ASC final rule with that were established for pass-through
payment rates for those years. comment period that finalizes the payment as of January 1, 2007, C1821
Brachytherapy sources, which are now expiration date for pass-through status (Interspinous process distraction device
separately paid in accordance with for device category C1820. Therefore, as (implantable)) and L8690 (Auditory
section 1833(t)(2)(H) of the Act, are an of January 1, 2008, we will discontinue osseointegrated device, includes all
exception to this established policy pass-through payment for device internal and external components),
(with the exception of brachytherapy category code C1820. In accordance would be active categories for pass-
sources for prostate brachytherapy, with our established policy, we will through payment for 2 years as of
which were packaged in the CY 2003 package the costs of the device assigned December 31, 2008. Therefore, we are
OPPS only). to this device category into the costs of proposing that these categories expire
the procedures with which the device from pass-through device payment as of
was billed in CY 2006, the year of December 31, 2008.
TABLE 40.—CURRENT PASS-THROUGH DEVICE CATEGORIES BY EXPIRATION DATE
Date(s) Expiration
HCPCS code Category long descriptor populated date
C1820 ............... Generator, neurostimulator (implantable) ................................................................................. 1/1/06 12/31/07

C1821 ............... Interspinous process distraction device (implantable) ............................................................. 1/1/07 12/31/08
L8690 ................ Auditory osseointegrated device, includes all internal and external components ................... 1/1/07 12/31/08
2. Proposed Provisions for Reducing device related costs because device C- For CY 2004, we modified our policy
Transitional Pass-Through Payments To code cost data were not available until for applying offsets to device pass-
Offset Costs Packaged Into APC Groups CY 2003. For CY 2003, we calculated a through payments. Specifically, we
(If you choose to comment on issues median cost for every APC based on indicated that we would apply an offset
in this section, please include the single claims with device codes but to a new device category only when we
caption ‘‘OPPS: Offset Costs’’ at the without packaging the costs of could determine that an APC contains
beginning of your comment.) associated C-codes for device categories costs associated with the device. We
that were billed with the APC. We then continued our existing methodology for
a. Background calculated a median cost for every APC determining the offset amount,
In the November 30, 2001 OPPS final based on single claims with the costs of described earlier. We were able to use
rule, we explained the methodology we the associated device category C-codes this methodology to establish the device
used to estimate the portion of each that were billed with the APC packaged offset amounts for CY 2004 because
APC payment rate that could reasonably into the median. Comparing the median providers reported device codes
be attributed to the cost of the APC cost without device packaging to (generally C-codes) on the CY 2002
associated devices that are eligible for the median APC cost including device claims used for the CY 2004 OPPS
pass-through payments (66 FR 59904). packaging that was developed from the update. For the CY 2005 update to the
Beginning with the implementation of claims with device codes also reported OPPS, our data consisted of CY 2003
the CY 2002 OPPS quarterly update enabled us to determine the percentage claims that did not contain device codes
(April 1, 2002), we deducted from the of the median APC cost that was and, therefore, for CY 2005, we utilized
pass-through payments for the attributable to the associated pass- the device percentages as developed for
identified devices an amount that through devices. By applying those CY 2004. In the CY 2004 OPPS update,
reflected the portion of the APC percentages to the APC payment rates, we reviewed the device categories
payment amount that we determined we determined the applicable amount to eligible for continuing pass-through
was associated with the cost of the payment in CY 2004 to determine
be deducted from the pass-through
device, as required by section whether the costs associated with the
payment, the ’’offset’’ amount. We
1833(t)(6)(D)(ii) of the Act. In the device categories were packaged into
created an offset list comprised of any
November 1, 2002 interim final rule the existing APCs. Based on our review
APC for which the device cost was at
with comment period, we published the of the data for the device categories
least 1 percent of the APC’s cost.
applicable offset amounts for CY 2003 existing in CY 2004, we determined that
(67 FR 66801). The offset list that we published for there were no close or identifiable costs
For the CY 2002 and CY 2003 OPPS CY 2002 through CY 2004 was a list of associated with the devices relating to
updates, to estimate the portion of each offset amounts associated with those the respective APCs that were normally
APC payment rate that could reasonably APCs with identified offset amounts billed with them. Therefore, for those
be attributed to the cost of an associated developed using the methodology device categories, we set the offset
device eligible for pass-through described above. As a rule, we do not amount to $0 for CY 2004. We
payment, we used claims data from the know in advance which procedures continued this policy of setting the
period used for recalibration of the APC residing in certain APCs may be billed offset amount to $0 for the device
rates. That is, for CY 2002 OPPS with new device categories. Therefore, categories that continued to receive
updating, we used CY 2000 claims data, an offset amount was applied only when pass-through payment in CY 2005.
and for CY 2003 OPPS updating, we a new device category was billed with For the CY 2006 OPPS update, CY
used CY 2001 claims data. For CY 2002, a HCPCS procedure code that was 2004 hospital claims were available for
we used median cost claims data based assigned to an APC appearing on the analysis. Hospitals billed device C-
on specific revenue centers used for offset list. codes in CY 2004 on a voluntary basis.
We reviewed our CY 2004 data and of Neurostimulator). We announced an CY 2003 OPPS to determine an
found that the numbers of claims for offset amount for device category C1820 appropriate device offset percent for
services in many of the APCs for which when billed with a procedure code that those APCs with which the new
we calculated device percentages using maps to APC 0039, in Program category would be reported.
CY 2004 data were quite small. We also Transmittal No. 1209, dated March 21,
b. Proposed Policy
found that many of these APCs already 2007.)
had relatively few single claims For CY 2006, we used available For CY 2008, we are proposing to
available for median calculations partial year CY 2005 hospital claims continue to review each new device
compared with the total bill frequencies, data to calculate device percentages and category on a case-by-case basis as we
because of our inability to use many potential offsets for CY 2006 have done since CY 2004, to determine
multiple bills in establishing median applications for new device categories. whether device costs associated with
costs for all APCs. In addition, we found Effective January 1, 2005, we require the new category are packaged into the
that our claims demonstrated that hospitals to report device HCPCS codes existing APC structure. If we determine
relatively few hospitals specifically and their charges when hospitals bill for that, for any new device category, no
coded for devices utilized in CY 2004. services that utilize devices described device costs associated with the new
Thus, we were not confident that CY by the existing device category codes. In category are packaged into existing
2004 claims reporting device HCPCS addition, during CY 2005 we APCs, we are proposing to continue our
codes represented the typical costs of all implemented device edits for many current policy of setting the offset
hospitals providing the services. services that require devices and for amount for the new category to $0 for
Therefore, we did not use CY 2004 which appropriate device category CY 2008. There are currently two new
claims with device codes to calculate HCPCS codes exist. Therefore, we device categories that will continue for
CY 2006 device offset amounts. In expected that the number of claims that pass through payment in CY 2008.
addition, we did not use the CY 2005 included device codes and their These categories, described by HCPCS
methodology, for which we utilized the respective costs to be much more robust codes L8690 and C1821, currently have
device percentages as developed for CY and representative for CY 2005 than for an offset amount equal to $0 because we
2004. Two years had passed since we CY 2004. could not identify device related costs
developed the device offsets for CY For CY 2007, we reviewed the two in the procedural APCs we expect
2004, and the device offsets originally new device categories, C1821 and would be billed with either of the two
L8690, to determine whether device categories L8690 or C1821, that is, in
calculated from CY 2002 hospital claims
costs associated with the new categories APC 0256 or APC 0050, respectively.
data may either have overestimated or
were packaged into the existing APC We are proposing that the offsets for CY
underestimated the contributions of
structure based on CY 2005 claims data. 2008 for L8690 and C1821 remain set to
device costs to total procedural costs in
As indicated earlier, under our $0, because we cannot identify device
the outpatient hospital environment of
established policy, if we determine that costs packaged in the related procedural
CY 2006. In addition, a number of the
the device costs associated with a new APCs that are closely identifiable with
APCs on the CY 2004 and CY 2005
category are closely identifiable to these device categories, based on the
device offset percent lists were either no
device costs packaged into existing claims data for CY 2006, the claims data
longer in existence or were so
APCs, we set the offset amount for the year for our CY 2008 OPPS update.
significantly reconfigured that the past We are proposing to continue our
new category to an amount greater than
device offsets likely did not apply. existing policy of establishing new
$0. Our review of the related services
For CY 2006, we reviewed the single indicated that the median costs for the categories in any quarter when we
new device category established, C1820, applicable APC 0256 (Level V ENT determine that the criteria for granting
to determine whether device costs Procedures (for L8690)) and APC 0050 pass through status for a device category
associated with the new category were (Level II Musculoskeletal Procedures are met. If we create a new device
packaged into the existing APC Except Hand and Foot (for C1821)) did category and determine that our CY
structure based on partial CY 2005 not contain costs for devices that were 2006 claims data contain a sufficient
claims data. Under our established similar to those described by the new number of claims with identifiable costs
policy, if we determine that the device device categories. Therefore, we set the associated with the new category of
costs associated with the new category respective offsets to $0. devices in any APC with which it is
are closely identifiable to device costs We believe that use of the most billed, we are proposing to establish an
packaged into existing APCs, we set the current claims data to establish offset offset amount greater than $0 and to
offset amount for the new category to an amounts when they are needed to reduce the transitional pass through
amount greater than $0. Our review of ensure appropriate payment is payment for the device by the related
the service indicated that the median consistent with our stated policy; procedural APC offset amount. If we
cost for the applicable APC 0222 therefore, we are proposing to continue determine that a device offset amount
(Implantation of Neurological Device) to do so for the CY 2008 OPPS. greater than $0 is appropriate for any
contained costs for neurostimulators Specifically, if we create a new device new category that we create, we are
that were similar to neurostimulators category for payment in CY 2008, to proposing to announce the offset
described by the new device category calculate potential offsets we are amount in the program transmittal that
C1820. Therefore, we determined that a proposing to examine the most current announces the new category.
device offset would be appropriate. We available claims data, including device In summary, for CY 2008, we are
announced a CY 2006 offset amount for costs, to determine whether device costs proposing to use CY 2006 hospital
that category in Program Transmittal associated with the new category are claims data to calculate device
No. 804, dated January 3, 2006. (We already packaged into the existing APC percentages and potential offsets for
subsequently were informed that some structure, as indicated earlier. If we new device categories established in CY
rechargeable neurostimulators described conclude that some related device costs 2008. We are proposing to publish
by device category C1820 may also be are packaged into existing APCs, we are through program transmittals any new
used and billed with a CPT code that proposing to use the methodology or updated offsets that we calculate for
maps to APC 0039 (Level I Implantation described earlier and first used for the CY 2008, corresponding to newly
created categories or existing categories assigned status indicator ‘‘G’’ in rate is equal to the average price for the
eligible for pass-through payment, Addenda A and B to this proposed rule. drug or biological for all competitive
respectively. Section 1833(t)(6)(D)(i) of the Act acquisition areas and the year
specifies that the pass-through payment established as calculated and adjusted
V. Proposed OPPS Payment Changes for amount, in the case of a drug or by the Secretary. Section 1847B of the
Drugs, Biologicals, and biological, is the amount by which the
Radiopharmaceuticals Act, as added by section 303(d) of Pub.
amount determined under section L. 108–173, establishes the payment
A. Proposed Transitional Pass-Through 1842(o) (or, if the drug or biological is methodology for Medicare Part B drugs
Payment for Additional Costs of Drugs covered under a competitive acquisition and biologicals under the competitive
and Biologicals contract under section 1847B, an acquisition program (CAP). The Part B
(If you choose to comment on issues amount determined by the Secretary drug CAP was implemented July 1,
in this section, please include the equal to the average price for the drug 2006, and includes approximately 180
caption ‘‘OPPS: Pass-Through Drugs’’ at or biological for all competitive of the most commonPart B drugs
the beginning of your comment.) acquisition areas and year established provided in the physician’s office
under such section as calculated and setting. The list of drugs and biologicals
1. Background adjusted by the Secretary) for the drug covered under the Part B drug CAP,
Section 1833(t)(6) of the Act provides or biological exceeds the portion of the their associated payment rates and the
for temporary additional payments or otherwise applicable Medicare OPD fee Part B drug CAP pricing methodology
‘‘transitional pass-through payments’’ schedule that the Secretary determines can be found on the CMS Web site at
for certain drugs and biological agents. is associated with the drug or biological. http://www.cms.hhs.gov/Competitive
As originally enacted by the Medicare, This methodology for determining the AcquisforBios.
Medicaid, and SCHIP Balanced Budget pass-through payment amount is set
For CYs 2005, 2006, and 2007, we
Refinement Act (BBRA) of 1999 (Pub. L. forth in § 419.64 of the regulations,
estimated the OPPS pass-through
106–113), this provision requires the which specifies that the pass-through
payment amount for drugs and
Secretary to make additional payments payment equals the amount determined
biologicals to be zero based on our
to hospitals for current orphan drugs, as under section 1842(o) of the Act minus
interpretation that the ‘‘otherwise
designated under section 526 of the the portion of the APC payment that
applicable Medicare OPD fee schedule’’
Federal Food, Drug, and Cosmetic Act CMS determines is associated with the
amount was equivalent to the amount to
(Pub. L. 107–186); current drugs and drug or biological. Section 1847A of the
be paid for pass-through drugs and
biological agents and brachytherapy Act, as added by section 303(c) of Pub.
biologicals under section 1842(o) of the
sources used for the treatment of cancer; L. 108–173, establishes the use of the
Act (or section 1847B of the Act, if the
and current radiopharmaceutical drugs average sales price (ASP) methodology
drug or biological is covered under a
and biological products. For those drugs as the basis for payment for drugs and
competitive acquisition contract). We
and biological agents referred to as biologicals described in section
concluded for those years that the
‘‘current,’’ the transitional pass-through 1842(o)(1)(C) of the Act that are
resulting difference between these two
payment began on the first date the furnished on or after January 1, 2005.
rates would be zero.
hospital OPPS was implemented (before The ASP methodology uses several
enactment of the Medicare, Medicaid, sources of data as a basis for payment, The pass-through application and
and SCHIP BenefitsImprovement and including ASP, wholesale acquisition review process is explained on the CMS
Protection Act (BIPA) of 2000 (Pub. L. cost (WAC), and average wholesale Web site at: http://www.cms.hhs.gov
106–554), on December 21, 2000). price (AWP). In this proposed rule, the /HospitalOutpatientPPS/04_pass
Transitional pass-through payments term ‘‘ASP methodology’’ and ‘‘ASP through_payment.asp.
are also provided for certain ‘‘new’’ based’’ are inclusive of all data sources 2. Drugs and Biologicals With Expiring
drugs and biological agents that were and methodologies described therein. Pass-Through Status in CY 2007
not being paid for as an HOPD service Additional information on the ASP
as of December 31, 1996, and whose methodology can be found on the CMS Section 1833(t)(6)(C)(i) of the Act
cost is ‘‘not insignificant’’ in relation to Web site at: http://www.cms.hhs.gov/ specifies that the duration of
the OPPS payments for the procedures McrPartBDrugAvgSalesPrice/ transitional pass through payments for
or services associated with the new drug 01_overview.asp#TopOfPage. drugs and biologicals must be no less
or biological. Under the statute, As noted above, section than 2 years and no longer than 3 years.
transitional pass-through payments can 1833(t)(6)(D)(i) of the Act also states that In Table 41, we list the seven drugs and
be made for at least 2 years but not more if a drug or biological is covered under biologicals whose pass through status
than 3 years. Proposed CY 2008 pass- a competitive acquisition contract under will expire on December 31, 2007, that
through drugs and biologicals are section 1847B of the Act, the payment meet that criterion.
TABLE 41.—PROPOSED DRUGS AND BIOLOGICALS FOR WHICH PASS-THROUGH STATUS EXPIRES DECEMBER 31, 2007
CY 2007 and Proposed CY
HCPCS code Short descriptor proposed CY CY 2007 SI 2008 SI
2008 APC
J2278 ................ Ziconotide injection ....................................................................................... 1694 G K

J2503* ............... Pegaptanib sodium injection ........................................................................ 1697 G K

J7311 ................ Fluocinolone acetonide ................................................................................ 9225 G K
J8501 ................ Oral aprepitant .............................................................................................. 0868 G K
J9027 ................ Clofarabine injection ..................................................................................... 1710 G K
J9264* ............... Paclitaxel protein bound ............................................................................... 1712 G K
Q4079 ............... Natalizumab injection ................................................................................... 9126 G K
* Indicates that the drug was paid at a rate determined by the Part B drug CAP methodology while identified as pass-through under the OPPS.
3. Drugs and Biologicals with Proposed Thus, we are proposing for CY 2008 to We are proposing to use payment
Pass-Through Status in CY 2008 pay for pass-through drugs and rates based on the ASP data from the
We are proposing to continue pass- biologicals that are not part of the Part fourth quarter of CY 2006 for budget
through status in CY 2008 for 13 drugs B drug CAP at ASP+6 percent, neutrality estimates, impact analyses,
and biologicals. These items, which equivalent to the rate these drugs and and completion of Addenda A and B to
were approved for pass-through status biologicals would receive in the this proposed rule because these are the
between April 1, 2006 and July 1, 2007, physician’s office setting in CY 2008. most recent data available to us at this
are listed in Table 42. The APCs and Section 1842(o) of the Act also states time. These payment rates are also the
HCPCS codes for these drugs and that if a drug or biological is covered basis for drug payments in the
biologicals listed in Table 42 are under a competitive acquisition contract physician’s office setting, effective April
assigned status indicator ‘‘G’’ in under section 1847B of the Act, the 1, 2007. As updated data will be
Addenda A and B to this proposed rule. payment rate is equal to the average available during the development of our
Section 1833(t)(6)(D)(i) of the Act sets price for the drug or biological for all final rule, we are proposing to use ASP
the amount of pass-through payment for data from the second quarter of 2007
competitive acquisition areas and year
pass-through drugs and biologicals (the (which are the basis for drug payments
established as calculated and adjusted
pass-through payment amount). The in the physician’s office setting,
by the Secretary. For CY 2008, we are
pass-through payment amount is the effective October 1, 2007) in budget
proposing to provide payment for drugs
difference between the amount neutrality estimates, impact analyses,
and biologicals with pass-through status
authorized under section 1842(o) of the and completion of Addenda A and B to
that are offered under the Part B drug
Act (or, if the drug or biological is the CY 2008 OPPS/ASC final rule with
CAP at a rate equal to the Part B drug
covered under a competitive acquisition comment period. In addition, we are
CAP rate. Therefore, considering ASP+5
contract under section 1847B, an proposing to update these pass-through
percent to be the otherwise applicable
amount determined by the Secretary payment rates on a quarterly basis on
fee schedule portion associated with
equal to the average price for the drug our Web site during CY 2008 if later
these drugs or biologicals, the difference quarter ASP submissions (or more
or biological for all competitive
between the Part B drug CAP rate and recent WAC or AWP information, as
acquisition areas and year established
ASP+5 percent would be the pass- applicable) indicate that adjustments to
under such section as calculated and
through payment amount for these the payment rates for these pass-through
adjusted by the Secretary) and the
drugs and biologicals. HCPCS codes that drugs and biologicals are necessary.
portion of the otherwise applicable fee
are offered under the CAP program as of Although there are no pass-through
schedule amount that the Secretary
April 1, 2007 are identified in Table 42 radiopharmaceuticals at this time for CY
determines is associated with the drug
with an asterisk. 2008, the payment rate for a
or biological. Given our CY 2008
proposal to provide payment for In section V.B.3.b. of this proposed radiopharmaceutical with pass-through
nonpass-through separately payable rule, we discuss our proposal to make status would also be adjusted
drugs and biologicals at ASP+5 percent separate payment in CY 2008 for new accordingly.
as described further in section V.B.3 of drugs and biologicals with a HCPCS If a drug that has been granted pass-
this proposed rule, we believe it would code, consistent with the provisions of through status for CY 2008 becomes
be most consistent with the statute to section 1842(o) of the Act, at a rate that covered under the Part B drug CAP, we
provide payment for drugs and is equivalent to the payment they would are proposing to make the appropriate
biologicals with pass through status that receive in a physician’s office setting (or adjustments to the payment rates for
are not part of the Part B drug CAP at under section 1847B of the Act, if the these drugs and biologicals on a
a rate of ASP+6 percent, compared to drug or biological is covered under a quarterly basis. For drugs and
ASP+5 percent as the otherwise competitive acquisition contract) only if biologicals that are currently covered
applicable fee schedule portion we have received a pass-through under the CAP, we are proposing to use
associated with the drug or biological. application for the item and pass- the payment rates calculated under that
The difference between ASP+6 percent through status has been subsequently program that are in effect as of April 1,
and ASP+5 percent, therefore, would be granted. Otherwise, we are proposing to 2007. We are proposing to update these
the CY 2008 pass-through payment pay ASP+5 percent for these products in payment rates if the rates change in the
amount for these drugs and biologicals. CY 2008. future.
TABLE 42.—PROPOSED DRUGS AND BIOLOGICALS WITH PASS-THROUGH STATUS IN CY 2008

CY 2007 and CY 2007 and
HCPCS code Short descriptor proposed CY proposed CY
2008 APC 2008 SI
C9232 .......... Injection, idursulfase ........................................................................................................................ 9232 G

C9233 .......... Injection, ranibizumab ...................................................................................................................... 9233 G
C9235 .......... Injection, panitumumab .................................................................................................................... 9235 G
C9350 .......... Porous collagen tube per cm ........................................................................................................... 9350 G
C9351 .......... Acellular derm tissue percm2 .......................................................................................................... 9351 G
J0129 ........... Injection, abatacept .......................................................................................................................... 9230 G
J0348 ........... Anadulafungin injection .................................................................................................................... 0760 G
J0894* ......... Injection, decitabine ......................................................................................................................... 9231 G

J1740 ........... Injection ibandronate sodium ........................................................................................................... 9229 G
J2248 ........... Injection, micafungin sodium ............................................................................................................ 9227 G
J3243 ........... Injection, tigecycline ......................................................................................................................... 9228 G
J3473 ........... Hyaluronidase recombinant ............................................................................................................. 0806 G
J9261 ........... Nelarabine injection .......................................................................................................................... 0825 G
* Indicates that the drug is paid at a rate determined by the Part B drug CAP methodology while identified as pass-through under the OPPS.
B. Proposed Payment for Drugs, packaging determination for oral and with industry and government practices,
Biologicals, and Radiopharmaceuticals injectable 5HT3 forms of anti emetic and that the PPI is an appropriate
Without Pass-Through Status products. We discuss in section V.B.2. mechanism to gauge Part B drug
of this proposed rule our proposed CY inflation. While we are not proposing
1. Background
2008 payment policy for anti emetic for CY 2008 to change this established
Under the CY 2007 OPPS, we products. approach to establishing the general
currently pay for drugs, biologicals, and packaging threshold for drugs,
radiopharmaceuticals that do not have 2. Proposed Criteria for Packaging
Payment for Drugs and Biologicals biologicals, and radiopharmaceuticals,
pass-through status in one of two ways: in view of our proposed packaging
packaged payment within the payment (If you choose to comment on issues approach for the CY 2008 OPPS as
for the associated service or separate in this section, please include the outlined in section II.A.4. of this
payment (individual APCs). We caption ‘‘OPPS: Packaging Drugs and proposed rule and our desire to move
explained in the April 7, 2000 OPPS Biologicals’’ at the beginning of your the OPPS toward a more encounter-
final rule with comment period (65 FR comment.) based and episode-based payment in the
18450) that we generally package the As indicated above, in accordance future, we will consider expanded
cost of drugs and radiopharmaceuticals with section 1833(t)(16)(B) of the Act, packaging of payment for drugs,
into the APC payment rate for the the threshold for establishing separate biologicals, and radiopharmaceuticals
procedure or treatment with which the APCs for drugs and biologicals was set for a future OPPS update. We believe
products are usually furnished. to $50 per administration during CYs that consideration of expanded
Hospitals do not receive separate 2005 and 2006. In CY 2007, we used the packaging for drugs and biologicals is
payment from Medicare for packaged fourth quarter moving average Producer particularly important given the
items and supplies, and hospitals may Price Index (PPI) levels for prescription substantial increase that has occurred in
not bill beneficiaries separately for any preparations to trend the $50 threshold
recent years in the proportion of HCPCS
packaged items and supplies whose forward from the third quarter of CY
codes for drugs, biologicals, and
costs are recognized and paid within the 2005 (when the Pub. L. 108–173
radiopharmaceuticals that are paid
national OPPS payment rate for the mandated threshold became effective) to
separately, from 30 percent in CY 2003
associated procedure or service. the third quarter of CY 2007. We then
to 50 percent in CY 2007. We are
(Program Memorandum Transmittal A rounded the resulting dollar amount to
proposing for CY 2008 to expand the
01 133, issued on November 20, 2001, the nearest $5 increment in order to
packaging of certain drugs and
explains in greater detail the rules determine the CY 2007 threshold
radiopharmaceuticals, specifically
regarding separate payment for adjustment amount of $55.
Following the CY 2007 methodology contrast agents and diagnostic
packaged services.)
Packaging costs into a single aggregate (which is discussed in more detail in radiopharmaceuticals as discussed in
payment for a service, procedure, or the CY 2007 OPPS/ASC final rule with detail in section II.A.4. of this proposed
episode of care is a fundamental comment period (71 FR 68085 through rule. However, we believe that increased
principle that distinguishes a 68086)), we used updated fourth quarter packaging of payment for drugs,
prospective payment system from a fee moving average PPI levels to trend the biologicals, and radiopharmaceuticals
schedule. In general, packaging the costs $50 threshold forward from the third more generally under the OPPS could
of items and services into the payment quarter of CY 2005 to the third quarter provide significant incentives for
for the primary procedure or service of CY 2008 and again rounded the hospital efficiency in adopting the most
with which they are associated resulting dollar amount ($57.78) to the cost-effective approaches to patient care,
encourages hospital efficiencies and nearest $5 increment, which yielded a while providing hospitals with
also enables hospitals to manage their figure of $60. In performing this maximum flexibility in managing their
resources with maximum flexibility. calculation, we used the most up-to-date resources. Therefore, we are interested
Section 1833(t)(16)(B) of the Act, as forecasted, quarterly PPI estimates from in public comments regarding
added by section 621(a)(2) of Pub. L. CMS’ Office of the Actuary (OACT). As recommended approaches to increase
108–173, sets the threshold for actual inflation for past quarters packaging of these products under the
establishing separate APCs for drugs replaced forecasted amounts, the PPI OPPS and issues we should consider as
and biologicals at $50 per estimates for prior quarters have been we evaluate alternative methodologies
administration for CYs 2005 and 2006. revised (compared with those used in for the future.
Therefore, for CYs 2005 and 2006, we the CY 2007 OPPS/ASC proposed rule) To determine their CY 2008 proposed
paid separately for drugs, biologicals, and have been incorporated into our packaging status, we calculated the per
and radiopharmaceuticals whose per calculation for this CY 2008 proposed day cost of all drugs, biologicals, and
day cost exceeded $50 and packaged the rule. Based on the calculations radiopharmaceuticals that had a HCPCS
costs of drugs, biologicals, and described above, we are proposing a code in CY 2006 and were paid (via
radiopharmaceuticals whose per day packaging threshold for CY 2008 of $60. packaged or separate payment) under
cost was equal to or less than $50 into As stated in the CY 2007 OPPS/ASC the OPPS using claims data from
the procedures with which they were final rule with comment period (71 FR January 1, 2006, to December 31, 2006.
billed. For CY 2007, the packaging 68086), we believe that packaging In order to calculate the per day costs
threshold for drugs, biologicals, and certain items is a fundamental for drugs, biologicals, and
radiopharmaceuticals that are not new component of a prospective payment radiopharmaceuticals to determine their
and do not have pass through status was system, that packaging these items does packaging status in CY 2008, we are
established to be $55. The methodology not lead to beneficiary access issues and proposing to use the methodology that
used to establish the $55 threshold for does not create a problematic site of was described in detail in the CY 2006
CY 2007 and our proposed approach for service differential, that the packaging OPPS proposed rule (70 FR 42723
future years are discussed in more detail threshold is reasonable based on the through 42724) and finalized in the CY
in section V.B.2. of this proposed rule. initial establishment in law of a $50 2006 OPPS final rule with comment
In addition, for CY 2005 to CY 2007, threshold for the CY 2005 OPPS, that period (70 FR 68636 through 70 FR
we have provided an exemption to this updating the $50 threshold is consistent 68638). To calculate the proposed CY
2008 per day costs, we used an from their packaged status determined chemotherapy and other therapies with
estimated payment rate for each drug based on the data we are using for this side effects of nausea and vomiting,
and biological of ASP+5 percent (which proposed rule. Under such anti-emetic use is often an integral part
is the payment rate we are proposing for circumstances, we are proposing to of the treatment regimen. We believe
separately payable drugs and biologicals apply the following policies to these that we should continue to ensure that
in CY 2008, as discussed in more detail drugs, biologicals, and Medicare payment rules do not impede
subsequently). As noted in section radiopharmaceuticals whose a beneficiary’s access to the particular
V.A.3. of this proposed rule, we used relationship to the $60 threshold anti-emetic that is most effective for him
the manufacturer submitted ASP data changes based on the final updated data: or her as determined by the beneficiary
from the fourth quarter of CY 2006 (rates • Drugs, biologicals, and and his or her physician.
that were used for payment purposes in radiopharmaceuticals that were paid
the physician’s office setting, effective separately in CY 2007 and that are TABLE 43.—PROPOSED ANTI-EMETICS
April 1, 2007). For items that did not proposed for separate payment in CY TO EXEMPT FROM PROPOSED CY
have an ASP based payment rate, we 2008, and then have per day costs equal 2008 $60 PACKAGING THRESHOLD
used their mean unit cost derived from to or less than $60 based on the updated
the CY 2006 hospital claims data to ASPs and hospital claims data used for HCPCS
determine their per day cost. We the CY 2008 final rule with comment Short descriptor
Code
packaged items with per day cost less period, would continue to receive
than or equal to $60 and identified separate payment in CY 2008. J1260 .......... Dolasetron mesylate
items with per day cost greater than $60 • Drugs, biologicals, and J1626 .......... Granisetron HCl injection
as separately payable. Consistent with radiopharmaceuticals that are packaged J2405 .......... Ondansetron HCl injection
in CY 2007 and that are proposed for J2469 .......... Palonosetron HCl
our past practice, we crosswalked Q0166 ......... Granisetron HCl 1 mg oral
historical OPPS claims data from the CY separate payment in CY 2008, and then
Q0179 ......... Ondansetron HCl 8 mg oral
2006 HCPCS codes that were reported to have per day costs equal to or less than Q0180 ......... Dolasetron mesylate oral
the CY 2007 HCPCS codes that we $60 based on the updated ASPs and
display in Addendum B to this hospital claims data used for the CY
3. Proposed Payment for Drugs and
proposed rule for payment in CY 2008. 2008 final rule with comment period,
Biologicals Without Pass-Through
We note that HCPCS code A9568 would remain packaged in CY 2008.
• Drugs, biologicals, and Status That Are Not Packaged
(Technetium Tc–99 arcitumomab,
diagnostic, per study dose, up to 45 radiopharmaceuticals for which we are a. Payment for Specified Covered
millicuries), replaced HCPCS code proposing packaged payment in CY Outpatient Drugs
A9549 (Technetium Tc–99 2008 but then had per day costs greater
arcitumomab, diagnostic, per study than $60 based on the updated ASPs
in this section, please include the
dose, up to 25 millicuries) beginning and hospital claims data used for the CY
caption OPPS: Specified Covered
January 1, 2007. Our CY 2006 claims 2008 final rule with comment period,
Outpatient Drugs’’ at the beginning of
data indicate that HCPCS code A9549 would receive separate payment in CY
your comment.)
was billed an average of one time per 2008.
day. As we do not have claims data We note that in sections II.A.4.c.(5) (1) Background
available for ratesetting purposes for and (6) of this proposed rule that we are Section 1833(t)(14) of the Act, as
HCPCS code A9568, we estimated the proposing to package payment for all added by section 621(a)(1) of Pub. L.
number of units per day to also be one. diagnostic radiopharmaceuticals and 108–173, requires special classification
Our policy during previous cycles of contrast agents that would not otherwise of certain separately paid
the OPPS has been to use updated data be packaged according to the proposed radiopharmaceuticals, drugs, and
to establish final determinations of the CY 2008 packaging threshold for drugs, biologicals and mandates specific
packaging status of drugs, biologicals, biologicals and radiopharmaceuticals. payments for these items. Under section
and radiopharmaceuticals. We note it is Tables 17 and 19 in sections II.A.4.c.(5) 1833(t)(14)(B)(i) of the Act, a ‘‘specified
also our policy to make an annual and (6) of this proposed rule list the covered outpatient drug’’ is a covered
packaging determination only when we diagnostic radiopharmaceuticals and outpatient drug, as defined in section
develop the OPPS final rules. Only contrast agents, respectively, that we are 1927(k)(2) of the Act, for which a
items that are identified as separately proposing to package in CY 2008. We separate APC exists and that either is a
payable in the final rule will be subject discuss our reasons for treating radiopharmaceutical agent or is a drug
to quarterly updates as discussed in diagnostic radiopharmaceuticals and or biological for which payment was
section V.B.3. of this proposed rule. For contrast agents differently from other made on a pass through basis on or
our calculation of per day costs of drugs, drugs, biologicals, and therapeutic before December 31, 2002.
biologicals, and radiopharmaceuticals in radiopharmaceuticals below. Under section 1833(t)(14)(B)(ii) of the
the CY 2008 OPPS/ASC final rule with For CY 2008, we also are proposing to
Act, certain drugs and biologicals are
comment period, we are proposing to continue exempting the oral and
designated as exceptions and are not
use ASP data from the first quarter of injectable forms of 5HT3 anti-emetic
included in the definition of ‘‘specified
CY 2007, which would be the basis for products from packaging, thereby
covered outpatient drugs.’’ (SCODs)
calculating payment rates for drugs and making separate payment for all of the
These exceptions are—
biologicals in the physician’s office 5HT3 anti-emetic products. As we
setting using the ASP methodology, stated in the CY 2005 OPPS final rule • A drug or biological for which
effective July 1, 2007, along with the with comment period (69 FR 65779 payment is first made on or after
updated hospital claims data from CY through 65780), it is our understanding January 1, 2003, under the transitional
2006. that chemotherapy is very difficult for pass-through payment provision in
Consequently, the packaging status for many patients to tolerate, as the side section 1833(t)(6) of the Act.
drugs, biologicals, and effects are often debilitating. In order for • A drug or biological for which a
radiopharmaceuticals for the final rule Medicare beneficiaries to achieve the temporary HCPCS code has not been
using the updated data may be different maximum therapeutic benefit from assigned.
• During CYs 2004 and 2005, an our reasons for using these data, we recommended plan involves CMS
orphan drug (as designated by the refer readers to section V.B.3.a. of the working with interested stakeholders to
Secretary). CY 2006 OPPS final rule with comment develop a system of defining pharmacy
Section 1833(t)(14)(A)(iii) of the Act, period (70 FR 68639 through 68644). overhead categories for outpatient drugs
as added by section 621(a)(1) of Pub. L. As we noted in the CY 2006 OPPS that require different levels of pharmacy
108 173, requires that payment for final rule with comment period, resources. In addition, this phase
SCODs in CY 2006 and subsequent findings from a MedPAC survey of includes a provision recommending that
years be equal to the average acquisition hospital charging practices indicated CMS provide payment for pharmacy
cost for the drug for that year as that hospitals set charges for drugs, overhead costs by setting payment rates
determined by the Secretary, subject to biologicals, and radiopharmaceuticals for the developed categories through
any adjustment for overhead costs and high enough to reflect their pharmacy New Technology APCs, presumably
taking into account the hospital handling costs as well as their while collecting hospital cost data on
acquisition cost survey data collected by acquisition costs. In consideration of these services. The second phase of the
the Government Accountability Office this information, we stated in the CY recommended plan calls for CMS to
(GAO) in CYs 2004 and 2005. If hospital 2006 OPPS final rule with comment review estimates of pharmacy overhead
acquisition cost data are not available, period that payment rates derived from costs as identified by the GAO and
the law requires that payment be equal hospital claims data also included MedPAC, and to consider external
to payment rates established under the acquisition and pharmacy handling survey data from stakeholders. The third
methodology described in section costs because they are derived directly and final phase of the recommended
1842(o), section 1847A, or section from hospital charges (70 FR 68642). In plan calls for specific billing of
1847B of the Act as calculated and CYs 2006 and 2007, we finalized a pharmacy overhead costs using HCPCS
adjusted by the Secretary as necessary. policy of providing payment to HOPDs codes (corresponding to the categories
In establishing the CY 2006 payment for drugs, biologicals, and associated developed in phase one, with payment
rates, we evaluated the three data pharmacy handling costs at a rate of rates resulting from submitted hospital
sources that were available to us for ASP+6 percent. In addition, in CY 2006 claims data) on the same claim as a drug
setting the CY 2006 payment rates for we had proposed to collect pharmacy administration service. The APC Panel
drugs and biologicals. As described in overhead charge data via special recommended that the overhead
the CY 2006 OPPS final rule with pharmacy overhead HCPCS codes that payments be made in addition to the
comment period (70 FR 68639 through hospitals would report. We did not current ASP+6 percent payment rates
68644), these data sources were the finalize this proposal for CY 2006 for separately payable drugs and
GAO reported average purchase prices because of hospital concerns regarding biologicals that do not have pass-
for 55 specified covered outpatient drug the administrative burden associated through status. We also have met with
categories for the period July 1, 2003, to with reporting pharmacy overhead with interested stakeholders who have
June 30, 2004, collected via a survey of these special HCPCS codes (70 FR presented proposals similar to the APC
1,400 acute care Medicare-certified 68657 through 68665). Panel’s recommended plan with various
hospitals; ASP data; and mean costs
(2) Proposed Payment Policy modifications to that recommendation,
derived from CY 2004 hospital claims
The provision in section including suggestions for the
data. For the CY 2006 OPPS final rule
1833(t)(14)(A)(iii) of the Act, as assignment of specific drugs and
with comment period, we used ASP
described above, continues to be biologicals to various overhead
data from the second quarter of CY
applicable to determining payments for categories and potential overhead
2005, which were used to set payment
SCODs for CY 2008. This provision payment rates for such categories in the
rates for drugs and biologicals in the
physician’s office setting effective requires that in CY 2008 payment for first phase of the APC Panel’s
October 1, 2005, and updated claims SCODs be equal to the average recommended plan. In addition, some
data. acquisition cost for the drug for that stakeholders have recommended that
In our data analysis for the CY 2006 year as determined by the Secretary, CMS conduct a survey of pharmacy
OPPS final rule with comment period, subject to any adjustment for overhead overhead costs in the second phase of
we compared the payment rates for costs and taking into account the the APC Panel’s recommended plan.
drugs and biologicals using data from all hospital acquisition cost survey data While we appreciate the APC Panel’s
three sources described above. We collected by the GAO in CYs 2004 and recommendation, as well as similar
estimated aggregate expenditures for all 2005. If hospital acquisition cost data suggestions from other stakeholders, we
drugs and biologicals that would be are not available, the law requires that are not proposing to adopt the APC
separately payable in CY 2006 and for payment be equal to payment rates Panel’s recommendation for CY 2008.
the 55 drugs and biologicals reported by established under the methodology As discussed in section II.A.4. of this
the GAO using mean costs from the described in section 1842(o), section proposed rule, for CY 2008, we are
claims data, the GAO mean purchase 1847A, or section 1847B of the Act as proposing to expand packaging for a
prices, and the ASP-based payment calculated and adjusted by the Secretary number of different groups of services.
amounts (ASP+6 percent in most cases), as necessary. In addition, section Given our belief that packaging can be
and then calculated the equivalent 1833(t)(14)(E)(ii) authorizes the helpful in promoting hospital efficiency
average ASP-based payment rate under Secretary to adjust APC weights for and long-term cost containment, we do
each of the three payment SCODs to take into account the MedPAC not believe it would be desirable to take
methodologies. We excluded report relating to overhead and related steps that would ultimately lead to
radiopharmaceuticals in our analysis expenses, such as pharmacy services payment for pharmacy overhead costs
because they were paid at hospital and handling costs. being unpackaged under the OPPS. In
charges reduced to cost during CY 2006. During the March 2007 APC Panel addition, we note that the APC Panel
The results based on updated ASP and meeting, the APC Panel recommended recommended that CMS establish
claims data were published in Table 24 that CMS implement a three-phase plan separate payment amounts for pharmacy
of the CY 2006 OPPS final rule with to address OPPS payment for pharmacy overhead in addition to the current
comment period. For a full discussion of overhead costs. The first phase of the combined payment for drug acquisition
costs and pharmacy overhead of ASP+6 a single bundled payment representing pharmacy overhead for separately
percent. As we discussed in the CY average hospital acquisition costs and payable drugs is packaged with the
2006 OPPS final rule with comment associated pharmacy overhead costs. As payment for the drug.
period (70 FR 68657) and in the CY stated previously, we believe that We note that, in the case of current
2007 OPPS/ASC final rule with hospitals are including pharmacy OPPS payment for packaged drugs,
comment period (71 FR 68089 through overhead costs in their charges for payment for both the drugs and their
68092), findings from a MedPAC survey drugs, consistent with MedPAC’s associated pharmacy overhead costs is
of hospital charging practices indicated findings. While we continue to believe already packaged into payment for the
that hospitals set charges for drugs, that a combined payment amount for associated separately payable
biologicals, and radiopharmaceuticals drug acquisition costs and pharmacy procedures, including drug
high enough to reflect their pharmacy overhead based on our claims data is a administration services as discussed in
handling costs as well as their reasonable methodology, adequately detail in section II.A.1.b.(2) of this
acquisition costs. We believe that our accounts for acquisition costs and proposed rule. Packaging pharmacy
payment rates for drug acquisition costs overhead, and is consistent with our overhead for separately payable drugs
and pharmacy overhead should be broader packaging efforts, we have and biologicals into the payments for
determined based on the costs reflected decided to propose a slight variant of drug administration would enhance the
in our claims data, as these costs reflect this approach for CY 2008 instead. accuracy of payments by packaging
both acquisition costs and overhead For CY 2008, we are proposing to overhead for similar drugs into the
costs. We also believe that establishing continue our methodology of providing commonly associated separately payable
additional payment for pharmacy a combined payment rate for drug and services, for example, by packaging the
overhead beyond our proposed payment biological acquisition costs and pharmacy overhead for a chemotherapy
rates based on claims data would distort pharmacy overhead. However, in drug with the chemotherapy drug
the relative relationship of costs across addition, we are proposing to instruct administration code also included on
HOPD services, which is the basis of the hospitals to remove the pharmacy the claim. In addition, this methodology
OPPS. overhead charge from the charge for the is consistent with the increased
While we are not proposing to adopt drug or biological and instead report the packaging efforts discussed earlier in
the APC Panel’s recommendation for CY pharmacy overhead charge on an this proposed rule. Because we would
2008, we considered several other uncoded revenue code line on the claim not expect to have claims data reflecting
options for payment for drug acquisition beginning in CY 2008. This proposed these reporting changes until CY 2010,
costs and pharmacy overhead for CY change, from a CY 2007 policy where
we are proposing to continue to provide
2008. First, we considered proposing hospitals include pharmacy overhead in
a combined payment rate for acquisition
again the methodology we had proposed their charges for the drug or biological
costs and pharmacy overhead for
for CY 2006, which involved the to a CY 2008 policy of including the
separately payable drugs and biologicals
establishment of three drug overhead pharmacy overhead charges on an
in CY 2008 similar to the combined
categories that hospitals would use to uncoded revenue code line, would
payment rate provided in CYs 2006 and
report pharmacy overhead charges allow us to package pharmacy overhead
2007 that represents the average
associated with a drug provided in the costs for drugs and biologicals into
hospital acquisition cost and pharmacy
HOPD. Until such data were available payment for the associated procedure,
overhead cost.
for ratesetting purposes, we considered likely a drug administration procedure,
continuing our CY 2007 methodology of in future years when the CY 2008 claims Under our proposal, hospitals would
bundling average hospital acquisition data become available for ratesetting. be asked to report pharmacy overhead
and pharmacy overhead payments. We are proposing to apply this policy to charges on an uncoded revenue code
While this approach has the advantage the reporting of charges for all drugs and line. By having hospitals report
of not paying separately for pharmacy biologicals, including contrast agents, pharmacy overhead on an uncoded
overhead until we would have claims irrespective of the item’s packaged or revenue code line, they would have the
data on which to establish separate separately payable status for the CY flexibility to decide whether they
payment rates for drug acquisition costs 2008 OPPS. We are not proposing to reported a pharmacy overhead charge
and pharmacy overhead, its goal would apply this policy to the reporting of per drug or per episode of drug
still be to ultimately unpackage OPPS overhead charges for administration services. The pharmacy
payment for pharmacy overhead. We radiopharmaceuticals given the explicit overhead charges reported through an
have decided not to propose this option instructions we gave hospitals uncoded revenue code line would be
because we believe it is undesirable to beginning in CY 2006 to include the like any other charge for an uncoded
take steps that would ultimately lead to charges for radiopharmaceutical revenue code line on the claim. For
pharmacy overhead being unpackaged overhead and handling in the charges example, hospitals may already report
at the same time that we are proposing for the radiopharmaceutical product. charges for some drugs or pharmacy-
measures to expand packaging under This proposal would not change our related services through an uncoded
the OPPS and are considering moving current policy of packaging payment for revenue code charge. Our proposal
toward more episode-based and pharmacy overhead with payment for would mean that hospitals would be
encounter-based payment. Furthermore, another item or service. Rather, in future reporting pharmacy overhead on an
we note that, as we considered this years it would only change the types of uncoded revenue code line, in addition
approach, we were mindful of the items or services with which pharmacy to any drugs or pharmacy-related
comments we received in response to overhead is packaged. Once CY 2008 services that they may already be
our CY 2006 proposed rule expressing claims data become available for reporting in that manner. According to
concern about the additional ratesetting, this proposal would lead to our standard OPPS ratesetting
administrative burden on staff and pharmacy overhead for separately methodology, we would package all
coders that this methodology might payable drugs being packaged with such uncoded revenue code lines on the
cause. payment for the associated procedure, claim to develop the median cost for the
Second, we considered continuing likely a drug administration procedure, separately payable service with which
our CY 2007 methodology of providing rather than the current policy where the pharmacy charges are reported.
We note that when we proposed mean costs from the hospital claims MPFS final rule, we will include the
establishing specific HCPCS codes for data and the ASP-based payment actual figure for the percent change in
hospitals to report pharmacy overhead amounts, and calculated the equivalent the CPI for medical care for the 12-
for CY 2006, commenters expressed a average ASP-based payment rate under month period ending June 2007, and the
number of concerns about how this both payment methodologies. updated furnishing fee for CY 2008 we
reporting and charging methodology The results of our data analysis have calculated based on that figure.
would be different from the approach indicate that using mean unit cost to set Because the furnishing fee update is
for other private payers. Some the payment rates for the drugs and based on the percentage increase in the
commenters voiced concern that while biologicals that would be separately CPI for medical care for the 12 month
the proposal would have required payable in CY 2008 would be equivalent period ending with June of the previous
hospitals to modify their billing systems to basing their payment rates, on year and the Bureau of Labor Statistics
to separate the pharmacy overhead average, at ASP+5 percent. Therefore, releases the applicable CPI data after the
charge from the drug charge for we are proposing to continue to provide OPPS and MPFS proposed rules are
Medicare claims, hospitals would need a bundled payment for CY 2008 at published, we have not been able to
to bill them as a single line item for ASP+5 percent while hospitals change include the actual updated furnishing
other payers. Some commenters were their charge practices to bill pharmacy fee in the CY 2006 through CY 2008
concerned that this might require overhead charges on an uncoded OPPS and MPFS proposed rules. Rather,
hospitals to charge Medicare differently revenue center line as discussed above. we announced in these proposed rules
from all other payers for the same As stated previously, we believe that that we intended to include the actual
services. With regard to our current this methodology would continue to
figure for the percent change in the
proposal for CY 2008 to have hospitals provide accurate payments for average
applicable CPI, and the updated
report a charge for the drug and a charge acquisition costs of Part B drugs and
furnishing fee calculated based on that
for pharmacy overhead via an uncoded pharmacy overhead costs during this
figure in the associated final rule. Given
revenue code line, we believe our transition. In addition, as described in
the timing of the availability of the
current approach is consistent with section II.A.4. of this proposed rule, for
applicable data and our timeframe for
Medicare regulations. So long as contrast agents we are proposing a
preparing proposed rules, this process is
hospitals provide the same total charge supplemental approach which would
unavoidable and likely to remain
to all payers, it would be acceptable to package payment for all contrast media
unchanged in the future. We believe
report that charge as a line item for one under the CY 2008 OPPS, and our
specific rationale for this modified that including a discussion of the
payer and two (or more) line items for
approach is described in our discussion furnishing fee update in annual
another payer.
For this proposed rule, we evaluated of payment for diagnostic rulemaking does not provide an
two data sources that we have available radiopharmaceuticals included in advantage over other means of
to us for setting the CY 2008 payment section V.A.3.a.(4)(b) of this proposed announcing this information, so long as
rates for drugs and biologicals. The first rule. the current statutory update
source of drug pricing information that methodology continues in effect. We
(3) Proposed Payment for Blood Clotting believe that the public’s need for
we have is the ASP data from the fourth
quarter of CY 2006, which were used to Factors information and adequate notice
set payment rates for drugs and (If you choose to comment on issues regarding the updated furnishing fee can
biologicals in the physician’s office in this section, please include the be better met by issuing program
setting, effective April 1, 2007. We have caption ‘‘OPPS: Blood Clotting Factors’’ instructions which will eliminate the
ASP-based prices for approximately 500 at the beginning of your comment.) discussion of the furnishing fee update
drugs and biologicals (including For CY 2007, we are providing annually in rulemaking. In addition, by
contrast agents) payable under the payment for blood clotting factors under communicating the updated furnishing
OPPS. However, we currently do not the OPPS at ASP+6 percent plus an fee in program instruction, the actual
have any ASP data on additional payment for the furnishing figure for the percent change in the
radiopharmaceuticals. fee that is also a part of the payment for applicable CPI and the updated
The second source of cost data that blood clotting factors furnished in furnishing fee calculated based on that
we have for drugs, biologicals, and physicians’ offices under Medicare Part figure can be announced more timely
radiopharmaceuticals is the mean and B. The CY 2007 updated furnishing fee than when included as part of the
median costs derived from the CY 2006 is $0.152 per unit. annual rulemaking process. Because the
hospital claims data. As section For the CY 2008 OPPS, we are furnishing fee update process is
1833(t)(14)(A)(iii) of the Act clearly proposing to pay for blood clotting statutorily determined and is based on
specifies that payment for SCODs in CY factors at ASP+5 percent and to an index that is not affected by
2008 be equal to the ‘‘average’’ continue our policy for payment of the administrative discretion or public
acquisition cost for the drug, we limited furnishing fee using the updated comment, we do not believe our
our analysis to the mean costs of drugs amount for CY 2008 as presented in the proposed means of communicating the
determined using the hospital claims CY 2008 MPFS final rule. update will adversely affect
data, instead of using median costs. We have consistently noted that we stakeholders or the public. Therefore,
In our data analysis, we compared the would update the payment amount for for CY 2009 and thereafter, until such
payment rates for drugs and biologicals the furnishing fee each year (based on time as the update methodology may be
using data from both sources described the consumer price index) so that the modified, we are proposing to announce
above. After determining the proposed payment amount for the furnishing fee the blood clotting furnishing fee using
CY 2008 packaging status of drugs and is equal to the furnishing fee payment applicable program instructions and
biologicals, we estimated aggregate amount noted in the MPFS final rule. As posting on the CMS Web site. For
expenditures for all drugs and discussed in greater detail in the CY additional information and instructions
biologicals (excluding 2008 MPFS proposed rule, the CPI data on how to submit comments on this
radiopharmaceuticals) that would be for the 12 month period ending in June proposal, we refer readers to the CY
separately payable in CY 2008 using 2007 is not yet available. In the CY 2008 2008 MPFS proposed rule.
(4) Proposed Payment for the OPPS. We are pleased to note that single aggregate payment for a service,
Radiopharmaceuticals we have had many discussions over this encounter, or episode of care is a
(a) Background past year with interested parties fundamental principle that
regarding the availability and distinguishes a prospective payment
Section 303(h) of Pub. L. 108–173 limitations of radiopharmaceutical cost system from a fee schedule. In general,
exempted radiopharmaceuticals from data. In addition, we have received packaging the costs of items and
ASP pricing in the physician’s office several suggestions from interested services into the payment for the
setting. Beginning in the CY 2005 OPPS parties on how to structure future primary procedure or service with
final rule with comment period, we payment methodologies. Many of the which they are associated encourages
have exempted radiopharmaceutical proposals we have received have hospital efficiencies and also enables
manufacturers from reporting ASP data suggested that we consider hospitals to manage their resources with
for payment purposes under the OPPS differentiating radiopharmaceutical maximum flexibility. The proportion of
(for more information, we refer readers products into two different categories by drugs, biologicals, and
to the CY 2005 OPPS final rule with cost, at least in part because radiopharmaceuticals that are separately
comment period and the CY 2006 OPPS stakeholders have speculated that paid has increased in recent years, from
final rule with comment period, 69 FR charge compression leads to 30 percent of HCPCS codes for these
65811 and 70 FR 68655, respectively). inappropriately low calculated costs for products in CY 2003 to 50 percent in CY
Consequently, we do not have ASP data expensive radiopharmaceuticals. For CY 2007, a pattern that has been noted
for radiopharmaceuticals for 2008, we are making separate payment previously for procedural services as
consideration for CY 2008 OPPS proposals for diagnostic well. Our proposal to package payment
ratesetting. In accordance with section radiopharmaceuticals and therapeutic for diagnostic radiopharmaceuticals and
1833(t)(14)(B)(i)(I) of the Act, radiopharmaceuticals. While we have contrast agents regardless of per day
radiopharmaceuticals are classified not grouped radiopharmaceuticals based cost furthers the fundamental principles
under the OPPS as SCODs. Accordingly, on cost, we note that the therapeutic of a prospective payment system.
payments for radiopharmaceuticals are radiopharmaceuticals typically are more We believe our proposal to treat
to be made at average acquisition cost as expensive than the diagnostic diagnostic radiopharmaceuticals and
determined by the Secretary and subject radiopharmaceuticals. We identified all contrast agents differently from other
to any adjustment for overhead costs. diagnostic radiopharmaceuticals SCODs is appropriate for several
Radiopharmaceuticals are also subject to specifically as those Level II HCPCS reasons. First, the statutory requirement
the policies affecting all similarly codes that include the term ‘‘diagnostic’’ that we must pay separately for drugs
classified OPPS drugs and biologicals, along with a radiopharmaceutical in and biologicals for which the per day
such as pass-through payments and their long code descriptors. Therefore, cost exceeds $50 under section
packaging determinations, discussed we were able to distinguish therapeutic 1833(t)(16)(B) of the Act has expired.
earlier in this proposed rule. radiopharmaceuticals from diagnostic Therefore, we are not restricted to the
For CYs 2006 and 2007, we used radiopharmaceuticals as those Level II extent to which we can package
mean unit cost data from hospital HCPCS codes that have the term payment for SCODs and other drugs, nor
claims to determine each ‘‘therapeutic’’ along with a are we required to treat all classes of
radiopharmaceutical’s packaging status, radiopharmaceutical in their long code drugs in the same manner with regard
and implemented a temporary policy to descriptors. We note that all to whether they are packaged or
pay for separately payable radiopharmaceutical products fall into separately paid. We have used this
radiopharmaceuticals based on the one category or the other; their use as flexibility to make different packaging
hospital’s charge for each a diagnostic radiopharmaceutical or determinations for several years with
radiopharmaceutical adjusted to cost therapeutic radiopharmaceutical is regard to specific anti-emetic drugs.
using the hospital’s overall CCR. This mutually exclusive. While we are proposing to continue to
methodology was finalized as an interim establish an updated cost threshold for
proxy for average acquisition cost (b) Proposed Payment for Diagnostic packaging drugs, biologicals, and
because of the unique circumstances Radiopharmaceuticals radiopharmaceuticals, we are also
associated with providing (If you choose to comment on issues proposing an approach specific to
radiopharmaceutical products to in this section, please include the diagnostic radiopharmaceuticals and
Medicare beneficiaries. The single OPPS caption ‘‘OPPS: Payment for Diagnostic contrast agents that would otherwise be
payment represented Medicare payment Radiopharmaceuticals’’ at the beginning separately paid.
for both the acquisition cost of the of your comment.) Second, we see diagnostic
radiopharmaceutical and its associated As discussed in section II.A.4. of this radiopharmaceuticals and contrast
pharmacy overhead costs. We clearly proposed rule, we are proposing to agents as functioning effectively as
stated in both the CY 2006 and CY 2007 package payment for diagnostic supplies that enable the provision of an
OPPS final rules with comment period radiopharmaceuticals and contrast independent service. More specifically,
that we did not intend to maintain this agents with per day costs over $60 as contrast agents are always provided in
methodology permanently (70 FR 68656 part of our packaging proposal for CY support of a diagnostic or therapeutic
and 71 FR 68096, respectively), and that 2008. Radiopharmaceuticals and procedure that involves imaging and
we would continue to actively seek contrast agents currently are defined as diagnostic radiopharmaceuticals are
other methodologies for setting SCODs in section 1833(t)(14)(B) of the always provided in support of a
payments for radiopharmaceuticals in Act, and we currently package payment diagnostic nuclear medicine scan. This
future years. for diagnostic radiopharmaceuticals and is different from many other SCODs, for
During the CY 2006 and CY 2007 contrast agents with per day costs of $55 example, therapeutic
rulemaking processes, we encouraged or less. However, our proposal for CY radiopharmaceuticals, where the
hospitals and the radiopharmaceutical 2008 also includes packaging payment therapeutic radiopharmaceutical itself is
stakeholders to assist us in developing for all diagnostic radiopharmaceuticals the primary therapeutic modality. Given
a viable long-term prospective payment and contrast agents, regardless of their the inherent function of contrast agents
methodology for these products under per day cost. Packaging costs into a and diagnostic radiopharmaceuticals as
supportive to the performance of an separate, prospective payment rates for diagnostic nuclear medicine study that
independent procedure, we view the diagnostic radiopharmaceuticals with is the primary service. For separately
packaging of payment for contrast per day costs exceeding our general payable therapeutic
agents and diagnostic packaging threshold (analogous to our radiopharmaceuticals, we are proposing
radiopharmaceuticals as a logical initial proposal for therapeutic to establish CY 2008 payment rates
step to expand packaging for SCODs. As radiopharmaceuticals). However, we are based on their mean unit costs from our
we consider moving to additional proposing to package all diagnostic CY 2006 OPPS claims data.
encounter-based and episode-based radiopharmaceuticals because we In the CY 2007 OPPS/ASC final rule
payment in future years, we may believe additional packaging of payment with comment period (71 FR 68095), we
consider additional options for for supportive and ancillary services, again reiterated our intent to develop a
packaging more SCODs in the future. including diagnostic suitable prospective payment
Third, section 1833(t)(14)(A)(iii) of radiopharmaceuticals, would provide methodology for radiopharmaceutical
the Act requires that payment for additional incentives for efficiency and products paid under the OPPS in future
SCODs be set prospectively based on a greater flexibility for hospitals to years, beginning in CY 2008. Since the
measure of average hospital acquisition manage their resources. start of the temporary cost-based
cost. While we have ASP data for In the case of contrast agents, while payment methodology for
contrast agents, the lack of ASP data as we have ASP data that can be a proxy radiopharmaceuticals in CY 2006, we
a source of average acquisition cost for for average hospital acquisition cost and have met with several interested parties
radiopharmaceuticals and the varying associated handling and preparation on this topic and have received several
inclusion of overhead and handling costs, payment for almost all contrast suggestions from these stakeholders
costs in the charge for a agents would be packaged under the regarding payment methodologies that
radiopharmaceutical resulted in OPPS for CY 2008 based on the $60 per we could employ for future use under
payment for radiopharmaceuticals at day packaging threshold. Therefore, as the OPPS.
charges reduced to cost on a temporary discussed in more detail in section In considering payment options for
basis for CYs 2006 and 2007. V.B.3.a.(4) of this proposed rule, we therapeutic radiopharmaceuticals for CY
We now believe our claims data offer believe it would be most appropriate to 2008, we examined several alternatives.
an acceptable proxy for average hospital package payment for all contrast agents First, we considered retaining the CY
acquisition cost and associated handling for CY 2008, to better provide for 2007 methodology of providing
and preparation costs for accurate payment for the associated payment for therapeutic
radiopharmaceuticals. We believe that tests and procedures that promotes radiopharmaceuticals at a hospital’s
hospitals have adapted to the CY 2006 hospital efficiency. charges reduced to cost using the
coding changes for In summary, we view diagnostic hospital’s overall CCR. While this
radiopharmaceuticals and responded to radiopharmaceuticals and contrast option would provide consistency in the
our instructions to include charges for agents as ancillary and supportive of the payment methodology from year to year,
radiopharmaceutical handling in their diagnostic tests and therapeutic we have noted on several occasions,
charges for the radiopharmaceutical procedures in which they are used. In including in the CY 2007 OPPS/ASC
products. This issue is discussed in light of our authority to make different final rule with comment period and in
greater detail under section packaging determinations, and the various public forums such as the APC
V.B.3.a.(4)(c) of this proposed rule improved reporting of hospital charges Panel meetings, that this methodology
regarding our proposed CY 2008 for radiopharmaceutical handling in the was not intended to be the basis of
payment methodology for therapeutic CY 2006 claims data, we propose to providing payment to hospitals for these
radiopharmaceuticals. We have relied package payment for contrast agents and products beyond CY 2007. Payment on
on mean unit costs derived from our diagnostic radiopharmaceuticals for CY a claim-specific cost basis is not
claims data as one proxy for average 2008. consistent with the payment of items
acquisition cost and pharmacy and services on a prospective basis
(c) Proposed Payment for Therapeutic
overhead, and we use these data to under the OPPS and may lead to
determine the packaging status for Radiopharmaceuticals extremely high or low payments to
SCODs. However, in light of improved (If you choose to comment on issues hospitals for radiopharmaceuticals, even
data for radiopharmaceuticals in the CY in this section, please include the when those products would be expected
2006 claims, we believe that the line caption ‘‘OPPS: Payment for to have relatively predictable and
item estimated cost for a diagnostic Therapeutic Radiopharmaceuticals’’ at consistent acquisition and handling
radiopharmaceutical in our claims data the beginning of your comment.) costs across individual clinical cases
is a reasonable approximation of average For CY 2008, we are proposing to and hospitals. In addition, we have
acquisition and preparation and continue separate payment for stated that we believe that using
handling costs for diagnostic therapeutic radiopharmaceuticals that hospitals’ overall CCRs to determine
radiopharmaceuticals. Further, because have a mean per day cost of more than payments could result in an
the standard OPPS packaging $60, consistent with the packaging overstatement of radiopharmaceutical
methodology packages the total methodology applied to other nonpass- costs, which are likely reported in
estimated cost for each through drugs and biologicals. We several cost centers, such as diagnostic
radiopharmaceutical on each claim believe that therapeutic radiology, that have lower CCRs than
(including the full range costs observed radiopharmaceuticals are distinct from hospitals’ overall CCRs (71 FR 68095).
on the claims) with the cost of diagnostic radiopharmaceuticals For these reasons, we are not proposing
associated nuclear medicine procedures because the primary purpose of to use this methodology to set their
for ratesetting, this packaging approach providing a therapeutic payment rates for CY 2008.
is consistent with considering the radiopharmaceutical is the The second option we considered,
average cost for radiopharmaceuticals, radiopharmaceutical treatment itself, and are proposing, as a methodology for
rather than the median. We also note whereas a diagnostic providing payment for therapeutic
that we believe our improved claims radiopharmaceutical is administered in radiopharmaceuticals in CY 2008, is to
data could support the establishment of support of the performance of a establish prospective payment rates for
separately payable therapeutic decrease. We indicated that this trend is applying our trimming methodology
radiopharmaceuticals using mean costs consistent with the agency’s increased the mean unit cost reported in
derived from the CY 2006 claims data, expectations that hospitals would Table 44.
where the costs are determined using comply with our instructions to include As a payment system based on
our standard methodology of applying charges for radiopharmaceutical relative payment weights, altering the
hospital-specific departmental CCRs to handling in their charges for the trimming methodology for a particular
radiopharmaceutical charges, defaulting radiopharmaceutical products for CY set of services could unduly influence
to hospital-specific overall CCRs only if 2006. Therefore, we believe that setting the relativity of the resulting payment
appropriate departmental CCRs are CY 2008 prospective payment rates weights for those particular services and
unavailable. As we stated in the CY based on CY 2006 hospital claims data could inappropriately redistribute
2007 OPPS/ASC proposed rule, we as described above serves as an payments in a budget neutral OPPS. We
believe this methodology provides us acceptable combined proxy for average have no reason to believe that hospitals
with the most consistent, accurate, and hospital acquisition costs and report costs differently for
efficient methodology for prospectively radiopharmaceutical handling. radiopharmaceuticals than they do for
establishing payment rates for During meetings with external other items. As we discuss further in
separately payable therapeutic stakeholders over the past year, we have section II.A.1. of this proposed rule,
radiopharmaceuticals (71 FR 49587). We been presented with several other what is important for setting appropriate
believe that adopting prospective suggestions regarding OPPS payment for payment rates under a prospective
payment based on historical hospital payment system is accuracy in
therapeutic radiopharmaceuticals in CY
claims data is appropriate because it estimating the relative costliness of
2008. One of these options included a
serves as our most accurate available services, and not the nominal value of
suggestion that we employ alternative
proxy for the average hospital the observed cost. Second, we are not
trimming methodologies in order to
acquisition cost of separately payable convinced that employing an alternative
produce a claims-based mean cost that
therapeutic radiopharmaceutical trimming methodology would result in
would more accurately reflect hospital
products. In addition, we have found the most appropriate cost estimates for
purchase prices for these products.
that our general prospective payment therapeutic radiopharmaceuticals. We
However, no specific trimming
methodology based on historical believe that because hospitals were paid
approaches for radiopharmaceuticals
hospital claims data results in more in CY 2006 for each therapeutic
were offered for our consideration for radiopharmaceutical they reported
consistent, predictable, and equitable CY 2008. We have chosen not to
payment amounts across hospitals and according to a claim-specific charge that
propose a methodology based on special was reduced to cost for payment,
likely provides incentives to hospitals OPPS data trimming for the CY 2008
for efficiently and economically hospitals had an incentive to accurately
proposed payment of therapeutic account for the full costs of these
providing these outpatient services. radiopharmaceuticals for the following
Therefore, we expect that the hospital- products in establishing their charges.
reasons. First, the OPPS has a standard In addition, we have no way of knowing
specific payment variability found data trimming methodology to calculate
under a charge-reduced-to-cost the specific clinical scenario that
drug, biological, and resulted in any given claim with certain
methodology would no longer affect radiopharmaceutical per day costs from
these products under our CY 2008 reported units and charges for a
hospital claims data. This includes both therapeutic radiopharmaceutical.
proposal. a specific trim on units for drugs, Therefore, we do not believe it would be
Although we received comments to biologicals, and radiopharmaceuticals appropriate to utilize a ratesetting
our CY 2007 proposed rule indicating that is ±3 standard deviations from the methodology that could disregard
that CY 2005 claims data used for that geometric mean, and a standard trim of correctly coded claims. While we
update did not incorporate associated any line-item with a cost per unit that appreciate this recommendation, we are
overhead charges into the is ±3 standard deviations from the not proposing a payment methodology
radiopharmaceutical charge, in the CY geometric mean that is applied across that includes additional trimming of
2007 OPPS/ASC final rule with all items and services. Both trims are hospital claims data for therapeutic
comment period (71 FR 68095) we conducted on the transformed variable, radiopharmaceutical products for CY
stated that we expected that hospitals taking the natural log of both units and 2008.
would have adapted to the CY 2006 cost per unit, in order to trim evenly Recommendations other than
HCPCS coding changes for some relative to the center of the distribution. trimming have centered around
radiopharmaceuticals and responded to Both units and costs per unit are never providing CMS with external data on
our instructions to include their charges negative, and there are some therapeutic radiopharmaceutical costs. One specific
for radiopharmaceutical handling in radiopharmaceuticals with very high recommendation that we received from
their charges for the units and costs per unit in our hospital interested stakeholders requested that
radiopharmaceutical products so these claims data. These trims are we allow hospitals to submit their
costs would be reflected in the CY 2008 conservative and typically eliminate invoices to CMS. With the invoice
ratesetting process. This continues to be only the most egregious observations, information, CMS could establish a
our expectation, and we believe that the ones that could be due to erroneous prospective payment rate for
CY 2006 claims data that we are using reporting. For therapeutic radiopharmaceuticals that would be
to set the CY 2008 OPPS payment rates radiopharmaceuticals, the unit trim calculated taking into consideration the
reflect both the radiopharmaceutical alone removed all items that would total amount invoiced for the
charge and associated overhead charges. have been eliminated under the cost radiopharmaceutical, transportation
As discussed at the March 2007 APC trim, and with the exception of HCPCS costs, and applicable rebates. While this
Panel meeting, our CY 2006 claims data code A9563 (Sodium phosphate P–32, payment rate would not include
show that a greater proportion of therapeutic, per millicurie), this trim payment for certain
radiopharmaceuticals experienced an removed observations with unit costs radiopharmaceutical overhead and
increase in their median costs from CY below the mean unit cost listed in Table handling costs, stakeholders suggested
2005 to CY 2006 than experienced a 44 below. That is, overall, the result of that these costs could be packaged into
the associated procedure payment rather generally exclude the costs of the based on external data would likely
than the payment for the hospital’s handling of the present a burden to those hospitals that
radiopharmaceutical. Stakeholders also radiopharmaceuticals. However, we have been working over the past 2 years
generally have recommended that we note that we do not currently identify to align their charging practices with
could collect external data from various separate costs for this our stated instructions. Adoption of any
sources (such as manufacturers, nuclear radiopharmaceutical handling that we methodology systematically relying on
pharmacies, and others) to use for could then package into the costs of the external data also would be
therapeutic radiopharmaceutical associated diagnostic nuclear medicine administratively burdensome for CMS
ratesetting purposes in CY 2008. studies and treatment procedures. because we would need to collect,
We are not proposing a methodology Moreover, hospitals currently have the process, and review external
using external data for CY 2008 for the information to ensure that it was valid,
flexibility to set their charges for
following reasons. First, any approach reliable, and representative of a diverse
therapeutic radiopharmaceuticals,
relying on external data has the same group of hospitals so that it could be
disadvantage previously discussed of taking into account a variety of factors,
including acquisition costs and used to establish rates for all hospitals.
differentially influencing the relativity For these reasons, we are not proposing
of payment weights for transportation costs, so we believe it is
likely that hospitals are already taking to collect hospital invoices or otherwise
radiopharmaceuticals in the budget
this information into consideration rely on external data in order to
neutral OPPS payment system, where
when establishing their charges. establish prospective payment rates for
we utilize a standard ratesetting
Further, we have already instructed therapeutic radiopharmaceuticals for CY
methodology for other services. In
hospitals to include overhead charges 2008.
addition, it is not clear that invoice
information from hospitals or cost for radiopharmaceuticals in the charge The eight therapeutic
information from nuclear pharmacies for the radiopharmaceutical product. radiopharmaceuticals that we are
would be more accurate than hospitals’ We have received several reports that proposing to pay separately in CY 2008
costs for radiopharmaceuticals that we hospitals have made these changes, under our proposed methodology of
currently calculate based on hospitals’ when necessary, and that other changes mean units costs calculated from CY
charges reduced to cost by application are in process to conform to our 2006 hospitals claims are listed in Table
of a CCR, and such information would instructions. A ratesetting approach 44 below.
TABLE 44.—THERAPEUTIC RADIOPHARMACEUTICALS PROPOSED FOR PROSPECTIVE PAYMENT IN CY 2008

Pro- Pro- Proposed
HCPCS posed posed
code CY 2008 CY 2008 mean cost
APC SI
A9517 ...... I131 iodide cap, rx ........................................................................................................................ 1064 ..... K ........... $6.22
A9530 ...... I131 iodide sol, rx ......................................................................................................................... 1150 ..... K ........... 11.74
A9543 ...... Y90 ibritumomab, rx ..................................................................................................................... 1643 ..... K ........... 12,030.02
A9545 ...... I131 tositumomab, rx .................................................................................................................... 1645 ..... K ........... 8,283.41
A9563 ...... P32 Na phosphate ........................................................................................................................ 1675 ..... K ........... 118.02
A9564 ...... P32 chromic phosphate ................................................................................................................ 1676 ..... K ........... 122.17
A9600 ...... Sr89 strontium .............................................................................................................................. 0701 ..... K ........... 610.07
A9605 ...... Sm 153 lexidronm ......................................................................................................................... 0702 ..... K ........... 1,446.05
We note that we have received proposed rule, while we are not related to payment for
anecdotal reports from some industry proposing to implement adjustments for radiopharmaceuticals, including
stakeholders asserting that the mean charge compression for CY 2008 based evaluating claims data for different
costs for the most expensive on the RTI Report, which focused only classes of radiopharmaceuticals and
radiopharmaceuticals are understated in on inpatient charges, we are proposing ensuring that a nuclear medicine
our claims data. We specifically invite steps to explore this issue further for the procedure claim always includes at least
comment on how the CY 2008 OPPS future. We are proposing to develop an one reported radiopharmaceutical agent.
payment rates that we are proposing for all-charges model that would compare As discussed in section II.A.4. of this
therapeutic radiopharmaceuticals variation in CCRs with variation in proposed rule, we are proposing to
compare with the acquisition and charges to establish disaggregated CCRs accept the APC Panel’s
associated handling costs of an efficient that could be applied to both inpatient recommendation, and we welcome
provider. We also are soliciting and outpatient charges. We are also public comment on the burden hospitals
suggestions on approaches that could be proposing to evaluate the results of that would experience should we require
adopted by Medicare or industry groups methodology for purposes of such precise reporting. We also are
to promote improvements in hospital determining whether the resulting seeking comment specifically on the
reporting of charges and costs for disaggregated CCRs should be proposed importance of such a requirement in
therapeutic radiopharmaceuticals to the for to adjust for charge compressions in light of our discussion in section II.A.4.
extent that they are warranted and developing the CY 2009 OPPS payment of this proposed rule on the
feasible. Some stakeholders have stated rates. representation of radiopharmaceuticals
that charge compression may be During its March 2007 meeting, the in the single claims for diagnostic
adversely affecting our estimates of the APC Panel made two recommendations nuclear medicine procedures, the
mean cost for expensive regarding radiopharmaceuticals. First, presence of uncoded revenue code
radiopharmaceuticals. As discussed in the APC Panel recommended that CMS charges specific to diagnostic
more detail in section II.A.1 of this work with stakeholders on issues radiopharmaceuticals on claims without
a coded radiopharmaceutical, and our equivalent to the payment they received radiopharmaceuticals with HCPCS
proposal to package payment for all in the physician’s office setting, codes as of January 1, 2008, but which
diagnostic radiopharmaceuticals for CY established in accordance with the ASP do not have pass-through status, on the
2008. methodology. WACs for these products as ASP data
Second, the APC Panel recommended As discussed in the CY 2005 OPPS for radiopharmaceuticals are not
that we consider the use of external data final rule with comment period (69 FR available. In addition, we note that if the
and work with stakeholders to 65797), and the CY 2006 OPPS final rule WACs are also unavailable, we would
determine the correct code descriptor with comment period (70 FR 68666), make payment for the therapeutic
units for each radiopharmaceutical, new drugs, biologicals, and radiopharmaceuticals at 95 percent of
including HCPCS code A9524 (Iodine I– radiopharmaceuticals may be expensive, their most recent AWPs. Analogous to
131 iodinated serum albumin, and we are concerned that packaging new drugs and biologicals, we are
diagnostic, per 5 microcuries). We these new items might jeopardize proposing to assign status indicator ‘‘K’’
appreciate the APC Panel’s beneficiary access to them. In addition, to HCPCS codes for new therapeutic
recommendation. We are always open to we do not want to delay separate radiopharmaceuticals for which we
meeting with interested stakeholders payment for these items solely because have not received a pass-through
and examining any data they may a pass-through application was not application. Consistent with other ASP-
provide to us. However, we are unable submitted. However, we note that for based payments, we are proposing to
to accept the APC Panel’s CY 2008 we are proposing to explicitly make any appropriate adjustments to
recommendation concerning the account for the pass-through payment the payment amounts for drugs and
development of specific code amount associated with pass-through biologicals in the CY 2008 OPPS/ASC
descriptors because decisions regarding drugs and biologicals, in the context of final rule with comment period and also
the creation of permanent HCPCS codes, our CY 2008 proposal for the payment on a quarterly basis on our Web site
including code descriptors, are of separately payable nonpass-through during CY 2008 if later quarter ASP
coordinated by the National HCPCS drugs and biologicals at ASP+5 percent. submissions (or more recent WACs or
Panel and are outside the scope of the Therefore, for CY 2008, we are AWPs) indicate that adjustments to the
OPPS. For further information on the proposing to provide payment for these payment rates for these drugs and
HCPCS coding process, we refer readers new drugs and biologicals with HCPCS biologicals are necessary. The payment
to the CMS Web site at: http:// codes as of January 1, 2008, but which rates for new therapeutic
www.cms.hhs.gov/MedHCPCSGenInfo/ do not have pass-through status and are radiopharmaceuticals would also be
01_Overview.asp#TopOfPage. We without OPPS hospital claims data, at adjusted accordingly. We also are
encourage interested parties to submit ASP+5 percent, consistent with our proposing to make appropriate
requests for revisions of code proposed payment methodology for adjustments to the payment rates for
descriptors to the National HCPCS Panel other nonpass-through drugs and new drugs and biologicals in the event
for its consideration. biologicals. This proposal would ensure that they become covered under the
that we are treating new nonpass- CAP in the future. We note that the new
b. Proposed Payment for Nonpass-
through drugs and biologicals like other CY 2008 HCPCS codes for drugs,
Through Drugs, Biologicals, and
drugs and biologicals under the OPPS, biologicals, and therapeutic
Radiopharmaceuticals with HCPCS
unless they are granted pass-through radiopharmaceuticals are not available
Codes, but without OPPS Hospital
status. Only if they were pass-through at the time of the development of this
Claims Data
drugs and biologicals would they
(If you choose to comment on issues proposed rule; however, they will be
receive a different payment for CY 2008,
in this section, please include the included in the CY 2008 OPPS/ASC
generally equivalent to the payment
caption OPPS: Nonpass-Through Coded final rule with comment period.
these drugs and biologicals would
Drugs, Biologicals, and receive in the physician’s office setting, There are several nonpass-through
Radiopharmaceuticals without Claims consistent with the requirements of the drugs and biologicals that were payable
Data.) statute. in CY 2006 and/or CY 2007 for which
Pub. L. 108–173 does not address the In accordance with the ASP we do not have any CY 2006 hospital
OPPS payment in CY 2005 and after for methodology, in the absence of ASP claims data. In order to determine the
drugs, biologicals, and data, we are proposing to continue the packaging status of these items for CY
radiopharmaceuticals that have assigned policy we implemented during CYs 2008, we calculated an estimate of the
HCPCS codes, but that do not have a 2005, 2006, and 2007 of using the WAC per day cost of each of these items by
reference AWP or approval for payment for the product to establish the initial multiplying the payment rate for each
as pass-through drugs or biologicals. payment rate. However, we note that if product based on ASP+5 percent,
Because there is no statutory provision the WAC is also unavailable, we would similar to other nonpass-through drugs
that dictated payment for such drugs make payment at 95 percent of the and biologicals paid under the OPPS, by
and biologicals in CY 2005, and because product’s most recent AWP. We are also an estimated average number of units of
we had no hospital claims data to use proposing to assign status indicator ‘‘K’’ each product that would typically be
in establishing a payment rate for them, to HCPCS codes for new drugs and furnished to a patient during one
we investigated several payment options biologicals for which we have not administration in the hospital
for CY 2005 and discussed them in received a pass-through application. We outpatient setting. We are proposing to
detail in the CY 2005 OPPS final rule further note that with respect to new package items for which we estimate the
with comment period (69 FR 65797 items for which we do not have ASP per administration cost to be less than
through 65799). data, once their ASP data become or equal to $60, which is the general
For CYs 2005, 2006, and 2007, we available in later quarter submissions, packaging threshold that we are
finalized our policy to provide separate their payment rates under the OPPS will proposing for drugs, biologicals, and
payment for new drugs, biologicals, and be adjusted so that the rates are based radiopharmaceuticals in CY 2008. We
radiopharmaceuticals with HCPCS on the ASP methodology and set to are proposing to pay separately for items
codes, but which did not have pass ASP+5 percent. We are also proposing with an estimated per administration
through status at a rate that was to base payment for new therapeutic cost greater than $60 (with the
exception of diagnostic similar to other separately payable is also unavailable, we would make
radiopharmaceuticals and contrast nonnpass-through drugs and biologcals payment at 95 percent of the most
agents which we are proposing to under the OPPS. In accordance with the recent AWP available.
package regardless of cost, as discussed ASP methodology used in the physician Table 45A below lists all of the
in more detail above). We are proposing office setting, in the absence of ASP nonpass-through drugs and biologicals
that the CY 2008 payment for separately data, we would use the WAC for the without available CY 2006 claims data
payable items without CY 2006 claims product to establish the initial payment to which these policies would apply in
data would be based on ASP+5 percent, rate. However, we note that if the WAC CY 2008.
TABLE 45A.—DRUGS AND BIOLOGICALS WITHOUT CY 2006 CLAIMS DATA

Estimated aver- Pro-
ASP-Based
HCPCS age number of posed
Short descriptor payment
code units per admin- CY 2008
rate istration SI
C9234 ...... Inj, alglucosidase alfa ...................................................................................................... $126.00 130 K

J0288 ....... Ampho b cholesteryl sulfate ............................................................................................ 11.89 35 K
J0364 ....... Apomorphine hydrochloride ............................................................................................ 2.96 6 N
J1324 ....... Enfuvirtide injection ......................................................................................................... 22.69 180 K
J1562 ....... Immune globulin subcutaneous ...................................................................................... 12.60 130 K
J2170 ....... Mecasermin injection ....................................................................................................... 11.81 15.6 K
J2315 ....... Naltrexone, depot form .................................................................................................... 1.88 380 K
J3355 ....... Urofollitropin, 75 iu .......................................................................................................... 50.22 2 K
J7345 ....... Non-human, non-metab tissue ........................................................................................ 35.76 16 K
J8650 ....... Nabilone oral ................................................................................................................... 16.80 6 K
J9261 ....... Nelarabine injection ......................................................................................................... 82.54 52.5 K
Q4085 ...... Euflexxa, inj ..................................................................................................................... 115.19 1 K
During the March 2007 APC Panel effect on our payment methodology for unrecognized HCPCS codes, we would
meeting, the APC Panel reiterated its drugs. We are proposing to allow determine the packaging status and
August 2006 recommendation to allow hospitals to submit claims by reporting resulting status indicator for each
hospitals to report all HCPCS codes for any HCPCS code for a Part B drug that HCPCS code according to the general
drugs. In general, OPPS recognizes the is covered under the OPPS, regardless of code-specific methodology for
lowest available administrative dose of the unit determination in the HCPCS determining a code’s packaging status
a drug if multiple HCPCS codes exist for code descriptor, beginning in CY 2008. for a given update year. We plan to
the drug; for the remainder of the doses, Stakeholders have told us that this closely follow our claims data to ensure
we assign a status indicator ‘‘B’’ policy would reduce the administrative that our annual packaging
indicating that another code exists for burden associated with our current determinations for the different HCPCS
OPPS purposes. For example, if drug X requirement that hospitals report drugs codes describing the same drug do not
has 2 HCPCS codes, 1 for a 1 ml dose using only the HCPCS codes with the create inappropriate payment incentives
and a second for a 5 ml dose, the OPPS lowest increments in their code
for hospitals to report certain HCPCS
would assign a payable status indicator descriptors. Whenever possible, we seek
codes instead of others. In our analysis
to the 1 ml dose and status indicator to reduce hospitals’ administrative
‘‘B’’ to the 5 ml dose. Hospitals would burden in submitting claims for for this proposed rule, we also estimated
then need to bill the appropriate payment under the OPPS, and we the packaging status of these currently
number of units for the 1 ml dose in appreciate the APC Panel’s unrecognized HCPCS codes by adjusting
order to receive payment under the recommendation in this area. the calculated average number of units
OPPS. While we were not prepared to As these HCPCS codes were per day for the associated recognized
accept this recommendation when we previously unrecognized in the OPPS, HCPCS code with claims data to
developed the CY 2007 OPP/ASC final we do not have claims data to determine account for the different dosage
rule with comment period, we indicated the appropriate packaging status. descriptors. We then multiplied this
in that rule that we would continue to Therefore, we are proposing to assign adjusted average number of units per
consider the APC Panel’s these HCPCS codes the same status day value by the most recent ASP data
recommendation for future OPPS indicator as the associated recognized available for the unrecognized HCPCS
updates (71 FR 68083 through 68084). HCPCS code (that is, the lowest dose), code (listed in Table 45B). We note this
After further consideration of this issue, as shown in Table 45B. We believe that methodology yielded the same
we are now accepting the APC Panel’s this approach is the most appropriate packaging determinations and resulting
recommendation because we have and reasonable way to implement this status indicators for the currently
concluded that recognizing all of these proposed change without impacting unrecognized HCPCS codes for CY 2008
HCPCS codes for payment under the payment. However, once claims data are as for the recognized HCPCS code for
OPPS should not have a significant available for these previously the same drug.
TABLE 45B.—PREVIOUSLY UNRECOGNIZED HCPCS CODES AND PROPOSED STATUS INDICATORS FOR CY 2008
Associated
HCPCS Pro-
CY Fourth quar- HCPCS
codes not posed
2007 Short descriptor ter CY 2006 code rec-
recognized CY 2008
SI ASP ognized in
in CY 2007 SI
CY 2007
J1470 ....... B ....... Gamma globulin 2 CC inj ........................................................................................... $23.66 J1460 ....... K
J1480 ....... B ....... Gamma globulin 3 CC inj ........................................................................................... 35.47 .................. K
J1550 ....... B ....... Gamma globulin 10 CC inj ......................................................................................... 118.27 .................. K
J1560 ....... B ....... Gamma globulin > 10 CC inj ...................................................................................... 118.24 .................. K
J8521 ....... B ....... Capecitabine, oral, 500 mg ........................................................................................ 13.18 J8520 ....... K
J9094 ....... B ....... Cyclophosphamide lyophilized, 200 mg ..................................................................... 3.97 J9093 ....... N
J9095 ....... B ....... Cyclophosphamide lyophilized, 500 mg ..................................................................... 9.93 .................. N
J9096 ....... B ....... Cyclophosphamide lyophilized, 1g ............................................................................. 17.09 .................. N
J9097 ....... B ....... Cyclophosphamide lyophilized, 2g ............................................................................. 39.71 .................. N
J9140 ....... B ....... Dacarbazine 200 MG inj ............................................................................................ 9.34 J9130 ....... N
J9290 ....... B ....... Mitomycin 20 MG inj .................................................................................................. 68.52 J9280 ....... K
J9291 ....... B ....... Mitomycin 40 MG inj .................................................................................................. 137.03 .................. K
J9062 ....... B ....... Cisplatin 50 MG injection ........................................................................................... 12.26 J9060 ....... N
J9080 ....... B ....... Cyclophosphamide 200 MG inj .................................................................................. 3.83 J9070 ....... N
J9090 ....... B ....... Cyclophosphamide 500 MG inj .................................................................................. 15.75 .................. N
J9091 ....... B ....... Cyclophosphamide 1.0 grm inj ................................................................................... 19.17 .................. N
J9092 ....... B ....... Cyclophosphamide 2.0 grm inj ................................................................................... 38.34 .................. N
J9110 ....... B ....... Cytarabine hcl 500 MG inj ......................................................................................... 8.22 J9100 ....... N
J9182 ....... B ....... Etoposide 100 MG inj ................................................................................................. 5.13 J9181 ....... N
J9260 ....... B ....... Methotrexate sodium inj, 50 mg ................................................................................. 2.59 J9250 ....... N
J9375 ....... B ....... Vincristine sulfate 2 MG inj ........................................................................................ 15.41 J9370 ....... N
J9380 ....... B ....... Vincristine sulfate 5 MG inj ........................................................................................ 38.52 .................. N
There are seven drugs and biologicals, TABLE 45C.—DRUGS AND payments under the hospital OPPS. For
shown in Table 45C below, that were BIOLOGICALS WITHOUT INFORMATION a year before CY 2004, the applicable
payable in CY 2006 for which we lack ON PER DAY COST THAT ARE PRO- percentage was 2.5 percent; for CY 2004
CY 2006 claims data and for which we POSED FOR PACKAGING IN CY and subsequent years, we specify the
are not able to determine the per day applicable percentage up to 2.0 percent.
2008—Continued
cost based on the ASP methodology. As If we estimate before the beginning of
we are unable to determine the Pro- the calendar year that the total amount
packaging status and subsequent HCPCS posed of pass-through payments in that year
Short descriptor
payment rates, if applicable, for these code CY 2008 would exceed the applicable percentage,
SI
drugs and biologicals for CY 2008 based section 1833(t)(6)(E)(iii) of the Act
on the ASP methodology or claims data, J1452 ....... Intraocular N requires a uniform reduction in the
we are proposing to package payment Fomivirsen na. amount of each of the transitional pass-
for these drugs and biologicals in CY through payments made in that year to
2008. VI. Proposed Estimate of OPPS ensure that the limit is not exceeded.
Transitional Pass-Through Spending We make an estimate of pass-through
TABLE 45C.—DRUGS AND for Drugs, Biologicals, spending to determine not only whether
BIOLOGICALS WITHOUT INFORMATION Radiopharmaceuticals, and Devices payments exceed the applicable
ON PER DAY COST THAT ARE PRO- percentage, but also to determine the
appropriate reduction to the conversion
POSED FOR PACKAGING IN CY 2008 in this section, please include the
factor for the projected level of pass-
caption ‘‘OPPS: Estimated Transitional
through spending in the following year.
Pro- Pass-Through Spending’’ at the
HCPCS Short descriptor posed beginning of your comment.) For devices, developing an estimate of
code CY 2008 pass-through spending in CY 2008
SI A. Total Allowed Pass-Through entails estimating spending for two
Spending groups of items. The first group of items
90393 ....... Vaccina ig, im .......... N
90477 ....... Adenovirus vaccine, N Section 1833(t)(6)(E) of the Act limits consists of those device categories that
type 7. the total projected amount of were eligible for pass-through payment
90581 ....... Anthrax vaccine, sc .. N transitional pass-through payments for in CY 2006 or CY 2007, or both years,
90727 ....... Plague vaccine, im ... N drugs, biologicals, and that would continue to be eligible
J0200 ....... Alatrofloxacin N radiopharmaceuticals, and categories of for pass-through payment in CY 2008.
mesylate. devices for a given year to an The second group contains items that
J0395 ....... Arbutamine HCl in- N ‘‘applicable percentage’’ of projected we know are newly eligible, or project
jection. total Medicare and beneficiary would be newly eligible, for device
pass-through payment in the remainder the first group of drugs and biologicals claims data for the procedures
of CY 2007 or beginning in CY 2008. requiring a pass-through payment associated with a device category, we
For drugs and biologicals, section estimate consists of those products that are proposing to project these data
1833(t)(6)(D)(i) of the Act establishes the were eligible for pass-through payment forward using inflation and utilization
pass-through payment amount for drugs in CY 2006 or CY 2007, or both years, factors based on total growth in OPPS
and biologicals eligible for pass-through and that would continue to be eligible services as projected by CMS’ Office of
payment as the amount by which the for pass-through payment in CY 2008. the Actuary (OACT) to estimate the
The second group contains products upcoming year’s pass-through spending
amount authorized under section
that we know are newly eligible, or for this first group of device categories.
1842(o) of the Act (or, if the drug or
project would be newly eligible, for As we stated in the CY 2007 OPPS/ASC
biological is covered under a
drug or biological pass-through payment final rule with comment period (71 FR
competitive acquisition contract under
in the remainder of CY 2007 or 68101), we may use an alternate growth
section 1847B, an amount determined
beginning in CY 2008. The sum of the factor for any specific device category
by the Secretary equal to the average CY 2008 pass-through estimates for
price for the drug or biological for all based on our claims data or the device’s
these two groups of drugs and clinical characteristics, or both. We
competitive acquisition areas and year biologicals would equal the total CY
established under such section as developed estimated OPPS utilization of
2008 pass-through spending estimate for the procedures and costs associated
calculated and adjusted by the drugs and biologicals with pass-through
Secretary) exceeds the portion of the with the two device categories
status.
otherwise applicable fee schedule continuing for pass-through payment
amount that the Secretary determines is B. Proposed Estimate of Pass-Through into CY 2008, based upon examination
associated with the drug or biological. Spending of our historical claims data,
Because we are proposing to pay for We are proposing to set the applicable information provided in the pass-
nonpass-through separately payable percentage limit at 2.0 percent of the through device category applications,
drugs and biologicals under the CY 2008 total OPPS projected payments for CY and the devices’ clinical characteristics.
OPPS at the ASP+5 percent, which 2008, consistent with our OPPS policy Based on these estimates, we estimate
represents the otherwise applicable fee from CY 2004 through CY 2007. pass-through spending attributable to
schedule amount associated with a pass- As we discuss in section IV.B. of this the first group (that is, the two device
through drug or biological, while we proposed rule there are two device categories continuing in CY 2008)
would pay for pass-through drugs and categories receiving pass-through described above to be $18.1 million for
biologicals at the ASP+6 percent or the payment in CY 2007 that would CY 2008. The two device categories
Part B drug CAP rate, if applicable, our continue for payment during CY 2008. continuing in CY 2008, which are
estimate of drug and biological pass- In accordance with the methodology we reflected in this $18.1 million estimate
through payment for CY 2008 is not have used to make estimates in previous for CY 2008 pass-through spending, are
zero. Similar to estimates for devices, years, in cases where we have relevant listed in Table 46A.
TABLE 46A.—PROPOSED CY 2008 DEVICES WITH CURRENT PASS-THROUGH CATEGORIES CONTINUING INTO CY 2008
HCPCS APC Current pass-through device category
code
C1821 ....... 1821 ........ Interspinous process distraction device (implantable).

L8690 ....... 1032 ......... Auditory osseointegrated device, includes all internal and external components.
To estimate CY 2008 pass-through specific new device category based on spending in CY 2008 incorporate both
spending for device categories in the our claims data or the device’s clinical CY 2008 estimates of pass-through
second group (that is, device categories characteristics, or both. At this time, we spending for device categories made
that we know at the time of the anticipate that any new categories for effective January 1, 2007, and estimates
development of this proposed rule January 1, 2008, would be determined for those device categories projected to
would be newly eligible for pass- after the publication of this proposed be approved during subsequent quarters
through payment in CY 2007 continuing rule, but before publication of the CY of CY 2007 and CY 2008.
into CY 2008 (of which there are none); 2008 final rule with comment period. If To estimate CY 2008 pass-through
additional device categories that we we do not have any relevant CY 2006 spending for drugs and biologicals in
estimate could be approved for pass- claims data upon which to base a the first group, specifically those drugs
through status subsequent to the spending estimate for CY 2008, we are and biologicals initially eligible for
development of this proposed rule and proposing to use price information and pass-through status in CY 2006 or CY
before January 1, 2008; and projections utilization estimates from applicants. To 2007 and proposed for continuation of
for new categories that could be account for the contingency of new pass-through payment in CY 2008, we
established in the second through fourth device categories that we project could are proposing to utilize the most recent
quarters of CY 2008), we are proposing become eligible for pass-through status Medicare physician’s office data
to use the following approach. In in the second, third, or fourth quarter of regarding their utilization, information
general, as described for the first group CY 2008, we are proposing to use the provided in the pass-through
of device categories above, if we have general methodology as described applications, historical hospital claims
relevant claims data, we may project above, while also considering the most data, pharmaceutical industry
these data forward using OACT inflation recent OPPS experience in approving information, and clinical information
and utilization factors based on total new pass-through device categories. regarding the products, in order to
growth in OPPS services, or we may use Therefore, we are proposing that the project the CY 2008 OPPS utilization of
an alternate growth factor for any estimate of pass-through device the products. For the 13 known drugs
and biologicals that are proposed for the projected CY 2008 OPPS utilization $1.3 million for CY 2008. This $1.3
continuation of pass-through payment of these products. Based on these million estimate of CY 2008 pass-
in CY 2008, we then estimated the total estimates, we estimate pass-through through spending for the first group of
pass-through payment amount as the spending attributable to the first group pass-through drugs reflects the 13
difference between ASP+6 percent or (that is, the drugs and biological current pass-through drugs that are
the Part B drug CAP rate, as applicable, continuing with pass-through eligibility continuing on pass-through status into
and ASP+5 percent, aggregated across in CY 2008) described above to be about CY 2008, which are listed in Table 46B.
TABLE 46B.—PROPOSED CY 2008 PASS-THROUGH DRUGS WITH CURRENT PASS-THROUGH STATUS CONTINUING INTO
CY 2008
CY 2007 and
HCPCS Short descriptor proposed CY
code 2008 APC
C9232 ...... Injection, idursulfase ...................................................................................................................................................... 9232

C9233 ...... Injection, ranibizumab .................................................................................................................................................... 9233
C9235 ...... Injection, panitumumab ................................................................................................................................................. 9235
C9350 ...... Porous collagen tube per cm ........................................................................................................................................ 9350
C9351 ...... Acellular derm tissue per cm2 ....................................................................................................................................... 9351
J0129 ....... Injection, abatacept ....................................................................................................................................................... 9230
J0348 ....... Anadulafungin injection ................................................................................................................................................. 0760
J0894* ..... Injection, decitabine ....................................................................................................................................................... 9231
J1740 ....... Injection ibandronate sodium ........................................................................................................................................ 9229
J2248 ....... Injection, micafungin sodium ......................................................................................................................................... 9227
J3243 ....... Injection, tigecycline ...................................................................................................................................................... 9228
J3473 ....... Hyaluronidase recombinant ........................................................................................................................................... 0806
J9261 ....... Nelarabine injection ....................................................................................................................................................... 0825
To estimate CY 2008 pass-through through spending attributable to this that we specified in the CY 2005 OPPS
spending for drugs and biologicals in second group of drugs and biologicals to final rule with comment period.
the second group (that is, drugs and be about $0.6 million for CY 2008. However, we do not believe that pass
biologicals that we know at the time of Therefore, we are proposing that the through spending for new
the development of this proposed rule estimate of pass through drug and radiopharmaceuticals in CY 2008 will
would be newly eligible for pass- biological spending in CY 2008 be significant enough to materially
through payment in CY 2007 continuing incorporate both CY 2008 estimates of affect our estimate of total pass-through
into CY 2008 (of which there are none); pass-through spending for drugs and spending in CY 2008. Therefore, we are
additional drugs and biologicals that we biologicals with pass-through status in not including radiopharmaceuticals in
estimate could be approved for pass- CY 2007 that would continue for CY our proposed estimate of pass through
through status subsequent to the 2008 and estimates for those drugs and spending for CY 2008. We discuss the
development of this proposed rule and biologicals projected to be approved
methodology for determining the CY
before January 1, 2008; and projections during subsequent quarters of CY 2007
2008 payment amount for new
for new drugs and biologicals that could and CY 2008. The total estimate of pass-
radiopharmaceuticals without pass
be initially eligible for pass-through through spending for drugs and
payment in the second through fourth biologicals under the CY 2008 OPPS is through status in section V.B.3.b. of this
quarters of CY 2008), we are proposing nearly $2 million. proposed rule.
to use the following approach. At this In the CY 2005 OPPS final rule with In accordance with the methodology
time, we anticipate that any new drugs comment period (69 FR 65810), we described above, we estimate that total
and biologicals for January 1, 2008, indicated that we are accepting pass- pass-through spending for the 2 device
would be determined after the through applications for new categories and 13 drugs and biologicals
publication of this proposed rule, but radiopharmaceuticals that are assigned a that are continuing for pass-through
before publication of the CY 2008 final HCPCS code on or after January 1, 2005. payment into CY 2008 and those that
rule with comment period. We are (Prior to this date, radiopharmaceuticals first become eligible for pass-through
proposing to use utilization estimates were not included in the category of status subsequent to this proposed rule
from applicants, pharmaceutical drugs paid under the OPPS, and, in CY 2007 or during CY 2008 would
industry data, and clinical information therefore, were not eligible for pass- equal approximately $54 million, which
to base pass through spending estimates through status.) There are no represents 0.15 percent of total OPPS
for these drugs and biologicals for CY radiopharmaceuticals that were eligible projected payments for CY 2008.
2008. To account for the contingency of for pass-through payment in CY 2005 or
new drugs and biologicals that we at the time of publication of this Because we estimate that pass-
project could become eligible for pass proposed rule in CY 2007. In addition, through spending in CY 2008 would not
through status in the second, third, or we have no information identifying new amount to 2.0 percent of total projected
fourth quarter of CY 2008, we are radiopharmaceuticals to which a HCPCS OPPS CY 2008 spending, we are
proposing to use the general code might be assigned on or after proposing to return 1.85 percent of the
methodology as described above, while January 1, 2008, for which pass through pass-through pool to adjust the
also considering the most recent OPPS payment status would be sought. We conversion factor, as we discuss in
experience in approving new pass- also have no data regarding payment for section II.C. of this proposed rule.
through drugs and biologicals. Based on new radiopharmaceuticals with pass-
these estimates, we estimate pass- through status under the methodology
VII. Proposed Payment for and to submit a report on its study to status indicator ‘‘K’’ to ensure that ‘‘K’’
Brachytherapy Sources the Congress and the Secretary, appropriately describes brachytherapy
(If you choose to comment on issues including recommendations on the sources to accommodate the use of ‘‘K’’
in this section, please include the appropriate payments for such devices. for prospective payment for
caption ‘‘OPPS: Brachytherapy’’ at the This report was due to Congress and to brachytherapy sources (71 FR 68110).
the Secretary no later than January 1, Subsequent to publication of the CY
beginning of your comment.)
2005. The GAO’s final report, ‘‘Medicare 2007 OPPS/ASC final rule with
A. Background Outpatient Payments: Rates for Certain comment period, section 107(a) of the
Section 1833(t)(2)(H) of the Act, as Radioactive Sources Used in MIEA–TRHCA amended section
added by section 621(b)(2)(C) of Pub. L. Brachytherapy Could Be Set 1833(t)(16)(C) of the Act by extending
108–173, mandated the creation of Prospectively’’ (GAO–06–635), was the payment period for brachytherapy
separate groups of covered OPD services published on July 24, 2006. We sources based on a hospital’s charges
summarized and discussed the report’s adjusted to cost for one additional year.
that classify brachytherapy devices
findings and recommendations in the This requirement for cost-based
separately from other services or groups
CY 2007 OPPS/ASC final rule with payment ends after December 31, 2007.
of services. The additional groups must
comment period (71 FR 68103 through Therefore, we have continued payment
reflect the number, isotope, and
68105). The GAO report principally for sources based on charges reduced to
radioactive intensity of the devices of
recommended that we use OPPS cost through CY 2007. We also have
brachytherapy furnished, including
historical claims data to determine continued using status indicator ‘‘H’’ to
separate groups for palladium-103 and
prospective payment rates for two of the denote nonpass through brachytherapy
iodine-125 devices.
most frequently used brachytherapy sources paid on a cost basis as a result
Section 1833(t)(16)(C) of the Act, as
sources, iodine-125 and palladium-103, of enactment of this provision rather
added by section 621(b)(1) of Pub. L.
and also recommended that we consider than using status indicator ‘‘K’’ to
108–173, established payment for
using claims data for the third source denote prospective payment for
devices of brachytherapy consisting of a nonpass-through brachytherapy sources,
studied, high dose rate (HDR) iridium-
seed or seeds (or radioactive source) as finalized in the CY 2007 OPPS/ASC
192.
based on a hospital’s charges for the The GAO report concluded that CMS final rule with comment period.
service, adjusted to cost. The period of could set prospective payment rates Section 107(b)(1) of the MIEA–
payment under this provision is for based on claims data for iodine and TRHCA amended section 1833(t)(2)(H)
brachytherapy sources furnished from palladium sources, because the sources’ of the Act by adding a requirement for
January 1, 2004, through December 31, unit costs are generally stable, both the establishment of separate payment
2006. Under section 1833(t)(16)(C) of sources have identifiable unit costs that groups for ‘‘stranded and non-stranded’’
the Act, charges for the brachytherapy do not vary substantially and brachytherapy devices beginning July 1,
devices may not be used in determining unpredictably over time, and reasonably 2007. Section 107(b)(2) of the MIEA
any outlier payments under the OPPS accurate claims data are available. On TRHCA authorized the Secretary to
for that period of payment. Consistent the other hand, the GAO report implement this new requirement by
with our practice under the OPPS to explained that it was not able to ‘‘program instruction or otherwise.’’
exclude items paid at cost from budget determine a suitable methodology for This new requirement is in addition to
neutrality consideration, these items paying separately for HDR iridium. The the requirement for separate payment
were excluded from budget neutrality report noted that iridium is reused groups based on the number, isotope,
for that time period as well. across multiple patients, making its unit and radioactive intensity of
In the OPPS interim final rule with cost more difficult to determine. brachytherapy devices previously
comment period published on January However, the report also indicated that established by section 1833(t)(2)(H) of
6, 2004 (69 FR 827), we implemented CMS has outpatient claims data from all the Act. We note that commenters on
sections 621(b)(1) and (b)(2)(C) of Pub. hospitals that have used iridium and the CY 2007 proposed rule asserted that
L. 108–173. In that rule, we stated that that in order to identify a suitable stranded sources, which they described
we would pay for the brachytherapy methodology for separate payment, CMS as embedded into the stranded suture
sources (that is, brachytherapy devices) would be able to use these data to material and separated within the strand
listed in Table 4 of the interim final rule establish an average cost and evaluate by material of an absorbable nature at
with comment period (69 FR 828) on a whether that cost varies substantially specified intervals, had greater
cost basis, as required by the statute. and unpredictably. production costs than non-stranded
Since January 1, 2004, we have used In our CY 2007 annual OPPS sources (71 FR 68113 through 68114).
status indicator ‘‘H’’ to denote nonpass rulemaking, we proposed and finalized As a result of the statutory
through brachytherapy sources paid on a policy of prospective payment based requirement to create separate groups
a cost basis, a policy that we finalized on median costs for the 11 for stranded and non-stranded sources
in the CY 2005 final rule with comment brachytherapy sources for which we had as of July 1, 2007, we established several
period (69 FR 65838). claims data. We based the prospective coding changes via program transmittal,
Furthermore, we adopted a standard rates on median costs for each source effective July 1, 2007 (Program
policy for brachytherapy code from our CY 2005 claims data (71 FR Transmittal No. 1259, dated June 1,
descriptors, beginning January 1, 2005. 68102 through 71 FR 68114). We also 2007). From comments to our CY 2007
We included ‘‘per source’’ in the HCPCS indicated that we would assign future proposed rule and industry input, we
code descriptors for all those new HCPCS codes for new are currently aware of three sources that
brachytherapy source descriptors for brachytherapy sources to their own are currently available in stranded and
which units of payment were not APCs, with prospective payment rates non-stranded forms: iodine-125;
already delineated. set based on our consideration of palladium-103; and cesium-131.
Section 621(b)(3) of Pub. L. 108–173 external data and other relevant Therefore, in Program Transmittal No.
required the GAO to conduct a study to information regarding the expected 1259, we created six new HCPCS codes
determine appropriate payment costs of the sources to hospitals (71 FR to differentiate the stranded and non-
amounts for devices of brachytherapy, 68112). We changed the definition of stranded versions of these three sources.
These six new HCPCS codes replace the code for the non stranded source, the However, under section 1833(t)(2)(H) of
three prior brachytherapy source HCPCS hospital should bill the stranded source the Act, we are still required to create
codes for iodine, palladium and cesium under C2698 (stranded NOS source) APC groupings that classify devices of
(C1718, C1720, and C2633, all of which until a specific stranded billing code for brachytherapy separately from other
are deleted as of July 1, 2007), the source is established. services or groups of services in a
respectively, effective July 1, 2007. In In Program Transmittal No. 1259, we manner reflecting the number, isotope,
this program transmittal, we also reiterated our longstanding policy that and radioactive intensity of the devices
provided specific billing instructions to hospitals and other parties are invited to of brachytherapy furnished. In addition,
hospitals on how to report stranded submit recommendations to us for new section 1833(t)(2)(H) of the Act, as
sources. We instructed providers, when HCPCS codes to describe new sources amended by section 107(b)(1) of the
billing for stranded sources, to bill the consisting of a radioactive isotope, MIEA–TRHCA, requires separate
number of units of the appropriate including a detailed rationale to support payment groups based on stranded and
source HCPCS C-code according to the recommended new sources. We will non-stranded brachytherapy devices on
number of brachytherapy sources in the continue to endeavor to add new or after July 1, 2007.
strands and specifically not to bill as brachytherapy source codes and We are proposing to pay separately for
one unit per strand. If a hospital applies descriptors to our systems for payment each of the sources listed in Table 48
both stranded and non-stranded sources on a quarterly basis. Such below on a prospective basis for CY
to a patient in a single treatment, the recommendations should be directed to 2008, with payment rates to be
hospital should bill the stranded and the Division of Outpatient care, Mail determined using the CY 2006 claims-
non-stranded sources separately, Stop C4–05–17, Centers for Medicare based median cost per source for each
according to the differentiated HCPCS and Medicaid Services, 7500 Security brachytherapy device. Consistent with
codes listed in the table found in that Boulevard, Baltimore, MD 21244. our policy regarding APC payments
program transmittal and included in Finally, we note that in the CY 2007 made on a prospective basis, we are
Table 48 below. We expect that these OPPS/ASC final rule with comment proposing that the cost of brachytherapy
instructions will clearly indicate how period, we established a definition for sources be subject to the outlier
hospitals are to bill for stranded and brachytherapy source for which separate provision of section 1833(t)(5) of the
non-stranded brachytherapy sources, payment under section 1833(t)(2)(H) of Act. As indicated in section II.A.2. of
and that hospital reporting of sources the Act is required (71 FR 68113). We this proposed rule, for CY 2008 we are
according to these instructions will considered the definition of proposing specific prospective payment
promote accurate claims data for the ‘‘brachytherapy source’’ in the context rates for brachytherapy sources, which
various source codes in the future. In of current medical practice and in will be subject to scaling for budget
regard to the language in section neutrality.
Program Transmittal No. 1259, we also
1833(t)(2)(H) of the Act, which refers to We believe that adopting prospective
added the term ‘‘non-stranded’’ to the
brachytherapy sources as ‘‘a seed or payment for brachytherapy sources is
descriptors for all sources that currently
seeds (or radioactive source).’’ We appropriate for a number of reasons.
have only non-stranded versions of a
believed that this provision of the Act The general OPPS payment
source.
mandating separate payment refers to methodology is a prospective payment
In Program Transmittal No. 1259, we sources that are themselves radioactive, system using median costs based on
indicated that if we receive information meaning that the source contains a claims data. This prospective payment
that any of the other sources now radioactive isotope. Furthermore, we methodology results in more consistent,
designated as non-stranded are indicated that the statutory language is predictable and equitable payment
marketed as a stranded source, we will likewise clear that devices of amounts per source across hospitals,
create coding information for the brachytherapy paid separately must and it prevents some of the extremely
stranded source. We also established reflect the number, isotope, and high and low payment amounts found
two ‘‘Not Otherwise Specified’’ (NOS) radioactive intensity of such devices under a charges reduced to cost
codes for billing stranded and non- furnished. Accordingly, we further methodology. The proposed prospective
stranded sources that are not yet known believed that section 1833(t)(2)(H) of the payment would also provide hospitals
to us and for which we do not have Act applies only to radioactive devices with incentives for efficiency in the
source-specific codes. If a hospital of brachytherapy. In the CY 2007 OPPS/ provision of brachytherapy services to
purchases an FDA-approved and ASC final rule with comment period, we Medicare beneficiaries. Moreover, the
marketed radioactive source consisting also stated that we would not consider proposed approach is consistent with
of a radioactive isotope (consistent with specific devices, beams of radiation, or our payment methodology for the vast
our definition of a brachytherapy source equipment that do not constitute majority of items and services paid
eligible for separate payment as separate sources that utilize radioactive under the OPPS. Indeed, section
discussed below), for which we do not isotopes to deliver radiation to be 1833(t)(2)(C) of the Act requires us to
yet have a separate source code brachytherapy sources for separate establish prospective payment rates for
established, it should bill such sources payment, as such items do not meet the the OPPS system based on median costs
using the appropriate NOS code listed statutory requirements provided in (or mean costs if elected by the
in Program Transmittal No. 1259, that section 1833(t)(2)(H) of the Act (71 FR Secretary). As of CY 2007, only pass-
is, C2698 (Brachytherapy source, 68113). through devices, radiopharmaceuticals,
stranded, not otherwise specified, per and brachytherapy sources were paid at
source) for stranded NOS sources, or B. Proposed Payments for charges reduced to cost. Based on the
C2699 (Brachytherapy source, non Brachytherapy Sources proposals in this CY 2008 proposed
stranded, not otherwise specified, per As indicated above, the provision to rule, only pass-through devices would
source) for non-stranded NOS sources, pay for brachytherapy sources at charges continue to be paid at charges reduced
which are also listed in Table 48 below. reduced to cost expires after December to cost for CY 2008. We note that section
For example, if a new FDA-approved 31, 2007, in accordance with section 107(a) of the MIEA–TRHCA specifically
stranded source comes onto the market 1833(t) (16)(C) of the Act, as amended extended the payment period for
and there is currently only a billing by section 107(a) of the MIEA–TRHCA. brachytherapy sources based on a
hospital’s charges adjusted to cost for methodology for most brachytherapy in Table 47, for 9 of the 11
only one additional year, CY 2007. sources. We note that estimated median brachytherapy HCPCS codes that were
Analysis of the CY 2006 claims data cost under the proposed approach is in existence in CY 2006 and had claims
suggests that the estimated median cost calculated based on the relevant data, the estimated median cost based
under the proposed prospective department CCR whereas payments on the departmental CCR is higher than
payment approach is higher than the under a charge reduced to cost the median estimated payment under
estimated median payment amount methodology are calculated based on the charges reduced to cost
under a charges reduced to cost each hospital’s overall CCR. As shown methodology.
TABLE 47.—COMPARISON OF CY 2006 ESTIMATED MEDIAN PAYMENTS UNDER CHARGES REDUCED TO COSTS AND
ESTIMATED MEDIAN COSTS
CY 2006 median
CY estimated pay- CY 2006 median
2006 ment charges re- cost (based on
CY 2006 short descriptor
HCPCS duced to cost departmental
code (based on overall CCR)
CCR)
C1716 Brachytx source, Gold 198 ............................................................................................................. $29.30 $31.56

C1717 Brachytx source, HDR Ir-192 .......................................................................................................... 143.20 171.26
C1718 Brachytx source, Iodine 125 ........................................................................................................... 31.41 37.71
C1719 Brachytx source,Non-HDR Ir-192 ................................................................................................... 18.75 56.69
C1720 Brachytx source, Palladium 103 ..................................................................................................... 46.90 55.05
C2616 Brachytx source, Yttrium-90 ............................................................................................................ 10,811.30 11,796.07
C2632 Brachytx sol, I–125, per mCi .......................................................................................................... 21.80 28.27
C2633 Brachytx source, Cesium-131 ......................................................................................................... 63.67 63.61
C2634 Brachytx source, HA, I–125 ............................................................................................................ 26.03 29.56
C2635 Brachytx source, HA, P–103 ........................................................................................................... 40.85 46.48
C2636 Brachytx linear source, P–103 ........................................................................................................ 56.39 36.64
Note: The short descriptions for some of the HCPCS codes in this table were revised after CY 2006. See Table 48 for the current long
descriptions.
With the proposed adoption of the median costs for stranded and non– distribution in our aggregate CY 2006
prospective payment for brachytherapy stranded (low activity) iodine–125, claims data, we are proposing to
sources, there would be opportunities palladium–103, and cesium–131 based calculate the median cost for these 3
for hospitals to receive additional on our CY 2006 aggregate claims data. stranded sources based on the top 80
payments under certain circumstances As stated above, commenters to our CY percent of the cost distribution for our
through the outlier provisions and the 2007 proposed rule stated that the cost aggregate data. This approach to
7.1 percent rural adjustment. As noted of stranded iodine, palladium and calculating median costs for stranded
previously, consistent with our policy cesium sources are higher than non- and non-stranded iodine-125,
regarding APC payments made on a stranded versions of these sources but palladium-103, and cesium-131 sources
prospective basis, we are proposing that provided no data. Given the reported results in proposed Medicare payment
the cost of brachytherapy sources be cost differences between stranded and rates based on the 60th percentile of our
subject to the outlier provision of non-stranded sources and the statutory aggregate data for stranded sources and
section 1833(t)(5) of the Act. Therefore, requirement that we establish separate the 40th percentile of our aggregate data
the source could receive an outlier payment groups for stranded and non- for non-stranded sources, which, after
payment, if the costs of furnishing stranded sources, we believe it is examining the range of our cost data for
brachytherapy sources exceed the appropriate to establish different these sources, appear to provide a
outlier threshold. Also, as noted in stranded and non-stranded payment reasonable cost differential between
section II.F. of this proposed rule, as a rates for iodine-125, palladium-103, and stranded and non-stranded sources,
result of our CY 2008 proposal to pay cesium-131 sources. However, in order until we have claims data reported
prospectively for brachytherapy sources, to establish separate stranded and nonseparately for stranded and non-
we also are proposing to include stranded payment rates for these three stranded sources.
brachytherapy payments in the group of sources, we are proposing to make the We are proposing this approach for
services eligible for the 7.1 percent following assumptions in our stranded and non-stranded iodine-125,
payment increase for rural SCHs, calculation of their median costs. palladium-103, and cesium-131 sources
including EACHs. Assuming that the reportedly lower cost as a transitional measure, until we have
We are proposing a payment non-stranded sources would be unlikely sufficient claims data for separately
methodology for separately paid to be in the top 20 percent of the cost coded stranded and non-stranded
brachytherapy sources for CY 2008 distribution in our aggregate (stranded sources upon which to calculate the
based upon their median unit costs and non-stranded) CY 2006 claims data, median costs for these sources
calculated using CY 2006 claims data. we are proposing to calculate the specifically. (The first partial year
Because we are required to create median cost for these 3 non-stranded claims data for separately coded
separate APC groups for stranded and sources based on the bottom 80 percent stranded and non-stranded sources will
non stranded sources and because our of the cost distribution in our aggregate be available in CY 2007 claims data for
CY 2006 billing codes do not claims data for each source. Likewise, ratesetting in CY 2009.) This
differentiate stranded and non–stranded assuming that the reportedly higher cost methodology has the benefits of a
sources, we are proposing to make stranded sources would be unlikely to prospective payment methodology
certain assumptions when we estimate be in the bottom 20 percent of the cost discussed above and complies with the
requirements of the MIEA–TRHCA to to implement this policy beginning in proposing to not recognize HCPCS code
recognize separate payment for stranded CY 2008. C2637, and again we are assigning it to
and non-stranded sources. There is currently one brachytherapy status indicator ‘‘B’’ under the OPPS for
Furthermore, we are proposing to pay source, Ytterbium-169 (HCPCS C2637, CY 2008. However, if in public
the two NOS codes, C2698 and C2699, Brachytherapy Source, Ytterbium-169, comments to this proposed rule or later
based on a rate equal to the lowest per source), which has its own HCPCS in CY 2007 or CY 2008, we receive
stranded or non-stranded prospective code, but for which we believe we lack relevant and reliable information on the
payment rate for such sources, claims data on its costs. In the CY 2007 hospital cost for Ytterbium-169 and
respectively, paid on a per source basis OPPS/ASC proposed rule (71 FR 49598 information that this source is being
(as opposed, for example, to per mci). through 49599), we indicated that it was marketed, we would propose to
This payment methodology for NOS our understanding that Ytterbium-169 establish a prospective payment rate for
sources provides payment to a hospital had not yet been marketed, and Ytterbium-169 in the CY 2008 final rule
for new sources, while encouraging furthermore that we had no CY 2005 or in a quarterly OPPS update,
interested parties to quickly bring new claims data, external data, or other respectively.
sources to our attention, so specific information on its pricing on which to Table 48 includes a complete listing
coding and payment can be established. base its payment rate for CY 2007. In of the HCPCS codes, long descriptors,
As noted earlier, we may establish new response to the CY 2007 proposed rule, and APC assignments that we currently
brachytherapy source codes on a we received no cost data or other use for brachytherapy sources paid
quarterly basis. information that we could use to under the OPPS as of July 1, 2007, and
establish an informed prospective the status indicators, estimated median
Because brachytherapy sources will payment rate for Ytterbium-169. costs, and payment rates that we are
no longer be paid on the basis of their Therefore, in the CY 2007 OPPS/ASC proposing for CY 2008. We note that
charges reduced to cost after December final rule with comment period (71 FR some of the HCPCS codes for which we
31, 2007, we are proposing to 68112), we finalized a policy of are proposing payment rates for CY
discontinue our use of payment status assigning HCPCS code C2637, 2008 are not shown in Addendum B of
indicator ‘‘H’’ for APCs assigned to Ytterbium-169, with the nonpayable this proposed rule because that
brachytherapy sources. For CY 2008, we status indicator ’’B’’ and indicated that addendum is based on HCPCS codes
are proposing to use status indicator if we later receive relevant information, effective as of April 2007. As indicated
‘‘K’’ for all brachytherapy source APCs. we could establish a payable status earlier, there are some brachytherapy
As indicated earlier, the definition of indicator and appropriate payment rate source HCPCS codes that were added as
status indicator ‘‘K’’ was changed for CY for the Ytterbium source in a future of July 1, 2007. While these HCPCS
2007 to accommodate prospective OPPS quarterly update. This policy was codes are not shown in Addendum B,
payment for brachytherapy sources. superceded by section 107(a) of the the proposed payment rates for all
For CY 2008, we also are proposing to MIEA–TRHCA, which required payment brachytherapy sources are shown in
implement the policy we established in for brachytherapy sources in CY 2007 Table 48.
the CY 2007 OPPS/ASC final rule with based on charges reduced to costs. For While we are inviting public
comment period (which was superseded this CY 2008 proposed rule, we believe comment on all aspects of this CY 2008
by section 107 of the MIEA–TRHCA) that we continue to lack claims data or proposal, we particularly encourage
regarding payment for new other information on the costs of comment on our proposed median costs
brachytherapy sources for which we Ytterbium-169 on which to base an estimates for stranded and non-stranded
have no claims data. As discussed informed prospective payment rate. Our iodine-125, palladium-103, and cesium-
above, we are proposing to assign future CY 2006 claims data show three claims 131, including the submission of any
new HCPCS codes for new for HCPCS code C2637, Ytterbium-169, available information or data on cost
brachytherapy sources to their own with a median cost of $718.08. We differences between stranded and non
APCs, with prospective payment rates believe these three claims may be stranded sources. We also are interested
set based on our consideration of incorrectly coded claims that do not in receiving information regarding the
external data and other relevant represent claims for Ytterbium-169, as historical and current relative market
information regarding the expected the manufacturer of Ytterbium- share for stranded versus non-stranded
costs of the sources to hospitals. commented on the CY 2007 OPPS sources, particularly as used in the care
Because we are proposing to pay proposed rule that Ytterbium-169 would of Medicare beneficiaries and with
prospectively for brachytherapy sources first become available for market in respect to brachytherapy treatments for
beginning in CY 2008, we are proposing 2007. Consequently, at this time, we are different clinical conditions.
TABLE 48.—PROPOSED SEPARATELY PAYABLE BRACHYTHERAPY SOURCES FOR CY 2008

Pro-
Proposed
Proposed posed
HCPCS CY 2008
Long descriptor APC CY 2008 CY 2008
code payment
median cost status
rate indicator
A9527 ....... Iodine I–125, sodium iodide solution, therapeutic, per millicurie ................... 2632 $28.27 $28.62 K
C1716 ....... Brachytherapy source, non-stranded, Gold-198, per source ......................... 1716 31.56 31.95 K
C1717 ....... Brachytherapy source, non-stranded, High Dose Rate Iridium-192, per 1717 171.26 173.40 K
source.
C1719 ....... Brachytherapy source, non-stranded, Non-High Dose Rate Iridium-192, per 1719 56.69 57.40 K
source.
C2616 ....... Brachytherapy source, non-stranded, Yttrium-90, per source ....................... 2616 11,796.07 11,943.79 K
C2634 ....... Brachytherapy source, non-stranded, High Activity, Iodine-125, greater 2634 29.56 29.93 K
than 1.01 mCi (NIST), per source.
TABLE 48.—PROPOSED SEPARATELY PAYABLE BRACHYTHERAPY SOURCES FOR CY 2008—Continued

Pro-
Proposed
Proposed posed
HCPCS CY 2008
Long descriptor APC CY 2008 CY 2008
code payment
median cost status
rate indicator
C2635 ....... Brachytherapy source, non-stranded, High Activity, Palladium-103, greater 2635 46.48 47.06 K
than 2.2 mCi (NIST), per source.
C2636 ....... Brachytherapy linear source, non-stranded, Palladium-103, per 1MM .......... 2636 36.64 37.09 K
C2637 ....... Brachytherapy source, non-stranded, Ytterbium-169, per source ................. 2637 N/A N/A B
C2638 ....... Brachytherapy source, stranded, Iodine-125, per source .............................. 2638 *42.33 42.86 K
C2639 ....... Brachytherapy source, non-stranded, Iodine-125, per source ....................... 2639 **31.51 31.91 K
C2640 ....... Brachytherapy source, stranded, Palladium-103, per source ........................ 2640 *61.47 62.24 K
C2641 ....... Brachytherapy source, non-stranded, Palladium-103, per source ................. 2641 **44.73 45.29 K
C2642 ....... Brachytherapy source, stranded, Cesium-131, per source ............................ 2642 *96.52 97.72 K
C2643 ....... Brachytherapy source, non-stranded, Cesium-131, per source .................... 2643 **50.72 51.35 K
C2698 ....... Brachytherapy source, stranded, not otherwise specified, per source .......... 2698 42.33 42.86 K
C2699 ....... Brachytherapy source, non-stranded, not otherwise specified, per source ... 2699 29.56 29.93 K
* Estimated median cost for stranded version is based on the 60th percentile of the aggregate (stranded and non stranded) claims data for this
source.
** Estimated median cost for non-stranded version is based on the 40th percentile of the aggregate (stranded and non stranded) claims data
for this source.
VIII. Proposed OPPS Drug report office-based drug administration level APC structure for drug
Administration Coding and Payment services. These G-codes were developed administration services. We assigned all
(If you choose to comment on issues in anticipation of substantial revisions CY 2007 HCPCS codes for drug
in this section, please include the to the drug administration CPT codes by administration services to six new drug
caption ‘‘OPPS: Drug Administration’’ at the CPT Editorial Panel that were administration APCs (as listed in Table
the beginning of your comment.) expected for CY 2006. 34 of the CY 2007 OPPS/ASC final rule
In CY 2006, as anticipated, the CPT with comment period), with payment
A. Background Editorial Panel revised its coding rates based on median costs for the
In CY 2005, in response to the structure for drug administration APCs as calculated from CY 2005 claims
recommendations made by commenters services, incorporating new concepts data. In that final rule, we provided a
and the hospital industry, OPPS such as initial, sequential, and crosswalk that illustrated how we
transitioned to the use of CPT codes for concurrent services into a structure that performed our annual payment rate
drug administration services. (For previously distinguished services based update methodology for these services
information on coding for drug on type of administration using CY 2005 data.
administration services prior to CY (chemotherapy/nonchemotherapy),
method of administration (injection/ As indicated in the CY 2007 OPPS/
2005, see 71 FR 68115.) These CPT ASC final rule with comment period (71
codes allowed for more specific infusion/push), and for infusion
services, first hour and additional hours. FR 68122), because the newly
reporting of services, especially
For CY 2006, we implemented 20 of the recognized CPT codes discriminate
regarding the number of hours for an
33 CY 2006 drug administration CPT among services more specifically than
infusion, and provided consistency in
codes that did not reflect the concepts the CY 2006 C-codes, as was the case
coding between Medicare and other
of initial, sequential, and concurrent when the OPPS transitioned from more
payers. However, at that time, we did
services, and we created 6 new HCPCS general Q-codes to more specific CPT
not have any data to revise the CY 2005
C-codes that generally paralleled the CY codes for the reporting of drug
per-visit APC payment structure for
2005 CPT codes for the same services. administration services in CY 2005, for
infusion services. In order to collect
We chose not to implement the full set a period of 2 years drug administration
data for future ratesetting purposes, we
implemented claims processing logic of CY 2006 CPT codes because of our services will be paid based on the costs
that collapsed payments for drug concerns regarding the interface of their predecessor HCPCS codes until
administration services and paid a between the complex claims processing updated data are available for review.
single APC amount for those services for logic required for correct payments and B. Proposed Coding and Payment for
each visit, unless a modifier was used hospitals’ challenges in correctly coding Drug Administration Services
to identify drug administration services their claims to receive accurate
provided in a separate encounter on the payments for these services. During the March 2007 APC Panel
same day. Hospitals were instructed to For CY 2007, as a result of comments meeting, the APC Panel recommended
bill all applicable CPT codes for drug to our proposed rule and feedback from that CMS pay separately for CPT code
administration services provided in a the hospital community and the APC 90768 (Intravenous infusion, for
HOPD, without regard to whether or not Panel, we implemented the full set of therapy, prophylaxis, or diagnosis
the CPT code would receive a separate CPT codes, including the concepts of (specify substance or drug); concurrent
APC payment during OPPS claims initial, sequential and concurrent. In infusion (list separately in addition to
processing. addition, the CY 2007 update process code for primary procedure)) at the
While hospitals just began adopting offered us the first opportunity to same rate as CPT code 90767
CPT codes for outpatient drug consider data gathered from the use of (Intravenous infusion, for therapy,
administration services in CY 2005, CY 2005 CPT codes for purposes of prophylaxis, or diagnosis (specify
physicians paid under the MPFS were ratesetting. For CY 2007, we used CY substance or drug); additional
using HCPCS G-codes in CY 2005 to 2005 claims data to implement a six- sequential infusion, up to 1 hour (list
separately in addition to code for As data are not available for drug or diagnostic injection (specify material
primary procedure)). administration services for purposes of injected); intra-arterial), had a higher
As discussed in section II.A.4. of this CY 2008 ratesetting, and as we believe median cost that was more similar to the
proposed rule, in deciding whether to that the costs for the drug costs of other services also assigned to
package a service or pay for it administration services identified by APC 0438. We continue to believe that
separately, we consider a variety of CPT code 90768 are included in our this intra-arterial injection procedure is
factors, including whether the service is hospital claims data used for ratesetting similar from both clinical and hospital
normally provided separately or in purposes, we are not accepting the APC resource perspectives to the related
conjunction with other services; how Panel’s recommendation to provide a intravenous push injection procedures
likely it is for the costs of the packaged separate APC payment for this service. that are assigned to the same clinical
code to be appropriately mapped to the Furthermore, we note that in section APC and, therefore, we are proposing to
separately payable codes with which it II.A.4. of this proposed rule, we have except APC 0438 from the 2 times rule
was performed; and whether the proposed to expand packaging of certain for CY 2008. We continue to ask
expected cost of the service is relatively (nondrug administration) services. We hospitals to report all CPT drug
low. As we discussed in the CY 2007 believe that continuing to package CPT administration codes, and we expect
OPPS/ASC final rule with comment code 90786 is consistent with these hospitals to report CPT codes
period (71 FR 68122), CPT code 90768 broader efforts. consistently with CPT coding guidelines
was first introduced in CY 2007 and For CY 2008, we examined CY 2006
and applicable instructions.
consistent with our established claims data available for this proposed
ratesetting methodology, we do not rule and continue to believe the CY We note that in this section of the CY
anticipate OPPS hospital claims data 2007 drug administration APC 2007 proposed rule we discussed IVIG
from CY 2007 to be available for configuration reflects clinically and preadministration-related services; for
ratesetting purposes until CY 2009. In resource homogeneous groupings of CY 2008, this topic is discussed in
addition, as the services identified with procedures. We note that there is a section III.C.2.b. of this proposed rule.
CPT code 90768 were provided in violation of the 2 times rule in APC
IX. Proposed Hospital Coding and
previous years, it is our determination 0438 (Level III Drug Administration) as
that these costs are already represented proposed for CY 2008. The violation is Payments for Visits
in our currently available hospital related to the comparatively low median A. Background
claims data. Payment for these services cost of CPT code 90773 (Therapeutic,
was provided in previous years through prophylactic or diagnostic injection Currently, CMS instructs hospitals to
the billing of more general drug (specify substance or drug); intra- use the CY 2007 CPT codes, as well as
administration codes. Although more arterial) for which we have a six HCPCS codes that became effective
exhaustive codes for drug significantly greater number of CY 2006 January 1, 2007, to report clinic and
administration services are now single claims available for ratesetting emergency department visits and
available, this does not indicate that than previous years. The CY 2005 critical care services on claims paid
these services did not receive OPPS predecessor code for this service, CPT under the OPPS. The codes are listed
payments in previous years. code 90783 (Therapeutic, prophylactic below in Table 49.
TABLE 49.—CY 2007 CPT EVALUATION AND MANAGEMENT (E/M) AND LEVEL II HCPCS CODES USED TO REPORT
CLINIC AND EMERGENCY DEPARTMENT VISITS AND CRITICAL CARE SERVICES
HCPCS Descriptor
code
Clinic Visit HCPCS Codes
99201 ....... Office or other outpatient visit for the evaluation and management of a new patient (Level 1).
99211 ....... Office or other outpatient visit for the evaluation and management of an established patient (Level 1).
99241 ....... Office consultation for a new or established patient (Level 1).
Emergency Department Visit HCPCS Codes

99281 ....... Emergency department visit for the evaluation and management of a patient (Level 1).
G0380 ...... Type B emergency department visit (Level 1).
TABLE 49.—CY 2007 CPT EVALUATION AND MANAGEMENT (E/M) AND LEVEL II HCPCS CODES USED TO REPORT
CLINIC AND EMERGENCY DEPARTMENT VISITS AND CRITICAL CARE SERVICES—Continued
HCPCS Descriptor
code

Critical Care Services HCPCS Codes
99291 ....... Critical care, evaluation and management of the critically ill or critically injured patient; first 30–74 minutes.
99292 ....... Each additional 30 minutes.
G0390 ...... Trauma response associated with hospital critical care services.
Presently, there are three types of visit mix of services provided by hospitals that each hospital’s internal guidelines
codes to describe three types of services: during visits of clinic and emergency should follow the intent of the CPT code
Clinic visits, emergency department department patients and critical care descriptors, in that the guidelines
visits, and critical care services. CPT encounters. In the April 7, 2000 OPPS should be designed to reasonably relate
indicates that office or other outpatient final rule with comment period (65 FR the intensity of hospital resources to the
visit codes are used to report E/M 18434), we instructed hospitals to report different levels of effort represented by
services provided in the physician’s facility resources for clinic and the codes. In the CY 2007 OPPS/ASC
office or in an outpatient or other emergency department visits using CPT proposed rule (71 FR 49607), we
ambulatory facility. For OPPS purposes, E/M codes and to develop internal proposed to establish five new codes to
we refer to these as clinic visit codes. hospital guidelines to determine what replace hospitals’ reporting of the CPT
CPT also indicates that emergency level of visit to report for each patient. clinic visit E/M codes for new and
department visit codes are used to While awaiting the development of a established patients listed in Table 49
report E/M services provided in the national set of facility-specific codes above. In the CY 2007 OPPS/ASC final
emergency department, defined as an and guidelines, we have advised rule with comment period (71 FR 68127
‘‘organized hospital-based facility for hospitals that each hospital’s internal through 68128), we specified that we
the provision of unscheduled episodic guidelines should follow the intent of would not create new codes to replace
services to patients who present for the CPT code descriptors, in that the existing CPT E/M codes for reporting
immediate medical attention. The guidelines should be designed to hospital visits until national guidelines
facility must be available 24 hours a reasonably relate the intensity of are developed, in response to
day.’’ For OPPS purposes, we refer to hospital resources to the different levels commenters who were concerned about
these as emergency department visit of effort represented by the codes. implementing hospital-specific Level II
codes that specifically apply to the Critical care services are considered to HCPCS codes without national
reporting of visits to Type A emergency be outpatient visits, and our current guidelines. We also discussed our
departments on or after January 1, 2007, payment policy for trauma activation intention to reconsider whether G-codes
as discussed in further detail later in ties separate payment to the reporting of would be appropriate for the OPPS once
this section. We established five new hospital critical care services. We are national guidelines are established.
Level II HCPCS codes to report visits to not proposing to change our OPPS In that same rule (71 FR 68138), we
Type B emergency departments payment policy for critical care services finalized our proposal to pay clinic
beginning in CY 2007 because there are for CY 2008, and our CY 2008 proposal visits at five payment rates, rather than
currently no CPT codes that fully for payment of trauma activation is three payment rates. Prior to CY 2007,
describe services provided in this type described in section II.A.4. of this under the OPPS, outpatient visits
of facility. CPT defines critical care proposed rule. Therefore, we will no provided by hospitals were paid at three
services as the ‘‘direct delivery by a longer include references to critical care payment levels for clinic visits, even
physician(s) of medical care for a services in the sections below that though hospitals reported five resource-
critically ill or critically injured describe hospital outpatient visits. based coding levels of clinic visits using
patient.’’ It also states that ‘‘critical care B. Proposed Policies for Hospital CPT E/M codes. Because the three
is usually, but not always, given in a Outpatient Visits payment rates for clinic visits were
critical care area, such as * * * the based on five levels of CPT codes, in
emergency care facility.’’ In addition to 1. Clinic Visits: New and Established general the two lowest levels of CPT
reporting critical care services, hospitals Patient Visits and Consultations codes (Levels 1 and 2) were assigned to
may utilize the new HCPCS code G0390 As discussed earlier, the majority of the low level visit APC and the two
for the reporting of a trauma response in all CPT code descriptors are applicable highest levels of CPT codes (Levels 4
association with critical care services for to both physician and facility resources and 5) were assigned to the high level
the CY 2007 OPPS. associated with specific services. visit APC, while the single middle level
The majority of CPT code descriptors However, we believe that CPT E/M CPT code (Level 3) was assigned to the
are applicable to both physician and codes were defined to reflect the mid-level visit APC. Historical hospital
facility resources associated with activities of physicians and do not claims data have generally reflected
specific services. However, we have describe well the range and mix of significantly different median costs for
acknowledged from the beginning of the services provided by hospitals during the two levels of services assigned to the
OPPS that we believe that CPT E/M visits of clinic and emergency low and high level visit APCs. We noted
codes were defined to reflect the department patients. While awaiting the that payment at only three levels may
activities of physicians and do not development of a national set of not be the most accurate method of
necessarily describe well the range and guidelines, we have advised hospitals payment for those very common
hospital levels of visits that clearly visit APCs to develop median costs for 2006 claims data processed through
demonstrated differential hospital these APCs. We mapped the CPT E/M December 31, 2006, displays the HCPCS
resources. Consequently, for the CY codes and other HCPCS codes to the code and APC median costs at the five
2007 OPPS, we mapped the data from clinic visit APCs based on their median payment levels that we are proposing
the CY 2005 CPT E/M codes and other costs and clinical homogeneity for the CY 2008 OPPS.
HCPCS codes assigned previously to the considerations. Table 50, which
three clinic visit APCs to five new clinic includes the median costs based on CY
TABLE 50.—PROPOSED ASSIGNMENT OF CLAIMS DATA FROM CY 2006 CPT E/M AND LEVEL II HCPCS CODES TO VISIT
APCS FOR CY 2008
Proposed CY APC service
CY 2008 HCPCS
CY 2008 APC title 2008 APC frequency Short descriptor
APC code
median (million)
Level 1 Hospital Clinic Visits ............... 0604 $52.72 3.8 92012 Eye exam established pat.
99201 Office/outpatient visit, new (Level 1).
99211 Office/outpatient visit, est (Level 1).
99241 Office consultation (Level 1).
G0101 CA screen; pelvic/breast exam.
G0245 Initial foot exam pt lops.
G0379 Direct admit hospital observ.
Level 2 Hospital Clinic Visits ............... 0605 $63.01 7.3 90862 Medication management.
92002 Eye exam, new patient.
92014 Eye exam and treatment.
99242 Office Consultation (Level 2).
99243 Office Consultation (Level 3).
99431 Initial care, normal newborn.
G0246 Followup eval of foot pt lop.
G0344 Initial preventive exam.
M0064 Visit for drug monitoring.
Level 3 Hospital Clinic Visits ............... 0606 $85.96 2.9 92004 Eye exam, new patient.
Level 4 Hospital Clinic Visits ............... 0607 $108.08 .8 99204 Office/outpatient visit, new (Level 4).
Level 5 Hospital Clinic Visits ............... 0608 $138.88 .08 99205 Office/outpatient visit, new (Level 5).
G0175 OPPS service, sched team conf.
In the CY 2007 OPPS/ASC proposed ‘‘established’’ patient to the hospital. Observation and Visit Subcommittee of
rule (71 FR 49617), we solicited The opposite could be true if the the APC Panel discussed whether the
comment as to whether a distinction physician has a longstanding coding distinction between new and
between new and established visits was relationship with the patient, in which established patient visits is necessary.
necessary because we were planning to case the patient would be an Ultimately, the APC Panel
transition to G-codes and did not want ‘‘established’’ patient with respect to the recommended that CMS eliminate the
to unnecessarily create codes for both physician and a ‘‘new’’ patient to the ‘‘new’’ and ‘‘established’’ patient
new and established patients. The AMA hospital. distinctions in the reporting of hospital
defines an established patient as ‘‘one Some commenters who responded to clinic visits. During its discussion, the
who has received professional services prior OPPS rules have stated that the APC Panel suggested that hospitals bill
from the physician or another physician hospital resources used for new and the appropriate level clinic visit code
of the same specialty who belongs to the established patients to provide a according to the resources expended
same group practice, within the past 3 specific level of service are very similar, while treating the beneficiary, based on
years.’’ To apply this definition to and that it is unnecessary and each hospital’s internal guidelines. The
hospital visits, we stated in the April 7, burdensome from a coding perspective APC Panel also suggested that each
2000 final rule with comment period (65 to distinguish between the two types of hospital’s internal guidelines reflect
FR 18451) that the meanings of ‘‘new’’ visits. On the other hand, other resource cost differences (if a difference
and ‘‘established’’ pertain to whether or commenters have noted, and CY 2005 exists) between new and established
not the patient already has a hospital and CY 2006 claims data have shown, patients. For example, a visit that
medical record number. If the patient that it may be appropriate to continue involves certain interventions may be
has a hospital medical record that was using different codes for new and coded as Level 3 for a new patient and
created within the past 3 years, that established patients because of the Level 2 for an established patient. The
patient is considered an established observed median cost differences in the APC Panel also made another
patient to the hospital. The same patient claims data. In addition, during the recommendation which is contingent
could be ‘‘new’’ to the physician but an March 2007 APC Panel meeting, the upon CMS adopting its recommendation
to eliminate the new and established recommendation would ensure that in response to the CY 2007 OPPS/ASC
patient distinction reporting each visit level would receive its own final rule with comment period. For CY
requirement. That is, the APC Panel payment rate, rather than both the Level 2008, because hospitals will be
further recommended that CMS map 2 and 3 patient visit codes receiving the reporting CPT E/M codes for clinic
each of the five levels of outpatient same payment rate. visits, which distinguish between new
clinic visit codes (which do not During CY 2006 and earlier, there was and established patients, and because
distinguish between new and no payment difference between new and we see meaningful and consistent cost
established patients) to five separate established patient visits of the same differences between visits for new and
APCs, thereby paying at five payment level, as both were always mapped to established patients, we are proposing
rates. For example, the APC Panel the same clinical APC. However, to continue to recognize the CPT codes
recommended mapping the Level 1 hospital claims data regarding the for new and established patient clinic
patient visit to the Level 1 Clinic Visit median costs of the specific CPT clinic visits under the OPPS, consistent with
APC, mapping the Level 2 patient visit visit E/M codes consistently indicate their CPT code descriptors. Further, we
that new patients are more resource- are not adopting the recommendation of
to the Level 2 Clinic Visit APC, and
intensive than established patients the APC Panel to eliminate this
mapping the Level 3 patient visit to the
across all visit levels. The CY 2006 differentiation for the reasons noted. We
Level 3 Clinic Visit APC. In the current
claims data confirm that the cost are proposing to reexamine whether the
and proposed clinic visit APC difference between new and established
configuration, as indicated in Table 50, coding distinction between new and
patient visits increases as the visit level established patient visits is necessary as
the APC level assignment does not increases.
always correspond to the visit level we consider national guidelines. We
In both the CY 2007 OPPS/ASC
described by each code. For example, continue to encourage public comment
proposed and final rules (71 FR 49617
CPT 99213 is a Level 3 clinic visit code and 71 FR 68128), respectively, we about hospitals’ experiences with
for an established patient, which would encouraged public comment that assigning visit levels to new and
seem to logically map to the Level 3 discussed the potential differences in established patients according to their
Clinic Visit APC. However, because CPT hospital clinic resource consumption own internal guidelines.
99213 has a proposed median cost of between new and established patient Table 51 lists the CY 2008 proposed
$64.73, we mapped this code to the visits. We received only a few median costs of new and established
Level 2 Clinic Visit APC, which has a comments related to this distinction in patient clinic visit codes which are
proposed median cost of $63.01. The response to the CY 2007 OPPS/ASC based on CY 2006 claims data processed
APC Panel indicated that its proposed rule and even fewer comments through December 31, 2006.
TABLE 51.—PROPOSED CY 2008 MEDIAN COSTS OF NEW AND ESTABLISHED PATIENT VISIT CPT CODES
Proposed CY
Proposed CY 2008 established
Clinic visit level 2008 new patient patient visit
visit median cost median cost
Level 1 ............................................................................................................................................................. $56.08 $50.70

Level 2 ............................................................................................................................................................. 63.18 58.84
Level 3 ............................................................................................................................................................. 74.99 64.73
Level 4 ............................................................................................................................................................. 109.12 84.17
Level 5 ............................................................................................................................................................. 138.06 102.89
As noted above, the APC Panel also Clinic Visit APC, which results in the patient visit to the Level 3 Clinic Visit
recommended that CMS map each level Level 1 Clinic Visit APC containing both APC, consistent with the APC Panel
of patient visits to its corresponding the Level 1 new and established patient recommendation. We are proposing to
APC, thereby paying at five payment visit codes, in accordance with the APC map the Level 4 established patient visit
levels. The APC Panel members noted Panel recommendation. Similarly, we to the Level 3 Clinic Visit APC and the
that this mapping system would are proposing to map both the Level 2 Level 5 established patient visit to the
eliminate any payment incentive to new and established patient visit codes Level 4 Clinic Visit APC. The only CPT
distinguish between new and to the Level 2 Clinic Visit APC. E/M code that we are proposing to map
established patients but would ensure However, we also are proposing to map to the Level 5 Clinic Visit APC for CY
five payment levels. the Level 3 established patient visit 2008 payment is the Level 5 new patient
For CY 2008, we are proposing to map code to the Level 2 Clinic Visit APC
visit. These APC assignments that we
the clinic visit codes for new patients to because our cost data indicate that the
are proposing for CY 2008, consistent
the five Clinic Visit APCs, one code to costs associated with a Level 3
each level, based on the hospital established patient visit most closely with the CY 2007 APC assignments,
resources observed in historical claims resemble the costs associated with the were determined for each HCPCS code
data as they are mapped for CY 2007 Level 2 Clinic Visit APC and the Level based on CY 2008 proposed rule median
and in accordance with the APC Panel’s 2 new and established patient visits. If cost data and clinical considerations.
recommendation. However, for CY CPT code 99213 for an established Level We are not persuaded by the APC Panel
2008, we are proposing to maintain the 3 clinic visit was mapped to the Level recommendation, which would require
CY 2007 mapping for the clinic visit 3 Clinic Visit APC, which has a us to ignore significant cost differences
codes for established patients. As proposed median cost of $85.96, we based on resource data that are
indicated in Table 51 above, we are would significantly overpay CPT 99213 clinically consistent and instead map
proposing to map the Level 1 every time it was billed. We are each code to its corresponding level
established patient visit to the Level 1 proposing to map the Level 3 new APC.
Historical cost data for these surprising that particularly among visits We performed data analyses to
frequently provided services are for established patients in the middle of determine how the median costs of the
extremely consistent. In addition, from the range, such as a Level 2 established clinic visit APCs would change if we
a clinical perspective, we believe that in patient visit and a Level 3 established fully adopted the APC Panel’s
some cases, in the context of a five level patient visit, the hospital resource costs recommendation and mapped all of the
structure for visit reporting, the hospital calculated from claims data are similar new and established patient visit codes
resources required for a given visit level because these patients would often to the corresponding level of clinic visit
may only be slightly different from utilize reasonably comparable hospital APC. Our results are shown in Table 52.
those used for a visit that is one level resources.
higher or lower. For example, it is not
TABLE 52.—CY 2008 MEDIAN COST COMPARISON OF CLINIC VISIT APCS IN TWO DIFFERENT CONFIGURATIONS
APC median cost
APC median cost in the
in the proposed
APC recommended
CY 2008 APC panel
configuration configuration
Level 1 Clinic Visit ........................................................................................................................................... $53 $53

Level 2 Clinic Visit ........................................................................................................................................... 63 60
The APC median cost distribution to work on developing national consultation CPT codes if either a new
does not improve when mapping each guidelines. or established patient visit code
new and established patient visit code The APC Panel also recommended accurately describes the service
to its corresponding level of APC. In that CMS not recognize the CPT provided. We stated that we were
fact, the APC Panel’s recommended consultation codes: CPT 99241 (Office particularly interested in hearing
configuration results in lower payment consultation for a new or established whether consultation codes are a useful
rates for the Levels 2 through 5 Clinic patient (Level 1)), CPT 99242 (Office measure of hospital resource use under
Visit APCs, and an identical payment consultation for a new or established the OPPS, and how consultation visits
rate for the Level 1 Clinic Visit APC patient (Level 2)), CPT 99243 (Office are different, from a hospital resource
because our proposed mapping and the consultation for a new or established perspective, from new patient visits and
APC Panel’s recommendation for this patient (Level 3)), CPT 99244 (Office established patient visits. We observed
APC are the same. In general, under the consultation for a new or established that we did not want to create an
OPPS, we rely on resource cost data patient (Level 4)), and CPT 99245 incentive for hospitals to bill a
calculated from hospital claims data to (Office consultation for a new or consultation code instead of a new or
determine appropriate APC mapping of established patient (Level 5)). The APC established patient code because we did
HCPCS codes and to set payment rates. Panel recommended that CMS instruct not believe that consultation codes
While we acknowledge that it might be hospitals to build consultation services necessarily reflected different resource
more predictable for hospitals to receive into their internal hospital guidelines utilization than either new or
the same payment rate for new and related to reporting outpatient clinic established patient codes (71 FR 68138).
established patients of the same visit visit levels based on the complexity and Therefore, for CY 2007, we finalized a
level, robust cost data clearly indicate resources used for these outpatient payment policy that assigned the
that this would not be the most accurate visits. consultation code to the same clinical
payment method. Historical hospital CPT defines a consultation as ‘‘a type APC as the established patient visit code
cost data indicate that new patient visits of service provided by a physician for each level of service. For example,
are costlier than established patient whose opinion or advice regarding CPT code 99242, the Level 2
visits of the same level, a finding that is evaluation and/or management of a consultation code is mapped to APC
consistent with the perspective of our specific problem is requested by another 0605 (Level 2 Clinic Visits), which is
medical advisors. Because we are physician or other appropriate source.’’ where CPT code 99212, the Level 2
proposing that hospitals continue to use CPT recognizes two subcategories of established patient code, is mapped for
CPT E/M codes to report clinic visits for consultations, specifically office or CY 2007. Moving the consultation codes
CY 2008, including separate codes for other outpatient and inpatient to the same APC as the corresponding
new and established patients, we see no consultations, although only the office established patient visit code eliminated
reason to adjust the clinic visit APC consultations would be applicable any incentive for hospitals to bill a
configurations. Therefore, for CY 2008, under the OPPS. Nevertheless, the consultation code instead of a new or
we are proposing to map the CPT E/M differentiation of consultations from established patient code.
codes and other Level II HCPCS codes new and established patient clinic visits
to the Clinic Visit APCs as configured in would appear to be clinically TABLE 53.—CY 2008 MEDIAN COSTS
Table 50 and not fully adopt the APC unnecessary under the OPPS in order to AND FREQUENCIES OF CPT CON-
Panel’s recommendation to map each provide proper OPPS payment for SULTATION VISIT CODES
code to its corresponding APC level. We hospital outpatient visits.
will reexamine using the claims data for In the CY 2007 OPPS/ASC final rule Code descriptor Median cost Frequency
CY 2009 OPPS ratesetting and will also with comment period (71 FR 68128), we
reconsider whether this mapping is noted our belief that it may be Level 1 Con-
appropriate in the future as we continue unnecessary for hospitals to report sultation ......... $66.48 62,000
TABLE 53.—CY 2008 MEDIAN COSTS 2. Emergency Department Visits visits for the treatment of emergency
AND FREQUENCIES OF CPT CON- As described above, CPT defines an medical conditions on an urgent basis
SULTATION VISIT CODES—Contin- emergency department as ‘‘an organized without requiring a previously
ued hospital based facility for the provision scheduled appointment.
of unscheduled episodic services to We believe that every emergency
department that meets the CPT
Code descriptor Median cost patients who present for immediate
Frequency
definition of emergency department also
medical attention. The facility must be
Level 2 Con- qualifies as a dedicated emergency
available 24 hours a day.’’ Prior to CY
sultation ......... 65.78 73,000 department under EMTALA. However,
2007, under the OPPS, we restricted the
Level 3 Con- we are aware that there are some
sultation ......... 81.95 155,000 billing of emergency department CPT departments or facilities of hospitals
Level 4 Con- codes to services furnished at facilities
that meet the definition of a dedicated
sultation ......... 109.96 176,000 that met this CPT definition. Facilities emergency department under the
Level 5 Con- open less than 24 hours a day should
EMTALA regulations but that do not
sultation ......... 139.61 94,000 not report the emergency department
meet the more restrictive CPT definition
CPT codes. of an emergency department. For
Consultation services are provided Sections 1866(a)(1)(I), 1866(a)(1)(N),
example, a hospital department or
with much less frequency than all levels and 1867 of the Act impose specific
facility that meets the definition of a
of established patient visits and low obligations on Medicare-participating
dedicated emergency department may
level new patient visits but are provided hospitals and CAHs that offer not be available 24 hours a day, 7 days
more frequently than high level new emergency services. These obligations
a week. Nevertheless, hospitals with
patient visits. The median costs for concern individuals who come to a
such departments or facilities incur
consultation codes are generally similar hospital’s dedicated emergency EMTALA obligations with respect to an
to or slightly higher than the department and request examination or individual who presents to the
corresponding median costs of the same treatment for medical conditions, and department and requests, or has
level of new patient visits. apply to all of these individuals, requested on his or her behalf,
regardless of whether or not they are examination or treatment for an
Aside from the APC Panel beneficiaries of any program under the
recommendation, we have received few Act. Section 1867(h) of the Act emergency medical condition. However,
comments from the public related to because they did not meet the CPT
specifically prohibits a delay in requirements for reporting emergency
this issue. We continue to believe that providing required screening or
consultation codes are unnecessary and stabilization services in order to inquire visit E/M codes, prior to CY 2007, these
superfluous in the hospital outpatient facilities were required to bill clinic
about the individual’s payment method visit codes for the services they
setting because hospitals could or insurance status. Section 1867(d) of
appropriately bill either a new or furnished under the OPPS. We had no
the Act provides for the imposition of way to distinguish in our hospital
established patient visit code, instead of civil monetary penalties on hospitals
a consultation, as appropriate in these claims data the costs of visits provided
and physicians responsible for failing to in dedicated emergency departments
cases. In the interest of simplifying meet the provisions listed above. These
billing, for CY 2008, we are proposing that did not meet the CPT definition of
provisions, taken together, are emergency department from the costs of
to assign status indicator ‘‘B’’ to the frequently referred to as the Emergency
consultation codes (that is, not paid clinic visits.
Medical Treatment and Labor Act Some hospitals requested that they be
under the OPPS) and instruct hospitals (EMTALA). EMTALA was passed in
to bill a new or established visit code permitted to bill emergency department
1986 as part of the Consolidated visit codes under the OPPS for services
instead of an office consultation code, Omnibus Budget Reconciliation Act of
thereby adopting the APC Panel’s furnished in a facility that met the CPT
1985, Pub. L. 99–272 (COBRA). definition for reporting emergency
recommendation not to recognize these Section 489.24 of the EMTALA department visit E/M codes, except that
consultation codes. As appropriate, regulations defines ‘‘dedicated they were not available 24 hours a day.
hospitals may build consultation emergency department’’ as any These hospitals believed that their
services into their internal hospital department or facility of the hospital, resource costs were more similar to
guidelines related to reporting clinic regardless of whether it is located on or those of emergency departments that
visit levels based on the complexity and off the main hospital campus, that meets
met the CPT definition than they were
resources used for these visits. at least one of the following to the resource costs of clinics.
In summary, for CY 2008, we are requirements: (1) It is licensed by the Representatives of such facilities argued
proposing that hospitals continue to use State in which it is located under that emergency department visit
the CPT codes to bill for clinic visits applicable State law as an emergency payments would be more appropriate,
and to distinguish between new and room or emergency department; (2) It is on the grounds that their facilities
established patient visits. For CY 2008, held out to the public (by name, posted treated patients with emergency
the CPT codes for new and established signs, advertising, or other means) as a conditions whose costs exceeded the
visits would continue to be payable place that provides care for emergency resources reflected in the clinic visit
under the OPPS, but we would medical conditions on an urgent basis APC payments, even though these
reconsider in the future whether there without requiring a previously emergency departments were not
should be a distinction between new scheduled appointment; or (3) During available 24 hours per day. In addition,
and established patient visits as we the calendar year immediately these hospital representatives indicated
continue to work on developing preceding the calendar year in which a that their facilities had EMTALA
national guidelines. For CY 2008, we are determination under the regulations is obligations and should, therefore, be
proposing to change the status of the being made, based on a representative able to receive emergency department
consultation codes so that these codes sample of patient visits that occurred visit payments. While these emergency
are no longer recognized for payment during that calendar year, it provides at departments may have provided a
under the OPPS. least one-third of all of its outpatient broader range and intensity of hospital
services and required significant obligations but do not meet more department visit codes.’’ We believed
resources to assure their availability and prescriptive expectations that are the creation of G-codes for Type B
capabilities in comparison with typical consistent with the CPT definition of an emergency departments was necessary
hospital outpatient clinics, the fact that emergency department (referred to as because there were no CPT codes that
they did not operate with all capabilities Type A emergency departments) have fully described this type of facility. If we
full-time suggested that hospital different resource costs than visits to were to continue instructing Type B
resources associated with visits to either clinics or Type A emergency emergency departments to bill clinic
emergency departments or facilities departments, in the CY 2007 OPPS/ASC visit codes, we would have no way to
available less than 24 hours a day might final rule with comment period (71 FR track resource costs for Type B
not be as great as the resources 68132), we finalized a set of five G-
emergency department visits as distinct
associated with emergency departments codes for use by hospitals to report
from clinic visits. In that rule we
or facilities that were available 24 hours visits to all entities that meet the
definition of a dedicated emergency explained that these new G-codes would
a day and that fully met the CPT
definition. department under the EMTALA serve as a vehicle to capture median
To determine whether visits to regulations in § 489.24 but that are not cost and resource differences among
emergency departments or facilities Type A emergency departments, as visits provided by Type A emergency
(referred to as Type B emergency described in Table 54 below. These departments, Type B emergency
departments) that incur EMTALA codes are called ‘‘Type B emergency departments, and clinics (71 FR 68132).
TABLE 54.—CY 2007 FINAL LEVEL II HCPCS CODES TO BE USED TO REPORT EMERGENCY DEPARTMENT VISITS
PROVIDED IN TYPE B EMERGENCY DEPARTMENTS
HCPCS Short descriptor Long descriptor
code
G0380 ...... Lev 1 hosp type B ED visit ........................................................... Level 1 hospital emergency department visit provided in a Type
B emergency department. (The ED must meet at least one of
the following requirements: (1) It is licensed by the State in
which it is located under applicable State law as an emer-
gency room or emergency department; (2) It is held out to the
public (by name, posted signs, advertising, or other means)
as a place that provides care for emergency medical condi-
tions on an urgent basis without requiring a previously sched-
uled appointment; or (3) During the calendar year immediately
preceding the calendar year in which a determination under
this section is being made, based on a representative sample
of patient visits that occurred during that calendar year, it pro-
vides at least one-third of all of its outpatient visits for the
treatment of emergency medical conditions on an urgent basis
without requiring a previously scheduled appointment).

TABLE 54.—CY 2007 FINAL LEVEL II HCPCS CODES TO BE USED TO REPORT EMERGENCY DEPARTMENT VISITS
PROVIDED IN TYPE B EMERGENCY DEPARTMENTS—Continued
HCPCS Short descriptor Long descriptor
code
For CY 2007, we assigned the five adjust their charges appropriately to emergency department visit E/M codes
new Type B emergency department visit reflect differences in Type A and Type listed in Table 49 above. Our intention
codes for services provided in a Type B B emergency departments. The OPPS was to allow hospital-based emergency
emergency department to the five rulemaking cycle for CY 2009 will be departments or facilities that were
newly-established Clinic Visit APCs, the first year that we will have cost data historically appropriately reporting CPT
0604, 0605, 0606, 0607, and 0608 (71 FR for these new Type B emergency emergency department visit E/M codes
68140). This payment policy for Type B department HCPCS codes available for to bill these new Type A emergency
emergency department visits is similar analysis. department visit codes. In the CY 2007
to our previous policy which required In the CY 2007 OPPS/ASC proposed OPP/ASC, final rule with comment
services furnished in emergency rule (71 FR 49609), we proposed to period (71 FR 68132), we postponed
departments that had an EMTALA create five G-codes to be reported by the finalizing G-codes to replace CPT codes
obligation but did not meet the CPT subset of provider-based emergency for Type A emergency department visits
definition of emergency department to departments or facilities of the hospital, until national guidelines are
be reported using CPT clinic visit E/M called Type A emergency departments, established, and stated that we would
codes, resulting in payments based that are available to provide services 24 again consider their possible utility
upon clinic visit APCs. As mentioned hours a day, 7 days per week and meet once the national guidelines are
above, CPT and CMS required an one or both of the following adopted. However, for CY 2007, we
emergency department to be open 24 requirements related to the EMTALA finalized the definition of Type A
hours per day in order for it to be definition of a dedicated emergency emergency departments to distinguish
eligible to bill emergency department department, specifically: (1) It is them from Type B emergency
E/M codes. While maintaining the same licensed by the State in which it is departments. For CY 2007 (71 FR
payment policy for Type B emergency located under the applicable State law 68140), we assigned the five CPT E/M
department visits in CY 2007, we as an emergency room or emergency emergency department visit codes for
believe the reporting of specific G-codes department; or (2) It is held out to the services provided in a Type A
for emergency department visits public (by name, posted signs, emergency departments to the five
provided in Type B emergency advertising, or other means) as a place newly-created Emergency Department
departments would permit us to that provides care for emergency Visit APCs, 0609, 0613, 0614, 0615, and
specifically collect and analyze the medical conditions on an urgent basis 0616.
hospital resource costs of visits to these without requiring a previously We believe that our distinction
facilities in order to determine in the scheduled appointment. These codes between Type A and Type B emergency
future whether a proposal of an were called ‘‘Type A emergency visit departments refined and clarified the
alternative payment policy might be codes’’ and were proposed to replace CPT definition of ‘‘emergency
warranted. We expected hospitals to hospitals’ reporting of the CPT department’’ for use in the hospital
context. As we have previously noted, because the main emergency department is assess separately identifiable areas
the CPT codes were defined to reflect available 24 hours a day. It may be individually for their status as Type A
the activities of physicians and do not appropriate for a Type A emergency or Type B emergency departments. We
department to ‘carve out’ portions of the
always describe well the range and mix emergency department that are not available
are interested specifically in comments
of services provided by hospitals during 24 hours a day, where visits would be more that describe how this policy could be
visits of emergency department patients. appropriately billed with Type B emergency further clarified in light of hospitals’
For example, one feature that department codes.’’ operational responsibility to efficiently
distinguishes Type A hospital In response to the questions we provide emergency services, holding
emergency departments from other received, we posted on the CMS Web constant the definitions that were
departments of the hospital is that Type site a ‘‘Frequently Asked Questions’’ list developed for CY 2007 and described
A emergency departments do not that described various examples of above. We do not believe a policy
generally provide scheduled care, but treating an emergency department as change in the reporting of these Type A
rather regularly operate to provide either a Type A emergency department and Type B emergency department
immediately available unscheduled or a Type B emergency department. In codes would be appropriate for CY
services. each case, the posted answer stated that 2008, in light of our desire to capture
We were pleased that the majority of hospitals should contact their fiscal consistent and accurate hospital cost
commenters to the CY 2007 OPPS/ASC intermediary to ensure that the fiscal data by HCPCS code for consideration
proposed rule agreed with our general intermediary and the hospital are in for the CY 2009 OPPS. For CY 2008, we
distinction between Type A and Type B agreement regarding the emergency are proposing that Type A emergency
emergency departments. We note that room status as either Type A or Type B. department visits would continue to be
after the publication of the CY 2007 The response to the posted examples paid based on the five Emergency
OPP/ASC final rule with comment has been positive and the number of Department Visit APCs, while Type B
period, numerous readers requested inquiries we are receiving has subsided. emergency department visits would
clarification about one paragraph that Notwithstanding our subsequent continue to be paid based on the five
appeared in that final rule. The clarification, we are not proposing to Clinic Visit APCs.
paragraph is reprinted below (71 FR modify the definitions of Type A or
68132). C. Proposed Visit Reporting Guidelines
Type B emergency departments for CY
‘‘We are aware that hospitals operate many 2008 because we believe that our 1. Background
types of facilities which they view in current definition accurately As described in section IX.A. of this
aggregate as an integrated healthcare system. distinguishes between these two types proposed rule, since April 7, 2000, we
For purposes of determining EMTALA
obligations, under § 489.24(b) of the
of emergency departments. While we have instructed hospitals to report
regulations, each hospital is evaluated will not know definitively until CY facility resources for clinic and
individually to determine its own particular 2009 how the costs of services provided emergency department outpatient
obligations. As we have discussed in Type A emergency departments differ hospital visits using the CPT E/M codes
previously, hospital facilities or departments from the costs of services provided in and to develop internal hospital
of the hospital that meet the definition of a Type B emergency departments, we guidelines for reporting the appropriate
dedicated emergency department consistent believe that our current distinction visit level.
with the EMTALA regulations may bill Type between Type A and B emergency During the January 2002 APC Panel
A emergency department codes (CPT
departments is appropriate and is most meeting, the APC Panel recommended
emergency department visit codes) or Type B
emergency department codes (HCPCS G- likely to capture any resource cost that CMS adopt the American College of
codes), depending on whether or not the differences between the two types of Emergency Physicians (ACEP)
dedicated emergency department meets the emergency departments. However, we intervention-based guidelines for
definition of a Type A emergency are specifically soliciting public facility coding of emergency department
department, which includes operating 24 comment regarding any additional visits and develop guidelines for clinic
hours per day, 7 days a week. For purposes operational clarifications that we could visits that are modeled on the ACEP
of determining whether to bill Type A or provide to assist hospitals in guidelines.
Type B emergency department codes, each In the August 9, 2002 OPPS proposed
determining whether an emergency
hospital must be evaluated individually and
should make a decision specific to each area department is considered to be Type A rule (67 FR 52133), we proposed 10 new
of the hospital to determine which codes or Type B. G-codes (Levels 1–5 Facility Emergency
would be appropriate. Where a hospital We specifically indicated for CY 2007 Services and Levels 1–5 Facility Clinic
maintains a separately identifiable area or that hospitals should individually Services) for use in the OPPS to report
part of a facility which does not operate on consider separately identifiable areas or hospital visits, with the goal of
the same schedule (that is, 24 hours per day, parts of facilities that did not operate on ultimately applying national guidelines
7 days a week) as its emergency department, the same schedule as the main to these codes and discontinuing the use
that area or facility would not be considered emergency department that was open 24 of CPT E/M codes under the OPPS. We
an integral part of the emergency department
that operates 24 hours per day, 7 days a week
hours a day, 7 days per week to also solicited public comments
for purposes of determining its emergency determine the appropriate codes for regarding national guidelines for
department type for reporting emergency reporting services provided in those hospital coding of emergency
visit services. Instead, the facility or area separately identifiable areas. Because department and clinic visits. We
would be evaluated separately to determine we consider the main distinguishing discussed different types of models,
whether it is a Type A emergency feature between Type A and Type B reflecting on the advantages and
department, Type B emergency department, emergency departments to be the full- disadvantages of each. We reviewed in
or clinic. We would expect the hospital time versus part-time availability of detail the considerations around various
providing services in such facilities or areas
to evaluate the status of those areas and bill
staffed areas for emergency medical discrete types of specific guidelines,
accordingly. In general, it is not appropriate care, not the process of care or the site including guidelines based on staff
to consider a satellite emergency department of care (on the hospital’s main campus interventions, based upon staff time
or an area of the emergency department as if or offsite), our final CY 2007 policy spent with the patient, based on
it were available 24 hours a day simply explained that hospitals needed to resource intensity point scoring, and
based on severity acuity point scoring Panel, comprised of members with Error Rate Testing (CERT) work. While
related to patient complexity. In that coding, health information management, a review of documentation and
proposed rule, we also stated that we documentation, billing, nursing, assignment of visit levels based on the
were concerned about counting finance, auditing, and medical modified AHA/AHIMA guidelines to
separately paid services (for example, experience. This panel included 12,500 clinic and emergency
intravenous infusions, x-rays, representatives from the AHA, AHIMA, department visits was initially planned,
electrocardiograms, and laboratory tests) ACEP, Emergency Nurses Association, the study was terminated after a pilot
as ‘‘interventions’’ or including their and American Organization of Nurse review of only 750 visits. The contractor
associated ‘‘staff time’’ in determining Executives. CMS and AMA identified a number of elements in the
the level of service. We believed that the representatives observed the meetings. guidelines that were difficult for coders
level of service should be determined by On June 24, 2003, the AHA and AHIMA to interpret, poorly defined, nonspecific,
resource consumption that is not submitted their recommended or regularly unavailable in the medical
otherwise captured in payments for guidelines, hereafter referred to as the records. The contractor’s coders were
other separately payable services. AHA/AHIMA guidelines, for reporting unable to determine any level for about
In response to comments, in the three levels of hospital clinic and 25 percent of the clinic cases and about
November 1, 2002 OPPS final rule (67 emergency department visits and a 20 percent of the emergency cases
FR 66793), we stated that we would not single level of critical care services to reviewed. The only agreement observed
create new codes to replace existing CMS, with the hope that CMS would between the levels reported on the
CPT E/M codes for reporting hospital publish the guidelines in the CY 2004 claims and levels according to the
visits until national guidelines are OPPS proposed rule. The AHA and modified AHA/AHIMA guidelines was
developed. We noted that an AHIMA acknowledged that ‘‘continued the classification of Level 1 services,
independent panel of experts would be refinement will be required as in all where the review supported the level on
an appropriate forum to develop codes coding systems. The Panel * * * looks the claims 54 to 70 percent of the time.
and guidelines that are simple to forward to working with CMS to In addition, the vast majority of the
understand and implement. We incorporate any recommendations clinic and emergency department visits
explained that organizations such as the raised during the public comment reviewed were assigned to Level 1
American Hospital Association (AHA) period’’ (AHA/AHIMA guidelines during the review. Based on these
and the American Health Information report, page 9). The AHA and AHIMA findings, we believed that it was not
Management Association (AHIMA) had indicated that the guidelines were field- necessary to review additional records
such expertise and would be capable of tested several times by panel members after the initial sample. The contractor
creating hospital visit guidelines and at different stages of their development. advised that multiple terms in the
providing ongoing provider education. The guidelines are based on an guidelines required clearer definition
We also articulated a set of principles intervention model, where the levels are and believed that more examples would
that any national guidelines for facility determined by the numbers and types of be helpful. Although we believe that all
visit coding should satisfy, including interventions performed by nursing or of the visit documentation for each case
that coding guidelines should be based ancillary hospital staff. Higher levels of was available for the contractor’s
on facility resources, should be clear to services are reported as the number and/ review, we were unable to determine
facilitate accurate payments and be or complexity of staff interventions definitively that this was the case. Thus,
usable for compliance purposes and increase. there is some possibility that the
audits, should meet HIPAA Although we did not publish the
contractor’s assignments would have
requirements, should only require guidelines, the AHA and AHIMA
differed if additional documentation
documentation that is clinically released the guidelines through their
from the medical records were available
necessary for patient care, and should Web sites. Consequently, we received
for the visits. In summary, while testing
not facilitate upcoding or gaming. We numerous comments from providers
of the modified AHA/AHIMA
stated that the distribution of codes and associations, some in favor and
guidelines was helpful in illuminating
reported for each type of hospital some opposed to the guidelines. We
areas of the guidelines that would
outpatient visit (clinic or emergency undertook a critical review of the
benefit from refinement, we were unable
department) should result in a normal recommendations from the AHA and
to draw conclusions about the
curve. We concluded that we believed AHIMA and made some modifications
the most appropriate forum for to the guidelines based on comments we relationship between the distribution of
development of code definitions and received from other hospitals and current hospital reporting of visits using
guidelines was an independent expert associations on the AHA/AHIMA CPT E/M codes that are assigned
panel that would make guidelines, clinical review, and according to each hospital’s internal
recommendations to CMS. changing payment policies under the guidelines and the distribution of codes
The AHA and AHIMA originally OPPS regarding some separately payable under the AHA/AHIMA guidelines, nor
supported the ACEP model for services. were we able to demonstrate a normal
emergency department visit coding. In an attempt to validate the modified distribution of visit levels under the
However, we expressed concern that the AHA/AHIMA guidelines and examine modified AHA/AHIMA guidelines. In
ACEP guidelines allowed counting of the distribution of services that would CY 2007, we posted to the CMS Web
separately payable services in result from their application to hospital site a summary of the contractor’s
determining a service level, which clinic and emergency department visits report.
could result in the double counting of paid under the OPPS, we contracted for Despite the inconclusive findings
hospital resources in establishing visit a study that began in September 2004 from the validation study, after
payment rates and payment rates for and concluded in September 2005 to reviewing the AHA/AHIMA guidelines,
those separately payable services. retrospectively code, under the as well as approximately a dozen other
Subsequently, on their own initiative, modified AHA/AHIMA guidelines, guidelines for outpatient visits
the AHA and AHIMA formed an hospital visits by reviewing hospital submitted by various hospitals and
independent expert panel, the Hospital visit medical chart documentation hospital associations, we stated in the
Evaluation and Management Coding gathered through the Comprehensive CY 2007 OPPS/ASC final rule with
comment period (71 FR 68141) that we guidelines and our modified draft hospital outpatient specialty clinics had
believed that the AHA/AHIMA version. already successfully implemented these
guidelines are the most appropriate and We continue to commit that we would as their internal guidelines, but
well-developed guidelines for use in the provide a minimum of 6 to 12 months requested that CMS designate them as
OPPS of which we are aware. Our notice to hospitals prior to the national wound care clinic
particular interest in these guidelines is implementation of national guidelines guidelines. One provider group tested
based upon the broad-based input into to provide sufficient time for providers several sets of guidelines that resembled
their development, the desire for CMS to make the necessary systems changes the ACEP model and compared the
to move to promulgate national and educate their staff. results across a set of hospitals. This
outpatient hospital visit coding 2. CY 2007 Work on Visit Guidelines provider group believes that an ACEP-
guidelines in the near future, and full type model would be the most
There are several areas of the AHA/ successful type of national guidelines,
consideration of the characteristics of AHIMA guidelines that we identified in
alternative types of guidelines. We also assuming that the guidelines were
the CY 2007 OPPS/ASC final rule with flexible in serving as a guide to visit
believe that hospitals would react comment period that would require
favorably to guidelines developed and level reporting. While using several
refinement and further input from the varieties of ACEP-type guidelines in
supported by the AHA and AHIMA, public prior to implementation as
national organizations that have great different hospitals, the group noted that
national guidelines. These areas include across hospitals a specific intervention
interest in hospital coding and payment the need for five rather than three levels
issues, and possess significant medical, was almost always assigned to the same
of codes for clinic and emergency clinic visit level. The group concluded
technical and practical expertise due to department visits to accommodate the
their broad membership, which that this indicated that the ACEP model
current five levels of OPPS payment; and its variations could likely be
includes hospitals and health clarification of documentation that
information management professionals. successfully implemented as national
would support certain interventions;
guidelines. Another association
Anecdotally, we have been told that a reconsideration of the inclusion of
reviewed and tested the CMS modified
number of hospitals are successfully separately payable services as proxies
AHA/AHIMA guidelines that were
utilizing the AHA/AHIMA guidelines to for hospital resources used in visits;
posted to the CMS Web site. This
report levels of hospital visits. However, examination of the valuing of certain
association found it cumbersome to
other organizations have expressed interventions; assessment of the need
assign the Level 2 and Level 4 Clinic
concern that the AHA/AHIMA for modifications to address the
Visit codes because those levels could
guidelines may result in a significant different clinical characteristics of
only be assigned when a certain number
redistribution of hospital visits to higher specialty clinic visits; consistency with
the Americans with Disabilities Act; of interventions and/or contributory
levels, reducing the ability of the OPPS
reevaluation of the way in which factors were performed. The association
to discriminate among the hospital suggested changes to the CMS modified
resources required for various different additional hospital resources required
for the treatment of new patients are AHA/AHIMA guidelines for ease of use
levels of visits. We, too, remain and application to specialty clinics,
concerned about the potential captured; and recommendations for
guidelines for the reporting of visits to particularly oncology clinics. One
redistributive effect on OPPS payments developer of national clinic and
for other services or among levels of Type B emergency departments.
We have had a number of meetings emergency department visit guidelines
hospital visits when national guidelines noted that many hospitals had
for outpatient visit coding are adopted. and discussions with interested
stakeholders over the past several successfully used the presenting
We recognize that there may be problem-based guidelines that it had
difficulty crosswalking historical months regarding the AHA/AHIMA
guidelines, the CMS modified draft created. The developer noted that its
hospital claims data from current CPT system was easy to use, produced
E/M codes reported based on individual version, the contractor pilot work to test
the guidelines, the concerns we consistent coding decisions resulting in
internal hospital guidelines to payments a normal distribution of visits, and even
identified in the CY 2007 OPPS/ASC
for any new coding system developed, served as a tool to track effectiveness
final rule, and alternative guidelines.
in order to provide appropriate payment and efficiency.
We are aware that the AHA and AHIMA
levels for hospital visits reported based
are having an ongoing dialogue with We appreciate the thoughtful
on national guidelines in the future.
members of their Hospital Evaluation information that has been provided to
There are several types of concerns and Management Coding Panel and us so far regarding hospitals’
with the AHA/AHIMA guidelines that reviewing their previously experiences and the insightful responses
have been identified based upon recommended model guidelines as well by the public to our concerns about the
extensive staff review and contractor as other models currently in use. We AHA/AHIMA model. We are currently
use of the guidelines during the have not received any additional actively engaged in evaluating and
validation study. We believe the AHA/ suggestions or modifications from the comparing various guideline models
AHIMA guidelines would require AHA and AHIMA to date. We have and suggestions that have been provided
refinement prior to their adoption by the received a number of new suggestions to us, and we continue to welcome
OPPS, as well as continued refinement for guidelines from other stakeholders, additional public input on this
over time after their implementation. including individual hospitals and important and complex area of the
Our modified version of the AHA/ associations, that have engaged in a OPPS. The public input we have
AHIMA guidelines provides some variety of data collection and pilot received continues to reflect a wide
possibilities for addressing certain application activities in preparing their variety of perspectives on the types and
issues. Our eight general areas of recommendations. For example, one content of the guidelines different
concern regarding the AHA/AHIMA wound care organization created and commenters recommend that we should
model are reviewed below. In addition, presented an independent model that implement nationally for the OPPS, and
we have posted to the CMS Web site could apply to certain specialty clinics. no single approach appears to be
both the original AHA/AHIMA The organization claimed that several broadly endorsed by the stakeholder
community. In addition, commenters various classes of hospitals. We include the five G-codes that describe
have described the successful analyzed frequency data from claims Type B emergency departments because
application of many types of internal with dates of service from March 1, they became effective January 1, 2007,
hospital guidelines with diverse 2002, through December 31, 2006, and we do not yet have a full year of
characteristics for the reporting of including those claims that were frequency data for those codes.
hospital clinic and emergency processed through December 31, 2006. The clinic visit data, displayed below
department visit levels that they believe To determine the national clinic visit in Figure 1, revealed a fairly normal
accurately capture the required hospital distribution, we reviewed frequency national distribution of clinic visits,
resources. data for each level of new patient visits, with the curve somewhat skewed to the
3. Proposed Visit Guidelines established patient visits, and left, consistent with our previous
We performed data analyses with the consultation codes. To determine the analysis of these data in CY 2002 (67 FR
goal of studying the current distribution national emergency department visit 66791). In addition, the visit
of each level of clinic and emergency distribution, we reviewed frequency distributions have been quite stable over
department visit codes billed nationally, data for the five CPT emergency the past 5 years.
as well as the distribution among department visit codes. We did not BILLING CODE 4120–01–P
The graph shown in Figure 1 how similar the annual distributions clinical care provided in HOPDs during
indicates that hospitals, on average, are appear from CY 2002 through CY 2006. these visits. Many Medicare patients are
billing all five levels of visit codes with We are not surprised that hospitals evaluated regularly in clinics by
varying frequency, in a consistent report a relatively high proportion of hospitals’ clinical staff to determine the
pattern over time. It is striking to note low level visits, given the typical status of their chronic medical
EP02AU07.000</GPH>
conditions and determine adjustments We also examined the billing patterns Level 4 and 5 visits. This too correlates
to treatment plans, and those visits may for various classes of hospitals, grouped well with our knowledge of the patient
frequently be reported as a low level by the hospital categories shown in the case-mix of large teaching hospitals,
visit if that is consistent with the impact table (Table 67) in section which tend to treat a higher proportion
hospital’s internal guidelines and fiscal XXII.B. of this proposed rule, to see how of very sick patients than nonteaching
intermediary instructions. Some the clinic visit distributions of levels hospitals. The distributions for urban
patients may receive minor services billed for these various categories and rural hospitals also closely
during low level visits that are not compared to the national distribution of resembled the national distribution,
described by more specific HCPCS clinic visit levels. For these including the rural SCH visit level
codes. We note that, in general, billing subcategories, we specifically focused
distribution. The smallest rural
a visit in addition to another service on the number of established patient
hospitals predictably reported a higher
merely because the patient interacted visits billed at each level. Generally, the
with hospital staff or spent time in a distribution for major teaching proportion of Level 1 and 2 visit codes
room for that service is inappropriate. If hospitals, minor teaching hospitals, and and a lower proportion of higher level
a visit and another service are both nonteaching hospitals looked visit codes, as compared to the national
billed, such as chemotherapy, a remarkably similar to the national average, consistent with their generally
diagnostic test, or a surgical procedure, distribution of established patient visits. lower case-mix severity.
the visit must be separately identifiable Nonteaching hospitals tended to bill a The national emergency department
from the other service because the greater proportion of Level 1 and 2 visit data, displayed below in Figure 2,
resources used to provide nonvisit patient visits as compared to major similarly revealed a normal national
services, including staff time, teaching hospitals, as would be distribution of emergency department
equipment, supplies, among others, are expected if their general patient acuity visit levels that was even more
captured in the line item for that was slightly lower. Nonteaching symmetrical than the national clinic
service. We believe that hospitals by hospitals include many community visit distribution. The national
and large are abiding by this guidance hospitals that treat a wide variety of distributions have been stable over the
because more than 90 percent of the CY patients, likely including a larger
past 5 years as well.
2006 claims for Level 1 established proportion of patients with minor
BILLING CODE 4120–01–P
patient visits available for this proposed ailments. Major teaching hospitals
rule are single claims. reported a slightly higher proportion of
BILLING CODE 4120–01–C proportions of Level 2 and 3 emergency These analyses are generally consistent
We also looked at various classes of department visits than the national with our understanding of the clinical
hospitals, grouped by the hospital average and slightly fewer Level 4 and and resource characteristics of different
categories that we show in the impact 5 visits. When subdividing rural levels of hospital outpatient clinic and
table (Table 67) in section XXII. of this hospitals into groupings based on size, emergency department visits.
proposed rule to see how the emergency the distribution for small, medium, and We specifically are inviting public
department visit distributions of levels large rural hospitals closely mirrored comment as to whether a pressing need
billed by hospitals in each of these the national average distribution. Large for national guidelines continues at this
various categories compared to the rural hospitals tended to report higher point in the maturation of the OPPS or
national distribution of emergency level emergency department visits than if the current system where hospitals
department visit levels. The emergency smaller rural hospitals. All of these create and apply their own internal
department visit distributions for major observations regarding the patterns of guidelines to report visits is currently
teaching hospitals, minor teaching reporting for rural hospitals are more practical and appropriately
hospitals, and nonteaching hospitals consistent with our expectations for care flexible for hospitals. Although we have
were almost identical to the national delivery of those hospitals. reiterated our goal since CY 2000 of
distribution of emergency department Overall, both the clinic and creating national guidelines, this
visits. No significant differences were emergency department visit complex undertaking for these
noted. The emergency department visit distributions indicate that hospitals are important and common hospital
distributions for urban and rural billing consistently over time and in a services is proving more challenging
hospitals also closely resembled the manner that distinguishes between visit than we initially thought as we receive
national distribution of emergency levels, resulting in relatively normal new and expanded information from the
department visits. Rural hospitals in the distributions nationally for the OPPS, as public on current hospital reporting
EP02AU07.001</GPH>
aggregate reported slightly higher well as for smaller classes of hospitals. practices that lead to appropriate
payment for the hospital resources • The coding guidelines should only public on visit guidelines, and we
associated with clinic and emergency require documentation that is clinically encourage continued submission of
department visits. Many hospitals have necessary for patient care (67 FR 66792). comments at any time that will assist us
worked diligently and carefully to • The coding guidelines should not and other stakeholders interested in the
develop and implement their own facilitate upcoding or gaming (67 FR development of national guidelines.
internal guidelines that reflect the scope 66792) Until national guidelines are
and types of services they provide We also are proposing the following established, hospitals should continue
throughout the hospital outpatient five additional principles that should using their own internal guidelines. We
system. Based on public comments, as apply to hospital specific guidelines, would not expect individual hospitals
well as our own knowledge of how based on our evolving understanding of to necessarily experience a normal
clinics operate, it seems unlikely that the important issues addressed by many distribution of visit levels across their
one set of straightforward national hospitals in developing their internal claims, although we would expect a
guidelines could apply to the reporting guidelines that now have been used for normal distribution across all hospitals
of visits in all hospitals and specialty a number of years. We believe it is as observed currently and as we would
clinics. In addition, the stable reasonable at this time to elaborate upon expect if national guidelines were
distribution of clinic and emergency the standards for hospitals’ internal implemented. We understand that,
department visits reported under the guidelines that we are proposing to based on different patterns of care, we
OPPS over the past several years apply in CY 2008, based on our could expect that a small community
indicates that hospitals, both nationally knowledge of hospitals’ experiences to hospital might provide more low level
in the aggregate and grouped by specific date with guidelines for visits. services than high level services, while
hospital classes, are generally billing in • The coding guidelines should be
an academic medical center or trauma
an appropriate and consistent manner as written or recorded, well-documented
center might provide more high level
we would expect in a system that and provide the basis for selection of a
services than low level services. We
accurately distinguishes among different specific code.
• The coding guidelines should be would also expect national guidelines to
levels of service based on the associated provide for five levels of coding, to
hospital resources. applied consistently across patients in
the clinic or emergency department to parallel the five payment levels that
Therefore, while we continue to currently exist.
evaluate the information and input we which they apply.
• The coding guidelines should not We hope to receive additional input
have received from the public during
change with great frequency. from stakeholders over the upcoming
CY 2007, as well as invite comments on • The coding guidelines should be
this proposed rule regarding the months to address whether there is a
readily available for fiscal intermediary definite contemporary need for national
necessity and feasibility of (or, if applicable, MAC) review.
implementing different types of national guidelines, given their potential to
• The coding guidelines should result redistribute payment under the OPPS
guidelines, we are not proposing to in coding decisions that could be
implement national visit guidelines for and the currently reassuring observed
verified by other hospital staff, as well patterns of OPPS visit services. While
clinic or emergency department visits as outside sources.
for CY 2008. Instead, hospitals will we understand the interest of some
We are inviting comment on these hospitals in our moving quickly to
continue to report visits during CY 2008 principles, specifically, whether
according to their own internal hospital promulgate national guidelines that will
hospitals’ guidelines currently meet ensure standardized reporting of
guidelines. these principles, how difficult it would
In the absence of national guidelines, outpatient hospital visit levels, we
be for hospitals’ guidelines to meet believe that the issues identified both by
we would continue to regularly these principles if they do not meet
reevaluate patterns of hospital us and others that may arise are
them already, and whether hospitals important and require serious
outpatient visit reporting at varying believe that certain standards should be
levels of disaggregation below the consideration prior to the
added or removed. We considered
national level to ensure that hospitals implementation of national guidelines.
stating that a hospital must use one set
continue to bill appropriately and Because of our commitment to provide
of emergency department visit
differentially for these services. In hospitals with 6–12 months notice prior
guidelines for all emergency
addition, we expect that hospitals’ to implementation of national
departments in the hospital, but thought
internal guidelines will comport with guidelines, we would not implement
that some departments that might be
the principles listed below. national guidelines prior to CY 2009.
considered emergency departments,
• The coding guidelines should Our goal is to ensure that OPPS national
such as the obstetrics department, may
follow the intent of the CPT code or hospital-specific visit guidelines
find it more practical and appropriate to
descriptor in that the guidelines should continue to facilitate consistent and
use a different set of guidelines than the
be designed to reasonably relate the general emergency department. accurate reporting of hospital outpatient
intensity of hospital resources to the Similarly, we find it possible that visits, in a manner that is resource-
different levels of effort represented by various specialty clinics in a hospital based and supportive of appropriate
the code (65 FR 18451). could have their own set of guidelines, OPPS payments for the efficient and
• The coding guidelines should be specific to the services offered in those effective provision of visits in hospital
based on hospital facility resources. The specialty clinics. However, if different outpatient settings.
guidelines should not be based on guidelines are implemented for different X. Proposed OPPS Payment for Blood
physician resources (67 FR 66792). clinics, hospitals should ensure that and Blood Products
• The coding guidelines should be these guidelines reflect comparable
clear to facilitate accurate payments and resource use at each level to the other (If you choose to comment on issues
be usable for compliance purposes and clinic guidelines that the hospital may in this section, please include the
audits (67 FR 66792). apply. caption ‘‘OPPS: Blood and Blood
• The coding guidelines should meet We appreciate all the comments we Products’’ at the beginning of your
the HIPAA requirements (67 FR 66792). have received in the past from the comment.)
A. Background used to adjust charges to costs for blood relatively stable, with a few significant
Since the implementation of the OPPS products in past years were too low. increases and decreases from the CY
in August 2000, separate payments have Past commenters indicated that this 2005 adjusted median costs for some
been made for blood and blood products approach resulted in an specific blood products. For the CY
through APCs rather than packaging underestimation of the true hospital 2006 OPPS, we adopted a payment
them into payments for the procedures costs for blood and blood products. In adjustment policy that limited
with which they were administered. response to these comments and the significant decreases in APC payment
Hospital payments for the costs of blood APC Panel recommendations from its rates for blood and blood products from
and blood products, as well as the costs February 2004 and September 2004 the CY 2005 OPPS to the CY 2006 OPPS
of collecting, processing, and storing meetings, we conducted a thorough to not more than 5 percent. We applied
analysis of the CY 2003 claims (used to this adjustment to 11 blood and blood
blood and blood products, are made
calculate the CY 2005 APC payment product APCs for the CY 2006 OPPS,
through the OPPS payments for specific
rates) to compare CCRs between those which we identified in Table 33 of the
blood product APCs. On April 12, 2001,
hospitals reporting a blood-specific cost CY 2006 OPPS final rule with comment
CMS issued the original billing
center and those hospitals defaulting to period (70 FR 68687). For the CY 2006
guidance for blood products to hospitals
the overall hospital CCR in the OPPS, we set the final median costs for
(Program Transmittal A–01–50). In
conversion of their blood product blood and blood products at the greater
response to requests for clarification of
charges to costs. As a result of this of: (1) The simulated median costs
these instructions, CMS issued Program
analysis, we observed a significant calculated from the CY 2004 claims
Transmittal 496 on March 4, 2005. The
difference in CCRs utilized for data; or (2) 95 percent of the CY 2005
comprehensive billing guidelines in conversion of blood product charges to OPPS adjusted median costs for these
Program Transmittal 496 also addressed costs for those hospitals with and products, as reflected in Table 33
specific concerns and issues related to without blood-specific cost centers. The published in the CY 2006 OPPS final
billing for blood-related services, which median hospital blood-specific CCR was rule with comment period.
the public had brought to our attention. almost two times the median overall In the CY 2007 OPPS, we established
In the CY 2000 OPPS, payments for hospital CCR. As discussed in the payment rates for blood and blood
blood and blood products were November 15, 2004 final rule with products by using the same simulation
established based on external data comment period, we applied a special methodology described in the November
provided by commenters due to limited methodology for hospitals not reporting 15, 2004 final rule with comment period
Medicare claims data. From the CY 2000 a blood-specific cost center, which (69 FR 65816), which utilizes hospital-
OPPS to the CY 2002 OPPS, payment simulated a blood-specific CCR for each specific actual or simulated CCRs for
rates for blood and blood products were hospital that we then used to convert blood cost centers to convert hospital
updated for inflation. For the CY 2003 charges to costs for blood products. charges for blood and blood products to
OPPS, as described in the November 1, Thus, we developed simulated medians costs. However, we provided a payment
2002 final rule with comment period (67 for all blood and blood products based transition for those blood products for
FR 66773), we applied a special on CY 2003 hospital claims data (69 FR which the difference between their CY
adjustment methodology to blood and 65816). 2006 adjusted median cost and their CY
blood products that had significant For the CY 2005 OPPS, we also 2007 simulated median cost was greater
reductions in payment rates from the CY identified a subset of blood products than 25 percent. Specifically, we set the
2002 OPPS to the CY 2003 OPPS, when that had less than 1,000 units billed in CY 2007 median costs upon which
median costs were first calculated from CY 2003. For these low-volume blood payments for blood and blood products
hospital claims. Using the adjustment products, we based the CY 2005 OPPS are based at the higher of the CY 2007
methodology, we limited the decrease in payment rate on a 50/50 blend of the CY unadjusted simulated median cost or 75
payment rates for blood and blood 2004 OPPS product-specific OPPS percent of the CY 2006 adjusted median
products to approximately 15 percent. median costs and the CY 2005 OPPS cost on which the CY 2006 payment is
For the CY 2004 OPPS, as recommended simulated medians based on the based.
by the APC Panel, we froze payment application of blood-specific CCRs to all
rates for blood and blood products at CY B. Proposed Payment for Blood and
claims. We were concerned that, given
2003 levels as we studied concerns Blood Products
the low frequency in which these
raised by commenters and presenters at products were billed, a few occurrences We are proposing to set the payment
the August 2003 and February 2004 of coding or billing errors may have led rates for blood and blood products for
APC Panel meetings. to significant variability in the median CY 2008 at the unadjusted median cost
For the CY 2005 OPPS, we established calculation. The claims data may not for these products, calculated using the
new APCs that allowed each blood have captured the complete costs of hospital specific simulated blood CCR
product to be assigned to its own these products to hospitals as fully as for each hospital that does not have a
separate APC, as several of the previous possible. This low-volume adjustment blood cost center. For this proposed
blood product APCs contained multiple methodology also allowed us to further rule, we calculated median costs for
blood products with no clinical study the issues raised by commenters blood and blood products using claims
homogeneity or whose product specific and by presenters at the September 2004 for services furnished on or after
median costs may not have been similar. APC Panel meeting, without putting January 1, 2006, and before January 1,
Some of the blood product HCPCS beneficiary access to these low volume 2007, and using the actual or simulated
codes were reassigned to the new APCs blood products at risk. We have adopted CCRs from the most recently available
(Table 34 of the November 15, 2004 the use of this modified CCR process for hospital cost reports. The median costs
final rule with comment period (69 FR calculating unadjusted median costs for derived from this data process are
65819)). blood and blood products each year relatively stable compared to the
We also noted in the November 15, since the CY 2005 OPPS. median costs on which payment is
2004 final rule with comment period Overall, median costs from CY 2003 based for CY 2007. (See Table 55
that public comments on previous OPPS (used for the CY 2005 OPPS) to CY 2004 below.) Of the 34 blood and blood
rules had stated that the CCRs that were (used for the CY 2006 OPPS) were products, median costs increase for 24
products and decline for 10 products reporting consistent with our detailed median costs for blood and blood
compared to the adjusted medians on blood billing guidelines issued in CY products decreased by more than 25
which payment is based in CY 2007. 2005. We are reassured by the relatively percent from the CY 2006 adjusted
Products with the largest declines are, stable or slightly increasing median median costs, was intended to provide
like the products with the greatest costs from CY 2005 to CY 2006 claims a reasonable transition to use of the
increases, mostly those products with data for most blood products, a pattern simulated median costs for payment of
low volume use in the hospital that we believe may reflect more blood and blood products under the
outpatient setting. The products whose accurate and complete hospital OPPS without further adjustment. The
costs decline more than 5 percent reporting and charging practices for medians that result from the use of the
account for less than 1 percent of the these products. Consistent with our simulated CCR process and the CY 2006
total volume of blood and blood billing guidelines, hospitals may now be claims generally result in median costs
products in the claims used to calculate taking into consideration all appropriate that we believe provide an appropriate
the proposed rates. No product’s median costs associated with providing blood basis for the relative weights on which
cost declines by more than 18 percent and blood products in charging for those the CY 2008 payments for blood and
in the proposed rule data, and thus no products under the OPPS. blood products would be based.
product shows a decline that would As we indicated in the CY 2007 Therefore, we are proposing to use the
have resulted in an adjustment under OPPS/ASC final rule with comment median costs derived from the
the final policy in place for CY 2007. period (71 FR 68147), we believe that application of blood cost center CCRs
The products whose median costs the simulated CCR methodology results for those hospitals that have blood cost
increase account for 79 percent of the in accurate reflections of the relative centers or simulated blood cost center
total volume of blood and blood estimated costs of these products for CCRs for those hospitals that do not
products in the claims used to calculate hospitals without blood cost centers have blood cost centers as the basis for
the proposed rates. We note that CY and, therefore, for these products in the CY 2008 payments for blood and
2006 claims are the first OPPS claims general. Our 1-year adjustment to the blood products without further
that represent a full year of hospitals’ median costs for CY 2007, where the adjustment.
TABLE 55.—PROPOSED CY 2008 MEDIAN COSTS FOR BLOOD AND BLOOD PRODUCTS
CY 2007 payment Difference between
Proposed median: higher of proposed CY 2008
CY 2008 CY 2007 OPPS simulated CCR me-
Proposed
HCPCS simulated simulated CCR median unit cost and
code* CCR median unit cost or CY 2007 adjusted
units dian unit 75% of CY 2006 simulated CCR me-
cost adjusted median dian unit cost (per-
unit cost cent)
P9010 .......... Whole blood for transfusion ........................................... 2,467 $279.14 $131.21 112.74%
P9011 .......... Blood split unit ............................................................... 288 133.59 136.42 ¥2.07
P9012 .......... Cryoprecipitate each unit ............................................... 4,941 43.05 48.31 ¥10.89
P9016 .......... RBC leukocytes reduced ............................................... 558,488 186.14 174.71 6.54
P9017 .......... Plasma 1 donor frz w/in 8 hr ......................................... 40,750 68.58 69.80 ¥1.75
P9019 .......... Platelets, each unit ........................................................ 18,466 68.15 58.61 16.28
P9020* ......... Plaelet rich plasma unit ................................................. 708 338.08 208.07 62.49
P9021 .......... Red blood cells unit ....................................................... 139,030 127.97 128.78 ¥0.63
P9022 .......... Washed red blood cells unit .......................................... 2,220 264.78 209.79 26.21
P9023* ......... Frozen plasma, pooled, sd ............................................ 343 75.37 57.11 31.97
P9031 .......... Platelets leukocytes reduced ......................................... 16,471 108.24 94.53 14.50
P9032 .......... Platelets, irradiated ........................................................ 8,889 130.48 128.81 1.30
P9033 .......... Platelets leukoreduced irrad .......................................... 4,401 127.57 124.60 2.38
P9034 .......... Platelets, pheresis .......................................................... 8,844 442.89 450.29 ¥1.64
P9035 .......... Platelet pheres leukoreduced ........................................ 44,607 502.95 485.89 3.51
P9036 .......... Platelet pheresis irradiated ............................................ 1,263 440.81 416.08 5.94
P9037 .......... Plate pheres leukoredu irrad ......................................... 22,378 631.62 613.39 2.97
P9038 .......... RBC irradiated ............................................................... 4,967 209.22 195.85 6.83
P9039 .......... RBC deglycerolized ....................................................... 831 364.46 356.22 2.31
P9040 .......... RBC leukoreduced irradiated ......................................... 69,722 240.24 216.29 11.07
P9043* ......... Plasma protein fract, 5%, 50ml ..................................... 21 90.53 50.96 77.67
P9044 .......... Cryoprecipitate reduced plasma .................................... 4,352 82.60 81.91 0.84
P9048* ......... Plasmaprotein fract, 5%, 250ml ..................................... 508 245.39 236.78 3.64
P9050* ......... Granulocytes, pheresis unit ........................................... 12 978.29 745.98 31.14
P9051* ......... Blood, l/r, cmv-neg ......................................................... 3,377 150.12 155.79 ¥3.64
P9052 .......... Platelets, hla-m, l/r, unit ................................................. 1,618 608.71 667.70 ¥8.83
P9053 .......... Plt, pher, l/r cmv-neg, irr ................................................ 1,437 678.13 701.26 ¥3.30
P9054 .......... Blood, l/r, froz/degly/wash .............................................. 584 210.86 209.82 0.50
P9055* ......... Plt, aph/pher, l/r, cmv-neg ............................................. 789 490.13 394.50 24.24
P9056 .......... Blood, l/r, irradiated ........................................................ 3,634 153.31 143.44 6.88
P9057 .......... RBC, frz/deg/wsh, l/r, irrad ............................................ 112 406.96 493.32 ¥17.51
P9058 .......... RBC, l/r, cmv-neg, irrad ................................................. 3,151 291.16 260.65 11.71
P9059 .......... Plasma, frz between 8–24hour ...................................... 2,820 78.35 76.32 2.66
P9060 .......... Fr frz plasma donor retested ......................................... 192 73.17 74.06 ¥1.20
*Indicates payment median for CY 2007 at 75 percent of the CY 2006 adjusted median.
XI. Proposed OPPS Payment for 2007 OPPS, meaning that the OPPS physicians that may take place after a
Observation Services claims processing logic determines physician has ordered the patient be
(If you choose to comment on issues whether the observation is packaged or released or admitted as an inpatient.
in this section, please include the separately payable. The OCE’s current 4. The number of units reported with
caption ‘‘OPPS: Observation Services’’ logic determines whether observation HCPCS code G0378 must equal or
at the beginning of your comment.) services billed under HCPCS code exceed 8 hours.
Observation care is a well-defined set G0378 is separately payable through
C. Additional Hospital Services
of specific, clinically appropriate APC 0339 (Observation), or whether
payment for observation services will be 1. The claim for observation services
services that include ongoing short-term
packaged into the payment for other must include one of the following
treatment, assessment, and reassessment
separately payable services provided by services in addition to the reported
before a decision can be made regarding
the hospital in the same encounter observation services. The additional
whether patients will require further
based on criteria discussed below. Also services listed below must have a line
treatment as hospital inpatients or if
since January 1, 2006, hospitals have item date of service on the same day or
they are able to be discharged from the
reported HCPCS code G0379 (Direct the day before the date reported for
hospital. Observation status is
admission of patient for hospital observation:
commonly assigned to patients with • An emergency department visit
unexpectedly prolonged recovery after observation care) for a direct admission
of a patient to observation care. The (APC 0609, 0613, 0614, 0615, or 0616);
surgery and to patients who present to or
the emergency department and who OPPS pays separately for that direct
admission reported under HCPCS code • A clinic visit (APC 0604, 0605,
then require a significant period of 0606, 0607, or 0608); or
treatment or monitoring before a G0379 in situations where payment for
the actual observation services reported • Critical care (APC 0617); or
decision is made concerning their next • Direct admission to observation
placement. under HCPCS G0378 are packaged and
where the direct admission meets reported with HCPCS code G0379 (APC
Payment for all observation care 0604).
under the OPPS was packaged prior to certain other criteria. The OCE logic
determines when HCPCS code G0379 is 2. No procedure with a ‘‘T’’ status
CY 2002. Since CY 2002, separate indicator can be reported on the same
payment of a single unit of an separately payable under the OPPS.
For CY 2007, we continued to apply day or day before observation care is
observation APC for an episode of provided.
observation care has been provided in the criteria for separate payment for
limited circumstances. Effective for observation care and the coding and D. Physician Evaluation
services furnished on or after April 1, payment methodology for observation
care that were implemented in CY 2006. 1. The beneficiary must be in the care
2002, separate payment for observation of a physician during the period of
was made if the beneficiary had chest Observation care is reported using
HCPCS code G0378 and observation that observation, as documented in the
pain, asthma, or congestive heart failure medical record by admission, discharge,
and met additional criteria for meets the criteria for separate payment
maps to APC 0339 (Observation). The and other appropriate progress notes
diagnostic testing, minimum and that are timed, written, and signed by
maximum limits to observation care current criteria for separate payment for
observation (APC 0339) are: the physician.
time, physician care, and 2. The medical record must include
documentation in the medical record A. Diagnosis Requirements documentation that the physician
(66 FR 59879). Payment for observation 1. The beneficiary must have one of explicitly assessed patient risk to
care that did not meet these specified three medical conditions: congestive determine that the beneficiary would
criteria was packaged. Between CY 2003 heart failure (CHF), chest pain, or benefit from observation care.
and CY 2006, several more changes asthma. The CY 2007 list of diagnoses eligible
were made to the OPPS policy regarding 2. Qualifying ICD–9–CM diagnosis as a criterion for separate payment for
separate payment for observation care, codes must be reported in Form Locator observation services may be found in
such as: clarification that observation is (FL) 76, Patient Reason for Visit, or FL Table 44 of the CY 2007 OPPS/ASC
not separately payable when billed with 67, principal diagnosis, or both in order final rule with comment period (71 FR
‘‘T’’ status procedures on the day of or for the hospital to receive separate 68152).
day before observation care; payment for APC 0339. If a qualifying For CY 2007, we made one minor
development of specific Level II HCPCS ICD–9–CM diagnosis code(s) is reported change in payment for direct admission
codes for hospital observation care and in the secondary diagnosis field, but is to observation. As part of the changes in
direct admission to observation care; not reported in either the Patient Reason APC assignments and payments for
and removal of the initially established for Visit field (FL 76) or in the principal clinic and emergency department visits,
diagnostic testing requirements for diagnosis field (FL 67), separate low level clinic visits were moved from
separately payable observation (67 FR payment for APC 0339 is not allowed. APC 0600 (Low Level Clinic Visits) to
66794, 69 FR 65828, and 70 FR 68688). APC 0604 (Level 1 Clinic Visits), with
Throughout this time period, we B. Observation Time a CY 2007 payment rate of $50.66.
maintained separate payment for 1. Observation time must be Under the circumstances where direct
observation care only for the three documented in the medical record. admission to observation is separately
specified medical conditions, and OPPS 2. A beneficiary’s time in observation payable, we finalized our CY 2007
payment for observation for all other (and hospital billing) begins with the assignment of HCPCS code G0379 to
clinical conditions remained packaged. beneficiary’s admission to an APC 0604, consistent with its CY 2006
Since January 1, 2006, hospitals have observation bed. placement in the APC for Low Level
reported observation services based on 3. A beneficiary’s time in observation Clinic Visits.
an hourly unit of care using HCPCS (and hospital billing) ends when all During the APC Panel’s August 2006
code G0378 (Hospital observation clinical or medical interventions have meeting, the Observation Subcommittee
services, per hour). This code has a been completed, including followup made several recommendations
status indicator of ‘‘Q’’ under the CY care furnished by hospital staff and regarding observation services. The first
of these was that CMS should consider dehydration to the current diagnoses dependent HOPD services, we are not
adding syncope and dehydration as eligible for separate payment would be accepting the Panel’s recommendation
diagnoses for which observation to lower the median for APC 0339 related to adding syncope and
services would qualify for separate slightly to $443, using the early partial dehydration to the list of diagnoses
payment. Second, the Observation 2006 data presented to the eligible for separate payment or to
Subcommittee recommended that CMS Subcommittee and Panel. For the study consider other clinical conditions for
perform claims analyses and present of ‘‘T’’ status procedures in relation to separate payment for observation care.
data that would allow CMS to consider observation, we identified relatively few We are proposing to package all
revising criteria for separately payable instances (5,162) where observation met observation services (reported with
observation care when certain all of the criteria for separate payment, HCPCS code G0378) as part of the
procedures that are assigned status including the current three conditions proposed changes to packaged services
indicator ‘‘T,’’ for example, insertion of of CHF, asthma, chest pain, except for discussed previously in section II.A.4.
a bladder catheter or laceration repair, the presence of a ‘‘T’’ status procedure. of this proposed rule. Because we are
are reported on the same claim with an Of these claims, very few had any proposing to package payment for all
emergency department visit and significant frequency. The most observation services, we are not
observation care, and all other criteria common procedures are those relating proposing to adopt the Panel’s
for separate observation payment (for to heart catheterization, angioplasty recommendation to study claims data
example, qualifying diagnosis code, procedures, and endoscopies. As we for separately payable observation care
number of hours) are met. The Panel have stated in the past, we believe that (including claims for observation for
also voted to change the name of the the observation services in these cases syncope and dehydration) that also
Observation Subcommittee to the may be related to these procedures and include specific minor or routine
Observation and Visit Subcommittee, we have no way of discerning from our procedures that have ‘‘T’’ status
based on the Panel’s interest in data whether the procedure happened indicators. We agree with the APC Panel
expanding the scope of that before or after the observation services. and the IOM that there is currently no
subcommittee’s work. The APC Panel made three compelling rationale for a different
In response to August 2006 APC Panel recommendations related to these OPPS payment approach for observation
recommendations and public comments topics. First, the Panel recommended care for only three specific clinical
to the CY 2007 proposed rule, we stated that CMS add syncope and dehydration conditions. We recognize that
in the CY 2007 OPPS/ASC final rule to the list of clinical conditions eligible observation care may play an important
with comment period that we intended for separate observation payment. role in the treatment of many Medicare
to perform a series of analyses over the Second, the Panel recommended that beneficiaries in the HOPD, decreasing
upcoming year to explore the potential CMS continue to evaluate the types of the need for short inpatient admissions
effects of adding syncope and diagnostic conditions that might qualify and ensuring safe discharges of patients
dehydration as qualifying diagnoses for for separate observation payment in the to their homes. Therefore, we believe
separately payable observation care, as future. Third, the Panel recommended that our proposed CY 2008 payment
well as the possibility of allowing that CMS make no changes to the policy that would package payment for
separate observation payment for claims criteria for separate observation all observation services consistently for
for observation care that also include payment related to the performance of Medicare beneficiaries regardless of
specific minor or routine procedures ‘‘T’’ status procedures. However, the their diagnoses is the most appropriate
that have ‘‘T’’ status indicators (71 FR Panel added that if CMS added syncope approach in every case of observation
68150). and dehydration to the list of conditions care. This proposed methodology
At the March 2007 meeting of the eligible for separate observation encourages hospital efficiency and
APC Panel, we discussed with the payment, the Panel requested that CMS provides a consistent payment policy
Observation and Visit Subcommittee reexamine the claims data once CMS that allows hospitals to thoughtfully
and the full Panel the results of the collects a year of observation claims plan for the role of observation services
requested data analyses regarding data, including the additional in the emergency and postsurgical care
syncope and dehydration, as well as the conditions, so the Panel could of patients with many different clinical
occurrences of claims for observation reconsider this recommendation at a conditions.
care that also include specific minor or future meeting. As discussed in section II.A.4. of this
routine procedures that have ‘‘T’’ status We have also taken into consideration proposed rule, observation care is one of
indicators. With respect to the diagnosis the June 2006 IOM Report entitled, seven categories of services for which
analyses, the data presented to the ‘‘Hospital-Based Emergency Care: At the we are proposing to make packaged
Subcommittee and Panel (consisting of Breaking Point.’’ This report encourages payment in CY 2008. In view of the
partial year 2006 claims data that are hospitals to apply tools to improve the recent rapid growth in HOPD services,
less complete than the claims data flow of patients through emergency we are proposing to move toward larger
available for this proposed rule) showed departments, especially through the use payment packages and bundles under
that there were 136,977 claims for of observation units (clinical decision the OPPS because we believe that
separately payable observation services units). The IOM report also recommends packaging creates incentives for
for the currently eligible conditions of that separate OPPS payment should be providers to furnish services in the most
chest pain, asthma, and congestive heart made for all conditions for which efficient way by maximizing their
failure, with a median cost of $453. The observation is indicated. flexibility to manage their resources,
frequency of claims for observation We appreciate the continued work thereby encouraging cost containment.
services for the diagnoses of syncope and dedication of the Observation and A detailed discussion of this proposal
and dehydration, when all other criteria Visit Subcommittee and the APC Panel, and our rationale for packaging
for separate payment of observation along with the findings and observation care may be found in the
services (other than diagnosis) were recommendations of the IOM. However, section referenced above.
met, was 46,961 claims, with a in light of the broader CY 2008 OPPS We are proposing to package
somewhat lower median cost of $416. proposal to move toward expanded observation care reported with HCPCS
The effect of adding both syncope and packaging of payment for supportive, code G0378 for CY 2008 because the
facility portion of observation care is payment methodology for direct this requirement would no longer be
supportive and ancillary to other admission to observation, with the applicable).
primary services being furnished in the exception of the prior requirement that
XII. Proposed Procedures That Will Be
HOPD. Payment for observation will be HCPCS code G0379 is only eligible for
Paid Only as Inpatient Procedures
made as part of the payment for the separate payment if observation care
separately payable independent services reported with HCPCS code G0378 does (If you choose to comment on issues
with which it is billed. As part of this not qualify for separate payment. That in this section, please include the
proposal, we would change the status requirement would no longer be caption ‘‘OPPS: Inpatient Procedures’’ at
indicator for HCPCS code G0378 from applicable, given our CY 2008 proposal the beginning of your comment.)
‘‘Q’’ to ‘‘N.’’ Although we would to provide packaged payment for all
observation care. Hospitals report A. Background
discontinue recognizing the criteria for
separate payment related to hospital HCPCS code G0379 when a patient is Section 1833(t)(1)(B)(i) of the Act
visits and qualifying conditions, we admitted directly to observation care gives the Secretary broad authority to
would retain as general reporting after being seen by a physician in the determine the services to be covered
requirements the criteria related to community. Thus, for CY 2008, we are and paid for under the OPPS. Before
physician evaluation, documentation proposing that in order to receive implementation of the OPPS in August
and observation beginning and ending separate payment for a direct admission 2000, Medicare paid reasonable costs for
time because those are more general into observation (APC 00604), the claim services provided in the outpatient
requirements that help to ensure proper must show: department. The claims submitted were
reporting of observation on hospital 1. Both HCPCS codes G0378 (Hospital subject to medical review by the fiscal
claims. The criteria for reporting of observation services, per hr) and G0379 intermediaries to determine the
observation services under HCPCS code (Direct admission of patient for hospital appropriateness of providing certain
G0378 that we are proposing to retain observation care) with the same date of services in the outpatient setting. We
are: service. did not specify in regulations those
2. That no services with a status services that were appropriate to
A. Observation Time indicator ‘‘T’’ or ‘‘V’’ or Critical Care provide only in the inpatient setting and
1. Observation time must be (APC 0617) were provided on the same that, therefore, should be payable only
documented in the medical record. day of service as HCPCS code G0379. when provided in that setting.
2. A beneficiary’s time in observation Even though we are proposing to
In the April 7, 2000 final rule with
(and hospital billing) begins with the package payment for all observation
comment period, we identified
beneficiary’s admission to an services reported by HCPCS code
procedures that are typically provided
observation bed. G0378, we believe it is necessary to
only in an inpatient setting and,
3. A beneficiary’s time in observation continue the OCE claims processing
therefore, would not be paid by
(and hospital billing) ends when all logic in order to make appropriate
Medicare under the OPPS (65 FR
clinical or medical interventions have payment for direct admission.
In summary, we are proposing to 18455). These procedures comprise
been completed, including followup what is referred to as the ‘‘inpatient
care furnished by hospital staff and package payment for observation care
reported with HCPCS code G0378 for list.’’ The inpatient list specifies those
physicians that may take place after a services that are only paid when
physician has ordered the patient be CY 2008. Payment for observation
would be made as part of the payment provided in an inpatient setting because
released or admitted as an inpatient. of the nature of the procedure, the need
for the separately payable independent
B. Physician Evaluation services with which it is billed. As part for at least 24 hours of postoperative
of this proposal, we would change the recovery time or monitoring before the
1. The beneficiary must be in the care
status indicator for HCPCS Code G0378 patient can be safely discharged, or the
of a physician during the period of
from ‘‘Q’’ to ‘‘N.’’ In addition, we would underlying physical condition of the
observation, as documented in the
discontinue recognizing the criteria for patient. As we discussed in the April 7,
medical record by admission, discharge,
separate payment related to hospital 2000 final rule with comment period (65
and other appropriate progress notes
visits and ‘‘T’’ status procedures, FR 18455) and the November 30, 2001
that are timed, written, and signed by
minimum number of hours, and final rule (66 FR 59856), we use the
the physician.
2. The medical record must include qualifying diagnoses. However, we following criteria when reviewing
documentation that the physician would retain as general requirements procedures to determine whether or not
explicitly assessed patient risk to the criteria related to physician they should be moved from the
determine that the beneficiary would evaluation, documentation, and inpatient list and assigned to an APC
benefit from observation care. observation beginning and ending time. group for payment under the OPPS:
We refer readers to section II.A.4. of Those are more general requirements • Most outpatient departments are
this proposed rule for further detailed that ensure the proper reporting of equipped to provide the services to the
background on our proposal to package observation care on correctly coded Medicare population.
these seven categories of services and hospital claims that reflect the charges • The simplest procedure described
for a specific discussion of observation associated with all hospital resources by the code may be performed in most
services. utilized to provide the reported services. outpatient departments.
Direct admission to observation We are proposing to continue the coding • The procedure is related to codes
(HCPCS code G0379, Direct admission and payment methodology for direct that we have already removed from the
of patient for hospital observation care) admission to observation status, as inpatient list.
is assigned to APC 0604 (Level 1 reported using HCPCS code G0379, with In the November 1, 2002 final rule
Hospital Clinic Visits) when the criteria the exception of the prior requirement with comment period (67 FR 66741), we
are met for separate payment. For CY that HCPCS code G0379 is only eligible added the following criteria for use in
2008, the proposed median cost of APC for separate payment if observation care reviewing procedures to determine
0604 is $52.58. We are proposing to reported under HCPCS code G0378 does whether they should be removed from
continue the current coding and not qualify for separate payment (since the inpatient list and assigned to an
APC group for payment under the on the inpatient list that are being specifically CPT code 64818
OPPS: widely performed on an outpatient (Sympathectomy, lumbar); and for
• We have determined that the basis. These procedures were then another procedure presented for
procedure is being performed in clinically reviewed for possible removal possible removal from the OPPS
numerous hospitals on an outpatient from the inpatient list. We solicited inpatient list by the public, specifically,
basis; or input from the APC Panel on the CPT code 20660 (Application of cranial
• We have determined that the appropriateness of removing 14 tongs caliper, or stereotactic frame,
procedure can be appropriately and procedures from the OPPS inpatient list including removal (separate
safely performed in an ASC and is on at its March 2007 meeting. Prior to procedure)). The APC Panel requested
the list of approved ASC procedures or publishing this OPPS proposed rule, we that CMS provide that additional
proposed by us for addition to the ASC received one other candidate HCPCS information to the APC Panel at its next
list. code for removal from the OPPS meeting.
We believe that these additional inpatient list based on a Therefore, we are proposing to accept
criteria help us to identify procedures recommendation from the public that the APC Panel’s recommendation to
that are appropriate for removal from was presented to the APC Panel during remove the 13 procedures from the
the inpatient list. its meeting on March 8, 2007. The APC OPPS inpatient list for CY 2008 and to
Panel recommended that 13 of the 14 assign them to clinically appropriate
B. Proposed Changes to the Inpatient procedures that CMS identified for APCs as shown in Table 56. We also are
List possible removal be removed from the accepting the recommendation from the
For the CY 2008 OPPS, we used the OPPS inpatient list. It also APC Panel to gather additional
same methodology as described in the recommended that CMS obtain utilization information for CPT codes
November 15, 2004 final rule with additional utilization data about 1 of the 20660 and 64818, which we will
comment period (69 FR 65835) to 14 procedures identified for possible provide to the APC Panel at its next
identify a subset of procedures currently removal from the OPPS inpatient list, meeting.
TABLE 56.—PROPOSED HCPCS CODES FOR REMOVAL FROM INPATIENT LIST AND THEIR PROPOSED APC ASSIGNMENTS
FOR CY 2008
Proposed Proposed
HCPCS code Long descriptor CY 2008 CY 2008
APC SI
21360 .......... Open treatment of depressed malar fracture, including zygomatic arch and malar tripod ................... 0254 T
21365 .......... Open treatment of complicated (eg, comminuted or involving cranial nerve foramina) fracture(s) of 0256 T
malar area, including zygomatic arch and malar tripod; with internal fixation and multiple surgical
approaches.
21385 .......... Open treatment of orbital floor blowout fracture; transantral approach (Caldwell-Luc type operation) 0256 T
25931 .......... Transmetacarpal amputation; re-amputation ......................................................................................... 0049 T
27006 .......... Tenotomy, abductors and/or extensor(s) of hip, open (separate procedure) ....................................... 0050 T
27720 .......... Repair of nonunion or malunion, tibia; without graft, (eg, compression technique) ............................. 0063 T
27722 .......... Repair of nonunion or malunion, tibia; with sliding graft ....................................................................... 0064 T
50580 .......... Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation or 0161 T
ureteropyelography, exclusive of radiologic service; with removal of foreign body or calculus.
51535 .......... Cystotomy for excision, incision, or repair of ureterocele ..................................................................... 0162 T
58805 .......... Drainage of ovarian cyst(s), unilateral or bilateral, (separate procedure); abdominal approach .......... 0195 T
60271 .......... Thyroidectomy, including substernal thyroid; cervical approach ........................................................... 0256 T
61770 .......... Stereotactic localization, including burr hole(s), with insertion of catheter(s) or probe(s) for place- 0221 T
ment of radiation source.
69970 .......... Removal of tumor, temporal bone ......................................................................................................... 0256 T
XIII. Proposed Nonrecurring Technical based rules as stated in § 413.65 of the through 50096 and 50114 through
and Policy Changes regulations. We are proposing to remove 50118). This proposed deletion of the
from both paragraphs (a)(1)(iii) and (f) reference in §§ 410.27(a)(1)(iii) and (f) to
A. Outpatient Hospital Services and
the phrase ‘‘at a location (other than an CMS ‘‘designating’’ a department of a
Supplies Incident to a Physician Service
RHC or an FQHC) that CMS designates provider under § 413.65 would make
(If you choose to comment on issues as a department of a provider under those sections consistent with the 2002
in this section, please include the § 413.65 of this chapter’’ and replace it amendments to the provider-based
caption ‘‘Hospital Services Incident to a with ‘‘at a department of a provider, as rules, in that under the amended
Physician Service’’ at the beginning of defined in § 413.65(a)(2) of this provider-based rules, a main provider is
your comment.) subchapter, that has provider-based no longer required to ask CMS to make
We are proposing to make a technical status in relation to a hospital under a determination that a facility or
change to §§ 410.27(a)(1)(iii) and (f) of § 413.65 of this subchapter.’’ organization is provider-based before
the regulations relating to outpatient Section 410.27 was codified in the the main provider can bill for services
hospital services and supplies incident April 7, 2000 OPPS final rule with of the facility as if the facility were
to a physician service to remove an comment period. The provider based provider-based, or before the main
outdated reference to ‘‘designation of a rules at § 413.65 were also codified in provider can include the costs of those
department of a provider’’ by CMS and the April 7, 2000 rule, but were services in its cost report.
replace it with language that conforms subsequently amended in the August 1, We also remind hospitals of the
to current policy under the provider 2002 IPPS final rule (67 FR 50078 requirements of § 410.27 concerning
services and supplies furnished incident such that a Medicare-certified ASC conforming changes to paragraphs (b)(1)
to a physician’s service to hospital would be able to provide ‘‘incident to’’ and (b)(2) by removing the words
outpatients. Section 410.27 applies to services under arrangement to hospital ‘‘surgical’’ to encompass all the
all ‘‘incident to’’ services covered under outpatients under § 410.27. Section procedures performed in HOPDs.
section 1861(s)(2)(B) of the Act. This 410.27 contains longstanding policy Finally, we are proposing to add a new
provision does not apply to services codified in the CY 2000 OPPS final rule paragraph (b)(3) to reflect the current
covered under other benefit categories, with comment period and applies to all policy of the application of a 50-percent
such as clinical diagnostic laboratory ‘‘incident to’’ services covered under reduction to the OPPS payment when a
services covered under section section1861(s)(2)(B) of the Act. While hospital reports modifier 52 for
1833(h)(1) of the Act or diagnostic the hypothetical example we discussed interrupted or discontinued services
services covered under section above involves ASCs providing services that do not require anesthesia.
1861(s)(2)(C) of the Act. Section under arrangement to an HOPD, the
C. Transitional Adjustments—Hold
410.27(a)(1) currently states that provision of § 410.27 applies more
Harmless Provisions
Medicare Part B pays for hospital broadly to all ‘‘incident to’’ services
services and supplies furnished incident provided either directly or under (If you choose to comment on issues
to a physician service to outpatients, arrangements made by the hospital with in this section, please include the
including drugs and biologicals that another entity. caption ‘‘Transitional Adjustments—
cannot be self-administered, if they are Hold Harmless:’’ at the beginning of
B. Interrupted Procedures your comment.)
furnished by or under arrangements
made by a participating hospital, except (If you choose to comment on issues Section 419.70(d) of the regulations
in the case of a resident of a skilled in this section, please include the relating to transitional adjustments to
nursing facility as provided in caption ‘‘Interrupted Procedures’’ at the payments for covered outpatient
§ 411.15(p); as an integral though beginning of your comment.) services furnished by small rural
incidental part of a physician’s services; Currently, when a procedure is hospitals and SCHs located in rural
and in the hospital or at a location interrupted after its initiation or the areas contains two outdated cross-
(other than a rural health clinic or a administration of anesthesia, hospitals references to § 412.63(b) (the definition
Federally qualified health center) that append modifier 74 (Discontinued of a hospital located in a ‘‘rural area’’).
CMS designates as a department of a outpatient procedure after anesthesia Several years ago, we made § 412.63
provider under § 413.65. administration) to the interrupted applicable from FY 1984 through FY
We recognize that hospitals consider procedure, and the full OPPS payment 2004 and established a new § 412.64,
a variety of business models in their for the procedure is made. In addition, effective for FY 2005 and subsequent
efforts to supply efficient and high when a procedure requiring anesthesia fiscal years, to incorporate provisions to
quality health care services to Medicare is discontinued after the beneficiary is reflect our adoption of OMB’s revised
beneficiaries and the general public, and prepared for the procedure and taken to CBSAs as geographic area applicable
we support such efforts to the extent the room where the procedure is to be under Medicare. We are proposing to
that they comply with all applicable performed, but before the make a technical correction to the
laws and regulations, including, but not administration of anesthesia, hospitals regulations by replacing the cross-
limited to, the Stark law and other anti- currently append modifier 73 reference to § 412.63(b) in
kickback laws. Recently, we have (Discontinued outpatient procedure §§ 419.70(d)(1)(i), (d)(2)(i), and (d)(4)(ii)
received an increasing number of prior to anesthesia administration) to with the more current applicable cross-
questions about a number of the discontinued procedure and receive reference to § 412.64(b).
hypothetical business arrangements 50 percent of the OPPS payment for the
planned procedure. Hospitals also D. Reporting of Wound Care Services
between hospitals and other entities,
including ASCs. We remind hospitals report modifier 52 to signify that a (If you choose to comment on issues
contemplating various business models service that did not require anesthesia in this section, please include the
that involve ‘‘incident to’’ services was partially reduced or discontinued at caption ‘‘Wound Care Services’’ at the
provided to hospital outpatients to the physician’s discretion. Modifier 52 beginning of your comment.)
consider the requirements of § 410.27. is reported under the OPPS for a variety Section 1834(k) of the Act, as added
Under § 410.27, ‘‘incident to’’ services of types of interrupted services, such as by section 4541 of the BBA, requires
that are provided to hospital outpatients radiology services. Under the OPPS, we payment under a prospective payment
must be furnished in the hospital or at apply a 50-percent reduction to the system for all outpatient therapy
a department of a provider as described facility payment for interrupted services, that is, physical therapy
in more detail earlier in our proposed procedures and services reported with services, speech-language pathology
technical update to §§ 410.27(a)(1)(iii) modifier 52. services, and occupational therapy
and (f). We are proposing to amend § 419.44 services. As provided under section
With regard to potential for ASCs to (Payment reductions for surgical 1834(k)(5) of the Act, we created a
provide ‘‘incident to’’ services under procedures) to more accurately reflect therapy code list based on a uniform
arrangements with HOPDs, we note that the current OPPS payment policy for coding system (that is, the HCPCS) to
the provider-based rules set forth at interrupted procedures. First, we are identify and track these outpatient
§ 413.65 do not apply to ASCs. In proposing to make a technical therapy services paid under the MPFS.
addition, our longstanding policy conforming change to the title of We provide this list of therapy codes
codified at § 416.30(f) for ASCs operated § 419.44 by removing the word along with their respective designation
by hospitals requires that ‘‘the ASC ‘‘surgical,’’ in order to encompass all the in the Medicare Claims Processing
participates and is paid only as an ASC, procedures performed in HOPDs. Manual Pub. 100–04, Chapter 5, section
without the option of converting to or Second, we are proposing to change the 20. Two of the designations that we use
being paid as a hospital outpatient heading of § 419.44(b) from in that manual denote whether the
department, unless CMS determines ‘‘Terminated procedures’’ to listed therapy code is an ‘‘always
there is good cause to do otherwise.’’ ‘‘Interrupted procedures.’’ We are therapy’’ service or a ‘‘sometimes
We do not believe good cause exists proposing to make further technical therapy’’ service. We define an ‘‘always
therapy’’ service as a service that must for physical therapy, GO for Services’’ at the beginning of your
be performed by a qualified therapist occupational therapy, and GN for comment.)
under a certified therapy plan of care, speech language pathology) or report Since the initiation of the OPPS,
and a ‘‘sometimes therapy’’ service as a their charges under a therapy revenue Medicare has paid for cardiac
service that may be performed by an code (that is, 0420, 0430, or 0440), or rehabilitation services in HOPDs using
individual outside of a certified therapy both, to receive payment under the CPT code 93797 (Physician services for
plan of care. MPFS. The OCE logic assigns these outpatient cardiac rehabilitation,
In the CY 2006 OPPS final rule with services to the appropriate APC for without continuous ECG monitoring
comment period (70 FR 68617), we payment under the OPPS if the services (per session)) and CPT code 93798
stated that the following CPT codes are not provided under a certified (Physician services for outpatient
were classified as ‘‘sometimes therapy’’ therapy plan of care, or will direct cardiac rehabilitation, with continuous
services that may be appropriately contractors to the MPFS established ECG monitoring (per session)). Both
provided under either a certified payment rates if the services are codes are assigned to status indicator
therapy plan of care or without a identified on hospital claims with a ‘‘S’’ and are currently mapped to APC
certified therapy plan of care: 97597 therapy modifier or therapy revenue 0095 (Cardiac Rehabilitation) for
(Removal of devitalized tissue from code as therapy services. payment.
For CY 2008, we are proposing to For CY 2008, we are proposing to
wound(s), selective debridement,
revise the list of therapy revenue codes discontinue recognizing the current CPT
without anesthesia (eg, high pressure
that may be reported with CPT codes codes for cardiac rehabilitation services
waterjet with/without suction, sharp
97597, 97598, 97602, 97605, and 97606 and to establish two new Level II
selective debridement with scissors,
to designate them as services that are HCPCS codes that we believe are more
scalpel and forceps) with or without appropriate for specifically reporting
performed by a qualified therapist under
topical application(s) for ongoing care, cardiac rehabilitation services under the
a certified therapy plan of care, and thus
may include use of a whirlpool, per OPPS. The proposed HCPCS codes are:
payable under the MPFS, to be
session; total wound(s) surface area less GXXX1 (Physician services for
consistent with the current billing
than or equal to 20 square centimeters); outpatient cardiac rehabilitation;
practices of hospitals and to ensure that
97598 (Removal of devitalized tissue without continuous ECG monitoring
we are making separate payment under
from wound(s), selective debridement, (per hour)) and GXXX2 (Physician
the OPPS only in appropriate situations.
without anesthesia (eg, high pressure We are proposing to revise the list of services for outpatient cardiac
waterjet with/without suction, sharp therapy revenue codes for reporting rehabilitation; with continuous ECG
selective debridement with scissors, these five CPT wound care codes as monitoring (per hour)). In contrast with
scalpel and forceps) with or without therapy services to include all revenue the current CPT codes, we believe the
topical application(s) for ongoing care, codes in the 042X series, which descriptors of these proposed G-codes
may include use of a whirlpool, per incorporates all revenue codes that more specifically reflect the way cardiac
session; total wound(s) surface area begin with 042, such as 0420, 0421, rehabilitation services are provided in
greater than 20 square centimeters); 0422, 0423, 0424, and 0429; the 043X HOPDs so that reporting would be more
97602 (Removal of revitalized tissue series, which includes all revenue codes straightforward for hospitals and would
from wound(s), non-selective that begin with 043, such as 0430, 0431, result in more accurate data for OPPS
debridement, without anesthesia (eg, 0432, 0434, and 0439; and the 044X ratesetting in 2 years. Consistent with
wet-to-moist dressings, enzymatic, series, which includes all revenue codes the current APC assignments of the
abrasion) including topical that begin with 044, such as 0440, 0441, cardiac rehabilitation CPT codes, we are
application(s), wound assessment, and 0442, 0443, 0444, and 0449. Therefore, proposing to assign these new HCPCS
instruction(s) for ongoing care, per for CY 2008 we are proposing that when codes to APC 0095 for CY 2008, with a
session), 97605 (Negative pressure services reported with CPT codes 97597, status indicator of ‘‘S.’’ Accordingly, we
wound therapy (eg, vacuum assisted 97598, 97602, 97605, and 97606 are are proposing to change the status
drainage collection), including topical performed by a qualified therapist under indicators for CPT codes 93797 and
application(s), wound assessment, and a certified therapy plan of care, 93798 from ‘‘S’’ to ‘‘B’’ to indicate that
instruction(s) for ongoing care, per providers should attach an appropriate alternative codes (GXXX1 and GXXX2)
session; total wound(s) surface area less therapy modifier (that is, GP for for cardiac rehabilitation services are
than or equal to 50 square centimeters); physical therapy, GO for occupational recognized for payment under the
and 97606 (Negative pressure wound therapy, and GN for speech-language OPPS.
therapy (eg, vacuum assisted drainage pathology) or report their charge under
collection), including topical F. Reporting of Bone Marrow and Stem
a therapy revenue code (that is, 042X,
application(s), wound assessment, and 043X, or 044X), or both, to receive Cell Processing Services
instruction(s) for ongoing care, per payment under the MPFS. Under other (If you choose to comment on issues
session; total wound(s) surface area circumstances, hospitals would receive in this section, please include the
greater than 50 square centimeters). We separate payment under the OPPS when caption ‘‘Bone Marrow and Stem Cell
further stated that hospitals would they bill for wound care services Processing Services’’ at the beginning of
receive separate payment under the described by CPT codes 97597, 97598, your comment.)
OPPS when they bill for wound care 97602, 97605, and 97606 that are The OPPS currently recognizes
services described by CPT codes 97597, furnished to hospital outpatients by HCPCS code G0267 (Bone marrow or
97598, 97602, 97605, and 97606 that are individuals independent of a certified peripheral stem cell harvest,
furnished to hospital outpatients by therapy plan of care. modification or treatment to eliminate

individuals independent of a therapy cell type(s)) for depletion services for
plan of care. In contrast, when such E. Reporting of Cardiac Rehabilitation hematopoietic progenitor cells, instead
services are performed by a qualified Services of the more specific CPT codes that
therapist under a certified therapy plan (If you choose to comment on issues describe these services, including CPT
of care, providers should attach an in this section, please include the codes 38210 (Transplant preparation of
appropriate therapy modifier (that is, GP caption ‘‘Cardiac Rehabilitation hematopoietic progenitor cells; specific
cell depletion within harvest, T-cell procedures, the total volume of these G0266, which would have been
depletion); 38211 (Transplant procedures has been increasing over the assigned to the same clinical APC if
preparation of hematopoietic progenitor past several years. Therefore, we believe they were paid under the OPPS.
cells; tumor cell depletion); 38212 that recognizing these six CPT codes for Although HCPCS code G0265 and
(Transplant preparation of bone marrow and stem cell processing G0266 have not historically been paid
hematopoietic progenitor cells; red services would yield more specific under the OPPS, we have a small
blood cell removal); 38213 (Transplant claims data and enable us to pay more number of HOPD single claims from CY
preparation of hematopoietic progenitor appropriately for these services in the 2006 for these two predecessor HCPCS
cells; platelet depletion); 38214 future. Consistent with our general codes (when they were paid off the
(Transplant preparation of OPPS practice, we are proposing to CLFS), respectively, and similar
hematopoietic progenitor cells; plasma assign the newly recognized CPT codes laboratory tissue cryopreservation and
(volume) depletion); and 38215 to the clinical APC that is most thawing services also are proposed for
(Transplant preparation of appropriate based on historical claims assignment to APC 0344 under the CY
hematopoietic progenitor cells; cell data for the predecessor HCPCS code 2008 OPPS. We believe this proposal
concentration in plasma, mononuclear, until we have more specific hospital would allow us to pay appropriately for
of buffy coat layer). These six CPT codes resource data available to assess the all of these bone marrow and stem cell
are currently assigned to status indicator specific CPT codes for possible
processing services and to collect more
‘‘B,’’ while HCPCS code G0267 is reassignment.
In addition, we are proposing to specific hospital resource data.
assigned to APC 0110 (Transfusion) for
payment, with a status indicator of ‘‘S.’’ discontinue recognition of HCPCS code XIV. Proposed OPPS Payment Status
For CY 2008, we are proposing to G0265 (Cyropreservation, freezing and and Comment Indicators
continue to assign the historical claims storage of cells for therapeutic use) and
data for HCPCS code G0267 to APC G0266 (Thawing and expansion of A. Proposed Payment Status Indicator
0110. In addition, we are proposing to frozen cells for therapeutic use), Definitions
discontinue recognizing HCPCS code currently assigned to status indicator
G0267 for CY 2008, assigning it to status ‘‘A’’ under the OPPS and paid according (If you choose to comment on issues
indicator ‘‘B,’’ and to recognize the six to the Medicare Clinical Laboratory Fee in this section, please include the
more specific CPT codes, which we are Schedule (CLFS), by assigning them to caption ‘‘OPPS: Status Indicators’’ at the
proposing to also assign to APC 0110 status indicator ‘‘B’’ for CY 2008. We are beginning of your comment.)
with a status indicator of ‘‘S.’’ proposing to recognize, instead, CPT The OPPS payment status indicators
Historically, under the OPPS we codes 38207 (Transplant preparation of (SIs) that we assign to HCPCS codes and
recognized the single G-code rather than hematopoietic progenitor cells; APCs play an important role in
the CPT codes for the individual cryopreservation and storage); 38208 determining payment for services under
transplant cell preparation services (Transplant preparation of the OPPS. They indicate whether a
because we believed that the services hematopoietic progenitor cells; thawing service represented by a HCPCS code is
would be uncommonly provided to of previously frozen harvest, without payable under the OPPS or another
Medicare beneficiaries in the outpatient washing); and 38209 (Transplant payment system and also whether
setting and would likely require similar preparation of hematopoietic progenitor particular OPPS policies apply to the
resources, so that distinguishing among cells; thawing of previously frozen code. Our proposed CY 2008 status
the services would not be necessary to harvest, with washing) for payment indicator assignments for APCs and
ensure appropriate OPPS payment. under the OPPS because we believe they HCPCS codes are shown in Addendum
Stakeholders have brought to our are similar to blood processing services A and Addendum B, respectively, to
attention that the current hospital that are currently paid under the OPPS, this proposed rule. We are proposing to
resources associated with the six not under the CLFS. We are proposing use the status indicators and definitions
different bone marrow and stem cell to assign the single cryopreservation that are listed in Addendum D1, which
processing procedures described by and two thawing CPT codes to APC we discuss below in greater detail.
these CPT codes may vary widely. 0344 (Level IV Pathology) based on their
While we recognize that the services clinical characteristics and resource 1. Proposed Payment Status Indicators
currently reported with G0267 under costs from historical hospital claims to Designate Services That Are Paid
the OPPS are not common HOPD data for HCPCS codes G0265 and under the OPPS
Indicator Item/code/service OPPS payment status
G .............................................................. Pass-Through Drugs and Biologicals ................... Paid under OPPS; Separate APC payment in-
cludes pass through amount.
H ............................................................... Pass-Through Device Categories ......................... Separate cost-based pass-through payment; Not
subject to coinsurance.
K ............................................................... (1) Non-Pass-Through Drugs and Biologicals ...... (1) Paid under OPPS; Separate APC payment.
(2) Therapeutic Radiopharmaceuticals ................. (2) Paid under OPPS; Separate APC payment.
(3) Brachytherapy Sources ................................... (3) Paid under OPPS; Separate APC payment.
(4) Blood and Blood Products ............................... (4) Paid under OPPS; Separate APC payment.
N ............................................................... Items and Services Packaged into APC Rates .... Paid under OPPS; Payment is packaged into
payment for other services, including outliers.
Therefore, there is no separate APC payment.
P ............................................................... Partial Hospitalization ............................................ Paid under OPPS; Per diem APC payment.
Indicator Item/code/service OPPS payment status
Q .............................................................. Packaged Services Subject to Separate Payment Paid under OPPS; Addendum B displays APC
Under OPPS Payment Criteria.. assignments when services are separately
payable.
(1) Separate APC payment based on OPPS pay-
ment criteria.
(2) If criteria are not met, payment is packaged
into payment for other services, including
outliers. Therefore, there is no separate APC
payment.
S ............................................................... Significant Procedure, Not Discounted when Mul- Paid under OPPS; Separate APC payment.
tiple.
T ............................................................... Significant Procedure, Multiple Reduction Applies Paid under OPPS; Separate APC payment.
V ............................................................... Clinic or Emergency Department Visit .................. Paid under OPPS; Separate APC payment.
X ............................................................... Ancillary Services .................................................. Paid under OPPS; Separate APC payment.
As stated in section VII.A. of this brachytherapy sources paid on a cost implement prospective payment for
proposed rule, subsequent to the basis. separately payable therapeutic
publication of the CY 2007 OPPS/ASC As discussed in section VII.B. of this radiopharmaceuticals under the OPPS
final rule with comment period, section proposed rule, we are proposing to in CY 2008. In accordance with this
107(a) of the MIEA TRHCA extended implement prospective payment for proposal, we also are proposing to
the payment period for brachytherapy brachytherapy sources paid under the discontinue our use of payment status
sources paid under the OPPS based on OPPS in CY 2008. In accordance with indicator ‘‘H’’ for APCs assigned to
a hospital’s charges adjusted to cost this proposal, we also are proposing to separately payable therapeutic
under section 1833(t)(16)(C) of the Act discontinue our use of payment status radiopharmaceuticals. For CY 2008, we
for one additional year. This indicator ‘‘H’’ for APCs assigned to are proposing to use payment status
requirement for cost-based payment brachytherapy sources. As indicated in indicator ‘‘K’’ to designate separately
ends after December 31, 2007. section VII.B. of this proposed rule for payable therapeutic
CY 2008, we are proposing to use radiopharmaceuticals that will be paid
Therefore, we have continued the OPPS
payment status indicator ‘‘K’’ to under the OPPS.
cost-based payment for brachytherapy
sources through CY 2007, and have designate all brachytherapy source 2. Proposed Payment Status Indicators
continued using status indicator ‘‘H’’ to APCs that will be paid under the OPPS. to Designate Services That Are Paid
designate nonpass-through As discussed in section V.B.3.a.(4) of Under a Payment System Other Than
this proposed rule, we are proposing to the OPPS
Indicator Item/code/service OPPS Payment Status
A ............... Services furnished to a hospital outpatient that are paid under a Not paid under OPPS. Paid by fiscal intermediaries under a fee
fee schedule or payment system other than OPPS, for exam- schedule or payment system other than OPPS.
ple:
• Ambulance Services
• Clinical Diagnostic Laboratory Services
• Non-Implantable Prosthetic and Orthotic Devices
• EPO for ESRD Patients
• Physical, Occupational, and Speech Therapy
• Routine Dialysis Services for ESRD Patients Provided in a
Certified Dialysis Unit of a Hospital
• Diagnostic Mammography
• Screening Mammography
C ............... Inpatient Procedures ..................................................................... Not paid under OPPS. Admit patient. Bill as inpatient.
F ............... Corneal Tissue Acquisition; Certain CRNA Services; and Hepa- Not paid under OPPS. Paid at reasonable cost.
titis B Vaccines.
L ............... Influenza Vaccine; Pneumococcal Pneumonia Vaccine ............... Not paid under OPPS. Paid at reasonable cost; Not subject to
deductible or coinsurance.
M .............. Items and Services Not Billable to the Fiscal Intermediary .......... Not paid under OPPS.
Y ............... Non-Implantable Durable Medical Equipment .............................. Not paid under OPPS. All institutional providers other than
home health agencies bill to DMERC.
3. Proposed Payment Status Indicators

to Designate Services That Are Not

Recognized Under the OPPS But That
May Be Recognized by Other
Institutional Providers
B ............... Codes that are not recognized by OPPS when submitted on an Not paid under OPPS.
outpatient hospital Part B bill type (12x and13x). • May be paid by intermediaries when submitted on a different
bill type, for example, 75x (CORF), but not paid under OPPS.
• An alternate code that is recognized by OPPS when sub-
mitted on an outpatient hospital Part B bill type (12x and 13x)
may be available.
4. Proposed Payment Status Indicators

to Designate Services That Are Not
Payable by Medicare
D ............... Discontinued Codes ...................................................................... Not paid under OPPS or any other Medicare payment system.
E ............... Items, Codes, and Services: ......................................................... Not paid under OPPS or any other Medicare payment system.
• That are not covered by Medicare based on statutory exclu-
sion
• That are not covered by Medicare for reasons other than stat-
utory exclusion
• That are not recognized by Medicare but for which an alter-
nate code for the same item or service may be available
• For which separate payment is not provided by Medicare
To address providers’ broader on a proposed APC assignment in the OPPS/ASC final rule with comment
interests and to make the published Proposed Rule; APC assignment is no period would be subject to comment
Addendum B more convenient for longer open to comment. during the comment period for the final
public use, we are displaying in • ‘‘NI’’—New code, interim APC rule with comment period.
Addendum B to this proposed rule all assignment; Comments will be accepted
on the interim APC assignment for the We are using the ‘‘CH’’ indicator in
active HCPCS codes that describe items
new code. this proposed rule to call attention to
or services that are: (1) Payable under
the OPPS; (2) paid under a payment In the November 10, 2005 final rule proposed changes in the payment status
system other than the OPPS; (3) not with comment period (70 FR 68702 and indicator and/or APC assignment for
recognized under the OPPS but that may 68703), we adopted a new comment HCPCS codes for CY 2008. The use of
be recognized by other institutional indicator: the comment indicator ‘‘CH’’ in
providers; and (4) not payable by • ‘‘CH’’—Active HCPCS codes in association with a composite APC
Medicare. The status indicators that we current and next calendar year; status indicates that the configuration of the
are proposing for CY 2008 for these indicator and/or APC assignment have composite APC is proposed for change
items and services are listed in the changed. in this proposed rule.
tables above. We implemented comment indicator
‘‘CH’’ to designate a change in payment In this proposed rule, the ‘‘CH’’
A complete listing of HCPCS codes indicator is appended to HCPCS codes
with proposed payment status status indicator and/or APC assignment
for HCPCS codes in Addendum B of the for which we have proposed changes in
indicators and APC assignments for CY
CY 2006 final rule with comment the payment status indicator and/or
2008 is also available electronically on
the CMS Web site at http:// period. We also stated that codes flagged APC assignment for CY 2008 compared
www.cms.hhs.gov/ with the ‘‘CH’’ indicator in that final to their assignment as of June 30, 2007.
HospitalOutpatientPPS/HORD/ rule would not be open to comment We believe that using the ‘‘CH’’
list.asp#TopOfPage. because the changes generally were indicator in this proposed rule will
previously subject to comment during facilitate the public’s review of the
B. Proposed Comment Indicator the proposed rule comment period. For changes that we are proposing to make
Definitions CY 2008, we are proposing to continue final in CY 2008. Use of the ‘‘CH’’
(If you choose to comment on issues that policy in the CY 2008 OPPS/ASC indicator in this proposed rule is
in this section, please include the final rule with comment period. When significant because it highlights changes
caption ‘‘OPPS: Comment Indicators’’ at used in an OPPS final rule, the ‘‘CH’’ that are subject to comment during the
the beginning of your comment.) indicator is only intended to facilitate proposed rule comment period.
In the November 15, 2004 final rule the public’s review of changes made
with comment period (69 FR 65827 and from one calendar year to another. We We are proposing to terminate
65828), we made final our policy to use are proposing to use the ‘‘CH’’ indicator comment indicator ‘‘NF’’ because its use
two comment indicators to identify in in the CY 2008 OPPS/ASC final rule is no longer relevant in the final rule(s).
an OPPS final rule the assignment status with comment period to indicate The two comment indicators, ‘‘NI’’ and
of a specific HCPCS code to an APC and HCPCS codes for which the status ‘‘CH,’’ that we are proposing to continue
the timeframe when comments on the indicator or APC assignment, or both, using in CY 2008 and their definitions
HCPCS APC assignment would be would change in CY 2008 compared to are listed in Addendum D2 to this
accepted. These two comment their assignment as of December 31, proposed rule.
indicators are listed below. 2007.
• ‘‘NF’’—New code, final APC However, only HCPCS codes with
assignment; Comments were accepted comment indicator ‘‘NI’’ in the CY 2008
XV. OPPS Policy and Payment and the regulations at Subpart C provide Section 109(b) of the MIEA–TRHCA,
Recommendations specific conditions for coverage for Pub. L.109–432, amended section
ASCs. 1833(i) of the Act, in part, by adding
A. MedPAC Recommendations
To establish the reasonable estimated new clause (iv) to paragraph (2)(D) and
The MedPAC submits reports to allowances for ASC facility services, by also adding new paragraph (7)(A),
Congress in March and June that section 1833(i)(2)(A)(i) of the Act which provides that the Secretary may
summarize payment policy required us to take into account the reduce the annual ASC update by 2
recommendations. The March 2007 audited costs incurred by ASCs to percentage points if an ASC fails to
MedPAC report included the following perform a procedure, in accordance submit data as required by the Secretary
recommendation relating specifically to with a survey. The ASC services benefit on selected measures of quality of care,
the hospital OPPS: was enacted by Congress through the including medication errors. Section
Recommendation 2A–1: The Congress Omnibus Reconciliation Act of 1980 109(b) of MIEA–TRCHA requires that
should increase payment rates for the (Pub. L. 96 499). For a detailed certain quality of care reporting
outpatient prospective payment system discussion of the legislative history requirements mandated for hospitals
in 2008 by the projected rate-of-increase related to ASCs, we refer readers to the paid under the OPPS by section 109(a)
in the hospital market basket index, June 12, 1998 proposed rule (63 FR of the MIEA–TRCHA be applied in a
concurrent with the implementation of 32291). similar manner to ASCs unless
a quality incentive payment program. Section 141(b) of the Social Security otherwise specified by the Secretary. We
CMS Response: We are proposing to Act Amendments of 1994, Pub. L. 103– refer readers to sections XVII.A. and H.
increase the payment rates for the CY 432, requires us to establish a process of this proposed rule for further
2008 OPPS by the projected rate-of- for reviewing the appropriateness of the discussion of this provision and our
increase in the hospital market basket payment amount provided under plans for future ASC implementation
index (as discussed in section II.C. of section 1833(i)(2)(A)(iii) of the Act for B. Rulemaking for the Revised ASC
this proposed rule) and to implement, intraocular lenses (IOLs) that belong to Payment System
effective for CY 2009, the reduction in a class of new technology intraocular
the annual update factor by 2.0 On August 23, 2006, we proposed in
lenses (NTIOLs). That process was the
percentage points for subsection (d) the Federal Register (71 FR 49635) a
subject of a separate final rule entitled
hospitals that do not meet the outpatient revised payment system for ASCs to be
‘‘Adjustment in Payment Amounts for implemented effective January 1, 2008,
hospital quality reporting required by New Technology Intraocular Lenses
section 1833(t)(17) of the Act, as added in accordance with section 626(b) of
Furnished by Ambulatory Surgical Pub. L. 108–173. The proposal included,
by section 109(b) of the MIEA-TRHCA. Centers,’’ published on June 16, 1999, in
Our proposal for implementing the among other things, revisions to the
the Federal Register (64 FR 32198). ASC list of covered surgical procedures
hospital quality reporting measures for Section 626(b) of the Medicare
the CY 2008 OPPS is discussed in detail for CY 2008 and the payment
Prescription Drug, Improvement, and methodology for the items and services
in section XVII. of this proposed rule. Modernization Act of 2003, Pub. L. 108– furnished by the ASC.
B. APC Panel Recommendations 173, repealed the requirement formerly We are publishing elsewhere in this
found in section 1833(i)(2)(A) of the Act issue of the Federal Register the final
Recommendations made by the APC that the Secretary conduct a survey of
Panel at its March 2007 meeting are rule for the revised ASC payment
ASC costs for purposes of updating ASC system, effective January 1, 2008,
discussed in sections of this proposed payment rates and required the
rule that correspond to topics addressed hereinafter referred to as the July 2007
Secretary to implement a revised ASC final rule for the revised ASC payment
by the APC Panel. Minutes of the APC payment system, to be effective not later system. In that final rule, we established
Panel’s March 7–9, 2007 meeting are than January 1, 2008. that we would address two components
available on the CMS Web site at: http: Section 5103 of the DRA, Pub. L. 109– of the ASC payment system annually as
//www.cms.hhs.gov/FACA/05_Advisory 171, amended section 1833(i)(2) of the part of the OPPS rulemaking cycle.
PanelonAmbulatoryPayment Act by adding a new subparagraph (E) Section 1833(i)(1) of the Act requires us
Classification Groups.asp. to place a limitation on payments for to specify, in consultation with
XVI. Proposed Update of the Revised surgical procedures in ASCs. The appropriate medical organizations,
Ambulatory Surgical Center Payment amended language provides that if the surgical procedures that are
System standard overhead amount under appropriately performed on an inpatient
section 1833(i)(2)(A) of the Act for an basis in a hospital but that can be safely
A. Legislative and Regulatory Authority ASC facility service for such surgical performed in an ASC, CAH, or an HOPD
for the ASC Payment System procedures, without application of any and to review and update the list of ASC
Section 1832(a)(2)(F)(i) of the Act geographic adjustment, exceeds the procedures at least every 2 years.
provides that benefits under the Medicare payment amount under the In the July 2007 final rule for the
Medicare Part B include payment for hospital OPPS for the service for that revised ASC payment system, we also
facility services furnished in connection year, without application of any adopted the method we will use to set
with surgical procedures specified by geographic adjustment, the Secretary payment rates for ASC services
the Secretary that are performed in an shall substitute the OPPS payment furnished in association with covered
ASC. To participate in the Medicare amount for the ASC standard overhead surgical procedures. Updating covered
program as an ASC, a facility must meet amount. This provision applies to surgical procedures and covered
the standards specified in section surgical procedures furnished in ASCs ancillary services, as well as their
1832(a)(2)(F)(i) of the Act, which are on or after January 1, 2007, and before payment rates, in association with the
implemented in 42 CFR Part 416, the effective date of the revised ASC annual OPPS rulemaking cycle is
Subpart B and Subpart C of our payment system (see the final rule for particularly important because the
regulations. The regulations at 42 CFR the revised ASC payment system OPPS relative payment weights and
416, Subpart B set forth general published elsewhere in this issue of the rates will be used as the basis for the
conditions and requirements for ASCs, Federal Register). payment of most covered surgical
procedures and covered ancillary b. Identification of Surgical Procedures methodology of the revised ASC
services under the revised ASC payment Eligible for Payment Under the Revised payment system.
system. This joint update process will ASC Payment System Just as we scale the OPPS relative
ensure that the ASC updates occur in a ASC ‘‘covered surgical procedures’’ payment weights each year to ensure
regular, predictable, and timely manner. are those surgical procedures for which that the OPPS is budget neutral from
The final rule included applicable payment is made under the revised ASC one year to the next, we will rescale
regulatory changes to 42 CFR Parts 410 payment system. Our final policy for relative weights each year for the
and 416. identifying surgical procedures eligible revised ASC payment system. The
for ASC payment excludes those purpose of scaling the relative weights
In this CY 2008 OPPS/ASC proposed is to ensure that the estimated aggregate
rule, we are proposing to update the surgical procedures that are on the
OPPS inpatient list, procedures that are payments under the ASC payment
revised ASC payment system for CY system for an upcoming year would be
packaged under the OPPS, CPT unlisted
2008, along with the OPPS. We are also neither greater than nor less than the
surgical procedure codes, and surgical
proposing to revise the regulations to procedures that are not recognized for aggregate payments that would be made
make practice expense payment to payment under the OPPS. Further, we in the prior year, taking into
physicians who perform noncovered exclude from ASC payment any consideration any changes or
ASC procedures in ASCs based on the procedure for which standard medical recalibrations for the upcoming year.
facility practice expense (PE) relative practice dictates that the beneficiary Rescaling enables us to compensate for
value units (RVUs) and to exclude would typically be expected to require the effects of changes in the OPPS
covered ancillary radiology services and active medical monitoring and care at relative payment weights from year to
covered ancillary drugs and biologicals midnight following the procedure year for services that are not performed
from the categories of designated health (overnight stay), and all surgical in ASCs (for example, due to sudden
services (DHS) that are subject to the procedures that could pose a significant increases or decreases in the costs of
safety risk to Medicare beneficiaries. hospital outpatient emergency
physician self-referral prohibition.
The criteria used under the revised ASC department visits) that could
C. Revisions to the ASC Payment System payment system to identify procedures inappropriately cause the estimated
Effective January 1, 2008 that could pose a significant safety risk ASC expenditures to increase or
when performed in an ASC include decrease as a function of those changes.
1. Covered Surgical Procedures Under To establish the budget neutrality
the Revised ASC Payment System those procedures that: generally result
adjustment for the revised ASC payment
in extensive blood loss; require major or
a. Definition of Surgical Procedure system, we used a model that accounts
prolonged invasion of body cavities; for the migration of surgical procedures
directly involve major blood vessels; are between ASCs, physicians’ offices, and
In order to delineate the scope of
emergent or life-threatening in nature; HOPDs as discussed in the July 2007
procedures that constitute ‘‘outpatient
or commonly require systemic final rule for the revised ASC payment
surgical procedures’’ for payment under thrombolytic therapy. These criteria for
the revised ASC payment system, in the system. The budget neutrality
evaluating surgical procedures are set adjustment for CY 2008 is based on
July 2007 final rule for the revised ASC forth in § 416.166(c).
payment system, we clarified what we updated proposed CY 2008 OPPS and
consider to be a ‘‘surgical’’ procedure. c. Payment for Covered Surgical MPFS rates, along with updated
Under the ASC payment system existing Procedures Under the Revised ASC utilization data. The estimated ASC CY
Payment System 2008 budget neutrality adjustment factor
through CY 2007, we define a surgical
is multiplied by the proposed OPPS
procedure as any procedure described (1) General Policies
conversion factor to establish the
within the range of Category I CPT To make payment for most covered proposed ASC conversion factor. The
codes that the CPT Editorial Panel of the surgical procedures, we utilize the standard ASC payment for most of the
AMA defines as ‘‘surgery’’ (CPT codes OPPS APCs as a ‘‘grouper’’ and the APC covered surgical procedures displayed
10000 through 69999). Under the relative payment weights as the basis for in Addendum AA of this proposed rule
revised payment system, we continue to ASC relative payment weights and for is calculated as the product of that
define surgery using that standard. We calculating ASC payment rates under proposed ASC conversion factor
also include within the scope of surgical the revised payment system, by multiplied by the proposed OPPS
procedures payable in an ASC those applying a uniform ASC conversion relative payment weight for each
procedures that are described by Level factor to the ASC payment weights. For separately payable procedure. A more
II HCPCS codes or by Category III CPT the first year of the revised ASC detailed discussion of the methodology
codes that directly crosswalk or are payment system, we adopted the OPPS is provided in section XVI.L. of this
clinically similar to procedures in the relative payment weights as the ASC proposed rule.
CPT surgical range that we have relative payment weights for most Beginning in CY 2010, we will update
determined do not pose a significant covered surgical procedures. the ASC conversion factor for the
safety risk and that we would not expect For future years, we will update the revised ASC payment system by the
to require an overnight stay when ASC relative payment weights annually percentage increase in the CPI–U (U.S.
performed in ASCs. Having established using the OPPS relative payment city average), as estimated for the 12-
weights for that calendar year, as well month period ending with the midpoint
what we consider to be a ‘‘surgical
as the practice expense payment of the year involved. At the same time,
procedure,’’ we defined criteria that
amounts under the MPFS schedule for we recognize that we continue to have
enable us to identify procedures that that calendar year, because some flexibility under the statute to employ a
could pose a significant safety risk when covered office-based surgical procedures different update mechanism under the
performed in an ASC or that we expect and covered ancillary services will be revised ASC payment system. As one
would require an overnight stay within paid according to MPFS amounts if example, we do not intend for the
the bounds of prevailing medical those amounts are less than the rates revised ASC payment system to result in
practice. calculated under the standard additional Medicare expenditures over
time. We will be monitoring this issue CY 2008 or later with MPFS nonfacility then set as equal to the device portion
closely in the coming years. PE RVUs; payment based on OPPS of the national unadjusted ASC payment
Consequently, we will reconsider the relative payment weight); ‘‘P3’’ (Office- rate for the procedure. We then
ASC update if expenditures increase based surgical procedure added to ASC calculate the service portion of the ASC
inappropriately in future years. list in CY 2008 or later with MPFS payment for device-intensive
nonfacility PE RVUs; payment based on procedures by applying the uniform
(2) Office-Based Procedures
MPFS nonfacility PE RVUs); and ‘‘R2’’ ASC conversion factor to the service
Among the procedures newly (Office-based surgical procedure added (nondevice) portion of the OPPS relative
identified as covered surgical to ASC list in CY 2008 or later without payment weight for the device-intensive
procedures for payment in ASCs MPFS nonfacility PE RVUs; payment procedure. Finally, we sum the ASC
beginning in CY 2008 are many based on OPPS relative payment device portion and ASC service portion
procedures that are performed most of weight). Those procedures for which the to establish the full payment for the
the time in physicians’ offices. These designation as office-based is newly device-intensive procedure under the
procedures neither pose a significant proposed for CY 2008 are identified in revised ASC payment system. For
safety risk nor are they expected to Addendum AA with comment indicator example, if the OPPS device offset
require an overnight stay when ‘‘CH’’ and those for which the payment percentage for the procedure is 80
performed in ASCs, and they generally indicator is a temporary designation are percent and the OPPS national
require a lower level of resource marked by an asterisk. The temporary unadjusted payment is $100, the device
intensity than do most other ASC designation means that the office-based cost included in that payment is $80.
covered surgical procedures. For those payment indicator (‘‘P2,’’ ‘‘ P3,’’ or Under the ASC payment system, we also
reasons, in the July 2007 final rule for ‘‘R2’’) assigned to the procedure is would pay $80 for the device portion of
the revised ASC payment system, we temporary because the code is a new the procedure but the service portion of
adopted a policy to include them as HCPCS code for which we have the OPPS payment, $20, would be
covered surgical procedures but to insufficient data upon which to base a adjusted by the budget neutrality
ensure that payment for the facility proposal for a final decision regarding adjustment factor (for example, using
resources associated with the the code’s office-based status. The the proposed budget neutrality factor,
procedures identified as ‘‘office-based’’ temporary designation will be the calculation would be: $20 x 0.65 =
would not be greater when provided in reevaluated by CMS when there are data $13) and, if it is subject to the transition
ASCs than when furnished in upon which to base a proposal for a (as set forth in section XVI.C.1.c.(5) of
physicians’ offices. final payment indicator. The remainder this proposed rule), it would also be
Under the revised ASC payment of the office-based procedure adjusted accordingly. If the procedure in
system, we cap payment for office-based designations was finalized in the July the example is not subject to the
surgical procedures for which ASC 2007 final rule for the revised ASC transition, its CY 2008 payment would
payment would first be allowed payment system. be equal to $93 ($80 + $13). This
beginning in CY 2008 or later years at example illustrates the contributions of
the lesser of the MPFS nonfacility (3) Device-Intensive Procedures
the device and service payment
practice PE RVU amount or the ASC rate Under the final policy of the revised amounts to the national unadjusted ASC
developed according to the standard ASC payment system, we use a payment rate; payment to an ASC for
methodology of the revised ASC modified payment methodology to the device-intensive service would be
payment system. For those office-based establish the ASC payment rates for subject to the 50 percent geographic
procedures for which there is no device-intensive procedures. We adjustment.
available MPFS nonfacility PE RVU identify device-intensive procedures as We also reduce the amount of
amount, we will implement the cap, as covered surgical procedures that, under payment made to ASCs for device-
appropriate, once a MPFS nonfacility PE the OPPS, are assigned to those device- intensive procedures assigned to certain
RVU amount is available. Once dependent APCs for which the ‘‘device OPPS APCs in those cases in which the
procedures are finalized as being office- offset percentage’’ is greater than 50 necessary device is furnished without
based procedures, they remain percent of the APC’s median cost. The cost to the ASC or the beneficiary, or
designated as office-based. We may device offset percentage is our best with a full credit for the cost of the
propose that additional HCPCS codes be estimate of the percentage of device cost device being replaced. A full discussion
classified as office-based in a proposed that is included in an APC payment of that policy may be found in section
rule for an annual ASC update after under the OPPS. The CY 2008 proposed XVI.F. of this proposed rule.
review of the most recent available device-dependent APCs and device
utilization data. We consider for offset percentages are discussed in (4) Multiple and Interrupted Procedure
additional designation as office-based section IV.A. of this proposed rule. Discounting
those procedures newly paid in ASCs in According to the final ASC policy, Under the revised ASC payment
CY 2008 or later years that our review payment for implantable devices is system, we discount payment for certain
concludes are performed predominantly packaged into payment for the covered multiple and interrupted procedures
(more than 50 percent of the time) in surgical procedures, but we utilize a performed in ASCs. While most covered
physicians’ offices, based on our modified ASC methodology based on surgical procedures will be subject to a
consideration of volume and site of OPPS data to establish payment rates for 50-percent reduction in ASC payment
service utilization data for the the device-intensive procedures under for the lower paying procedure when
procedures, as well as clinical the revised ASC payment system. more than one procedure is performed
information and comparable data for According to that modified payment in a single operative session, those
related procedures, if appropriate. methodology, we apply the OPPS device covered surgical procedures that we are
Procedures designated as office-based offset percentage to the OPPS national proposing to exempt from the multiple
for CY 2008 are identified in Addendum unadjusted payment to determine the procedure reduction in ASCs because
AA to this proposed rule and assigned device cost included in the OPPS they are proposed to not be subject to
payment indicators ‘‘P2’’ (Office-based payment rate for a device-intensive ASC this reduction under the OPPS are
surgical procedures added to ASC list in covered surgical procedure, which we identified in Addendum AA to this
proposed rule. Procedures requiring OPPS relative payment weight); ‘‘J8’’ surgical procedure); ambulance services;
anesthesia that are terminated after the (Device-intensive procedure added to leg, arm, back, and neck braces other
patient has been prepared for surgery ASC list in CY 2008 or later; paid at than those that serve the function of a
and taken to the operating room but adjusted rate); ‘‘P2’’ (Office-based cast or splint; artificial limbs; and
before the administration of anesthesia surgical procedure added to ASC list in nonimplantable prosthetic devices and
will be reported with modifier 73, and CY 2008 or later with MPFS nonfacility DME.
the ASC payment for the covered PE RVUs; payment based on OPPS
surgical procedure will be reduced by b. Payment Policies for Specific Items
relative payment weight); ‘‘P3’’ (Office-
50 percent. Procedures requiring and Services
based surgical procedure added to ASC
anesthesia that are terminated after list in CY 2008 or later with MPFS (1) Radiology Services
administration of anesthesia or nonfacility PE RVUs; payment based on Under the revised ASC payment
initiation of the procedure will be MPFS nonfacility PE RVUs); and ‘‘R2’’ system, we make separate payment to
reported with modifier 74, and the ASC (Office-based surgical procedure added ASCs for ancillary radiology services
payment for the covered surgical to ASC list in CY 2008 or later without designated as separately payable under
procedure will be made at 100 percent MPFS nonfacility PE RVUs; payment the OPPS, when those radiology
of the established payment rate. based on OPPS relative payment services are provided in the ASC
Procedures and services not requiring weight). integral to the performance of a covered
anesthesia that are partially reduced or surgical procedure provided on the
discontinued at the physician’s 2. Covered Ancillary Services Under the
Revised ASC Payment System same day. ASC payment for those
discretion are reported with modifier ancillary services is at the lower of the
52, and the ASC payment for the a. General Policies rate developed according to the
covered surgical procedure or covered
As described in § 416.163, payment is standard methodology of the revised
ancillary service is reduced by 50
made under the revised ASC payment ASC payment system or the MPFS
percent.
system for ASC services furnished in nonfacility PE RVU amount (specifically
(5) Transition to Revised ASC Payment connection with covered surgical for the technical component (TC) if the
Rates procedures. As set forth in § 416.2, ASC service is assigned a TC under the
Under the revised ASC payment services include both facility services, MPFS). No separate payment is made
system, we are providing a payment which are defined as services that are for those ancillary services that are
transition of 4 years for all services on furnished in connection with a covered designated as packaged under the OPPS.
the CY 2007 ASC list of covered surgical surgical procedure performed in an ASC We specify that a radiology service is
procedures. Beginning in CY 2008, the and for which payment is packaged into integral to the performance of a covered
contribution of CY 2007 ASC payment the ASC payment for the covered surgical procedure if it is required for
rates to the blended transitional rates surgical procedure, and covered the successful performance of the
will decrease by 25 percentage point ancillary services, which are defined as surgery and is performed in the ASC
increments each year of transitional those items and services that are integral immediately preceding, during, or
payment, until CY 2011, when we will to a covered surgical procedure and for immediately following the covered
fully implement the revised ASC which separate payment may be made surgical procedure. Payment under the
payment rates calculated under the final under the revised ASC payment system. revised ASC payment system for these
methodology of the revised payment Under the final policy of the revised ancillary radiology services is subject to
system. While we do not subject the ASC payment system, covered ancillary geographic adjustment, like payment for
device payment portion of the total ASC services are allowed separate payment. ASC surgical procedures. Only the ASC
payment for a device-intensive Covered ancillary services are defined at can receive payment for the facility
procedure to the transition policy, we § 416.164(b) as follows: brachytherapy resources required to provide the
transition the service payment portion sources; certain implantable items that ancillary radiology services, and ASCs
of the total ASC payment for the have pass-through status under the are no longer able to bill as independent
procedure over the 4 year phase-in OPPS; certain items and services that diagnostic testing facility (IDTF)
period. Procedures new to ASC payment we designate as contractor-priced suppliers to receive payment for
for CY 2008 or later calendar years (payment rate is determined by the ancillary radiology services that are
receive payments determined according Medicare contractor) including, but not integral to the performance of a covered
to the final methodology of the revised limited to, the procurement of corneal surgical procedure for which the ASC is
ASC payment system, without a tissue; certain drugs and biologicals for billing Medicare. Because the packaging
transition. which separate payment is allowed status of radiology services under the
ASC covered surgical procedures under the OPPS; and certain radiology revised ASC payment system parallels
listed in Addendum AA to this services for which separate payment is the OPPS, any changes to the packaging
proposed rule that are subject to the allowed under the OPPS. of radiology services under the OPPS
transition are assigned payment We continue to consider to be outside would also occur under the revised ASC
indicators ‘‘A2’’ (Surgical procedure on the scope of ASC services, as set forth payment system.
ASC list in CY 2007; payment based on in § 416.164(c), the following items and Radiology services include all
OPPS relative payment weight) and services, including, but not limited to: Category I CPT codes in the radiology
‘‘H8’’ (Device-intensive procedure on physicians’ services (including surgical range established by CPT, from 70000 to
ASC list in CY 2007; paid at adjusted procedures and all preoperative and 79999, and Category III CPT codes and
rate). ASC covered surgical procedures postoperative services that are Level II HCPCS codes that describe
listed in Addendum AA to this performed by a physician); anesthetists’ radiology services that crosswalk or are
proposed rule that are not subject to the services; radiology services (other than clinically similar to procedures in the
transition are assigned payment those integral to performance of a radiology range established by CPT.
indicators ‘‘G2’’ (Nonoffice-based covered surgical procedure); diagnostic This revised ASC payment system
surgical procedure added to ASC list in procedures (other than those directly policy for each calendar year applies to
CY 2008 or later; payment based on related to performance of a covered all radiology services that are separately
payable under the OPPS in that same application of the brachytherapy surgical procedure on ASC list; payment
calendar year. A listing that includes all sources is integrally related to the based on OPPS rate). We note that the
radiology services that we are proposing surgical procedures for insertion of brachytherapy source payment indicator
for separate payment under the CY 2008 brachytherapy needles and catheters. has changed for this proposed rule from
ASC payment system because they There is a statutory requirement that the the July 2007 final rule for the revised
would be separately payable under the OPPS establish separate payment groups ASC payment system, in which sources
proposed CY 2008 OPPS may be found for brachytherapy sources related to were designated with payment indicator
in Addendum BB to this proposed rule. their number, radioisotope, and H4, defined as ‘‘Brachytherapy source
Separately paid radiology services are radioactive intensity, as well as for paid separately when provided integral
assigned payment indicator ‘‘Z2’’ stranded and non-stranded sources as of to a surgical procedure on ASC list;
(Radiology service paid separately when July 1, 2007. OPPS procedure payments payment contractor-priced.’’ During CY
provided integral to a surgical specifically do not include payment for 2007, brachytherapy source payment is
procedure on ASC list; payment based brachytherapy sources. The ASC made under the OPPS, according to the
on OPPS relative payment weight) or brachytherapy source payment rate for a statute, at charges adjusted to cost. In
‘‘Z3’’ (Radiology service paid separately given calendar year is the same as the order to be consistent with that OPPS
when provided integral to a surgical OPPS payment rate for that year, policy under the revised ASC payment
procedure on ASC list; payment based without application of the ASC budget
system, our policy is to pay for
on MPFS nonfacility PE RVUs). neutrality adjustment or, if specific
brachytherapy sources under the revised
Payment for ancillary radiology services OPPS prospective payment rates are
ASC payment system using contractor-
that are packaged under the OPPS is unavailable, ASC payments for
brachytherapy sources are contractor- based pricing because we have no CCR
packaged under the revised ASC
priced. In addition, consistent with the data for ASCs that would enable us to
payment system, and these services are
identified in Addendum BB to this payment of brachytherapy sources pay at charges adjusted to cost like we
proposed rule with payment indicator under the OPPS, the ASC payment rates do under the OPPS. However, the CY
‘‘N1’’ (Packaged service/item; no for brachytherapy sources are not 2008 proposal for OPPS payment of
separate payment made). ASC payment adjusted for geographic wage brachytherapy sources, as described in
for these radiology services is not differences. Some Level II HCPCS codes section VII. of this proposed rule,
subject to the 4-year transition. and their proposed payment rates for proposes payment at prospective rates
brachytherapy sources for the CY 2008 calculated from historical claims data
(2) Brachytherapy Sources revised ASC payment system, the same and, therefore, the proposed ASC
Under the revised ASC payment as those proposed for the CY 2008 payment for brachytherapy sources
system, we provide separate payment to OPPS, are included in Addendum BB to would be at those same rates. The
ASCs for brachytherapy sources as this proposed rule. Brachytherapy HCPCS codes for all brachytherapy
covered ancillary services when they are sources are assigned payment indicator sources and their proposed ASC
implanted in conjunction with covered ‘‘H2’’ (Brachytherapy source paid payment amounts and ASC payment
surgical procedures billed by ASCs. The separately when provided integral to a indicators are listed in Table 57 below.
TABLE 57.—PROPOSED CY 2008 PAYMENTS FOR BRACHYTHERAPY SOURCES PROVIDED IN ASCS

ASC Proposed
HCPCS code Short descriptor payment CY 2008 ASC
indicator payment rate
A9527 ................................................................... Iodine I–125 sodium iodide ..................................................... H2 ............... $28.62

C1716 ................................................................... Brachytx, non-str, Gold-198 .................................................... H2 ................ 31.95
C1717 ................................................................... Brachytx, non-str, HDR Ir-192 ................................................ H2 ................ 173.40
C1719 ................................................................... Brachytx, NS, Non-HDR Ir-192 ............................................... H2 ................ 57.40
C2616 ................................................................... Brachytx, non-str,Yttrium-90 ................................................... H2 ................ 11,943.79
C2634 ................................................................... Brachytx, non-str, HA, I–125 ................................................... H2 ............... 29.93
C2635 ................................................................... Brachytx, non-str, HA, P–103 ................................................. H2 ................ 47.06
C2636 ................................................................... Brachy linear, non-str, P–103 ................................................. H2 ................ 37.09
C2638 ................................................................... Brachytx, stranded, I–125 ....................................................... H2 ................ 42.86
C2639 ................................................................... Brachytx, non-stranded, I–125 ................................................ H2 ............... 31.91
C2640 ................................................................... Brachytx, stranded, P–103 ...................................................... H2 ................ 62.24
C2641 ................................................................... Brachytx, non-stranded, P–103 .............................................. H2 ................ 45.29
C2642 ................................................................... Brachytx, stranded, C–131 ..................................................... H2 ................ 97.72
C2643 ................................................................... Brachytx, non-stranded, C–131 .............................................. H2 ................ 51.35
C2698 ................................................................... Brachytx, stranded, NOS ........................................................ H2 ................ 42.46
C2699 ................................................................... Brachytx, non-stranded, NOS ................................................. H2 ............... 29.93
The brachytherapy source HCPCS implemented under the OPPS in July (3) Drugs and Biologicals
codes listed in Table 57 are not all 2007 are not displayed in Addendum
included in Addendum BB to this BB to this proposed rule, they will be Under the revised ASC payment
proposed rule because they were new in included in Addendum BB to the CY system, we pay separately for all drugs
July 2007, and Addendum BB reflects 2008 OPPS/ASC final rule with and biologicals that are separately paid
under the OPPS, when they are
only those codes available for the April comment period and their final payment
provided integral to a covered surgical
2007 update to the OPPS. Although the will be effective under the revised ASC
procedure that is billed by the ASC to
proposed ASC payment rates for the payment system, beginning January 1, Medicare. We specify that a drug or
new brachytherapy source HCPCS codes 2008. biological is integral to a covered
surgical procedure if it is required for specifically HCPCS code C1821 adjust the labor-related portion of the
the successful performance of the (Interspinous process distraction device national ASC payment rates for
surgery and is provided to the (implantable)), and HCPCS code L8690 geographic wage differences. b.
beneficiary in the ASC immediately (Auditory osseointegrated device, Beneficiary Coinsurance
preceding, during, or immediately includes all internal and external Under the revised ASC payment
following the covered surgical components). We note that only the system, beneficiary coinsurance remains
procedure. Payments for separately surgical procedures associated with the at 20 percent for ASC services, except
payable drugs and biologicals under the implantation of HCPCS code L8690 are for screening flexible sigmoidoscopy
revised ASC payment system for a ASC covered surgical procedures for CY and screening colonoscopy procedures.
calendar year are equal to the OPPS 2008. As under the OPPS, ASC payment The coinsurance for screening
payment rates for that same year, for pass-through devices is not subject colonoscopies and screening flexible
without application of the ASC budget to the geographic wage adjustment. sigmoidoscopies is 25 percent, as
neutrality adjustment. In addition, The proposed pass-through device required by section 1834(d) of the Act,
consistent with the payment of drugs category HCPCS codes are included in with no deductible for those services
and biologicals under the OPPS, the Addendum BB to this proposed rule and under the revised ASC payment system.
ASC payment rates for these items are are assigned payment indicator ‘‘J7’’
not adjusted for geographic wage D. Proposed Treatment of New HCPCS
(OPPS pass-through device paid Codes
differences. separately when provided integral to a
A list of the drugs and biologicals that surgical procedure on ASC list; payment 1. Treatment of New CY 2008 Category
we are proposing for separate payment contractor-priced). Implantable devices I and III CPT Codes and Level II HCPCS
under the CY 2008 revised ASC that receive packaged payment because Codes
payment system and their proposed they do not have OPPS pass-through We finalized a policy in the July 2007
payment rates are included in status are also listed in Addendum BB
Addendum BB to the proposed rule. final rule for the revised ASC payment
to this proposed rule, where they are system to evaluate each year all new
Separately paid drugs and biologicals assigned payment indicator ‘‘N1’’
are assigned payment indicator ‘‘K2’’ HCPCS codes that describe surgical
(Packaged service/item; no separate procedures to make preliminary
(Drugs and biologicals paid separately payment made).
when provided integral to a surgical determinations regarding whether or not
The associated non-device facility they meet the criteria for payment in the
procedure on ASC list; payment based resources for the device implantation
on OPPS rate). Drugs and biologicals for ASC setting and, if so, whether they are
procedures are paid through the ASC office-based procedures. In the absence
which we are proposing to package surgical procedure service payment,
payment into the ASC payment for the of claims data that indicate where
based upon the payment weight for the procedures described by new codes are
covered surgical procedure in CY 2008 non-device portion of the related OPPS
because we are proposing to package being performed and reflect the facility
APC payment weight. resources required to perform them, we
under the OPPS for CY 2008, are also
listed in Addendum BB, where they are (5) Corneal Tissue Acquisition decided to use other available
assigned payment indicator ‘‘N1’’ information to make our interim
Under the revised ASC payment decisions regarding assignment of
(Packaged service/item; no separate system, we pay separately for corneal
payment made). payment indicators for the new codes.
tissue procurement provided integral to The other data available to us include
(4) Implantable Devices with Pass- the performance of an ASC covered our clinical advisors’ judgment, data
Through Status under the OPPS surgical procedure based on invoice regarding predecessor and related
Under the revised ASC payment costs. The HCPCS code for corneal HCPCS codes, information submitted by
system, we provide separate payment at tissue acquisition, V2785 (Processing, representatives of specialty societies
contractor-priced rates for devices that preserving and transporting corneal and professional associations, and
are included in device categories with tissue), is listed in Addendum BB to this information submitted by commenters
pass-through status under the OPPS proposed rule, and it is assigned during the public comment period
when the devices are an integral part of payment indicator ‘‘F4’’ (Corneal tissue following publication of the final rule
a covered surgical procedure. As we processing; paid at reasonable cost). with comment period in the Federal
have specified for drugs, biologicals, 3. General Payment Policies Register. We will publish in the annual
and ancillary radiology services, a pass- OPPS/ASC payment update final rule
a. Geographic Adjustment
through device would be considered the interim ASC determinations for the
integral to the covered surgical Under the revised ASC payment new codes to be effective January 1 of
procedure when it is required for the system policy, we utilize 50 percent as the update year. The interim payment
successful performance of the the labor related share. Fifty percent is indicators assigned to new codes under
procedure; is provided in the ASC significantly higher than the labor- the revised ASC payment system will be
immediately before, during, or related share used for the ASC payment subject to comment in that final rule.
immediately following the covered system through CY 2007 (34.45 percent) We will respond to those comments in
surgical procedure; and is billed by the but is also lower than the OPPS labor- the OPPS/ASC update final rule for the
ASC on the same day as the covered related share of 60 percent, a differential following calendar year, just as we
surgical procedure. we believe is appropriate given the currently respond to OPPS comments
In the future, new device categories broader range of labor-intensive services about APC and status indicator
may be established that will have OPPS provided in the HOPD setting. assignments for new procedure codes in
pass through status during all or a Consistent with the OPPS, we apply the OPPS update final rule for the year
portion of any calendar year. For CY to ASC payments the IPPS pre following publication of the code’s
2008, there are two device categories reclassification wage index values interim OPPS treatment.
with OPPS pass-through status that are associated with the June 2003 OMB After our review of public comments
proposed to continue in that status geographic localities, as recognized and in the absence of physicians’ claims
under the OPPS for CY 2008, under the IPPS and OPPS, in order to data, our determination that a new code
is an office based procedure and is, the OPPS treatment of HCPCS codes. As ASC payment indicators for new
thereby, subject to the payment discussed in the July 2007 final rule for Category III CPT codes that the AMA
limitation, would remain temporary and the revised ASC payment system, we releases in January, and that we
subject to review, until there are will provide a quarterly ASC update for determine are appropriate ASC covered
adequate data available to assess the each calendar quarter to recognize surgical procedures or covered ancillary
procedure’s predominant sites of newly created HCPCS codes for ASC services for implementation, as payable
service. Using those data, if we confirm payment and to update the payment in ASCs beginning in July of the same
our determination that the new code is rates for separately paid drugs and year. Likewise, as described above, we
office-based after taking into account the biologicals based on the most recently would implement annually for payment
most recent available volume and submitted ASP data. in the January update of the ASC
utilization data for the procedure code Under the OPPS and MPFS, CMS payment system any of the Category III
and/or, if appropriate, the clinical allows Category III CPT codes that are CPT codes that the AMA released the
characteristics, utilization, and volume released by the AMA in January to be previous July, along with new Category
of related codes, the code would be effective beginning July of the same I CPT codes that are determined to be
assigned permanently to the list of calendar year in which they are issued, appropriate for ASC payment. Interim
office-based procedures subject to the rather than deferring implementation of ASC payment indicators will be
ASC payment limitation. those codes to the following calendar assigned to those new mid-year
New HCPCS codes for ASC year update of the payment systems, as Category III CPT codes that are released
implementation on January 1, 2008, will is the case for the Category III codes that in January for implementation in July of
be designated in Addenda AA and BB are released in July by the AMA for a given calendar year, and the interim
to the OPPS/ASC final rule with implementation in January of the ASC indicators will be open to comment
comment period with comment upcoming calendar year. Therefore, in in the OPPS/ASC proposed rule for the
indicator ‘‘NI.’’ The ‘‘NI’’ comment contrast to the Category I CPT codes that following calendar year and their status
indicator is used to identify those are issued only once annually and that will be made final in the update year’s
HCPCS codes for which the assigned CMS recognizes as effective under the final rule.
ASC payment indicator is subject to MPFS and OPPS each January for the Of the Category III CPT codes the
public comment. (We refer readers to new calendar year, new Category III CPT AMA released January 1, 2007, we have
section XVI.J. of this proposed rule for codes are made effective under the determined that only one is appropriate
discussion of ASC payment and MPFS and OPPS biannually. In order to for payment in ASCs as a covered
comment indicators.) be consistent in this regard across the ancillary radiology service. The new
three payment systems, we are CPT code is 0182T (High dose rate
2. Proposed Treatment of New Mid-Year
proposing to adopt that same policy electronic brachytherapy, per fraction),
Category III CPT Codes
under the revised ASC payment system. and we are proposing to assign it to the
Twice each year, the AMA issues Some of the new Category III CPT list of covered ancillary services with
Category III CPT codes, which the AMA codes may describe services that our payment indicator ‘‘Z2’’ as noted in
defines as temporary codes for emerging medical advisors determine directly Table 58 below for payment in ASCs
technology, services, and procedures. crosswalk or are clinically similar to beginning January 1, 2008. This service
The AMA established Category III CPT HCPCS codes that describe ASC covered has no MPFS nonfacility PE RVUs
codes to allow collection of data specific surgical procedures. In those instances, assigned to it. Therefore, we are
to the service described by the code we may allow ASC payment for the new proposing that its CY 2008 ASC
which otherwise could only be reported Category III CPT code as a covered payment be calculated according to the
using a Category I CPT unlisted code. surgical procedure. Similarly, the new standard ASC payment system
The AMA releases Category III CPT code may represent an ancillary service methodology, based on the code’s OPPS
codes in January, for implementation that directly crosswalks or is clinically relative payment weight.
beginning the following July, and in similar to those for which separate ASC We do not believe that any of the
July, for implementation beginning the payment is allowed when it is other Category III CPT codes released in
following January. performed integral to a covered surgical January 2007 for implementation in July
CMS provides a predictable quarterly procedure, and the new code also may 2007 meet the criteria for inclusion on
update for the OPPS occurring be determined to be eligible for ASC the ASC list of covered surgical
throughout each calendar year (January, payment as a covered ancillary service. procedures or covered ancillary services
April, July, and October), and the final Therefore, beginning in CY 2008, we because they do not directly crosswalk
payment policies of the revised ASC are proposing to include in the July and are not clinically similar to
payment system parallel, in many cases, update to the ASC payment system, the established covered ASC services.
TABLE 58.—CATEGORY III CPT CODE IMPLEMENTED IN JULY 2007AND PROPOSED FOR CY 2008 ASC PAYMENT
Proposed
CY 2008
HCPCS code Long descriptor ASC Payment
Indicator
0182T .......................... High dose rate electronic brachytherapy, per fraction .............................................................................. Z2
3. Proposed Treatment of Level II provides a predictable quarterly update codes describing new procedures, drugs
HCPCS Codes Released on a Quarterly for the OPPS occurring throughout each and biologicals would be made payable
Basis calendar year (January, April, July, and in ASCs in the same calendar quarter as
In addition to the Category III CPT October). As discussed in the July 2007 they are initially paid under the OPPS.
codes that are released twice each year, final rule for the revised ASC payment We are proposing to assign payment
new Level II HCPCS codes may be system, we will provide a quarterly ASC indicator K2 to the 7 new codes for
created more frequently and are update for each calendar quarter to drugs to indicate that separate payment
implemented for the MPFS and OPPS recognize newly created Level II HCPCS would be made for those drugs when
on a quarterly basis. Level II HCPCS codes for ASC payment and to update
they are provided to beneficiaries in
codes are most commonly created for the payment rates for separately paid
ASCs integral to covered surgical
the purpose of reporting new drugs and drugs and biologicals based on the most
procedures. We are proposing to include
biologicals but also are created for recently submitted ASP data.
We are proposing to update the lists new Level II HCPCS code C9728
reporting some surgical procedures and (Placement of interstitial device(s) for
other services for which payment may of covered surgical procedures and
ancillary services that qualify for radiation/surgery guidance (e.g., fiducial
be made under the revised ASC markers, dosimeter), other than prostate
payment system, as it is under the separate payment in ASCs in CY 2008
by adding 8 new Level II HCPCS codes (any approach), single or multiple) as a
OPPS. covered surgical procedure with
We base the ASC payment policies for that were implemented in the OPPS in
covered surgical procedures, drugs, July 2007 and that were not addressed payment indicator ‘‘R2’’ because it is
biologicals, and certain other covered in the CY 2007 OPPS/ASC final rule clinically similar to CPT code 55876
ancillary services integral to ASC with comment period. Because of the (Placement of interstitial device(s) for
covered surgical procedures on the timing of this proposed rule, the new radiation therapy guidance (e.g., fiducial
OPPS and, therefore, we are proposing Level II HCPCS codes implemented markers, dosimeter), prostate (via
to update the coding and payment for through the July 2007 OPPS update are needle, any approach), single or
the services in ASCs at the same time not included in Addendum BB to this multiple) that we have included on the
that the OPPS is updated. In order to proposed rule and there were no Level list of covered surgical procedures with
maintain consistency across the OPPS II HCPCS codes included in the April payment indicator of ‘‘P3.’’ While we
and ASC payment systems, as discussed OPPS update that were eligible for believe both procedures are office-
in the July 2007 final rule for the revised payment under the OPPS. The new CY based, there are currently no nonfacility
ASC payment system, we are proposing 2007 Level II HCPCS codes we are PE RVUs available for the Level II
to recognize newly created Level II proposing for ASC payment beginning HCPCS code C9728, which was initially
HCPCS codes under the revised ASC in January 2008 are listed in Table 59. established in response to a New
payment system for payment on a Beginning in CY 2008, with Technology APC application under the
quarterly basis, consistent with the implementation of the revised ASC OPPS, and, therefore, its payment
quarterly updates to the OPPS. CMS payment system, the Level II HCPCS indicator is ‘‘R2.’’
TABLE 59.—LEVEL II HCPCS CODES IMPLEMENTED UNDER THE OPPS IN APRIL OR JULY 2007 AND PROPOSED FOR CY
2008 ASC PAYMENT
Proposed
CY 2008
HCPCS code Short descriptor ASC
payment
indicator
C9728 .................................... Place device/marker, non prostate .................................................................................................... R2

Q4087 .................................... Octagam injection .............................................................................................................................. K2
Q4088 .................................... Gammagard liquid injection ............................................................................................................... K2
Q4089 .................................... Rhophylac injection ............................................................................................................................ K2
Q4090 .................................... HepaGam B IM injection ................................................................................................................... K2
Q4091 .................................... Flebogamma injection ........................................................................................................................ K2
Q4092 .................................... Gamunex injection ............................................................................................................................. K2
Q4095 .................................... Reclast injection ................................................................................................................................. K2
In summary, beginning in CY 2008 E. Proposed Updates to Covered established our policies for determining
with implementation of the revised ASC Surgical Procedures and Covered which procedures are eligible to be
payment system, we are proposing to Ancillary Services considered ASC covered surgical
implement new Level II HCPCS codes procedures and, of those, which are
for ASC payment on a quarterly basis 1. Identification of Covered Surgical excluded from ASC payment because
each year and new Category III CPT Procedures they pose a significant risk to
codes on a semi annual basis, to parallel a. General Policies beneficiary safety or would be expected
the policies under the MPFS and OPPS to require an overnight stay. We adopted
for the recognition of those codes. Also, We published Addendum AA to the a definition of surgical procedure for the
consistent with the MPFS and OPPS July 2007 final rule for the revised ASC revised ASC payment system as those
policies, our final policy with regard to payment system as an illustrative list of procedures described by all Category I
Category I CPT codes is to publish the covered surgical procedures and CPT codes in the surgical range from
new codes and interim payment payment rates for the revised ASC 10000 through 69999 except unlisted
indicators annually in the OPPS/ASC payment system to be implemented procedure codes, as well as those
final rule with comment period. January 1, 2008. The final rule Category III CPT codes and Level II
HCPCS codes that crosswalk or are procedures, and procedures for which We are proposing to remove 13
clinically similar to ASC covered there is revised coding to identify any procedures from the OPPS inpatient list
surgical procedures. that we believe are appropriate for and, of those 13, we believe that 3 are
Section 1833(i)(1) of the Act requires coverage in ASCs because they do not safe for performance in ASCs. Therefore,
us to review and update the list of ASC pose significant risks to beneficiary at this time, we are proposing to add
procedures at least every 2 years. We safety and would not be expected to these three additional new surgical
finalized our policy to update the ASC require overnight stays. procedures to the ASC list of covered
list of covered surgical procedures In the July 2007 final rule for the surgical procedures eligible for
annually, in conjunction with annual revised ASC payment system, we
Medicare ASC payment in CY 2008. The
proposed and final rulemaking to finalized the addition of 793 new
proposed procedures and their ASC
update the OPPS and ASC payment covered surgical procedures for
systems. Each year we undertake a payment under the revised ASC payment indicators are displayed in
review of excluded procedures, new payment system beginning in CY 2008. Table 60.
TABLE 60.—PROCEDURES PROPOSED AS NEW ASC COVERED SURGICAL PROCEDURES FOR CY 2008
Proposed
ASC
indicator
25931 ..................................... Amputation follow-up surgery ............................................................................................................ G2

50580 ..................................... Kidney endoscopy & treatment ......................................................................................................... G2
58805 ..................................... Drainage of ovarian cyst(s) ............................................................................................................... G2
In this proposed rule, we are the office-based designation only to individual procedure code and/or, as
soliciting commenters’ procedures that would no longer be appropriate, the clinical characteristics,
recommendations regarding additional excluded from ASC payment beginning utilization, and volume of related codes.
surgical procedures that they believe in CY 2008 or later years and to exempt As a result of that review, we identified
should not be excluded from ASC all procedures on the CY 2007 ASC list 19 procedures assigned payment
payment beginning in CY 2008. We from application of the office based indicator ‘‘G2’’ in the July 2007 final
specifically encourage commenters to classification. We believe that the rule for the revised ASC payment
provide evidence, to the extent possible, resulting list accurately reflected system that we are proposing to assign
to support their recommendations Medicare practice patterns and was to the office-based procedure list with
regarding procedures and services they clinically consistent. In Addendum AA payment indicator ‘‘P2,’’ ‘‘P3,’’ or ‘‘R2,’’
believe should not be excluded from to the July 2007 final rule for the revised as appropriate. We refer readers to
ASC payment. ASC payment system, each of the office- Addendum DD1 to this proposed rule
b. Proposed Change in Designation of based procedures is identified by for the definitions of the ASC payment
Covered Surgical Procedures as Office- payment indicator ‘‘P2,’’ ‘‘P3,’’ or ‘‘R2,’’ indicators.
Based depending on whether we estimated it We will consider comments
would be paid according to the standard submitted timely on the proposed
According to our final policy for the ASC payment methodology based on its
revised ASC payment system, we designation of these 19 new procedures
OPPS relative payment weight or at the as office-based for CY 2008. For
designate as office-based procedures MPFS nonfacility PE RVU amount.
that are added to the ASC list of covered example, in the July 2007 final rule for
surgical procedures in CY 2008 or later Consistent with our final ASC policy the revised ASC payment system,
years and that we determine are to review and update annually the payment indicator ‘‘G2’’ was assigned to
predominantly performed in physicians’ surgical procedures for which ASC CPT code 64650 (Chemodenervation of
offices based on consideration of the payment is made and to identify new eccrine glands; both axillae). After
most recent available volume and procedures that may be appropriate for reviewing more recent CY 2006 data, we
utilization data for each individual ASC payment, in developing this discovered that the procedure is
procedure code and/or, if appropriate, proposed rule we reviewed the CY 2006 performed predominantly in physicians’
the clinical characteristics, utilization, utilization data for all those surgical offices and we believe the procedure
and volume of related codes. procedures newly added for ASC should be designated as an office-based
The list of codes that we identified as payment in CY 2008 that were assigned procedure. Therefore, we are proposing
office-based in the July 2007 final rule payment indicator ‘‘G2’’ as nonoffice- to assign payment indicator ‘‘P3’’ to CPT
for the revised ASC payment system based additions in the July 2007 final code 64650, effective for CY 2008. In
took into account the most recent rule for the revised ASC payment this proposed rule, we are proposing to
available CY 2005 volume and system. We based our evaluation of the assign an office-based payment
utilization data for each individual potential designation of a procedure as indicator for CPT code 64650 and 18
procedure code or related codes. In that office-based on the most recent available other procedures, as displayed in Table
rule, we finalized our policy to apply volume and utilization data for each 61.
TABLE 61.—PROPOSED CY 2008 NEW DESIGNATIONS OF ASC COVERED SURGICAL PROCEDURES AS OFFICE-BASED
ASC Pay- Proposed
ment CY 2008
Indicator in
HCPCS code Short descriptor ASC pay-
July 2007 ment
ASC Final indicator
Rule
24640 ............................... Treat elbow dislocation .................................................................................................. G2 ............... P3

26641 ............................... Treat thumb dislocation ................................................................................................. G2 ............... P2
26670 ............................... Treat hand dislocation ................................................................................................... G2 ............... P2
26700 ............................... Treat knuckle dislocation ............................................................................................... G2 ............... P2
26775 ............................... Treat finger dislocation .................................................................................................. G2 ............... P3
28630 ............................... Treat toe dislocation ...................................................................................................... G2 ............... P3
28660 ............................... Treat toe dislocation ...................................................................................................... G2 ............... P3
28890 ............................... High energy eswt, plantar fascia ................................................................................... G2 ............... P3
29035 ............................... Application of body cast ................................................................................................. G2 ............... P2
29305 ............................... Application of hip cast .................................................................................................... G2 ............... P2
29325 ............................... Application of hip casts .................................................................................................. G2 ............... P2
29505 ............................... Application, long leg splint ............................................................................................. G2 ............... P3
29515 ............................... Application lower leg splint ............................................................................................ G2 ............... P3
36469 ............................... Injection(s), spider veins ................................................................................................ G2 ............... R2
46505 ............................... Chemodenervation anal misc ........................................................................................ G2 ............... P3
62292 ............................... Injection into disk lesion ................................................................................................. G2 ............... R2
64447 ............................... Nblock inj fem, single ..................................................................................................... G2 ............... R2
64650 ............................... Chemodenerv, eccrine glands ....................................................................................... G2 ............... P3
64653 ............................... Chemodenerv, eccrine glands ....................................................................................... G2 ............... P3
We also reviewed the five procedures list and assign it to payment indicator ring segments) and no claims for 0124T
that were assigned temporary office- ‘‘P3’’ for CY 2008. In accordance with (Conjunctival incision with posterior
based payment indicators in the July the CY 2008 OPPS proposal to package juxtascleral placement of
2007 final rule for the revised ASC payment for CPT code 58110 pharmacological agent (does not include
payment system. Those codes are listed (Endometrial sampling (biopsy) supply of medication)) or CPT code
in Table 62 below. Using the most performed in conjunction with 55876 (Placement of interstitial
recent data available, we believe there colposcopy), we are also proposing to device(s) for radiation therapy guidance
are adequate claims data for two of the package payment for this procedure (e.g., fiduciary markers, dosimeter),
procedures upon which to base under the ASC payment system and prostate (via needle, any approach),
assignment of permanent office-based assign it payment indicator ‘‘N1’’ as single or multiple). We continue to
payment indicators. Table 62 shows that indicated in Table 62. believe these procedures are
we are proposing to assign CPT code We are proposing to maintain the
predominantly office-based. Therefore,
36598 (Contrast injection(s) for temporary office-based payment
radioisotope evaluation of existing indicator assignments for the other three we are not proposing to make any
central venous access device, including procedures listed in Table 62. We have change to the temporary office-based
fluoroscopy, image documentation and only a few claims for CPT code 0099T designation of these procedures at this
report) permanently to the office-based (Implantation of intrastromal corneal time.
TABLE 62.—PROPOSED PAYMENT INDICATORS FOR PROCEDURES ASSIGNED TEMPORARY OFFICE-BASED PAYMENT
INDICATORS IN THE JULY 2007 ASC FINAL RULE
Proposed Final
CY 2008 ASC
Payment
Temporary Indicator (or
Office Based * if HCPCS
Payment
HCPCS Code Short descriptor code will
Indicator in continue with
July 2007 temporary of-
ASC Final Rule fice-based
assignment for
CY 2008)
0099T ...................................... Implant corneal ring ......................................................................................... R2 ................... *
0124T ...................................... Conjunctival drug placement ........................................................................... R2 ................... *
36598 ...................................... Inj w/fluor, eval cv device ................................................................................ P2 ................... P3

55876 ...................................... Place rt device/marker, pros ............................................................................ P3 ................... *
58110 ...................................... Bx done w/colposcopy add-on ......................................................................... P3 ................... N1
c. Proposed Changes to Designation of the CY 2007 ASC list of covered surgical for ICD implantation.procedures as
Covered Surgical Procedures as Device- procedures that would be subject to this discussed in section III.D.7. of this
Intensive policy, as well as 15 new ASC covered proposed rule. In the July 2007 final
surgical procedures for CY 2008 to rule for the revised ASC payment
As explained in section XVI.C. of this which we expected the final policy to system, either payment indicator ‘‘H8’’
proposed rule, we adopted a modified apply. or ‘‘J8’’ was assigned to the procedures
payment methodology for calculating As a result of the proposed CY 2008 that we estimated would be designated
the ASC payment rates for ASC covered reconfiguration of several device- as device-intensive procedures for CY
surgical procedures that are assigned to dependent APCs under the OPPS and 2008. As displayed in Table 63 below,
the subset of device-dependent APCs the proposed updated APC device offset we are proposing to assign payment
under the OPPS with a device offset percentages, we are proposing to indicators ‘‘H8’’ or ‘‘J8,’’ as appropriate,
percentage greater than 50 percent designate as device-intensive for ASC to the covered surgical procedures
under the OPPS to ensure that payment payment in CY 2008 an additional 10 included in the table so that the
for the procedure is adequate to provide ASC covered surgical procedures. We payment for these surgical procedures
packaged payment for the high-cost are also proposing to remove 4 would be made consistent with our final
implantable devices used in those procedures from their estimated revised ASC payment system payment
procedures. In the July 2007 final rule designation as device-intensive because policy for device-intensive procedures
for the revised ASC payment system, we we are proposing to recognize CPT that are identified according to their
identified 24 procedures that were on codes instead of Level II HCPCS codes APC assignments under the OPPS.
TABLE 63.—PROPOSED ASC COVERED SURGICAL PROCEDURES PROPOSED FOR DESIGNATION AS DEVICE-INTENSIVE FOR
CY 2008
Proposed CY
Proposed CY 2008 device-
HCPCS code Short descriptor 2008 OPPS dependent
APC APC offset
percentage
33206 ................ Insertion of heart pacemaker .................................................................................................... 0089 74.02

33210 ................ Insertion of heart electrode ....................................................................................................... 0106 57.20
33211 ................ Insertion of heart electrode ....................................................................................................... 0106 57.20
33212 ................ Insertion of pulse generator ...................................................................................................... 0090 75.54
33213 ................ Insertion of pulse generator ...................................................................................................... 0654 75.86
33214 ................ Upgrade of pacemaker system ................................................................................................ 0655 74.59
33216 ................ Insert lead pace-defib, one ....................................................................................................... 0106 57.20
33217 ................ Insert lead pace-defib, dual ...................................................................................................... 0106 57.20
33224 ................ Insert pacing lead & connect .................................................................................................... 0418 81.38
33225 ................ Lventric pacing lead add-on ..................................................................................................... 0418 81.38
33240 ................ Insert pulse generator ............................................................................................................... 0107 89.43
33249 ................ Eltrd/insert pace-defib ............................................................................................................... 0108 89.26
33282 ................ Implant pat-active ht record ...................................................................................................... 0680 72.14
36566 ................ Insert tunneled cv cath ............................................................................................................. 0625 62.63
53440 ................ Male sling procedure ................................................................................................................ 0385 51.67
53444 ................ Insert tandem cuff ..................................................................................................................... 0385 51.67
53445 ................ Insert uro/ves nck sphincter ..................................................................................................... 0386 61.98
53447 ................ Remove/replace ur sphincter .................................................................................................... 0386 61.98
54400 ................ Insert semi-rigid prosthesis ....................................................................................................... 0385 51.67
54401 ................ Insert self-contd prosthesis ....................................................................................................... 0386 61.98
54405 ................ Insert multi-comp penis pros .................................................................................................... 0386 61.98
54410 ................ Remove/replace penis prosth ................................................................................................... 0386 61.98
54416 ................ Remv/repl penis contain pros ................................................................................................... 0386 61.98
55873 ................ Cryoablate prostate .................................................................................................................. 0674 59.34
61885 ................ Insrt/redo neurostim 1 array ..................................................................................................... 0039 82.15
61886 ................ Implant neurostim arrays .......................................................................................................... 0315 86.23
62361 ................ Implant spine infusion pump ..................................................................................................... 0227 79.69
62362 ................ Implant spine infusion pump ..................................................................................................... 0227 79.69
63650 ................ Implant neuroelectrodes ........................................................................................................... 0040 55.93
63685 ................ Insrt/redo spine n generator ..................................................................................................... 0222 83.29

64590 ................ Insrt/redo pn/gastr stimul .......................................................................................................... 0222 83.29
69930 ................ Implant cochlear device ............................................................................................................ 0259 83.03
2. Proposed Changes for Identification apply to covered surgical procedures payment to providers when a device is
of Covered Ancillary Services identified as office-based or device- replaced without cost or with full credit
In the July 2007 final rule for the intensive. for the cost of the device being replaced,
revised ASC payment system, we set The payment amounts provided in for those ASC covered surgical
forth our policy to make separate ASC Addendum AA to the July 2007 final procedures that are assigned to APCs
rule for the revised ASC payment under the OPPS to which this policy
payments for certain ancillary services,
system were illustrative only, and we applies. In the case of no cost or full
for which separate payment is made
are proposing to update them in this credit cases under the OPPS, we reduce
under the OPPS, when they are
proposed rule. We are not proposing to the APC payment to the hospital by the
provided integral to ASC covered
make any changes to the final policies device offset amount that we estimate
surgical procedures. Under the revised
established in the July 2007 final rule represents the cost of the device.
ASC payment system, we exclude from
for the revised ASC payment system Therefore, in accordance with the OPPS
the scope of ASC facility services, for
related to the methodology for policy implemented in CY 2007, and the
which payment is packaged into the
developing the relative payment weights ASC policy as finalized in the July 2007
ASC payment for the covered surgical
and rates. The differences in the final rule for the revised ASC payment
procedure, the following ancillary system, beginning in CY 2008, we
services that are integral to a covered payment rates for covered surgical
procedures with ‘‘G2’’ and ‘‘A2’’ reduce the amount of payment made to
surgical procedure: brachytherapy ASCs for certain covered surgical
sources; certain implantable items that payment indicators, reflected in
Addendum AA to this proposed rule, procedures when the necessary device
have pass-through status under the is furnished without cost to the ASC or
OPPS; certain items and services that compared with the July 2007 final rule
for the revised ASC payment system are the beneficiary or with a full credit for
we designate as contractor-priced, the cost of the device being replaced.
including, but not limited to, due to our use of updated CY 2006
utilization data, proposed payment We provide the same amount of
procurement of corneal tissue; certain payment reduction based on the device
drugs and biologicals for which separate policy changes for the CY 2008 OPPS,
including APC reassignments and offset amount in ASCs that would apply
payment is allowed under the OPPS; under the OPPS for performance of
and certain radiology services for which changes to packaged services, and the
proposed OPPS update factor. those procedures under the same
separate payment is allowed under the circumstances. Specifically, when a
We also are proposing to update the
OPPS. These covered ancillary services procedure that is listed in Table 64
payment amounts for the office-based
are specified in § 416.164(b) and fall below is performed in an ASC and the
procedures in this rule. Using the most
within the scope of ASC services, so case involves implantation of a no cost
recent available MPFS and OPPS data,
they are eligible for separate ASC or full credit device listed in Table 65,
including the proposed CY 2008 rates,
payment. the ASC must report the HCPCS ‘‘FB’’
we compared the estimated CY 2008
In this proposed rule, we are modifier on the line with the covered
rate for each of the office-based
proposing to make changes to the list of surgical procedure code to indicate that
procedures calculated according to the
covered ancillary services eligible for an implantable device in Table 65 was
standard methodology of the revised
separate ASC payment, as proposed in furnished without cost. The devices
ASC payment system and to the MPFS
Addendum BB to this proposed rule, to listed in Table 65 are the same proposed
nonfacility PE RVUs to determine which
comport with their proposed treatment devices to which the policy applies
is the lower payment amount that,
under the OPPS according to the final under the OPPS, and the procedures
therefore, is the rate we are proposing
payment policies of the revised ASC listed in Table 64 are those ASC covered
for payment of the procedure according
payment system, and to add new surgical procedures assigned to
to the final policy of the revised ASC
Category III CPT code 0182T (High dose proposed APCs under the OPPS to
payment system. The proposed update
rate electronic brachytherapy, per which the policy applies.
to the rates results in changes to the
fraction), as discussed in section As finalized in the July 2007 final rule
payment indicators, as well as the rates,
XVI.D.2 of this proposed rule. for the revised ASC payment system,
for several of the office-based
F. Proposed Payment for Covered when the ‘‘FB’’ modifier is reported
procedures. For example, a procedure
Surgical Procedures and Covered with a procedure code that is listed in
with payment indicator ‘‘P2’’ in the July
Table 64, the contractor reduces the
Ancillary Services 2007 final rule for the revised ASC
ASC payment by the amount of payment
payment system may be assigned
1. Proposed Payment for Covered that we attributed to the device when
payment indicator ‘‘P3’’ in this
Surgical Procedures the ASC payment rate was calculated.
proposed rule, depending on the
a. Proposed Update to Payment Rates The reduction of ASC payment in this
outcome of that rate comparison.
circumstance is necessary to pay
Our final payment policy for covered In addition, we are proposing to
appropriately for the covered surgical
surgical procedures under the revised update the payment amounts for the
procedure being furnished by the ASC.
ASC payment system is described in device intensive procedures in this rule,
section XVI.C. of this proposed rule. For based on the CY 2008 OPPS proposal (2) Proposed Policy When Implantable
CY 2008, payment for procedures with and updated OPPS claims data. Devices Are Replaced With Partial
payment indicator ‘‘G2’’ will be Credit
b. Payment Policies When Devices Are
calculated by multiplying the ASC Replaced at No Cost or With Credit Consistent with our CY 2008 OPPS
relative payment weight for the proposal discussed in section IV.A.3. of
procedure by the final ASC conversion (1) Policy When Devices Are Replaced this proposed rule, we are proposing to
factor. For those procedures with at No Cost or With Full Credit reduce the ASC payment by one half of
payment indicator ‘‘A2,’’ a blended rate Our final ASC policy with regard to the device offset amount for certain
will be used that is comprised of 25 payment for costly devices implanted in surgical procedures into which the
percent of the revised ASC payment rate ASCs is fully consistent with the current device cost is packaged, when an ASC
added to 75 percent of the CY 2007 OPPS policy. The ASC policy includes receives a partial credit toward
payment rate. Special payment policies adoption of the OPPS policy for replacement of an implantable device.
This partial payment reduction would packaged into the procedure payment. in Table 65 when used in a surgical
apply to covered surgical procedures in In the absence of OPPS claims data on procedure listed in Table 64. The
which the amount of the device credit which to base a reduction factor, but proposed policy related to partial device
is greater than or equal to 20 percent of taking into consideration what we have credits applies to the same devices and
the cost of the new replacement device been told is common industry practice, procedures to which our policy
being implanted. we believe that reducing the amount of governing payment when the device is
We also are proposing to base the payment for the device-dependent APC furnished to the ASC without cost or
beneficiary’s coinsurance on the and the related ASC covered surgical with full credit applies. We selected
reduced ASC payment rate so that the procedure by half of the estimated cost these devices because they have
beneficiary shares the benefit of the of the device packaging represents a substantial costs and because each
ASC’s reduced costs. This proposed reasonable reduction in these cases. device is implanted in one beneficiary
policy is set forth in proposed new Moreover, we are proposing to take at least temporarily and, therefore, can
§ 416.179(b)(2). this reduction only when the credit is be associated with an individual
We have no OPPS data to empirically for 20 percent or more of the cost of the beneficiary. Moreover, we believe that
determine by how much we should new replacement device, so that the this policy is a logical extension of our
reduce the payment for ASC surgical reduction is not taken in cases in which established policy regarding reduction
procedures into which the costs of these more than 80 percent of the cost of the of the ASC payment in cases in which
devices are packaged. Device replacement device has been incurred the facility furnishes the device without
manufacturers and hospitals have told by the facility. If the partial credit is less cost or with a full credit to the ASC and
us that a common scenario is that, if a than 20 percent of the cost of the new ensures that beneficiary and Medicare
device fails 3 years after implantation, replacement device, we believe that payments are appropriate and consistent
the hospital would receive a 50 percent reducing the payment for the device with costs incurred by ASCs.
credit towards a replacement device. We implantation procedure by 50 percent of This partial device credit policy that
do not believe that hospitals reduce the packaged device cost would provide we are proposing would enhance our
their device charges to reflect the credits too low a payment for necessary device ability to track the replacement of these
that may have been received, so the replacement procedures. This proposed implantable medical devices and may
lower facility costs associated with policy is discussed in section IV.A. of enable us to identify patterns of device
these partial credit scenarios would this proposed rule for the OPPS and is failure or limited longevity early in their
likely not be reflected in our proposed fully consistent with the proposed FY natural history so that appropriate
OPPS rates for these device-dependent 2008 Medicare payment policy for strategies to reduce future problems for
procedures. Therefore, we are proposing hospital inpatient services and the our beneficiaries may be developed. We
under the OPPS to reduce the payment proposed CY 2008 policy for hospital also are mindful of the opportunity to
for the relevant device-dependent APCs outpatient services. use our claims history data to promote
and, under the revised ASC payment Therefore, we are proposing that the high quality medical care with regard to
system, to reduce the payment for those new HCPCS partial credit modifier the devices and the services in which
ASC covered surgical procedures would be reported and the partial credit they are used. Collecting data on a
assigned to those APCs under the OPPS reduction would be taken only in cases wider set of device replacements under
by half of the reduction that applies in which the device credit is equal to or full and partial credit situations in all
when the hospital or ASC receives a greater than 20 percent of the cost of the sites of outpatient surgery, including
device without cost or receives a full new replacement device. The partial ASCs, would assist in developing
credit for a device being replaced. That credit reduction modifier would be comprehensive summary data, not just a
is, we are proposing to reduce the reported in all cases in which the ASC subset of data related to devices
payments by half of the offset amount receives a partial credit toward the replaced without cost or with a full
that represents the cost of the device replacement of a medical device listed credit to facilities.
TABLE 64.—PROPOSED ADJUSTMENTS TO PAYMENTS FOR ASC COVERED SURGICAL PROCEDURES IN CY 2008 IN CASES
OF DEVICES REPORTED WITHOUT COST OR FOR WHICH FULL OR PARTIAL CREDIT IS RECEIVED
50 Percent
Proposed of proposed
Proposed CY 2008
HCPCS CY 2008
Short descriptor CY 2008 APC title OPPS
code OPPS
OPPS APC offset offset
percentage percentage
61885 ....... Insrt/redo neurostim 1 array ...................... 0039 Level I Implantation of Neurostimulator .... 82.15 41.07
63560 ....... Implant neuroelectrodes ............................ 0040 Percutaneous Implantation of 55.93 27.97
64555 ....... Implant neuroelectrodes Neurostimulator Electrodes, Excluding
64560 ....... Implant neuroelectrodes Cranial Nerve.
64561 ....... Implant neuroelectrodes
63655 ....... Implant neuroelectrodes ............................ 0061 Laminectomy or Incision for Implantation 59.32 29.66
64575 ....... Implant neuroelectrodes of Neurostimulator Electrodes, Exclud-
64577 ....... Implant neuroelectrodes ing Cranial Nerve.

33206 ....... Insertion of heart pacemaker .................... 089 Insertion/Replacement of Permanent 74.02 37.01
33207 ....... Insertion of heart pacemaker Pacemaker and Electrodes.
33212 ....... Insertion of pulse generator ...................... 0090 Insertion/Replacement of Pacemaker 75.54 37.77
Pulse Generator.
TABLE 64.—PROPOSED ADJUSTMENTS TO PAYMENTS FOR ASC COVERED SURGICAL PROCEDURES IN CY 2008 IN CASES
OF DEVICES REPORTED WITHOUT COST OR FOR WHICH FULL OR PARTIAL CREDIT IS RECEIVED—Continued
50 Percent
Proposed of proposed
Proposed CY 2008
HCPCS CY 2008
Short descriptor CY 2008 APC title OPPS
code OPPS
OPPS APC offset offset
percentage percentage
33210 ....... Insertion of heart electrode ....................... 0106 Insertion/Replacement/Repair of Pace- 57.20 28.60
33211 ....... Insertion of heart electrode maker and/or Electrodes.
33216 ....... Insert lead pace-defib, one
33217 ....... Insert lead pace-defib, dual
33240 ....... Insert pulse generator ............................... 0107 Insertion of Cardioverter-Defibrillator ........ 89.43 44.72
33249 ....... Eltrd/insert pace-defib ............................... 0108 Insertion/Replacement/Repair of 89.26 44.63
Cardioverter-Defibrillator Leads.
63685 ....... Insrt/redo spine n generator ...................... 0222 Implantation of Neurological Device ......... 83.29 41.64
64590 ....... Insrt/redo perph n generator
64553 ....... Implant neuroelectrodes ............................ 0225 Implantation of Neurostimulator Elec- 80.84 40.42
64573 ....... Implant neuroelectrodes trodes, Cranial Nerve.
62361 ....... Implant spine infusion pump ..................... 0227 Implantation of Drug Infusion Device ........ 79.69 39.85
62362 ....... Implant spine infusion pump
69930 ....... Implant cochlear device ............................ 0259 Level VI ENT Procedures ......................... 83.03 41.52
61886 ....... Implant neurostim arrays .......................... 0315 Level II Implantation of Neurostimulator ... 86.23 43.12
53440 ....... Male sling procedure ................................. 0385 Level I Prosthetic Urological Procedures .. 51.67 25.83
53444 ....... Insert tandem cuff
54400 ....... Insert semi-rigid prosthesis
53445 ....... Insert uro/ves nck sphincter ...................... 0386 Level II Prosthetic Urological Procedures 61.98 30.99
53447 ....... Remove/replace ur sphincter
54401 ....... Insert self-contd prosthesis
54405 ....... Insert multi-comp penis pros
54410 ....... Remove/replace penis prosth
54416 ....... Remv/repl penis contain pros ...................
33224 ....... Insert pacing lead & connect .................... 0418 Insertion of Left Ventricular Pacing Elect 81.38 40.69
33225 ....... L ventric pacing lead add-on
36566 ....... Insert tunneled cv cath .............................. 0625 Level IV Vascular Access Procedures ...... 62.63 32.32
33213 ....... Insertion of pulse generator ...................... 0654 Insertion/Replacement of a permanent 75.86 37.93
dual chamber pacemaker.
33214 ....... Upgrade of pacemaker system ................. 0655 Insertion/Replacement/Conversion of a 74.59 37.30
33208 ....... Insertion of heart pacemaker permanent dual chamber pacemaker.
33282 ....... Implant pat-active ht record ...................... 0680 Insertion of Patient Activated Event Re- 72.14 36.07
corders.
TABLE 65.—PROPOSED DEVICES FOR TABLE 65.—PROPOSED DEVICES FOR 2. Proposed Payment for Covered
WHICH THE ‘‘FB’’ OR NEW HCPCS WHICH THE ‘‘FB’’ OR NEW HCPCS Ancillary Services
MODIFIER MUST BE REPORTED MODIFIER MUST BE REPORTED Our final CY 2008 payment policies
WITH THE PROCEDURE CODE WHEN WITH THE PROCEDURE CODE WHEN under the revised ASC payment system
FURNISHED WITHOUT COST OR FOR FURNISHED WITHOUT COST OR FOR for covered ancillary services vary
WHICH FULL OR PARTIAL CREDIT IS WHICH FULL OR PARTIAL CREDIT IS according to the particular type of
RECEIVED RECEIVED—Continued service and its payment policy under
the OPPS. Our overall policy provides
Device Device for separate ASC payment for certain
HCPCS Short descriptor HCPCS Short descriptor
code code ancillary services integrally related to
the provision of ASC covered surgical
C1721 ...... AICD, dual chamber. C1895 ...... Lead, AICD, endo dual coil. procedures if those services are paid
C1722 ...... AICD, single chamber. C1896 ...... Lead, AICD, non sing/dual. separately under the OPPS. Thus, we
C1764 ...... Event recorder, cardiac. C1897 ...... Lead, neurostim, test kit. established a policy to align ASC
C1767 ...... Generator, neurostim, imp. C1898 ...... Lead, pmkr, other than trans. payment bundles with those under the
C1771 ...... Rep dev, urinary, w/sling. C1899 ...... Lead, pmkr/AICD combination.
C1772 ...... Infusion pump, programmable. OPPS. Specifically, our final ASC
C1900 ...... Lead coronary venous. payment policies would provide
C1776 ...... Joint device (implantable).
C1777 ...... Lead, AICD, endo single coil. C2619 ...... Pmkr, dual, non rate-resp. separate ASC payment for
C1778 ...... Lead, neurostimulators. C2620 ...... Pmkr, single, non rate-resp. brachytherapy sources and drugs and
C1779 ...... Lead, pmkr, transvenous VDD. C2621 ...... Pmkr, other than sing/dual. biologicals that are separately paid
C1785 ...... Pmkr, dual, rate-resp. C2622 ...... Prosthesis, penile, non-inf. under the OPPS at the OPPS rates, while
C1786 ...... Pmkr, single, rate-resp. C2626 ...... Infusion pump, non-prog, temp. we would pay for radiology services at
C1813 ...... Prosthesis, penile, inflatab. C2631 ...... Rep dev, urinary, w/o sling.
C1815 ...... Pros, urinary sph, imp.
the lower of the MPFS nonfacility PE
L8614 ...... Cochlear device/system.
C1820 ...... Generator, neuro rechg bat sys. RVU (or technical component) amount
C1881 ...... Dialysis access system. or the rate calculated according to the
C1882 ...... AICD, other than sing/dual. standard methodology of the revised
C1891 ...... Infusion pump, non-prog, perm. ASC payment system based on the
OPPS relative payment weight for the that are not included on the ASC list of the delivery of surgical and related
service. covered surgical procedures and for nonsurgical services, to HOPDs.
As evidenced by our final policies for which Medicare does not allow facility Specifically, when services are provided
the CY 2008 revised ASC payment payments to ASCs, physicians are paid in ASCs, the ASC, not the physician,
system, our intention is to maintain for the PE component at the higher bears responsibility for the facility costs
consistent payment and packaging nonfacility PE RVUs (unless a associated with the service. This
policies across HOPD and ASC settings nonfacility rate does not exist, in which situation parallels the hospital facility
for covered ancillary services that are case Medicare pays the physician at the resource responsibility for hospital
integral to covered surgical procedures facility rate). These policies are set forth outpatient services. Therefore, we
performed in ASCs. Therefore, in § 414.22(b)(5)(i)(A) and (B), believe it would be more appropriate for
consistent with our policy to pay respectively. Furthermore, physician physicians to be paid for all services
separately only for those ancillary payment for nonsurgical services furnished in ASCs just as they would be
services that are paid separately under provided in ASCs, for which no facility paid for all services furnished in the
the OPPS, we also are proposing to payment is made to ASCs under the hospital outpatient setting. In addition,
package into the ASC payment for existing ASC payment system, varies because we have adopted a final policy
covered surgical procedures the costs of based on local Medicare contractor for the revised ASC payment system
those ancillary services that are policy. Some contractors pay physicians that identifies and excludes from ASC
proposed to be packaged under the only for the professional component payment only those procedures that
OPPS for CY 2008. Certain covered (PC) of the service and others make could pose a significant risk to
ancillary services that we are proposing payment to the physician for the beneficiary safety or would be expected
to package for the CY 2008 OPPS were technical component (TC) as well. to require an overnight stay, we believe
assigned payment indicator ‘‘Z2’’ or Under the current policy, as described that it would be incongruous with the
‘‘Z3’’ in the July 2007 final rule for the in the CY 2002 Physician Fee Schedule revised ASC payment system
revised ASC payment system, but they final rule with comment period (66 FR methodology to continue to pay the
are assigned payment indicator ‘‘N1’’ in 55264), Medicare payment to the higher nonfacility rate to physicians
Addendum BB to this proposed rule. physician for a noncovered surgical who furnish excluded ASC procedures.
We refer readers to section II.A.4 of this procedure performed in an ASC Because these excluded procedures
proposed rule for a description of the constitutes payment in full.This is so have been specifically identified by
CY 2008 OPPS packaging approach that even if the physician is paid the facility CMS as procedures that could pose a
we also are proposing to adopt in ASCs rate (because there is no nonfacility significant risk to beneficiary safety or
and that would package ASC payment rate). In this case, there is no beneficiary would be expected to require an
for certain covered ancillary services. In liability other than the deductible and overnight stay, we do not believe it
addition, proposed OPPS payments for copayment for the physician’s services. would be appropriate to provide
brachytherapy sources and separately According to the policy adopted in payment based on the higher nonfacility
payable drugs and biologicals are the July 2007 final rule for the revised PE RVUs to physicians who furnish
discussed in sections VII.B. and V. of ASC payment system, Medicare will them. In fact, we do not expect that the
this proposed rule, respectively. Other make facility payments to ASCs for all excluded procedures will be performed
separately paid covered ancillary covered surgical procedures except in ASCs after the revised ASC payment
services in ASCs, specifically corneal those that could pose a significant risk system is implemented on January 1,
tissue acquisition and devices with to beneficiary safety or would be
2008. Therefore, we are proposing to
OPPS pass-through status, do not have expected to require active medical
revise § 414.22(b)(5)(i)(A) and (B) to
prospectively established ASC payment monitoring and care at midnight
reflect this proposed policy.
rates according to the final policies of following the procedure (that is, an
the revised ASC payment system. overnight stay). The revised policy will We believe that the proposed revised
Payments for devices with pass-through result in a significant expansion in the policy would provide appropriate
status under the OPPS, for which number and type of surgical procedures payment to physicians for services
separate payment would be made to for which Medicare will make an ASC provided in the ASC facility setting and
ASCs at contractor-priced rates, are facility payment. The final payment would encourage the most appropriate
discussed in detail in section VI. of this policy for the revised ASC payment utilization of ASCs. For procedures that
proposed rule. system also allows separate payments to are not excluded from coverage under
ASCs for certain covered ancillary the revised ASC payment system, the
G. Physician Payment for Procedures ASC would be paid for the covered
services (for example, some drugs,
and Services Provided in ASCs brachytherapy sources, and certain surgical procedure and associated
If you choose to comment on issues in radiology services) that are provided covered ancillary services, and the
this section, please include the caption integral to an ASC covered surgical physician would be paid for the
‘‘Physician Payment for Procedures and procedure. According to the final professional work and facility PE
Services Provided in ASCs’’ at the policy, when covered ancillary services associated with performing the
beginning of your comment.) are integral to the successful procedure. In the case of noncovered
Under current policy, when performance of a covered surgical surgical procedures or other noncovered
physicians perform surgical procedures procedure and are performed on the services provided in ASCs, Medicare
in ASCs that are included on the ASC same day as the covered surgery, would make no payment to the ASC
list of covered surgical procedures, they immediately before, during or following under the revised ASC payment system
are paid under the MPFS for the PE the procedure, Medicare will allow and no payment to the physician under
component using the facility PE RVUs. separate ASC payment for those the MPFS for the facility resources
This is appropriate because the surgical services. associated with providing those
procedures are those for which The revised ASC payment system is services. Although the current MPFS
Medicare allows facility payment to based on the APC groups and payment payment policy provides payment to the
ASCs. However, when physicians weights of the OPPS. We believe ASCs physician for some facility costs as if the
perform surgical procedures in ASCs are facilities that are similar, insofar as service were being furnished in a
physician’s office, according to the final or into a body orifice because we do not placement of an item inserted during
policy of the revised payment system, believe that a physician would the ASC procedure.
these services would not be covered inappropriately subject a Medicare We are proposing to revise the
ASC services. These services have been patient to such a procedure. In addition, physician self-referral definition of
excluded from ASC payment for safety the definition of ‘‘radiology and certain ‘‘radiology and certain other imaging
reasons, because they are expected to other imaging services’’ excludes services’’ at § 411.351 to exclude those
require an overnight stay, or because radiology services that are integral to the radiology and imaging services that are
they are not surgical procedures, and performance of a nonradiological ‘‘covered ancillary services’’ (as defined
they would not be covered by Medicare medical procedure and performed at new § 416.164(b)) for which separate
either directly, under the ASC payment during the nonradiological medical payment is made under the revised ASC
system, or indirectly, through PE procedure or immediately following the payment system. That is, we propose
payments to the physicians who nonradiological medical procedure that those radiology and imaging
perform them. when necessary to confirm placement of procedures that are integral to a covered
In summary, under the proposed an item placed during the ASC surgical procedure and that are
policy, physicians would receive nonradiological medical procedure. performed immediately before, during,
payment for all surgical and nonsurgical Radiology and certain other imaging or immediately following the surgical
services furnished in ASCs based on the services performed before a procedure shall not constitute
facility PE RVUs and excluding the TC nonradiological medical procedure are ‘‘radiology and certain other imaging
payment, if applicable, consistent with DHS subject to the physician self- procedures’’ for purposes of the
physician payment for HOPD services. referral prohibition. physician self-referral law. If we do not
Medicare would make no payment for Taken together, these provisions revise the definition of radiology and
facility services to ASCs or physicians effectively exclude from the physician certain other imaging services for
for procedures or services that are self-referral prohibition referrals for physician self-referral purposes to
performed in ASCs but that are radiology services that are paid through exclude such radiological procedures,
excluded from the list of covered ASC the ASC composite payment rate, as the physician self-referral law would
surgical procedures or that are not well as any other radiology services that prohibit an ASC from billing Medicare
covered ancillary services. While are integral to the performance of an for such separately payable radiology
physicians would be paid for these ASC covered surgical procedure, that services rendered to patients who had
services based on the facility PE RVUs, are paid separately, and that are
been referred by a physician with an
physicians would no longer receive the ownership or investment interest in, or
performed in the ASC during the
additional payment for the associated compensation relationship with, the
surgical procedure or immediately after
facility resources. ASC, unless an exception applies.
Consistent with the current OPPS the surgical procedure if required to
Although there are a number of
payment policy that prohibits facility confirm placement of an item placed
compensation exceptions that may be
payments to the hospital for noncovered during the nonradiological medical
applicable, there are very few applicable
services (such as those surgical procedure. (For physician self-referral
ownership or investment exceptions.
procedures on the OPPS inpatient list) purposes, we have considered radiology
Thus, many physicians would not be
and makes the beneficiary liable for services that are performed while the
able to refer Medicare patients to ASCs
those charges, this proposed policy patient is still in the operating room to in which they have an ownership
would make beneficiaries responsible confirm that ASC surgery is effective to interest. We believe that this outcome
for the ASC charges for noncovered be performed during the surgical would be burdensome to our
services furnished to them in ASCs. procedure.) beneficiaries and contrary to Medicare
Through CY 2007, most radiology policies that support appropriate
H. Proposed Changes to Definitions of services performed as integral to ASC
‘‘Radiology and Certain Other Imaging surgery in ASCs, and we further believe
surgical procedures were either that our proposed revision to the
Services’’ and ‘‘Outpatient Prescription included in the ASC payment rate or
Drugs definition of ‘‘radiology and certain
were provided and billed by a separate other imaging services’’ would not pose
In section 1877(h)(6) of the Act, the entity. Effective beginning CY 2008, the a risk of program or patient abuse.
Congress defined the ‘‘designated health revised ASC payment system will cover Under our proposal, the DHS category
services’’ (DHS) that are subject to the a greater variety of surgical procedures of ‘‘radiology and certain other imaging
physician self-referral prohibition to performed in an ASC and make separate services’’ would continue to include
include 11 broad categories of services. payments (outside the ASC composite those radiology and imaging services
In our regulations at § 411.351, we rate) for certain radiology services that are not paid for under the revised
define each of the 11 DHS categories, performed in an ASC that are integral to ASC payment system (that is, those
including ‘‘radiology and certain other a covered surgical procedure and radiology and imaging services that are
imaging services.’’ In addition, we have performed immediately before, during, ‘‘excluded services’’ as defined at new
clarified that the term ‘‘designated or immediately after surgery. § 416.164(c)). For example, radiology
health services’’ excludes ‘‘services that Consequently, under the revised ASC and imaging services that are necessary
are reimbursed by Medicare as part of a payment system, we expect that more for the performance of a covered
composite rate (for example, ASC radiology procedures would be surgical procedure, but are not integral
services or SNF Part A services)’’ except performed in ASCs, and more of those to, a covered surgical procedure, such as
to the extent that the DHS categories are services would be subject to the preoperative studies not performed
themselves payable through a composite physician self-referral prohibition to the immediately before surgery, would be
rate. In the definition of ‘‘radiology and extent that those services are paid paid for under Part 414 of our
certain other imaging services’’ at outside the ASC composite rate and are regulations and would continue to be
§ 411.351, we exclude x-ray, performed either immediately before an considered DHS.
fluoroscopy, or ultrasound procedures ASC procedure or during or For the reasons that we believe
that require the insertion of a needle, immediately after an ASC procedure for warrant our revising the definition of
catheter, tube, or probe through the skin a purpose other than to confirm ‘‘radiology and certain other imaging
services’’ at § 411.351, we also propose (OBRA 1990), Public Law 101–508, CY 2008 that were finalized in the CY
to exclude from the definition of froze the IOL payment amount at $200 2007 OPPS/ASC final rule with
‘‘outpatient prescription drugs’’ at for IOLs furnished by ASCs in comment period (71 FR 68176 through
§ 411.351, drugs that are ‘‘covered conjunction with surgery performed 68181).
ancillary services’’ as defined at new during the period beginning November We modified the historical process of
§ 416.164(b) under the revised ASC 5, 1990 and ending December 31, 1992. using separate Federal Register notices
payment system. These drugs are We continued paying an IOL allowance to notify the public of requests to review
furnished, for example, during the of $200 from January 1, 1993, through lenses for membership in new NTIOL
immediate postoperative recovery December 31, 1993. classes, to solicit public comment on
period to a patient to reduce suffering Section 13533 of the Omnibus Budget requests, and to notify the public of
from nausea or pain. Under the revised Reconciliation Act of 1993 (OBRA CMS’ determinations concerning lenses
ASC payment system, an ASC would be 1993), Public Law 103–66, mandated assigned to classes of NTIOLs for which
permitted to furnish and bill separately that payment for an IOL furnished by an an ASC payment adjustment would be
for such outpatient prescription drugs, ASC be equal to $150 beginning January made. In the CY 2007 OPPS/ASC final
as appropriate. Under our proposal, 1, 1994, through December 31, 1998. rule with comment period (71 FR
such drugs would not constitute DHS. Section 141(b)(1) of the Social Security 68176), we specified that these NTIOL–
However, the physician self-referral Act Amendments of 1994 (SSAA 1994), related notifications would be fully
provisions would continue to prohibit Public Law 103 432, required us to integrated into the annual notice and
an ASC from furnishing outpatient develop and implement a process under comment rulemaking cycle for updating
prescription drugs for use in the which interested parties may request a the ASC payment rates, the specific
patient’s home. review of the appropriateness of the payment system in which NTIOL
For clarity, we would also make a payment amount for insertion of an IOL, payment adjustments are made. Our
technical correction to paragraph (2) of to ensure that the facility fee for the final policy for updating the revised
the definition of ‘‘radiology and certain procedure includes payment that is ASC payment system to be implemented
other imaging services’’ at § 411.351. reasonable and related to the cost of in January 2008 will utilize an annual
This paragraph currently excludes acquiring a lens that belongs to a class update process in coordination with
‘‘radiology procedures’’ that are integral of NTIOLs. notice and comment rulemaking for the
to the performance of a ‘‘nonradiological In the February 8, 1990 Federal OPPS. Aligning the NTIOL process with
procedure.’’ We would revise paragraph Register (55 FR 4526), we published a this annual update will promote
(2) to exclude ‘‘radiology and certain final notice entitled ‘‘Revision of coordination and efficiency, thereby
other imaging services’’ that are integral Ambulatory Surgery Center Payment streamlining and expediting the NTIOL
to the performance of ‘‘a medical Rate Methodology,’’ which notification, comment, and review
procedure that is not identified on the implemented Medicare payment for an process.
List of CPT/HCPCS Codes as a IOL furnished at an ASC as part of the Specifically, we established the
‘radiology or certain other imaging ASC facility fee for insertion of the IOL. following process:
service.’ ’’ We would revise the language In the June 16, 1999 Federal Register • We will announce annually in the
of paragraph (2) because we believe that, (64 FR 32198), we published a final rule Federal Register document that
neither radiology services, nor certain entitled ‘‘Adjustment in Payment proposes the update of ASC payment
Amounts for New Technology rates for the following calendar year, a
other imaging services should constitute
Intraocular Lenses Furnished by list of all requests to establish new
DHS if they are integral to the
Ambulatory Surgical Centers,’’ to add NTIOL classes accepted for review
performance of a medical procedure that
Subpart F (§§ 416.180 through 416.200) during the calendar year in which the
is neither a radiology service nor a
to 42 CFR Part 416, which established proposal is published and the deadline
certain other imaging service. We
a process for adjusting payment for submission of public comments
believe that this change would not
amounts for insertion of a class of regarding those requests. The deadline
result in any risk of program or patient
NTIOLs furnished by ASCs. for receipt of public comments will be
abuse.
Since June 16, 1999, we have issued 30 days following publication of the list
I. New Technology Intraocular Lenses a series of Federal Register notices to of requests.
list lenses for which we received • In the Federal Register document
1. Background
requests for an NTIOL payment that finalizes the update of ASC
At the inception of the ASC benefit on adjustment and to solicit comments on payment rates for the following calendar
September 7, 1982, Medicare paid 80 those requests, or to announce the year, we will—
percent of the reasonable charge for lenses that we have determined meet + Provide a list of determinations
IOLs supplied for insertion concurrent the criteria and definition of NTIOLs. made as a result of our review of all
with or following cataract surgery We last published a Federal Register requests and public comments; and
performed in an ASC (47 FR 34082, notice pertaining specifically to NTIOLs + Publish the deadline for submitting
August 5, 1982). Section 4063(b) of on April 28, 2006 (71 FR 25176). requests for review in the following
OBRA 1987, Public Law 100–203, calendar year.
amended the Act to mandate that we 2. Changes to the NTIOL Determination In determining whether a lens belongs
include payment for an IOL furnished Process Finalized for CY 2008 to a new class of NTIOLs and whether
by an ASC for insertion during or In the CY 2007 OPPS/ASC final rule the ASC payment amount for insertion
following cataract surgery as part of the with comment period, we finalized our of that lens in conjunction with cataract
ASC facility fee for insertion of the IOL, proposal to update and streamline the surgery is appropriate, we expect that
and that the facility fee include payment process for recognizing IOLs inserted the insertion of the candidate IOL
that is reasonable and related to the cost during or subsequent to cataract would result in significantly improved
of acquiring the class of lens involved extraction as belonging to a new, active clinical outcomes compared to currently
in the procedure. NTIOL class that is qualified for a available IOLs. In addition, to establish
Section 4151(c)(3) of the Omnibus payment adjustment. The following is a a new NTIOL class, the candidate lens
Budget Reconciliation Act of 1990 summary of the changes beginning for must be distinguishable from lenses
already approved as members of active ASCPayment/ approved as belonging to a new class of

or expired classes of NTIOLs that share 05_NTIOLs.asp#TopOfPage. NTIOLs, in the winter of CY 2007 we
a predominant characteristic associated As stated in the CY 2007 OPPS/ASC posted the guidance document to the
with improved clinical outcomes that final rule with comment period (71 FR CMS Web site regarding such requests
was identified for each class. In the CY 68180), there are three possible as described above. We did not receive
2007 final rule, we finalized our outcomes from our review of a request any review requests by the deadline of
proposal to base our determinations on for determination of a new NTIOL class. April 1, 2007 in response to the
consideration of the following factors: As appropriate, for each completed announcement made in the CY 2007
• The IOL must have been approved request for a candidate IOL that is OPPS/ASC final rule with comment
by the FDA and claims of specific received by the established deadline, period (71 FR 68181) soliciting CY 2008
clinical benefits and/or lens one of the following determinations requests for review of the
characteristics with established clinical would be announced annually in the appropriateness of the payment amount
relevance in comparison with currently final rule updating the ASC payment for new classes of NTIOLs furnished in
available IOLs must have been approved rates for the next calendar year: ASCs.
by the FDA for use in labeling and • The request for a payment We note that we have also issued a
advertising. adjustment is approved for the IOL for guidance document entitled ‘‘Revised
• The IOL is not described by an 5 full years as a member of a new Process for Recognizing Intraocular
active or expired NTIOL class; that is, it NTIOL class described by a new HCPCS Lenses Furnished by Ambulatory
does not share the predominant, class- code. Surgery Centers (ASCs) as Belonging to
defining characteristic associated with • The request for a payment an Active Subset of New Technology
improved clinical outcomes with adjustment is approved for the IOL for Intraocular Lenses (NTIOLs).’’ This
designated members of an active or the balance of time remaining as a guidance document can be accessed on
expired NTIOL class. member of an active NTIOL class. the CMS Web site at: http://
• Evidence demonstrates that use of • The request for a payment www.cms.hhs.gov/ASCPayment/
the IOL results in measurable, clinically adjustment is not approved. 05_NTIOLs.asp.
meaningful, improved outcomes in We also discussed our plan to
comparison with use of currently summarize briefly in the final rule the This guidance document provides
available IOLs. According to the statute, evidence that was reviewed, the public specific details regarding requests for
and consistent with previous examples comments, and the basis for our recognition of IOLs as belonging to an
provided by CMS, superior outcomes determinations. We established that existing, active NTIOL class, the review
that would be considered include the when a new NTIOL class is created, we process, and information required for a
following: would identify the predominant request to review. Currently, there is
+ Reduced risk of intraoperative or characteristic of NTIOLs in that class one active NTIOL class whose defining
postoperative complication or trauma; that sets them apart from other IOLs characteristic is the reduction of
+ Accelerated postoperative recovery; (including those previously approved as spherical aberration. CMS accepts
+ Reduced induced astigmatism; members of other expired or active requests throughout the year to review
+ Improved postoperative visual NTIOL classes) and is associated with the appropriateness of recognizing an
acuity; improved clinical outcomes. The date of IOL as a member of an active class of
+ More stable postoperative vision; implementation of a payment NTIOLs. That is, review of candidate
+ Other comparable clinical adjustment in the case of approval of an lenses for membership in an existing,
advantages, such as— IOL as a member of a new NTIOL class active NTIOL class is ongoing and not
++ Reduced dependence on other would be set prospectively as of 30 days limited to the annual review process
eyewear (for example, spectacles, after publication of the ASC payment that applies to the establishment of new
contact lenses, and reading glasses); update final rule, consistent with the NTIOL classes. We ordinarily would
++ Decreased rate of subsequent statutory requirement. The date of complete the review of such a request
diagnostic or therapeutic interventions, implementation of a payment within 90 days of receipt, and upon
such as the need for YAG laser adjustment in the case of approval of a completion of our review, we would
treatment; lens as a member of an active NTIOL notify the requestor of our
++ Decreased incidence of class would be set prospectively as of determination and post on the CMS
subsequent IOL exchange; the publication date of the ASC Web site notification of a lens newly
++ Decreased blurred vision, glare, payment update final rule. approved for a payment adjustment as
other quantifiable symptom or vision an NTIOL belonging to an active NTIOL
deficiency. 3. NTIOL Application Process for CY class when furnished in an ASC.
For a request to be considered 2008 Payment Adjustment
4. Classes of NTIOLs Approved for
complete, we require submission of the To provide process and information Payment Adjustment
information that is found in the requirements for applications requesting
guidance document entitled a review of the appropriateness of the Since implementation of the process
‘‘Application Process and Information payment amount for insertion of an IOL for adjustment of payment amounts for
Requirements for Requests for a New to ensure that the ASC payment for NTIOLs that was established in the June
Class of New Technology Intraocular covered surgical procedures includes 16, 1999 Federal Register, we have
Lens (NTIOL)’’ posted on the CMS Web payment that is reasonable and related approved three classes of NTIOLs, as
site at: http://cms.hhs.gov/ to the cost of acquiring a lens that is shown in the following table:
NTIOL cat- HCPCS $50 approved for services NTIOL characteristic IOLs eligible for adjustment
egory code furnished on or after
1 ............... Q1001 ...... May 18, 2000, through May Multifocal ............................. Allergan AMO Array Multifocal lens, model SA40N.
18, 2005.
NTIOL cat- HCPCS $50 approved for services NTIOL characteristic IOLs eligible for adjustment
egory code furnished on or after
2 ............... Q1002 ...... May 18, 2000, through May Reduction in Preexisting STAAR Surgical Elastic Ultraviolet-Absorbing Silicone
18, 2005. Astigmatism. Posterior Chamber IOL with Toric Optic, models
AA4203T, AA4203TF, and AA4203TL.
3 ............... Q1003 ...... February 27, 2006, through Reduced Spherical Aberra- Advanced Medical Optics (AMO) Tecnis IOL models
February 26, 2011. tion. Z9000, Z9001, Z9002, and ZA9003; Alcon Acrysof
IQ Model SN60WF; Bausch & Lomb Sofport AO mod-
els LI61AOV, and LI61AOV.
5. Payment Adjustment but we reiterate our intention, as stated the standard payment methodology of
in the CY 2007 final rule, to reevaluate the revised payment system, which
The current payment adjustment for a whether or not the ASC payment rates applies the ASC budget neutrality
5-year period from the implementation established for cataract surgery with IOL adjustment to the OPPS conversion
date of a new NTIOL class is $50. In the insertion are appropriate when a lens factor to calculate an ASC conversion
CY 2007 OPPS/ASC final rule with determined to be an NTIOL is furnished factor that is then multiplied by the ASC
comment period, we revised after we have implemented the revised payment weight for the surgical
§ 416.200(a) through (c) to clarify how ASC payment system in CY 2008. procedure to implant the IOL. CY 2008
the IOL payment adjustment will be ASC payment for the cost of a
made and how an NTIOL will be paid 6. Proposed CY 2008 ASC Payment for
conventional lens will be packaged into
after expiration of the payment Insertion of IOLs
the payment for the associated covered
adjustment, as well as made minor In accordance with the final policies surgical procedure performed by the
editorial changes to § 416.200(d). For CY of the revised ASC payment system for ASC. The proposed CY 2008 ASC
2008, we are not proposing to revise the CY 2008, payment for IOL insertion payment rates for IOL insertion
current payment adjustment amount, services will be established according to procedures are included in Table 66.
TABLE 66.—INSERTION OF IOL PROCEDURES AND THEIR PROPOSED CY 2008 ASC PAYMENT RATES
Proposed
HCPCS CY 2008
Long descriptor
code ASC pay-
ment
66983 ....... Intracapsular cataract extraction with insertion of intraocular lens prosthesis (one stage procedure) ............................ $980.43
66984 ....... Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or me- 980.43
chanical technique (eg, irrigation and aspiration or phacoemulsification).
66985 ....... Insertion of intraocular lens prosthesis (secondary implant), not associated with concurrent cataract removal ............. 870.18
66986 ....... Exchange of intraocular lens ............................................................................................................................................ 870.18
J. Proposed ASC Payment and Comment classifications as separately payable and BB to this proposed rule and are
Indicators radiology services, brachytherapy subject to comment during the 60-day
In addition to the payment indicators sources, OPPS pass-through devices, comment period provided for this
that we introduced in the July 2007 final corneal tissue acquisition services, proposed rule. ‘‘CH’’ will be used in
rule for the revised ASC payment drugs or biologicals, or NTIOLs. Addenda AA and BB to the CY 2008
system, we also are introducing We have also created new Addendum OPPS/ASC final rule with comment
comment indicators for the ASC DD2 to this proposed rule that lists the period to indicate that a new payment
payment system in this proposed rule. ASC comment indicators. Like the indicator (in comparison with that in
We created Addendum DD1 to define comment indicators used in the OPPS, the July 2007 final rule for the revised
ASC payment indicators that we will the ASC comment indicators to be used ASC payment system) has been assigned
use in Addenda AA and BB to provide in Addenda AA and BB to the OPPS/ to an active HCPCS code in the current
payment information regarding covered ASC final rule with comment period and next calendar year; that an active
surgical procedures and covered will serve to identify, for the revised
HCPCS code has been added to the list
ancillary services, respectively, under ASC payment system, the status of a
of procedures or services payable in
the revised ASC payment system. specific HCPCS code and its payment
ASCs; or that an active HCPCS code will
Analogous to the OPPS payment status indicator with respect to the timeframe
when comments would be accepted. be deleted at the end of the current
indicators that we define in Addendum
The comment indicator ‘‘NI’’ will be calendar year. These ‘‘CH’’ comment
D1 to the annual OPPS proposed and
used in the final rule to indicate new indicators that will be published in the
final rules, the ASC payment indicators
in Addendum DD1 are intended to HCPCS codes for which the interim CY 2008 OPPS/ASC final rule with
capture policy-relevant characteristics payment indicator assigned is subject to comment period will be provided to
of HCPCS codes that may receive comment in the final rule. alert our readers that a change has been
packaged or separate payment in ASCs, The changes for CY 2008 that we are made since the July 2007 final rule for
including: their ASC payment status proposing to the payment indicators the revised ASC payment system, but do
prior to CY 2008; their designations as assigned to HCPCS codes for procedures not indicate that the change is subject to
device-intensive; their designations as and services in the July 2007 final rule comment. The full definitions for the
office-based and the corresponding ASC for the revised ASC payment system are comment indicators are provided in
payment methodology; and their identified with a ‘‘CH’’ in Addenda AA Addendum DD2 to this proposed rule.
K. ASC Policy and Payment used as the basis for an ASC payment final our proposal to set the ASC
Recommendations system. The GAO determined, in fact, relative payment weight for certain
The GAO published the statutorily that there was less variation in the ASC office-based surgical procedures so that
mandated report entitled, ‘‘Medicare: setting between individual procedures’ the national unadjusted ASC payment
Payment for Ambulatory Surgical costs and the costs of their assigned rate does not exceed the MPFS
Centers Should Be Based on the APC groups than there is in the HOPD unadjusted nonfacility PE RVU amount.
Hospital Outpatient Payment System’’ setting. It concluded that, as a group, the Our final policy is to calculate ASC
(GAO–07–86) on November 30, 2006. costs of procedures performed in ASCs payment rates by multiplying the ASC
We considered the report’s have a relatively consistent relationship relative payment weights by the ASC
with the costs of the APC groups to conversion factor. In the July 2007 final
methodology, findings, and
which they are assigned under the rule for the revised ASC payment
recommendations in the development of
OPPS. The GAO’s analysis also found system, our estimate of the CY 2008
the July 2007 final rule for the revised
that procedures in the ASC setting had budget neutral ASC conversion factor
ASC payment system. The GAO
substantially lower costs than those was $42.542. In this proposed rule, the
methodology, results, and
same procedures in the HOPD. While proposed ASC conversion factor for CY
recommendations are summarized
ASC costs for individual procedures 2008 is $41.400. This new estimate of
below.
varied, in general, the median costs for the ASC conversion factor differs from
The GAO was directed to conduct a
procedures were lower in ASCs, relative the estimate in the July 2007 final rule
study comparing the relative costs of
to the median costs of their APC groups, for the revised ASC payment system for
procedures furnished in ASCs to those
than the median costs for the same a number of reasons, including: (1) Use
furnished in HOPDs paid under the
procedures in the HOPD setting. The of the proposed OPPS relative payment
OPPS, including examining the
median cost ratio among all ASC weights for CY 2008; (2) use of the
accuracy of the APC with respect to
procedures was 0.39 (0.84 when proposed MPFS nonfacility practice
surgical procedures furnished in ASCs. expense payment amounts for CY 2008;
Section 626(d) of Pub. L. 108–173 weighted by Medicare volume based on
CY 2004 claims), whereas the median and (3) use of updated utilization data
indicated that the report should include from CY 2006. Specific details regarding
recommendations on the following cost ratio among all OPPS procedures
was 1.04. our final methodology for estimating the
matters: CY 2008 ASC conversion factor may be
1. Appropriateness of using groups of The GAO found many similarities in
the additional items and services found in the July 2007 final rule for the
covered services and relative weights revised ASC payment system.
established for the OPPS as the basis of provided by ASCs and HOPDs for the
top 20 ASC procedures. However, of We were not able to provide the final
payment for ASCs. CY 2008 ASC conversion factor in the
2. If the OPPS relative weights are these additional items and services, few
resulted in additional payment in one July 2007 final rule for the revised ASC
appropriate for this purpose, whether payment system because the final CY
the ASC payments should be based on setting but not the other. HOPDs were
paid for some of the related services 2008 conversion factor will be based on
a uniform percentage of the payment the final OPPS relative payment weights
rates or weights under the OPPS, or separately, while in the ASC setting,
other Part B suppliers billed Medicare for CY 2008, the final MPFS nonfacility
should vary, or the weights should be practice expense payment amounts for
revised based on specific procedures or and received payment for many of the
related services. CY 2008, and updated and complete CY
types of services. 2006 utilization data, all of which are
3. Whether a geographic adjustment Finally, in its analysis of labor-related
costs, the GAO determined that the unavailable at the time we are
should be used for ASC payment and, publishing the July 2007 final rule for
if so, the labor and nonlabor shares of mean labor-related proportion of costs
was 50 percent. The range of the labor- the ASC revised payment system
such payment. elsewhere in this issue of the Federal
Based on its extensive analyses, the related costs for the middle 50 percent
of responding ASCs was 43 percent to Register. In this proposed rule, we use
GAO determined that the APC groups in the final methodology described in the
the OPPS accurately reflect the relative 57 percent of total costs.
Based on its findings from the study, July 2007 final rule for the revised ASC
costs of the procedures performed in payment system to calculate the
ASCs. The GAO’s analysis of the cost the GAO recommended that CMS
implement a payment system for proposed CY 2008 ASC conversion
ratios showed that the ASC-to-APC cost factor and proposed ASC relative
ratios were more tightly distributed procedures performed in ASCs based on
the OPPS, taking into account the lower payment weights and rates that will be
around their median cost ratio than made final in the CY 2008 OPPS/ASC
were the OPPS-to-APC cost ratios. The relative costs of procedures performed
in ASCs compared to HOPDs in final rule with comment period.
ASC-to-APC median cost ratio is a
comparison of the median cost of each determining ASC payment rates. 2. Budget Neutrality Requirement
of the 20 surgical procedures with the L. Proposed Calculation of the ASC Section 626(b) of Pub. L. 108–173
highest ASC claims volume to the Conversion Factor and ASC Payment amended section 1833(i)(2) of the Act by
median cost of the APC group in which Rates adding subparagraph (D) to require that
it would be placed under the OPPS, in the year the revised ASC system is
while the OPPS-to-APC cost ratio is a 1. Overview
implemented:
comparison of the median cost of each As discussed in section XVI.C. of this ‘‘ * * * [S]uch system shall be
of those same procedures under the proposed rule, we finalized our policy designed to result in the same aggregate
OPPS with the median cost of its to base ASC relative payment weights amount of expenditures for such
assigned APC group. These patterns and payment rates under the revised services as would be made if this
demonstrated that the APC groups ASC payment system on APC groups subparagraph did not apply, as
reflect the relative costs of procedures and relative payment weights estimated by the Secretary * * * ’’
performed by ASCs like they do for established under the OPPS in the July As discussed in the July 2007 final
procedures performed in HOPDs and, 2007 final rule for the ASC revised rule for the revised ASC payment
therefore, that the APC groups could be payment system. In that rule, we made system, the ASC conversion factor is
calculated so that estimated total 2007 final rule for the revised ASC estimated CY 2008 ASC payment rate
Medicare payments under the revised payment system. for the HCPCS code under the existing
ASC payment system would be budget ASC payment system, and then subtract
a. Estimated CY 2008 Medicare Program
neutral to estimated total Medicare beneficiary coinsurance for the
Payments (Excluding Beneficiary
payments under the current ASC procedure. The estimated CY 2008 ASC
Coinsurance) Under the Existing ASC
payment system as required by the payment rates are based on the CY 2007
statute. That is, application of the ASC Payment System
ASC payment rates, which were listed
conversion factor is designed to result in Step 1: Migration from HOPDs to in Addendum AA to the CY 2007 OPPS/
aggregate expenditures under the ASCs is valued using proposed CY 2008 ASC final rule with comment period (71
revised ASC payment system in CY OPPS payment rates. FR 68243 through 68283) and take into
2008 equal to aggregate expenditures (a) We multiply the estimated CY account the OPPS cap on payment for
that would have occurred in CY 2008 in 2008 HOPD utilization for each new ASC services as required by section
the absence of the revised system, taking ASC procedure by 0.125, consistent 5103 of Pub. L. 109–171 and reflect the
into consideration the cap on payments with our assumption that 25 percent of zero percent CY 2008 update for ASC
in CY 2007 as required under section the HOPD utilization for new ASC services mandated by section
5103 of Pub. L. 109–171. procedures will migrate to the ASC over 1833(i)(2)(C) of the Act. In estimating
We note that we considered the term the first 2 years of the revised ASC ASC utilization for CY 2008, we take
‘‘expenditures’’ in the context of section payment system, only half of which into account the impact of the multiple
626(b) of the Pub. L. 108–173 budget would occur in CY 2008. In estimating procedure discount (as discussed in
neutrality requirement to mean HOPD utilization for CY 2008, we take section V.C.3. of the July 2007 final rule
expenditures from the Medicare Part B into account the impact of the multiple for the revised ASC payment system).
Trust Fund. We did not consider procedure discount (as discussed in (b) We estimate the amount the
expenditures to include beneficiary more detail in section V.C.3. the July Medicare program would pay in CY
coinsurance and copayments. 2007 final rule for the revised ASC 2008 for implantable prosthetic devices
3. Calculation of the ASC Payment Rates payment system). and implantable DME for which ASCs
(b) For each new ASC procedure, we currently receive separate payment
for CY 2008
multiply the results of Step 1(a) by the under the DMEPOS fee schedule.
The following is a step-by-step proposed CY 2008 OPPS payment rate
illustration of the final budget neutrality (c) We sum the results of Steps 3(a)
for the procedure, and then subtract and 3(b) to estimate the aggregate
adjustment calculation as finalized in beneficiary coinsurance for the
the July 2007 final rule for the revised amount of expenditures that would be
procedure. made in CY 2008 for current covered
ASC payment system and as applied to (c) We sum the results of Step 1(b)
updated data available for this proposed surgical procedures under the existing
across all new ASC procedures. ASC payment system.
rule. Step 2: Migration of procedures from
The final methodology for Step 4: Sum the results of Steps 1–3.
physicians’ offices to ASCs is valued
establishing budget neutrality under the using proposed CY 2008 physician in- b. Estimated Medicare Program
revised ASC payment system takes into office payment rates. ‘‘Physician in- Payments (Excluding Beneficiary
account a 4-year transition to full office payment rate’’ is equal to the Coinsurance) Under the Revised ASC
implementation of the revised payment proposed MPFS nonfacility practice Payment System
rates and the effects of several expense RVUs multiplied by the
assumptions regarding migration of Step 5: HOPD migration is valued
proposed CY 2008 MPFS conversion
services across ASCs, HOPDs, and using proposed CY 2008 OPPS payment
factor.
physicians’ offices. Payments during the rates.
(a) We multiply the estimated
4-year transition to the fully This step is the same as Step 1, above.
physician office utilization for CY 2008
implemented revised ASC payment for each new ASC procedure by 0.0375, Step 6: We identify new ASC
rates will be based on a blend of the CY consistent with our assumption that 15 procedures that are office-based (as
2007 ASC payment rates and the revised percent of the physician’s office discussed in section III.C. of the July
ASC payment rates at 75/25 in CY 2008, utilization for new ASC procedures will 2007 final rule for the revised ASC
50/50 in CY 2009, and 25/75 in CY migrate to the ASC over the full 4-year payment system).
2010, with payment at 100 percent of transition period. Step 7: Migration of new ASC office-
the revised ASC payment rates in 2011. (b) For each new ASC procedure, we based procedures from physicians’
The methodology assumes no net cost or multiply the results of Step 2(a) by the offices to ASCs is valued based on
savings to Medicare from the migration proposed CY 2008 physician in-office proposed CY 2008 OPPS payment rates
of existing ASC services among ASCs, payment rate for the procedure, and capped at the proposed CY 2008
HOPDs, and physicians’ offices. It then subtract beneficiary coinsurance physician in-office payment rates, if
includes assumptions that 15 percent of for the procedure. appropriate.
physicians’ office utilization for new (c) We sum the results of Step 2(b) (a) For each new ASC procedure
ASC procedures, specifically those first across all new ASC procedures. determined to be office-based, we
added for ASC payment beginning in Step 3: CY 2007 ASC services are multiply the results of Step 2(a) above
CY 2008, will migrate to ASCs over a 4- valued using the estimated CY 2008 by the lesser of—
year period (3.75 percent each year) and ASC payment rates under the current (1) The proposed CY 2008 OPPS rate
that 25 percent of the new procedures’ ASC system. for the procedure; or
HOPD utilization will migrate over the To estimate the aggregate (2) The proposed CY 2008 physician
first 2 years under the revised payment expenditures that would be made in CY in-office payment rate for the procedure,
system (12.5 percent each year) and 2008 under the existing ASC payment and then subtract beneficiary
accounts for the Medicare costs and system: coinsurance for the procedure
savings associated with that movement. (a) We multiply the estimated CY (b) The results of Step 7(a) are
A detailed explanation of the model 2008 ASC utilization for each HCPCS summed across all new ASC procedures
may be found in section V.C. of the July code on the CY 2007 ASC list by the considered to be office-based.
Step 8: Migration of new ASC to take into account the fact that the payment rate does not exceed the MPFS
procedures not determined to be office- additional physician out-of-office unadjusted nonfacility practice expense
based from physicians’ offices to ASCs payment rates under the revised ASC amount. In addition, the ASC relative
is valued using the proposed CY 2008 payment system calculated in Step 9 payment weights for device-intensive
OPPS rates. must be fully offset by the budget covered surgical procedures are set
(a) For each new ASC procedure not neutrality adjustment to ASC services according to a modified payment
considered to be office-based, we under the revised payment system. methodology to ensure the same device
multiply the results of Step 2(a) above Furthermore, the budget neutrality payment under the revised ASC
by the proposed CY 2008 OPPS rate for calculation is calibrated to take into payment system as under the OPPS. We
the procedure, and then subtract account the CY 2008 transitional then calculated the proposed CY 2008
beneficiary coinsurance for the payment rates for procedures on the CY payment rate for procedures on the CY
procedure. 2007 ASC list of covered surgical 2007 ASC list of covered surgical
(b) The results of Step 8(a) are procedures. procedures using a blend of 75 percent
summed across all new ASC procedures The application of the above of the final CY 2007 ASC payment rate
not considered to be office-based. methodology to the data available for and 25 percent of the proposed CY 2008
Step 9: Migration of new ASC this proposed rule results in an ASC payment rate developed according
procedures from physicians’ offices to estimated budget neutrality adjustment to the methodology of the revised ASC
ASCs is valued using the proposed CY of 0.65. This number differs from the payment system, applying the special
2008 MPFS physician out-of-office estimated budget neutrality adjustment transition treatment to device-intensive
payment rate. ‘‘Physician out-of-office of 0.67 for the July 2007 final rule for procedures as discussed in section
payment rate’’ is equal to the proposed the revised ASC payment system that XVI.C of this proposed rule. See
facility practice expense RVUs was based on CY 2005 utilization and Addenda AA and BB to this proposed
multiplied by the proposed CY 2008 CY 2007 OPPS and MPFS payment rule for the proposed CY 2008 ASC
MPFS conversion factor. rates. The proposed budget neutrality payment weights and payment rates for
(a) For each new ASC procedure, we adjustment for CY 2008 reflects updated covered surgical procedures and
multiply the results of Step 2(a) from data, including CY 2006 utilization and covered ancillary services that are
above by the proposed CY 2008 proposed CY 2008 OPPS and MPFS expected to be paid separately under the
physician out-of-office payment rate for payment rates. The CY 2008 budget CY 2008 revised ASC payment system.
the procedure, and then subtract neutrality adjustment for the revised
beneficiary coinsurance for the ASC payment system, calculated based 4. Calculation of the ASC Payment Rates
procedure. on the methodology outlined above, will for CY 2009 and Future Years
(b) The results of Step 9(a) are be finalized in the CY 2008 OPPS/ASC a. Updating the ASC Relative Payment
summed across all new ASC final rule with comment period. Weights
procedures. d. Calculation of the Proposed CY 2008
Step 10: Current ASC services are In the July 2007 final rule for the
ASC Payment Rates revised ASC payment system, we
valued using the proposed CY 2008
OPPS payment rates. After developing the proposed CY finalized our policy to update the ASC
To estimate the aggregate amount of 2008 budget neutrality adjustment of relative payment weights in the revised
expenditures that would be made in CY 0.65 according to the policies ASC payment system each year using
2008, we use proposed CY 2008 OPPS established in the July 2007 final rule the national OPPS relative payment
payment amounts instead of estimated for the revised ASC payment system, to weights (and MPFS nonfacility PE RVU
CY 2008 ASC payment amounts under determine the proposed CY 2008 ASC amounts, as applicable) for that same
the current system, and we multiply the conversion factor, we multiplied the calendar year and to uniformly scale the
estimated CY 2008 ASC volume for each proposed CY 2008 OPPS conversion ASC relative payment weights for each
HCPCS code on the CY 2007 ASC list factor by the proposed ASC budget update year to make them budget
of covered surgical procedures by the neutrality adjustment. The proposed CY neutral. For example, holding ASC
proposed CY 2008 OPPS payment rate 2008 OPPS conversion factor is $63.693 utilization and the mix of services
for the HCPCS code, and then subtract and multiplying that by the 0.65 budget constant, for CY 2009, we will compare
beneficiary coinsurance for the neutrality adjustment yields our the total weight using the CY 2008 ASC
procedure. We sum the results over all proposed CY 2008 ASC conversion relative payment weights under the 75/
services on that ASC list. factor of $41.400. To determine the 25 blend (of the CY 2007 payment rate
Step 11: The results of Steps 5 and 7– proposed fully implemented ASC and the revised payment rate) with the
10 are summed. payment rates for this proposed rule, total weight using CY 2009 relative
including beneficiary coinsurance, payment weights under the 50/50 blend
c. Calculation of the Proposed CY 2008 according to the final payment (of the CY 2007 payment rate and the
Budget Neutrality Adjustment methodology that applies to covered revised payment rate), taking into
Step 12: The result of Step 4 is surgical procedures and covered account the changes in the OPPS
divided by the result of Step 11. ancillary radiology services under the relative payment weights between CY
Step 13: The application of the cap at revised ASC payment system, we 2008 and CY 2009. We will use the ratio
the proposed CY 2008 physician in- multiplied the proposed ASC of CY 2008 to CY 2009 total weight to
office payment rates that occurs in Step conversion factor by the proposed ASC scale the ASC relative payment weights
7 is dependent on the ASC conversion relative payment weight for each for CY 2009. Scaling of ASC relative
factor. The ASC budget neutrality procedure or service. As further payment weights would apply to
adjustment resulting from Step 12 is discussed in section XVI.C. of this covered surgical procedures and
calibrated to take into account the proposed rule, the ASC relative covered ancillary radiology services
interactive nature of the ASC conversion payment weights for certain office-based whose payment rates are related to
factor and the physician’s office surgical procedures and covered OPPS relative payment weights. Scaling
payment cap. The ASC budget ancillary radiology services are set so would not apply in the case of ASC
neutrality calculation is also calibrated that the national unadjusted ASC payment for other separately payable
covered ancillary services that have a A. Background through the reporting of quality
predetermined national payment measures developed specifically for
1. Reporting Hospital Outpatient
amount (that is, their national payment Quality Data for Annual Payment application in the hospital outpatient
amounts are not based on OPPS relative Update setting. We agreed with the commenters
payment weights) such as drugs and that assessment of hospital outpatient
biologicals that are separately paid Section 109(a) of the MIEA–TRHCA performance would ultimately be most
(Pub. L. 109–432) amended section appropriately based on reporting of
under the OPPS. Any service with a
1833(t) of the Act by adding a new hospital outpatient measures developed
predetermined national payment
subsection (17) that affects the payment
amount would be included in the specifically for this purpose. We stated
rate update applicable to OPPS
budget neutrality comparison, but our intent to condition the full OPPS
payments for services furnished by
scaling of the relative payment weights hospitals in outpatient settings on or payment rate update beginning in CY
would not apply to those services that after January 1, 2009. New section 2009 based upon hospital reporting of
have a predetermined payment amount. 1833(t)(17)(A) of the Act, which applies quality data beginning in CY 2008,
The ASC payment weights for those to hospitals as defined under section using effective measures of the quality
services without predetermined national 1886(d)(1)(B) of the Act, requires that of hospital outpatient care that have
payment amounts (that is, their national hospitals that fail to report data required been carefully developed and evaluated,
payment amounts would be based on for the quality measures selected by the and endorsed as appropriate, with
OPPS relative payment weights if a Secretary in the form and manner significant input from stakeholders.
payment limitation did not apply) required by the Secretary under section The amendments to the Act made by
would be scaled to eliminate any 1833(t)(17)(B) of the Act will incur a section 109(a) of the MIEA–TRHCA are
difference in the total payment weight reduction in their annual payment consistent with our intent and direction
between the current year and the update update factor by 2.0 percentage points. outlined in the CY 2007 OPPS/ASC
year. As we noted in the July 2007 final New section 1833(t)(17)(B) of the Act final rule with comment period. Under
rule for the revised ASC payment requires that hospitals submit quality these amendments, we are now
system, while we do not currently have data in a form and manner, and at a time statutorily required to establish a
a provider-level dataset of ASC that the Secretary specifies. New
program under which hospitals will
sections 1833(t)(17)(C)(i) and (ii) of the
utilization that accurately identifies report data on the quality of hospital
Act require the Secretary to develop
unique ASCs and their geographic outpatient care using standardized
measures appropriate for the
information that would allow us to measurement of the quality of care measures of care to receive the full
compare changes in geographic (including medication errors) furnished annual update to the OPPS payment
adjustment over time for budget by hospitals in outpatient settings and rate, effective for payments beginning in
neutrality purposes, we intend to take that these measures reflect consensus CY 2009. We will refer to the program
these changes into account in among affected parties and, to the extent established under these amendments as
maintaining budget neutrality for the feasible and practicable, include the Hospital Outpatient Quality Data
revised ASC payment system as soon as measures set forth by one or more Reporting Program (HOP QDRP).
our provider-level ASC data permit. national consensus building entities. In reviewing the measures currently
The Secretary is not prevented from available for care in the hospital
b. Updating the ASC Conversion Factor
selecting measures that are the same as outpatient settings, we continue to
Section 1833(i)(2)(C) of the Act (or a subset of) the measures for which believe that it would be most
requires that, if the Secretary has not data are required to be submitted under appropriate and desirable to use
updated the ASC payment amounts in a section 1886(b)(3)(B)(viii) of the Act for measures that have been specifically
calendar year after CY 2009, the the IPPS Reporting Hospital Quality developed for application in the
Data for Annual Payment Update hospital outpatient setting. Although we
payment amounts shall be increased by
(RHQDAPU) program. New section still believe that hospitals generally
the percentage increase in the CPI-U as
1833(t)(17)(D) of the Act, gives the function as integrated systems in
estimated by the Secretary for the 12- Secretary the authority to replace
month period ending with the midpoint inpatient and outpatient settings, we do
measures or indicators as appropriate,
of the year involved. Therefore, as not believe it is appropriate to use
such as when all hospitals are
discussed in the July 2007 final rule for participation in the IPPS RHQDAPU
effectively in compliance or when the
the ASC revised payment system, we program for the purpose of
measures or indicators have been
adopted a final policy to update the subsequently shown not to represent the implementing section 1833(t)(17) of the
ASC conversion factor using the CPI-U best clinical practice. New section Act in the hospital outpatient setting.
in order to adjust ASC payment rates for 1833(t)(17)(E) of the Act, requires the Nonetheless, section 1833(t)(17)(C)(ii) of
inflation. We will implement the annual Secretary to establish procedures for the Act indicates that the Secretary is
updates through an adjustment to the making data submitted available to the not prevented ‘‘from selecting measures
conversion factor under the revised ASC public. Such procedures must give that are the same as (or a subset of) the
payment system, beginning in CY 2010 hospitals the opportunity to review data measures for which data are required to
when the statutory requirement for a before these data are released. be submitted’’ under the IPPS
zero update no longer applies. In the CY 2007 OPPS/ASC final rule RHQDAPU program. In this proposed
with comment period (71 FR 68189), we rule, we are proposing to establish a
XVII. Reporting Quality Data for indicated our intent to establish, in CY separate reporting program and
Annual Payment Rate Updates 2009, an OPPS RHQDAPU program proposing quality measures that are
modeled after the current IPPS appropriate for measuring hospital
(If you choose to comment on issues RHQDAPU program in CY 2009. We outpatient quality of care, that reflect
in this section, please include the stated our belief that the quality of consensus among affected parties, and
caption ‘‘Quality Data’’ at the beginning hospital outpatient services would be are set forth by one or more of the
of your comment.) most appropriately and fairly rewarded national consensus building entities.
2. Reporting ASC Quality Data for patients receive many of the same • ED–AMI–2—Median Time to
Annual Payment Increase interventions as patients who are Fibrinolysis
evaluated and admitted at the same • ED–AMI–3—Fibrinolytic Therapy
Section 109(b) of the MIEA–TRHCA,
facility, whose care is currently assessed Received Within 30 Minutes of Arrival
Pub. L. 109–432 amended section
in measures that are endorsed by the • ED–AMI–4—Median Time to
1833(i) of the Act by adding new
National Quality Forum (NQF). NQF is Electrocardiogram (ECG)
sections 1833(i)(2)(D)(iv) and 1833(i)(7) • ED–AMI–5—Median Time to
to the Act. These amendments may a voluntary consensus standard-setting
organization established to standardize Transfer for Primary PCI
affect ASC payments for services • PQRI #5: Heart Failure:
health care quality measurement and
furnished in ASC settings on or after Angiotensin-Converting Enzyme (ACE)
reporting through its consensus
January 1, 2009. New section Inhibitor or
development process. Moreover, these
1833(i)(2)(D)(iv) of the Act authorizes • Angiotensin Receptor Blocker
are also inpatient AMI measures that
the Secretary to implement the revised (ARB) Therapy for Left Ventricular
have long been reported under the IPPS
payment system for services furnished Systolic Dysfunction (LVSD)
RHQDAPU program, and are published
in ASCs (established under section • PQRI #20 Perioperative Care:
on the Hospital Compare Web site at:
1833(i)(2)(D) of the Act), ‘‘so as to Timing of Antibiotic Prophylaxis
http://www.HospitalCompare.hhs.gov.
provide for a reduction in any annual
Transferred AMI patients historically • PQRI #21 Perioperative Care:
payment increase for failure to report on have not been included with the Selection of Prophylactic Antibiotic
quality measures.’’ directly-admitted patients for purposes • PQRI #59: Empiric Antibiotic for
New section 1833(i)(7)(A) of the Act of the calculation of the inpatient AMI Community-Acquired Pneumonia
authorizes the Secretary to provide that measures because of differences in data • PQRI #1: Hemoglobin A1c Poor
any ASC that fails to report data collection and reporting for the two Control in Type 1 or 2 Diabetes Mellitus
required for the quality measures As required by statute, consensus was
groups. With the input of provider and
selected by the Secretary in the form reached by affected parties, as the
practitioner experts in the field, we have
and manner required by the Secretary developed specifications for related measures were identified as appropriate
under new section 1833(i)(7) of the Act emergency department transfer for reporting on hospital outpatient care
will incur a reduction in any annual measures that, while consistent with the in collaboration with professionals and
payment increase of 2.0 percentage measure specifications for the related providers with experience in hospital
points. New section 1833(i)(7)(A) of the hospital inpatient measures, reflect the outpatient settings as well as with the
Act also specifies that a reduction for unique operational and clinical aspects Hospital Quality Alliance (HQA), a
one year cannot be taken into account of care in hospital outpatient settings. hospital-industry led, public-private
in computing the ASC update for a The processes of care encompassed by collaboration established to promote
subsequent year. these measures address care on arrival, public reporting on hospital quality of
New section 1833(i)(7)(B) of the Act the promptness of interventions, and care. CMS is currently finalizing the
provides that, ‘‘except as the Secretary discharge care for patients presenting to specifications for these 10 measures and
may otherwise provide,’’ the hospital a hospital with an AMI. expects to release these specifications to
outpatient quality data provisions of In addition to the five ED–AMI the public by Fall 2007. In addition,
section 1833(t)(17)(B) through (E) of the measures, we have identified five CMS expects to submit these measures
Act, summarized above, shall apply to quality measures that are directly for endorsement by the NQF.
ASCs. related to conditions treated or Nine of the ten measures are process
We refer readers to section XVII.H. of interventions provided in hospital measures, while one measure—
this proposed rule for a discussion of outpatient settings and that we believe Hemoglobin A1c >9.0 percent—is an
our intent to introduce implementation are also appropriate and fully developed intermediate outcome measure that has
of this provision in a later rulemaking. for use in the HOP QDRP. While not been risk-adjusted. While poor
currently specified in a form that quality of care can lead to poor diabetes
B. Proposed Hospital Outpatient control and elevated A1c levels, CMS
Measures assesses the care provided by
physicians, these measures are also recognizes the importance of
For the initial implementation of the directly relevant to assessing care at the compliance with prescribed treatment
HOP QDRP, we have identified 10 facility level. CMS is currently engaged regimen in improving diabetes control
quality measures that we believe are in reviewing, and where appropriate, and A1c levels. Patients with
both applicable to care provided in revising these measure specifications so comorbidities or diabetes complications
hospital outpatient settings and likely to that they explicitly assess care provided may experience challenges controlling
be sufficiently developed to permit data in hospital outpatient settings. The five their diabetes and may have higher A1c
collection consistent with the measures include one measure related levels. Therefore, CMS specifically
timeframes defined by statute. These to treatment of heart failure, two requests comments on this intermediate
measures address care provided to a measures related to surgical care outcome measure and how to balance
large number of adult patients in improvement, one measure addressing the desire for improved quality of care
hospital outpatient settings, across a treatment of community acquired with individual patient challenges that
diverse set of conditions, and were pneumonia, and one measure related to may affect results.
selected for the initial set of HOP QDRP diabetes care. CMS believes that an A1c level higher
measures based on their relevance as a Specifically, in order for hospitals to than 9.0 percent represents a level of
set to all hospitals. receive the full OPPS payment update control that is sufficiently poor enough
The first five of these measures for services furnished in CY 2009, we that it should not result in any
capture the quality of outpatient care in are proposing to require that hospital unintended consequences. The
hospital emergency departments (EDs), outpatient settings submit data on the scientific literature would suggest that
specifically for those adult patients with following 10 measures, effective with an A1c level of 8.0 percent or less might
acute myocardial infarction (AMI) who hospital outpatient services furnished represent the best control that could be
are treated and then transferred to on or after January 1, 2008: expected for some patients: therefore,
another facility for further care. These • ED–AMI–1—Aspirin at Arrival CMS believes that an A1c level of > 9.0
percent represents a level of control that These measures have not received below, as well as any additional
is poor enough that risk-adjustment is formal review by either the HQA or the measures, measure sets, or topics that
not warranted. Additionally, this A1c NQF as measures of HOP performance. should be developed for future
measure has been endorsed by the As noted in the chart, however, the reporting.
National Quality Forum (NQF) in 2006. inpatient or ambulatory versions of We would like to note that, while we
One of the criteria for evaluation of these measures have all been either are committed to identifying measures
measures within the NQF process is recommended by an NQF-subgroup for that are relevant to care in hospital
‘‘scientific acceptability,’’ which endorsement, are pending endorsement outpatient settings, it is also our intent
includes appropriate risk-adjustment. by the NQF, or are currently endorsed to develop, where feasible, hospital
Some measures are not endorsed by by the NQF. The measures present the outpatient measures that are
NQF if risk-adjustment is determined to diversity of services and clinical topics ‘‘harmonized’’ with measures for
be appropriate and is found to be provided to adult patients in hospital assessing comparable inpatient and
inadequate. CMS believes that outpatient settings. The measures
ambulatory care—that is, measures that
additional risk-adjustment is not address some aspects of care provided
are similar in both the care that is
necessary because the NQF endorsed to cancer patients, patients presenting
assessed and the manner in which data
this measure. We invite public comment with diabetes, pneumonia, chest pains,
are collected, regardless of the setting.
on our rationale for choosing a diabetes syncope, or depression, and patients
The goal of harmonization is to assure
outcome measures. receiving services related to bones, eyes,
that comparable care in different care
and problems associated with aging.
C. Other Proposed Hospital Outpatient settings can be evaluated in similar
While some of the measures relate to
Measures ways, which further assures that quality
acute care provided in a hospital
In addition to the 10 measures measurement and improvement can
outpatient setting, others assess care
identified above, we are considering a that a hospital outpatient clinic might focus more on the needs of a patient
number of other possible quality provide on an ongoing basis. We are with a particular condition than on the
measures for use in assessing the care of interested in receiving comments from specific program or policy attributes of
services provided by hospital outpatient the public concerning all dimensions of the setting at which the care is
settings, for the determination of CY these measures. provided.
2010 or subsequent calendar year We expect that once the HOP QDRP Therefore, we are seeking public
payments. These measures are, for the is established, we will expand the set of comment on the following 30 additional
most part, either currently in use or measures on which hospital outpatient measures, which have been identified as
were developed for use in settings other settings must report data. We are hospital outpatient-appropriate
than hospital outpatient. However, we interested in receiving comments measures and are under consideration
believe that these measures are concerning the relative priority that for inclusion in the HOP QDRP measure
applicable to the hospital outpatient should be assigned to each of the set, for CY 2010 or subsequent calendar
settings. measures or topics identified in the list years:
NQF endorsed for

Measure inpatient or Description
ambulatory setting
1 PQRI #2 Low Density Endorsed 2006 .............................. Percentage of patients aged 18–75 years with diabetes (type 1 or
Lipoprotein Control in Type 1 or type 2) who had most recent LDL–C level in control (less than 100
2 Diabetes Mellitus. mg/dl).
2 PQRI #3 High Blood Pressure Endorsed 2006 .............................. Percentage of patients aged 18–75 years with diabetes (type 1 or
Control in Type 1 or 2 Diabetes type 2) who had most recent blood pressure in control (less than
Mellitus. 140/80 mm Hg).
3 PQRI #4 Screening for Fall 2 year Endorsement until May 8, Percentage of patients aged 65 years and older who were screened
Risk. 2009. for fall risk (2 or more falls in the past year or any fall with injury in
the past year) at least once within 12 months.
4 PQRI #9 Antidepressant Medi- Endorsed 2006 .............................. Percentage of patients aged 18 years and older diagnosed with new
cation During Acute Phase for episode of major depressive disorder (MDD) and documented as
Patient with New Episode of treated with antidepressant medication during the entire 84-day (12
Major Depression. week) acute treatment phase.
5 PQRI #10 Stroke and Stroke 2 year Endorsement until May 8, Percentage of patients aged 18 years and older with a diagnosis of
Rehabilitation: Computed Tomog- 2009. ischemic stroke or transient ischemic attack (TIA) or intracranial
raphy (CT) or Magnetic Reso- hemorrhage undergoing CT or MRI of the brain within 24 hours of
nance Imaging (MRI) Reports. arrival to the hospital whose final report of the CT or MRI includes
documentation of the presence or absence of each of the following:
hemorrhage and mass lesion and acute infarction.
6 PQRI #11 Stroke and Stroke 2 year Endorsement until May 8, Percentage of patients aged 18 years and older with a diagnosis of
Rehabilitation: Carotid Imaging 2009. ischemic stroke or transient ischemic attack (TIA) whose final re-
Reports. ports of the carotid imaging studies performed, with characteriza-
tion of internal carotid stenosis in the 30–99% range, include ref-
erence to measurements of distal internal carotid diameter as the
denominator for stenosis measurement.

7 PQRI #24 Osteoporosis: Com- 2 year Endorsement until May 8, Percentage of patients aged 50 years and older treated for a hip,
munication with the Physician 2009. spine or distal radial fracture with documentation of communication
Managing Ongoing Care Post with the physician managing the patient’s ongoing care that a frac-
Fracture. ture occurred and that the patient was or should be tested or treat-
ed for osteoporosis.
NQF endorsed for

ambulatory setting
8 PQRI #46 Medication Rec- 2 year Endorsement until May 8, Percentage of patients aged 65 years and older discharged from any
onciliation. 2009. inpatient facility (e.g., hospital skilled nursing facility, or rehabilita-
tion facility) and seen within 60 days following discharge in the of-
fice by the physician providing on-going care who had a reconcili-
ation of the discharge medications with the current medication list
in the medical record documented.
9 PQRI #53 Asthma Pharma- Endorsed 2006 .............................. Percentage of patients aged 5 to 40 with a diagnosis of mild, mod-
cological Therapy. erate, or severe persistent asthma who were prescribed either the
preferred long-term control medication (inhaled corticosteroid) or an
acceptable alternative treatment.
10 PQRI #58 Assessment of 2 year Endorsement until May 8, Percentage of patients aged 18 years and older with a diagnosis of
Mental Status for Community-ac- 2009. community-acquired bacterial pneumonia with mental status as-
quired Pneumonia. sessed.
11 Radiation therapy is adminis- Endorsed May 9, 2007 .................. Radiation therapy to the breast initiated within 1 year of date of diag-
tered within 1 year of diagnosis nosis.
for women under age 70 receiv-
ing breast conserving surgery for
breast cancer.
12 Adjuvant chemotherapy is con- Endorsed May 9, 2007 .................. Consideration or administration of chemotherapy initiated within 4
sidered or administered within 4 months of date of diagnosis.
months of surgery to patients
under the age of 80 with AJCC III
(lymph node positive) colon can-
cer.
13 Adjuvant hormonal therapy ..... Endorsed May 9, 2007 .................. Cancer—Breast—consideration or administration of accompanying
hormonal therapy for treatment of breast cancer.
14 Needle biopsy to establish di- Endorsed May 9, 2007 .................. Patient whose date of needle biopsy precedes the date of surgery.
agnosis of cancer precedes sur-
gical excision/resection.
15 Osteo–02: Screening or Ther- 2 year Endorsement until May 8, Bone and joint conditions (osteoporosis)—Screening or therapy for
apy for Women Aged 65 years 2009. women aged 65 years and older.
and Older.
16 Osteo–03: Management fol- 2 year Endorsement until May 8, Bone and joint conditions (osteoporosis)—Management following
lowing fracture. 2009. fracture.
17 Osteo–04: Pharmacologic 2 year Endorsement until May 8, Bone and joint conditions (osteoporosis)—Pharmacologic therapy.
Therapy. 2009.
18 EC–01: Electrocardiogram 2 year Endorsement until May 8, Percentage of patients aged 40 years and older with an emergency
(ECG) for Patients with Non- 2009. department discharge diagnosis of nontraumatic chest pain who
Traumatic Chest Pain. had an electrocardiogram (ECG).
19 EC–03: ECG Performed for 2 year Endorsement until May 8, Percentage of patients aged 18 to 60 years with an emergency de-
Patients with Syncope. 2009. partment discharge diagnosis of syncope who had an ECG per-
formed.
20 EC–04: Vital Signs Recorded 2 year Endorsement until May 8, Percentage of patients aged 18 years and older with a diagnosis of
and Reviewed for Patients with 2009. community-acquired bacterial pneumonia with vital signs recorded
Community-Acquired Bacterial and reviewed.
Pneumonia.
21 Eye–01: Primary Open Angle 2 year Endorsement until May 8, Primary open angle glaucoma—optic nerve evaluation.
Glaucoma—Optic Nerve Evalua- 2009.
tion.
22 Eye–02: Age-Related Macular Recommended for Endorsement .. Age-related macular degeneration—antioxidant supplement pre-
Degeneration—Antioxidant Sup- scribed/recommended.
plement Prescribed/Rec-
ommended.
23 Eye–03: Age-Related Macular 2 year Endorsement until May 8, Age-related macular degeneration—dilated macular examination.
Degeneration—Dilated Macular 2009.
Examination.
24 Eye–07: Diabetic Retinop- 2 year Endorsement until May 8, Documentation of presence or absence of macular edema and level
athy—Documentation of Pres- 2009. of severity of retinopathy.
ence or Absence of Macular
Edema and Level of Severity of
Retinopathy.
25 EYE–08: Diabetic Retinop- 2 year Endorsement until May 8, Communication with the physician managing ongoing diabetes care.
athy—Communication with the 2009.

Physician Managing Ongoing Di-
abetes Care.
26 GI–09: Colonoscopy for Polyp Recommended for Endorsement .. Colonoscopy for polyp surveillance—description of polyp characteris-
Surveillance—Description of tics.
Polyp Characteristics.
27 GER–02: Advance Care Plan Recommended for Endorsement .. Advance care plan.
NQF endorsed for

ambulatory setting
28 GER–03: Urinary Inconti- 2 year Endorsement until May 8, Assessment of presence or absence of urinary incontinence in
nence—Assessment of Presence 2009. women aged 65 years and older.
or Absence of Urinary Inconti-
nence in Women Aged 65 Years
and Older.
29 GER–04: Urinary Inconti- 2 year Endorsement until May 8, Characterization of urinary incontinence in women aged 65 years and
nence—Characterization of Uri- 2009. older.
nary Incontinence in Women
Aged 65 Years and Older.
30 GER–05: Urinary Inconti- 2 year Endorsement until May 8, Plan of care for urinary incontinence in women aged 65 years and
nence—Plan of Care for Urinary 2009. older.
Incontinence in Women Aged 65
Years and Older.
While we are soliciting comments on made available to the public prior to its their payment update factor for the
these 30 additional measures for being made public. affected payment year.
inclusion in the HOP QDRP for CY 2010 We believe that assuring that Proposed requirements for
or subsequent calendar years, we also Medicare beneficiaries receive the care participation in the HOP QDRP are:
welcome comments on whether any of they need and that such services are of
these additional measures should be 1. Administrative Requirements
appropriately high quality are the
included effective for services furnished necessary initial steps to the To participate in the HOP QDRP, the
on or after January 1, 2008 for the CY incorporation of value-based purchasing hospital must complete several
2009 update. into the OPPS. We seek to encourage administrative steps. These steps, as in
D. Proposed Implementation of the HOP care that is both efficient and of high the current IPPS RHQDAPU program,
QDRP quality in the hospital outpatient require the hospital to:
setting. We plan to work quickly and • Identify a QualityNet Exchange
For purposes of CY 2009 payments, collaboratively with the hospital administrator who follows the
we would require hospitals to begin to community to develop and implement registration process and submits the
submit data on the 10 measures that we quality measures for the OPPS that are information through the CMS-
have identified under section XVII.B. of fully and specifically reflective of the designated contractor. The same person
this proposed rule. While we would quality of hospital outpatient services. may be the QualityNet Exchange
expect to focus on these 10 measures
We welcome the suggestion of other administrator for both the IPPS
and will consider comments on them for
additional measures and topics relevant RHQDAPU program and the HOP
the CY 2009 payment year, we will also
to the hospital outpatient setting for QDRP. This designation must be kept
consider the comments received from
future development of the measure set, current and must be done, regardless of
the public on the list of 30 additional
particularly measures from other whether the hospital submits data
measures cited above in developing the
settings (such as hospital inpatient, directly to the CMS designated
final lists of measures for future
physician office, and emergency care contractor or uses a vendor for
payment years.
As with the hemoglobin A1c diabetes settings) that would contribute to better transmission of data.
intermediate outcome measure coordination and harmonization of high • Register with the QualityNet
described in XVII.B of this preamble, we quality patient care. Exchange, regardless of the method used
invite public comment on the two for data submission.
E. Proposed Requirements for HOP
diabetes intermediate outcome measures Quality Data Reporting for CY 2009 and • Complete the Notice of
proposed in this list of 30 additional Subsequent Calendar Years Participation form. All hospitals must
measures—i.e., good control of blood send the form to a CMS-designated
pressure (less than 140/80 mm Hg) and To participate in the HOP QDRP for contractor no later than November 15,
LDL–C levels (less than 100 mg/dl). We CY 2009 and subsequent calendar years, 2007 for the CY 2009 HOP QDRP. At
invite comment on whether the use of hospitals must meet administrative, data this time, the participation form for the
these outcome measures will result in collection and submission, and data HOP QDRP is separate from the IPPS
unintended consequences. validation requirements. Hospitals not RHQDAPU program and completing a
As described below, procedures for participating in the program or that submission form for each program is
submission of hospital outpatient withdraw from the program will not required. Agreeing to participate
quality information will mirror as receive the full OPPS payment rate includes acknowledging that the data
closely as possible all procedures for update. Instead, in accordance with the submitted to the CMS designated
submission of inpatient quality law, those hospitals would receive a contractor will be submitted to CMS and
information. The inpatient procedures reduction of 2.0 percentage points in may be shared with a CMS contractor or
are identified on the QualityNet Web their updates for the affected payment contractors supporting the
site, at http://www.qualitynet.org. As year. implementation of this program.

required by new section 1833(t)(17)(E) Hospitals not meeting the Hospitals not wishing to participate
of the Act, we will develop procedures requirements of the HOP QDRP also will must submit a nonparticipation form.
to publicly report the measure results not receive the full OPPS payment rate Hospitals that have completed a notice
obtained under the HOP QDRP. update. Instead, in accordance with the of participation form and subsequently
Hospitals will have an opportunity to law, those hospitals also would receive wish to stop participating must submit
review the information that is to be a reduction of 2.0 percentage points in a withdrawal form.
To reduce the burden on hospitals, QIO contractor (or subcontractor) would submits for payment. To be considered
once a hospital has indicated its intent manage the OPPS Clinical Warehouse. ‘‘accurate’’, submissions must pass
to participate or not participate, we will Because the information in the OPPS validation.
consider the hospital to be in that status Clinical Warehouse also may be • Submit the aggregate numbers of
(either a participant or nonparticipant) considered QIO information, it may be outpatient episodes of care which were
until the hospital indicates a change in subject to the stringent QIO eligible for submission under the HOP
status by submitting a notice of confidentiality regulations in 42 CFR QRDP. These numbers would indicate
participation or a withdrawal form. part 480. the number of outpatient episodes of
For purposes of the CY 2009 annual care in the universe to which sampling
2. Data Collection and Submission payment update, we are proposing to criteria are applied.
Requirements require hospitals to submit data, for the New hospitals are expected to begin
We are proposing that, to be eligible finalized set of measures, beginning reporting data as soon as possible, but
for the full OPPS payment update in CY with services furnished on or after no later than beginning with services
2009 and subsequent years, hospitals January 1, 2008. The deadline for provided the first day of the calendar
must: submission of data for January 2008 quarter immediately following a
• Collect data required for the discharges will be 4 months from the hospital’s receipt of its Medicare
finalized set of measures, beginning last day of the month, May 31, 2008. provider number and the hospital’s
with the specifications of the finalized The deadline for submission for timely completion of the administrative
set of measures that will be identified in February–March 2008 discharges would requirements for participating in the
the CY 2008 OPPS/ASC final rule (for be August 1, 2008. Thereafter, HOP QDRP.
payment updates for CY 2009 services) participating hospitals would be
and that will be published and required to submit quarterly data on 3. HOP QDRP Validation Requirements
maintained in a specifications manual finalized measures 4 months from the We would require that data submitted
to be found on the Web site at: http:// last day of the calendar quarter for as under this program meet validation
www.qualitynet.org. long as the hospitals participated in the requirements. The proposed validation
• Submit the data according to a data HOP QDRP. The deadline for April-June requirements are similar to FY 2006
submission schedule that will be 2008 discharges, for example, would be IPPS RHQDAPU program validation
available on the QualityNet Exchange November 1, 2009. requirement (the initial year validation
Web site. We propose to have HOP data Hospitals will be expected to submit requirement was added to the IPPS
submitted through the QualityNet data under the HOP QDRP on outpatient RHQDAPU program) and include
Exchange secure Web site ( https:// episodes of care to which the required independent reabstraction of medical
www.qnetexchange.org). This Web site measures apply. For the purposes of the record data elements by a clinical data
meets or exceeds all current Health HOP QDRP, an outpatient episode of abstraction center (CDAC). The CMS
Insurance Portability and care is defined as care provided to a contractor will randomly select 5
Accountability Act requirements. The patient who has not been admitted as an medical records from all January 2008
submission deadline for January 2008 inpatient but who is registered on the discharge cases successfully submitted
discharges will be May 31, 2008. Except hospital’s medical records as an to the OPPS Clinical Warehouse. The
for January 2008 discharges, submission outpatient and receives services (rather CDAC will mail requests to the hospitals
deadlines will be 4 months after the last than supplies alone) directly from the to send the selected medical records to
day of the calendar quarter. Data must hospital. Every effort will be made to the CDAC within 30 calendar days. The
be submitted to the CMS designated assure that data elements common to CDAC will independently reabstract the
contractor using either the CMS both inpatient and outpatient settings medical record data elements. We will
Abstraction and Reporting Tool for are defined consistently (such as ‘‘time provide abstraction feedback to all
Outpatient Department measures of arrival’’). However, HOP QDRP hospitals on abstracted data elements.
(CART–OPD) or another third-party quality data, not quality data required to We are proposing the following chart
vendor that has a tool which has met the be submitted for a patient treated under audit validation requirements for full
measure specification requirements for the IPPS RHQDAPU program, would be CY 2009 payment updates:
data transmission to the QualityNet submitted under the HOP QDRP. • Apply to January 2008 discharges
Exchange. To be accepted by the CMS only.
Hospitals must submit quality data designated contractor, submissions • Require submission of 5 charts
through the CMS contractor’s secure would, at a minimum, need to be sampled from each hospital.
Web site. We will provide more detailed accurate, timely, and complete. Data are • Establish a passing threshold of 80
information about the Web site in the considered to have been ‘‘accepted’’ by percent reliability reflecting the
CY 2008 OPPS/ASC final rule, as we the CMS designated contractor, for accuracy of submitted data elements
anticipate awarding the contract to purposes of determining eligibility for used to calculate quality measures.
design and manage the OPPS Clinical the full payment rate update, only when • Use an upper bound of 95 percent
Warehouse before that final CY 2008 data are submitted prior to the reporting confidence interval to measure
OPPS/ASC final rule is published. We deadline and after they have passed all accuracy.
expect the CMS contractor’s Web site to CMS designated contractor edits. • Incorporate clustering of variability
meet or exceed all current Health • Submit complete and accurate data. at the chart level into the confidence
Insurance Portability and A ‘‘complete’’ submission is determined interval.
Accountability Act requirements for based on sampling criteria that will be Validation is intended to provide
security of personal health information. published and maintained in a some assurance of the accuracy of the
The OPPS Clinical Warehouse will specifications manual to be found on hospital abstracted data. We have
submit the data to CMS on behalf of the the Web site at http:// specifically chosen these validation
hospitals. While the CMS contract for www.qualitynet.org, and must requirements and thresholds to allow
managing the OPPS Clinical Warehouse correspond to both the aggregate this assurance, provide sufficient time
was not awarded prior to publishing number of cases submitted by a hospital to fully process validation data, and
this proposed rule, it is possible that a and the number of Medicare claims it minimize the burden on hospitals.
To receive the full OPPS payment rate hospital data would be considered that process will be posted to the
update in CY 2009, the hospital must validated. We are proposing to use the QualityNet Exchange Web site, http://
pass our validation requirement of a design-specific estimate of the variance www.qnetexchange.org. In this proposed
minimum of 80 percent reliability, for the confidence interval calculation, rule, we are seeking public comment
based upon our chart-audit validation which, in this case, is a single stage specifically on the need for a structured
process, for the January 2008 discharges. cluster sample, with unequal cluster reconsideration process for CY 2009 and
The 80-percent reliability threshold is sizes. (For reference, see Cochran, subsequent calendar years. We also
consistent with the inpatient RHQDAPU William G. (1977) Sampling request comment on what such a
validation reliability threshold. Based Techniques, John Wiley & Sons, New process should entail. For example,
on our previous RHQDAPU experience, York, chapter 3, section 3.12.) Each such a process, if established, could
we believe that this threshold is sampled medical record is considered as include—
reasonable and attainable by the vast a cluster for variance estimation • A limited time, such as 30 days
majority of hospitals. Several of the purposes, as documentation and from the public release of the decision,
measures used in the OPPS HOP QDRP abstraction errors are believed to be for requesting a reconsideration;
are similar in construction to inpatient clustered within specific medical • Specific individuals or functions in
measures used in the current RHQDAPU records. a hospital organization that can request
program. Based on the similar nature of such a reconsideration and that would
F. Publication of HOP QDRP Data
the inpatient and outpatient measure be notified of its outcome;
Collected • The specific factors that CMS will
sets, we believe that the 80-percent
reliability threshold is applicable in the New section 1833(t)(17)(E) of the Act consider in such a reconsideration, such
OPPS HOP QDRP. requires that the Secretary establish as an inability to submit data timely due
These data are due to the CMS procedures to make data collected under to CMS systems failures;
designated contractor by May 31, 2008. this program available to the public and • Specific requirements for
We will use confidence intervals, as to report the quality measures on the submitting a reconsideration request,
discussed below, to determine if a CMS Web site. Our intent is to make such as a written request for
hospital has achieved an 80-percent this information public in CY 2009 by reconsideration specifically stating all
reliability. The use of confidence posting it on the CMS Web site. reasons and factors why the hospital
intervals would allow us to establish an Participating hospitals will be granted believes it did meet the HOP QDRP
appropriate range below the 80 percent the opportunity to preview this program requirements;
reliability threshold that would information prior to its public posting as • Suggestions regarding the type of
demonstrate a sufficient level of we have recorded it. entity that should conduct the
reliability to allow the data to still be reconsideration process; and
G. Proposed Attestation Requirement for • The timeframe, such as 60 days, for
considered validated. We note that, for
Future Payment Years CMS to provide its reconsideration
both timing and burden reasons, we are
proposing to apply the validation CMS also solicits comments on decision to the hospital.
requirements only to January 2008 whether to implement an HOP QDRP We also are requesting comments on
discharges for purposes of determining attestation requirement in CY 2010 and the reasons for not establishing such a
eligibility for the full CY 2009 OPPS subsequent payment years similar to the reconsideration process. We plan to
payment rate update. However, proposed attestation requirement in the establish procedures that are as similar
hospitals would still be required to IPPS RHQDAPU program set out in the as possible to those used by the IPPS
submit data for subsequent time FY 2008 IPPS proposed rule (72 FR RHQDAPU program should we finalize
periods. 24808). Hospitals would be required to our proposal to implement a
We will use January 2008 discharges submit a written form to a CMS reconsideration process for HOP QDRP.
to estimate the hospitals’ validation contractor indicating that they formally
I. Reporting of ASC Quality Data
score for the CY 2009 validation attest to the accuracy and completeness
proposed requirement. The timeframe of their data, including the volume of As discussed above, section 109(b) of
for data collection, abstraction, and data submitted to the OPPS Data the MIEA–TRHCA (Pub. L. 109– 432)
validation tasks total about nine to ten Warehouse. We anticipate that the amended section 1833(i) of the Act by
months between patient discharges to attestation form submission deadlines redesignating clause (iv) as clause (v),
completion of validation appeals. We would parallel the HOP QDRP periodic adding new section 1833(i)(2)(D)(iv),
believe that using later discharges for data submission deadlines. and adding new section 1833(i)(7) to the
the CY 2009 annual payment update Act. These amendments authorize the
H. HOP QDRP Reconsiderations Secretary to require ASCs to submit data
would adversely impact CMS’ ability to
complete these tasks and apply the When the IPPS RHQDAPU program on quality measures and to reduce the
results to the CY 2009 annual payment was initially implemented, it did not annual increase in a year by 2.0
update. include a reconsideration submission percentage points for ASCs that fail to
Based on our proposed methodology, process for hospitals. Subsequently, we do so. These provisions permit, but do
the confidence interval will be slightly received many requests for not require, the Secretary to require
wider than is currently utilized for the reconsideration of those payment ASCs to submit such data and to reduce
IPPS RHQDAPU program due to the decisions, and as a result, identified a any annual increase for non-compliant
smaller sample size. However, given process by which participating hospitals ASCs.
this is the first year of the HOP QDRP, would submit requests for We are not proposing to introduce
we believe this is appropriate. We reconsideration. We anticipate similar quality measures for reporting in ASCs
would estimate the percent reliability concerns with the HOP QDRP and, for CY 2008 as we are for the OPPS as
based upon a review of five charts and therefore, we are proposing to establish described in sections XVII.B. through H.
then calculate the upper 95 percent a reconsideration process for the HOP of this proposed rule. While we believe
confidence limit for that estimate. If this QDRP for those hospitals that fail to that promoting high quality care in the
upper limit is above the required 80 meet the CY 2009 HOP QDRP ASC setting through quality reporting is
percent reliability threshold, the requirements. The procedural details of highly desirable and fully in line with
our efforts under other payment of a necessary provider designation. The campus facilities that they do not
systems, we also believe that the criteria used to qualify a CAH as a believe would be subject to CAH
transition to the revised payment system necessary provider were established by location requirements.
in CY 2008 poses such a significant each State in its Medicare Rural For the reasons noted below, we are
challenge to ASCs that it would be most Hospital Flexibility Program (MRHFP). taking a proactive approach by
appropriate to allow some experience The State’s MRHFP rural health care proposing a change in the regulation to
with the revised payment system before plan contains the necessary assurances be consistent with our belief that the
introducing other new requirements. that the plan was developed to further intent of the CAH program is to
Implementation of quality reporting at the goals of the statute and regulations maintain hospital-level services in rural
this time would require systems changes to ensure access to essential health care communities while ensuring access to
and other accommodations by ASCs, services for rural residents. The statute care. We believe that this proposed
facilities which do not have prior and regulations give some discretion change to the regulations will help to
experience with quality reporting as and flexibility within a Federal maintain the integrity of the MRHFP
hospitals already have for inpatient framework for a State to designate within the statutory requirements.
quality measures, at a time when they CAHs. States, in consultation with their 2. Co-Location of Necessary Provider
are implementing a significantly revised hospital associations and Offices of CAHs
payment system. We believe that our CY Rural Health, have defined those CAHs
2008 proposal to implement quality that provide necessary services to a Some necessary provider CAHs are
reporting for HOPs prior to establishing particular patient community in the co-located with other hospitals,
quality reporting for ASCs would allow event that the facility did not meet the particularly specialty psychiatric and or
time for ASCs to adjust to the changes required 35-mile (or, in the case of rehabilitation hospitals. Prior to the
mountainous terrain or in areas with enactment of section 405(g) of Pub. L.
in payment and case-mix that are
only secondary roads, 15-mile) distance 108–173, it is understandable that a
anticipated under the revised payment
requirement from the nearest hospital or State MRHFP might have allowed co-
system. We would also gain experience
CAH. Each State’s criteria are different, location of a CAH with a necessary
with quality measurement in the
but the criteria share certain similarities provider designation with the
ambulatory setting in order to identify
and all define a necessary provider specialized services of a psychiatric
the most appropriate measures for
related to the facility location. and/or an inpatient rehabilitation
quality reporting in ASCs prior to the
However, section 405(h)(1) of Pub. L. hospital. The State may have believed
introduction of the requirement in
108–173 amended section that beneficiary access to care would be
ASCs. We intend to implement the
1820(c)(2)(B)(i)(II) of the Act by adding enhanced through the provision of both
provisions of section 109(b) of the CAH and these specialized services at
MIEA–TRHCA, Pub. L. 109–432, in a language that ended States’ authority to
waive the location requirement for a the same location, and the CAH itself
future rulemaking. might have had difficulty in providing
CAH by certifying the CAH as a
XVIII. Proposed Changes Affecting necessary provider, effective January 1, such services within its permitted bed
Critical Access Hospitals (CAHs) and 2006. In addition, section 405(h)(2) of limits. However, section 405 of Pub. L.
Hospital Conditions of Participation Pub. L. 108–173 amended section 108 173 included several provisions that
(CoPs) 1820(h) of the Act to include a permit CAHs themselves to address
grandfathering provision for CAHs that such access to care issues.
A. Proposed Changes Affecting CAHs Specifically, section 405(e) of Pub. L.
were certified as necessary providers
(If you choose to comment on the prior to January 1, 2006. We 108–173 amended sections
issues in this section, please include the incorporated these amendments in 1820(c)(2)(B)(iii) and 1820(f) of the Act
caption ‘‘Necessary Provider CAHs’’ at § 485.610(c) of our regulations in the FY to increase the permitted number of
the beginning of your comment.) 2005 IPPS final rule (69 FR 49220). CAH inpatient beds from 15 to 25. In
Because those regulations did not addition, section 405(g) of Pub. L. 108–
1. Background 173 added section 1820(c)(2)(E) to the
address the situation where the
CAHs are subject to different grandfathered CAH is no longer the Act, which permits a CAH to operate
participation requirements than are same facility due to relocation, in the distinct part inpatient psychiatric and/
hospitals. Among other requirements, a FY 2006 IPPS final rule (70 FR 47490), or rehabilitation units, each subject to a
CAH must be located in a rural area (or we amended § 485.610 of our 10-bed limit that is not included as part
an area treated as rural), and, under regulations to add a new § 485.610(d) of the CAH’s 25-bed limit. Therefore, a
§ 485.610(c), must meet an additional that addressed the relocation criteria a CAH can operate a 45-bed facility
distance-related location requirement. necessary provider CAH has to meet to addressing a wide range of needs in the
Under this requirement, a CAH must be retain its necessary provider rural community it serves. We believe
located at least 35-miles (or, in the case designation. that CAHs seeking to provide access to
of mountainous terrain or in areas with Additional circumstances concerning specialized services should avail
only secondary roads, 15-miles) from CAHs with existing necessary provider themselves of the statutory provisions
the nearest hospital or other CAH. In designations have come to our attention governing distinct part units in CAHs
addition, CAHs receive payment for that we believe also need to be rather than making arrangements with
services furnished to Medicare addressed. Specifically, we have learned other hospital providers to share space
beneficiaries differently. CAHs receive that some CAHs with grandfathered at the CAH location.
cost-based payment for 101 percent of necessary provider designations are co- In light of these changes to the statute,
their reasonable costs. located with other hospitals, which we are proposing to no longer allow a
Prior to January 1, 2006, States were typically are PPS-excluded inpatient necessary provider CAH to enter into
permitted to waive the CAH minimum psychiatric facilities or inpatient co-location arrangements between CAHs
distance eligibility requirement by rehabilitation facilities. We are also and hospitals unless such arrangements
certifying that a CAH was a necessary aware that there is interest in the were in effect on or before January 1,
provider. Approximately 850 current creation or acquisition by CAHs with 2008 and the type and scope of services
CAHs entered the program on the basis necessary provider designation of off- offered by the facility co-located with
the necessary provider CAH do not Operations Manual 3210) to obtain CAH with a necessary provider designation,
change. We believe that this restriction status. Thus, grandfathered necessary there is no reason to assume that the
will help to ensure that the current provider CAH status, including distance exemption given to the CAH
necessary services will remain in the grandfathered co-location arrangements, should be extended without
community. Further, we are proposing would not transfer to a new CAH owner qualification to any location for that
to clarify that a change of ownership of who does not assume the provider CAH’s off-campus facilities.
the CAH, when the new owners assume agreement from the previous owner. To Accordingly, any CAH off-campus
the original provider agreement, does obtain CAH designation, the new locations must satisfy the current
not constitute a new co-location provider would have to comply with all statutory CAH distance requirements,
arrangement and, thereby, under our the CAH designation requirements, without exception and regardless of
proposal, a necessary provider CAH including the location requirements whether the main provider CAH is a
would be permitted to continue under relative to other providers, that is, more necessary provider CAH.
an existing co-location arrangement. than a 35-mile drive (or 15 miles in Therefore, we are proposing to clarify
We are concerned that, without this areas of mountainous terrain or that if a necessary provider CAH, or a
change, there may be situations where secondary roads). CAH that does not have a necessary
more necessary provider CAHs will co- provider designation, operates a
locate with PPS hospitals. Currently, co- 3. Provider-Based Facilities of CAHs
provider-based facility as defined in
location arrangements seem to involve We have consistently taken the
§ 413.65(a)(2), or a psychiatric or
psychiatric or rehabilitation hospitals. position that the intent of the CAH
rehabilitation distinct part unit as
We are concerned about co-location by program is to keep hospital-level
defined in § 485.647 that was created or
a necessary provider CAHs with a short- services in rural communities, thereby
acquired on or after January 1, 2008, it
term acute care hospital, including a ensuring access to care (FY 2006 IPPS
must comply with the distance
physician-owned specialty hospital. We final rule (70 FR 47469)). A CAH is
requirement of a 35-mile drive to the
also cannot rule out a scenario where permitted to create or acquire an off-
nearest hospital or CAH (or 15 miles in
two necessary provider CAHs could co- campus location, including a distinct
the case of mountainous terrain or in
locate after relocation. We believe the part unit that satisfies the location
criteria for a CAH and operates under areas with only secondary roads).
co-location of a necessary provider CAH
with another hospital or necessary the CAH’s provider agreement under the 4. Termination of Provider Agreement
provider CAH is not consistent with the provider-based rules at 42 CFR 413.65.
We note that, under section In the event that a CAH with a
CAH statutory framework that
1820(c)(2)(B)(i)(II) of the Act, a CAH necessary provider designation enters
establishes requirements for a CAH to be
does not have to meet the distance into a co-location arrangement after
a certain minimum distance from other
requirements relative to other hospitals January 1, 2008, or acquires or creates
hospitals or CAHs. We believe that the
elimination of States’ authority to or CAHs if it was certified prior to an off-campus facility after January 1,
designate necessary provider CAHs and January 1, 2006, as a necessary provider 2008, that does not satisfy the CAH
the ability for CAHs to operate by the State. We stated in the FY 2006 distance requirements in § 485.610(c),
psychiatric and rehabilitation units IPPS final rule (70 FR 47472), when we are proposing to terminate that
should provide sufficient flexibility for addressing the relocation criteria for a CAH’s provider agreement, in
necessary provider CAHs to operate necessary provider CAH, that the accordance with the provisions of
within the statutory framework without ‘‘necessary provider’’ designation is § 489.53(a)(3). The necessary provider
engaging in additional arrangements. specific to the physical location(s) of the CAH could avoid termination by
We also are clarifying in this CAH in existence at the time of the converting to a hospital that is paid
proposed rule that under certain designation. We believe the necessary under the IPPS, assuming that the
circumstances, a change of ownership of provider CAH designation cannot be facility satisfies all requirements for
any of the facilities (either the CAH or considered to extend to any new participation as a hospital in the
the existing co-located facility) with a facilities not in existence when the CAH Medicare program under the provisions
co-location arrangement that was in received its original necessary provider in 42 CFR Part 482. We also note that
effect before January 1, 2008, will not be designation. Accordingly, we believe if the necessary provider CAH corrects
considered to be a new co-location the creation of any new location that the situation that led to the
arrangement. If a change of ownership would cause any part of the CAH to be noncompliance, a termination action
should occur in a CAH with a situated at a location not in compliance will not be triggered. A CAH that is not
grandfathered co-location arrangement with the distance requirements at 42 a necessary provider CAH could not
on or after January 1, 2008, we note the CFR 485.610 would cause the entire have a co-location situation due to the
provider agreement is generally CAH to violate the distance distance requirements it is required to
automatically assigned to the new requirements. meet at 485.610 (c).
owner, unless the new owner rejects Of the approximately 1,300 CAHs, 5. Proposed Regulation Changes
assignment of the provider agreement or 453 CAHs have health clinics, 81 have
assignment of the provider agreement is psychiatric units, and 20 have We are proposing to amend § 485.610
otherwise not made. If the new owner rehabilitation units. We do not know by adding a new paragraph (e) to
does not get assignment of the provider how many of the existing clinics and address situations under our proposal
agreement, the new owner would have distinct part units are at off-site relating to off-campus and co-location
to go through the same enrollment locations. However, we are concerned requirements for CAHs with a necessary
process as any other new provider; that with CAHs creating or acquiring off- provider designation.
is, enrolling with the fiscal intermediary campus locations, including distinct
B. Proposed Revisions to Hospital CoPs
(or if applicable, the MAC), applying for part psychiatric and rehabilitation units,
participation, undergoing the Office of that do not comply with the CAH (If you choose to comment on the
Civil Rights clearance and an initial location requirement relative to other issues in this section, please include the
certification survey that meets all the facilities. Therefore, when such off- caption ‘‘Hospital CoPs’’ at the
current Medicare conditions (see State campus facilities are created by a CAH beginning of your comment.)
1. Background outpatient procedures and another 10 to procedures that were once done only on
On November 27, 2006, we published 15 percent performed on a same-day an inpatient basis are now routinely
a final rule in the Federal Register admission basis. These figures performed in outpatient settings.
entitled ‘‘Medicare and Medicaid combined translate to approximately 21 Therefore, the patient is not admitted or
Programs; Hospital Conditions of million surgical procedures performed registered as an outpatient until the day
Participation: Requirements for History each year in the U.S. on patients who of the procedure. Often this admission
and Physical Examinations; are admitted to the hospital on the day or registration is just hours before the
Authentication of Verbal Orders; of their procedure. A majority of these procedure is performed. In addition,
Securing Medications; and patients are also discharged from the there are many patients who are
Postanesthesia Evaluations’’ (71 FR hospital the same day that they are admitted as inpatients on the same day
68672). In that final rule (also frequently admitted. It is unclear whether these that they are scheduled for more
referred to as the ‘‘Carve-out rule’’), we numbers also include other procedures, complex procedures, which will then
such as diagnostic ones, which also require postoperative hospital stays.
finalized changes, which were based on
require anesthesia services, and which However, for patients admitted or
timely public comments submitted on
include all of the risks to patient safety registered for outpatient procedures as
the proposed rule published in the
inherent in such procedures. In either well as for those patients admitted on
March 25, 2005 Federal Register (70 FR
case, significant numbers of patients the same day as their surgery, there is
15266), to four of the current
undergo surgeries and other procedures currently no mechanism to ensure that
requirements (or conditions of
each year as either outpatients or same- these patients are examined for any
participation (CoPs)) that hospitals must
day admission patients. changes in their condition prior to
meet to participate in the Medicare and The current requirements for the
Medicaid programs. Specifically, that undergoing a procedure. Paragraph
completion of the medical history and (b)(1) of § 482.51 currently requires that
final rule revised and updated our CoP physical examination are found in the
requirements for: completion of the every patient have a complete medical
regulations at § 482.22 (Medical staff history and physical examination
history and physical examination in the CoP), § 482.24 (Medical record services
Medical staff and the Medical record documented in the chart prior to
CoP), and § 482.51 (Surgical services surgery, except in emergencies.
services CoPs; authentication of verbal CoP). We believe that these
orders in the Nursing services and the However, the timeframe requirements
requirements do not adequately address for this medical history and physical
Medical record services CoPs; securing the patient who is admitted for
medications in the Pharmaceutical examination contained under both
outpatient or same-day surgery or a § 482.22(c)(5) and § 482.24(c) (2)(i)(A)
services CoP; and, completion of the procedure requiring anesthesia services.
postanesthesia evaluation in the allow for a medical history and physical
The standards at § 482.22(c), Medical examination that may be as much as 30
Anesthesia services CoP. This action staff bylaws, and § 482.24(c), Content of
was initiated in response to broad days old. Without a requirement that an
record, both contain requirements for a updated examination be completed after
criticism from the medical community medical history and physical
that the then-current requirements admission and prior to surgery or other
examination, and an update of the procedure, any changes in a patient’s
governing these areas were burdensome medical history and physical
and did not reflect current practice. condition would most likely be missed
examination documenting any changes by hospital staff. Failing to identify
Since this final rule became effective in a patient’s condition if the medical
on January 26, 2007, we have received changes in a patient’s condition prior to
history and physical examination was
a great number of comments and surgery may adversely impact not only
completed within 30 days before
questions from providers about the the procedure but also consequently,
admission, to be completed and
timeframe requirements (for both the and perhaps more significantly, the
documented within 24 hours after
initial medical history and physical outcome of the procedure for the
admission. Under the Surgical services
examination and its update) as well as patient.
CoP at § 482.51(b)(1), there is a
about the postanesthesia evaluation provision that requires a complete We are proposing revisions to
requirements. In both areas, commenters history and physical workup to be in the §§ 482.22, 482.24, and 482.51 that
have sought clarification on the chart of every patient prior to surgery. would require an updated examination,
application of these requirements for However, there is currently no including any changes in a patient’s
patients undergoing outpatient surgeries requirement for an updated examination condition, to be completed and
and procedures. While the new of the patient, including any changes to documented for each patient after
requirements contained in the Carve-out the patient’s condition, to be completed admission or registration and prior to
rule provide hospitals greater flexibility and documented after admission or surgery or to a procedure requiring
in ensuring the quality of inpatient care, registration, and prior to any surgery or anesthesia services. These revisions
the issues surrounding outpatient care procedure being performed. For patients would ensure that any changes in the
in the hospital setting, particularly with who are admitted as inpatients for patient’s condition are discovered
regard to outpatient surgeries and surgery to be performed in the next day before a procedure is performed. With
procedures, are not clear. After or so, this does not pose a problem. the most up-to-date information
conducting a thorough review of the These inpatients will be followed while regarding a patient’s condition readily
hospital CoPs and the interpretive in the hospital with both daily progress available to hospital staff prior to a
guidelines, we have isolated the and nursing notes made in their medical procedure, the risks to patient safety
relevant issues regarding outpatient care record. In addition, as required under should be minimized and a poor
and are proposing revisions to the the current regulations, these patients outcome for the patient would be
current regulations to address these will also have an updated examination avoided. However, under these
concerns. for any changes in their condition proposed requirements, it is not our
According to the most recent data, 30 within 24 hours after their admission. intent to include those minor
million surgical procedures are As evidenced by the numbers of procedures that only require the
performed each year in the United outpatient and same day admission administration of local anesthetics, as
States with over 60 percent done as inpatient procedures discussed above, might be the case for procedures such as
biopsies of skin lesions or suturing of discharged well before 48 hours after § 482.24(c)(2), which we are proposing
noncomplex lacerations. surgery. to retain under this rule.
Conversely, the current requirements Therefore, we are proposing revisions Further, we are proposing to separate
at § 482.52, Anesthesia services, still to § 482.52(b) that would ensure that all the requirements for the medical history
distinguish between inpatients and patients who have received anesthesia and physical examination and for the
outpatients with regard to services, regardless of inpatient or updated examination under two
postanesthesia evaluation, with the outpatient status, have a postanesthesia provisions at § 482.22(c)(5)(i) and
requirements for outpatient evaluation evaluation completed and documented § 482.22(c)(5)(ii), respectively. At
actually being less stringent than those by an individual qualified to administer § 482.22(c)(5)(i), we are proposing to
for inpatients. When the current anesthesia before they are discharged or retain the current requirement that the
hospital regulations were originally transferred from the postanesthesia medical history and physical
written in 1986, these differences in recovery area. examination be completed by a
regulatory oversight may have been Finally, in our review of the CoPs, we physician (as defined in section 1861(r)
entirely appropriate. At that time there discovered a cross-reference under of the Act), an oromaxillofacial surgeon,
were still very clear differences between § 482.23, Nursing services, that is no or other qualified individual in
inpatient and outpatient procedures, longer valid. We are taking the accordance with State law and hospital
with inpatient procedures (and the opportunity in this proposed rule to policy. However, we are proposing to
anesthesia services required) considered correct this error through a technical add the words ‘‘and documented’’ after
much more serious and complex in amendment. ‘‘be completed’’ as well as ‘‘licensed’’
nature. Since that time, there has been after ‘‘qualified’’ to further clarify this
2. Provisions of the Proposed requirement. In addition, we are
a gradual blurring of the distinctions Regulations
between what were previously termed proposing to revise § 482.22(c)(5)(ii) to
‘‘inpatient’’ procedures and those that a. Proposed Timeframes for Completion require that the updated examination of
were classified as ‘‘outpatient’’ of the Medical History and Physical the patient must be completed and
procedures. Procedures that were once Examination documented by the same individuals as
done only on an inpatient basis are now proposed above. We also are proposing
The proposed revisions to to add the words ‘‘or registration’’ to
routinely performed in outpatient § 482.22(c)(5) would retain the
settings. While advances in medical follow ‘‘after admission’’ to reflect
requirement that the medical staff differences in terminology that may
technology and surgical technique have bylaws include a requirement that a exist with the admission of patients for
allowed for this shift, the complexity medical history and physical outpatient procedures. We are
and seriousness of these procedures still examination be completed no more than proposing this revision here as well as
remain as do the risks to patient health 30 days before or 24 hours after in § 482.24 and § 482.51, where
and safety. Along with the increased admission for each patient. We are appropriate.
complexity and types of outpatient proposing to revise this provision to We are proposing to revise the words
procedures being performed today, include the requirement that the ‘‘for any changes in the patient’s
come the higher levels of sedation and completion and documentation of the condition’’ to ‘‘including any changes in
anesthesia required for these medical history and physical the patient’s condition’’ at both
procedures. Thus, distinctions between examination (and the updated § 482.22(c)(5) and § 482.24(c)(2)(i)(B).
inpatients and outpatients in the examination) would also be required Under § 482.24(c), Content of record,
requirements for postanesthesia prior to surgery or a procedure requiring we are proposing to revise both
evaluations are less relevant than ever. anesthesia services. § 482.24(c)(2)(i)(A) and
In addition, the current language We also are proposing to retain the § 482.24(c)(2)(i)(B) by adding the
regarding the completion and current provision that the medical staff language ‘‘but prior to surgery or a
documentation of an evaluation ‘‘within bylaws contain a requirement for the procedure requiring anesthesia
48 hours after surgery’’ assumes that all completion and documentation of an services’’ with regard to both the
patients receiving anesthesia services updated examination within 24 hours completion and the documentation of
have undergone surgery. It also assumes after admission (when the medical the medical history and physical
that they have not been discharged from history and physical examination has examination and the updated
the hospital prior to the end of this 48- been completed within 30 days before examination.
hour timeframe and that they are still admission). However, we are proposing We are proposing to revise the
available for evaluation. Many patients to delete the language regarding the Surgical services CoP at § 482.51(b)(1)
who have received anesthesia services placement of the medical history and by deleting the language regarding
(either general anesthesia or monitored physical examination and the updated medical histories and physical
anesthesia care) have undergone examination in the medical record examinations that have been dictated
diagnostic or therapeutic procedures as within 24 hours after admission because but which are not yet recorded in the
opposed to surgical ones and are we believe that the proposed language patient’s chart. Our overall intent in this
discharged within hours after such requiring not only the completion, but proposed rule is to require that the most
procedures. Diagnostic and therapeutic also the documentation, of both the current information regarding a patient’s
procedures that require anesthesia medical history and physical condition be available to the hospital
services (either general anesthesia or examination and the updated staff prior to surgery or a procedure
monitored anesthesia care) include examination, achieves this purpose. In requiring anesthesia services so that
esophagogastroduodenoscopy (EGD), addition, requirements for the physical risks to patient safety can be minimized
colonoscopy, endoscopic retrograde placement of the medical history and and potential adverse outcomes can be
cholangiopancreatography (ERCP), and physical examination and the updated avoided.
electroconvulsive therapy (ECT). examination in the patient’s medical We are proposing to retain the
Furthermore, and as noted above, even record are currently, and more language regarding the requirement for
those patients who have undergone appropriately, contained under the a medical history and physical
inpatient surgical procedures are often ‘‘Medical record services’’ CoP at examination prior to surgery, except in
the case of emergencies, and are regardless of their assigned payment results of applying the revised ASC
proposing to extend this to a status or comment indicators under the payment system methodology
requirement for an updated OPPS, will be available to the public by established in the final rule for the
examination. We are proposing to clicking ‘‘Addendum A and Addendum revised ASC payment system published
divide the requirements for the medical B Updates’’ on the CMS Web site at: elsewhere in this issue of the Federal
history physical examination and the http://www.cms.hhs.gov/ Register, to the proposed CY 2008 OPPS
updated examination under two HospitalOutpatientPPS/. and MPFS ratesetting information.
separate provisions at § 482.51(b)(1)(i) For the convenience of the public, we Addendum DD1 defines the payment
and § 482.51(b)(1)(ii) in the Surgical are also including on the CMS Web site indicators that are used in Addenda AA
services CoP. a table that displays the HCPCS data in and BB to this proposed rule. Addenda
Addendum B sorted by APC AA and BB provide payment
b. Proposed Requirements for assignment, identified as Addendum C. information regarding covered surgical
Preanesthesia and Postanesthesia Addendum D1 defines payment status procedures and covered ancillary
Evaluations indicators that are used in Addenda A services under the revised ASC payment
At § 482.52(b)(1), under the ‘‘Delivery and B. Addendum D2 defines comment system. Addendum DD2 defines the
of services’’ standard of the ‘‘Anesthesia indicators that are used in Addendum comment indicators that we are
services’’ CoP, we are proposing to B. Addendum E lists HCPCS codes that proposing to use to provide additional
revise the requirement for a are only payable as inpatient procedures information about the status of ASC
preanesthesia evaluation to include the and are not payable under the OPPS. covered surgical procedures and
language ‘‘or a procedure requiring Addendum L contains the out-migration covered ancillary services. Those
anesthesia services’’ to include the wage adjustment for CY 2008. addenda and other supporting ASC data
range of procedures that require Addendum M lists the HCPCS codes files are included on the CMS Web site
anesthesia services, but that are not that are members of a composite APC at: http://www.cms.hhs.gov/
necessarily surgical in nature. We also and identifies the composite APC to ASCPayment/ in a format that can be
are proposing to add this language which they are assigned. This easily downloaded and manipulated.
under § 482.52(b)(3) for the addendum also identifies the status The final ASC relative weights and
postanesthesia evaluation requirement. indicator for the code and a change payment rates for CY 2008 will be
Further, we are proposing to revise indicator if there has been a change in published in the CY 2008 OPPS/ASC
this standard by deleting both the words the code’s status with regard to its final rule with comment period, and
‘‘with respect to inpatients’’ at membership in the composite APC. related data files will be included on the
§ 482.52(b)(3) and the entire provision at Each of the HCPCS codes included in CMS Web site as noted above. MPSF
§ 482.52(b)(4), which are the current Addendum M has a single procedure data files are located at http://
requirements for postanesthesia payment APC, listed in Addendum B, to www.cms.hhs.gov/PhysicianFeeSched/.
evaluations for patients. We are which it is assigned when the criteria The links to all of the FY 2008 IPPS
proposing to revise § 482.52(b)(3) by for assignment to the composite APC are wage index related tables (that would be
requiring that the postanesthesia not met. When the criteria for payment used for the CY 2008 OPPS) from the FY
evaluation be completed and of the code through the composite APC 2008 IPPS proposed rule (72 FR 24851
documented before discharge or transfer are met, one unit of the composite APC through 24960) and to the correction
from the postanesthesia recovery area. payment is paid, thereby providing notice for the FY 2008 IPPS proposed
As discussed above, the intent of this packaged payment for all services that rule that was published in the Federal
section of the proposed rule is to are assigned to the composite APC Register on June 7, 2007 (72 FR 31507)
eliminate the distinctions currently according to the specific OCE logic that are accessible on the CMS Web site at:
found in the regulations between applies to the APC. We refer readers to http://www.cms.hhs.gov/
inpatients and outpatients with regard the discussion of composite APCs in AcuteInpatientPPS/WIFN/
to anesthesia services. section II.A.4.d. of this proposed rule for list.asp#TopOfPage
a complete description of the proposed For additional assistance, contact
c. Proposed Technical Amendment to composite APCs. Chuck Braver, (410) 786–6719.
Nursing Services CoP Those addenda and other supporting
OPPS data files are available on the XX. Collection of Information
We are proposing to revise the cross- Requirements
reference to § 405.1910(c) currently CMS Web site at: http://
found under the nursing services CoP at www.cms.hhs.gov/ Under the Paperwork Reduction Act
§ 482.23(b)(1) as this citation has been HospitalOutpatientPPS. of 1995, we are required to provide 60-
changed and is no longer valid. We are day notice in the Federal Register and
B. Information in Addenda Related to
proposing a technical amendment to solicit public comment before a
the Revised CY 2008 ASC Payment
this provision to correct the cross- collection of information requirement is
System
reference to § 488.54(c). submitted to the Office of Management
Addenda AA, BB, DD1, and DD2 to and Budget (OMB) for review and
XIX. Files Available to the Public Via this proposed rule provide various data approval. In order to fairly evaluate
the Internet pertaining to the ASC covered surgical whether an information collection
procedures and the covered ancillary should be approved by OMB, section
A. Information in Addenda Related to services for which ASCs may receive
the Revised CY 2008 Hospital OPPS 3506(c)(2)(A) of the Paperwork
separate payment beginning in CY 2008 Reduction Act of 1995 (PRA) requires
Addenda A and B to this proposed when the ancillary service provided in that we solicit comment on the
rule provide various data pertaining to the ASC is integral to a covered surgical following issues:
the CY 2008 payment for items and procedure and provided immediately • The need for the information
services under the OPPS. Addendum A, before, during, or immediately following collection and its usefulness in carrying
a complete list of all APCs payable the covered surgical procedure. All out the proper functions of our agency.
under the OPPS, and Addendum B, a relative payment weights and payment • The accuracy of our estimate of the
complete list of all active HCPCS codes rates are proposed and exemplify the information collection burden.
• The quality, utility, and clarity of before or 24 hours after admission or (2) An updated examination of the
the information to be collected. registration, but prior to surgery or a patient, including any changes in the
• Recommendations to minimize the procedure requiring anesthesia services, patient’s condition, when the medical
information collection burden on the for each patient by a physician (as history and physical examination are
affected public, including automated defined in section 1861(r) of the Act), an completed within 30 days before
collection techniques. oromaxillofacial surgeon, or other admission or registration.
We are soliciting public comment on qualified licensed individual in Documentation of the updated
each of these issues for the following accordance with State law and hospital examination must be placed in the
sections included in this proposed rule policy. patient’s medical record within 24
that contain information collection The burden associated with this hours after admission or registration,
requirements. proposed requirement is the time and but prior to surgery or a procedure
Section 419.43(h) Adjustment to effort it would take for medical staff to requiring anesthesia services.
national program payment and document the patient’s medical history While the burden associated with
beneficiary co-payment amounts: and the results of a physical these two proposed requirements is
Applicable adjustments to conversion examination. While the burden subject to the PRA, we believe the
factor for CY 2009 and for subsequent associated with this proposed burden is exempt as defined in 5 CFR
calendar years requirement is subject to the PRA, we 1320.3(b)(2) because the time, effort,
believe the burden is exempt as defined and financial resources necessary to
Section 419.43(h) requires hospitals,
in 5 CFR 1320.3(b) (2) because the time, comply with the requirement would be
in order to qualify for the full annual
effort, and financial resources necessary incurred by persons in the normal
update, to submit quality data to CMS,
to comply with the requirement would course of their activities.
as specified by CMS. In this proposed
be incurred by persons in the normal
rule, we are proposing the specific Section 482.51 Condition of
course of their activities.
requirements related to the data that participation: Surgical services
must be submitted for the update for CY Proposed § 482.22(c)(5)(ii) would
require that an updated examination of Proposed § 482.51(b)(1) would require
2009. The burden associated with this
the patient, including any changes in medical staff, prior to surgery or a
section is the time and effort associated
the patient’s condition, be completed procedure requiring anesthesia services,
with collecting and submitting the data,
and documented within 24 hours after and except in the case of emergencies,
completing participating forms and
admission or registration, but prior to to document no more than 30 days
submitting charts for chart audit
surgery or a procedure requiring before or 24 hours after admission or
validation. We estimate that there will
anesthesia services, when the medical registration a patient’s medical history,
be approximately 3,500 respondents per
history and physical examination are the results of the patient’s physical
year.
For hospitals to collect and submit the completed within 30 days before examination, and any changes in the
information on the required measures, admission or registration. The updated patient’s condition.
we estimate it will take 30 minutes per examination must also be completed While the burden associated with
sampled case. Further, based on an and documented by the same these proposed requirements is subject
estimated ten percent sample size and individuals as required under proposed to the PRA, we believe the burden is
estimated populations of 2.5–5 million § 482.22(c)(5)(i). exempt as defined in 5 CFR 1320.3(b)(2)
outpatient visits per measure, we The burden associated with this because the time, effort, and financial
estimate a total of 1,800,000 cases per proposed requirement is the time and resources necessary to comply with the
year. In addition, we estimate that effort it would take for medical staff to requirement would be incurred by
completing participation forms with document any changes in the patient’s persons in the normal course of their
require approximately 4 hours per condition. While the burden associated activities.
hospital per year. We expect the burden with this proposed requirement is
Section 482.52 Condition of
for all of these hospitals to total 914,000 subject to the PRA, we believe the
participation: Anesthesia services
hours per year. burden is exempt as defined in 5 CFR
For CY 2009. our validation process 1320.3(b)(2) because the time, effort, Proposed § 482.52(b)(1) would require
requires participating hospitals to and financial resources necessary to a preanesthesia evaluation to be
submit 5 charts. The burden associated comply with the requirement would be completed and documented by an
with this requirement is the time and incurred by persons in the normal individual qualified to administer
effort associated with collecting, course of their activities. anesthesia, performed within 48 hours
copying, and submitting these charts. It prior to surgery or a procedure requiring
Section 482.24 Condition of anesthesia services. Proposed
will take approximately 2 hours per participation: Medical record services
hospital to submit the 5 charts. There § 482.52(b)(3) would require a
will be a total of approximately 17,500 Proposed § 482.24(c)(2)(i) would postanesthesia evaluation to be
charts (3,500 hospitals x 5 charts per require evidence of: completed and documented by an
hospital) submitted by the hospitals to (1) A medical history and physical individual qualified to administer
CMS for a total burden of 7,000 hours. examination completed and anesthesia, after surgery or a procedure
Therefore, the total burden for all documented no more than 30 days requiring anesthesia services, but before
hospitals would be 921,000 hours per before or 24 hours after admission or discharge or transfer from the
year. registration, but prior to surgery or a postanesthesia recovery area.
procedure requiring anesthesia services. While the burden associated with

Section 482.22 Condition of The medical history and physical these requirements is subject to the
participation: Medical staff examination must be placed in the PRA, we believe the burden is exempt
Proposed § 482.22(c)(5)(i) would patient’s medical record within 24 as defined in 5 CFR 1320.3(b)(2) because
require that a medical history and hours after admission or registration, the time, effort, and financial resources
physical examination be completed and but prior to surgery or a procedure necessary to comply with the
documented no more than 30 days requiring anesthesia. requirement would be incurred by
persons in the normal course of their (including potential economic, the revised ASC payment system. The
activities. environmental, public health and safety ASC budget neutrality adjustment and
We have submitted a copy of this effects, distributive impacts, and the resulting savings estimates in the
proposed rule to OMB for its review of equity). A regulatory impact analysis July 2007 final rule are calculated using
the information collection requirements (RIA) must be prepared for major rules CY 2005 utilization data, the current CY
described above. These requirements are with economically significant effects 2007 OPPS relative weights with an
not effective until they have been ($100 million or more in any 1 year). estimated update factor for CY 2008,
approved by OMB. We estimate that the effects of the and the CY 2007 MPFS PE RVUs
If you comment on these information OPPS provisions that would be trended forwarded to CY 2008. The ASC
collection and recordkeeping implemented by this proposed rule budget neutrality adjustment and the
requirements, please mail copies would result in expenditures exceeding resulting savings estimates in this
directly to the following: $100 million in any 1 year. We estimate proposed rule are calculated using the
Centers for Medicare & Medicaid the total increase (from changes in this newly available CY 2006 utilization
Services, Office of Strategic proposed rule as well as enrollment, data, the CY 2008 OPPS relative
Operations and Regulatory Affairs, utilization, and case-mix changes) in payment weights proposed in this
Division of Regulations Development, expenditures under the OPPS for CY proposed rule, and and the CY 2008
Attn: Melissa Musotto, (CMS–1392– 2008 compared to CY 2007 to be MPFS PE RVUs proposed in the CY
P), Room C4–26–05, 7500 Security approximately $3.3 billion. 2008 MPFS proposed rule (72 FR 38234
Boulevard, Baltimore, MD 21244– We estimate that implementing the through 38361). As we indicated in the
1850; and revised ASC payment system in CY July 2007 final rule, the estimates in that
Office of Information and Regulatory 2008 based on the July 2007 final rule rule are meant to be illustrative of the
Affairs, Office of Management and for the revised ASC payment system and final policies only, in large part because
Budget, Room 10235, New Executive the proposals in this CY 2008 OPPS/ they use the existing CY 2007 OPPS
ASC proposed rule (such as adding 4 relative payment weights and the
Office Building, Washington, DC
procedures to the ASC list of covered existing CY 2007 MPFS PE RVUs to
20503, Attn: Carolyn Lovett, CMS
surgical procedures and designating 19 estimate the CY 2008 values. Since the
Desk Officer, CMS–1392–P,
additional procedures as office-based) savings estimates in this proposed rule
carolyn_lovett@omb.eop.gov. Fax
will have no net effect on Medicare are based on the actual proposed CY
(202) 395–6974.
expenditures in CY 2008 compared to 2008 OPPS relative payment weights
XXI. Response to Comments the level of expenditures that would that have just become available in this
Because of the large number of public have occurred in CY 2008 in the proposed rule and the actual proposed
comments we normally receive on absence of the revised payment system. CY 2008 MPFS PE RVUs that recently
Federal Register documents, we are not A more detailed discussion of the effects became available in the CY 2008 MPFS
able to acknowledge or respond to them of the changes to the ASC list of covered proposed rule, the estimates in this
individually. We will consider all surgical procedures and the effects of proposed rule based on that newly
comments we receive by the date and the revisions to the ASC payment available information represent our best
system in CY 2008 is provided in estimates at this time. Our final budget
time specified in the DATES section of
section XXII.C. of this proposed rule. neutrality adjustment and savings
this proposed rule, and, when we While we estimate that there will be
proceed with a subsequent document(s), estimates will be provided in the CY
no net change in Medicare expenditures 2008 OPPS/ASC final rule.
we will respond to those comments in in CY 2008 as a result of implementing
the preamble to that document(s). This proposed rule is an economically
the revised ASC payment system and significant rule under Executive Order
XXII. Regulatory Impact Analysis the proposed ASC provisions of this 12866, and a major rule under 5 U.S.C.
proposed rule, we estimate that the 804(2).
A. Overall Impact revised system will result in savings of
(If you choose to comment on issues $200 million over 5 years due to 2. Regulatory Flexibility Act (RFA)
in this section, please include the migration of new ASC covered surgical The RFA requires agencies to
caption ‘‘Impact’’ at the beginning of procedures from HOPDs and physicians’ determine whether a rule would have a
your comment.) offices to ASCs over time. In addition, significant economic impact on a
We have examined the impacts of this we note that there will be a total substantial number of small entities. For
proposed rule as required by Executive increase in Medicare payments to ASCs purposes of the RFA, small entities
Order 12866 (September 1993, of approximately $240 million for CY include small businesses, nonprofit
Regulatory Planning and Review), the 2008 compared to Medicare organizations, and small governmental
Regulatory Flexibility Act (RFA) expenditures that would have occurred jurisdictions. Most hospitals and most
(September 19, 1980, Pub. L. 96–354), in the absence of the revised payment other providers and suppliers are small
section 1102(b) of the Social Security system. These additional payments to entities, either by nonprofit status or by
Act, the Unfunded Mandates Reform ASCs of approximately $240 million in having average annual revenues of $31
Act of 1995 (Pub. L. 104–4), and CY 2008 will be fully offset by savings million or less.
Executive Order 13132. from reduced Medicare spending in For purposes of the RFA, we have
HOPDs and physicians’ offices on determined that approximately 37
1. Executive Order 12866 percent of hospitals and 73 percent of
services that migrate from these settings
Executive Order 12866 (as amended to ASCs, as described in detail in ASCs would be considered small
by Executive Order 13258, which section XVI.L. of this proposed rule. entities according to the Small Business
merely reassigns responsibility of Our estimate in this proposed rule of Administration (SBA) size standards.
duties) directs agencies to assess all 5-year savings as a result of the revised We do not have data available to
costs and benefits of available regulatory ASC payment system and our estimate calculate the percentages of entities in
alternatives and, if regulation is of additional payments to ASCs in CY the pharmaceutical preparation,
necessary, to select regulatory 2008 differ slightly from the estimates manufacturing, biological products, or
approaches that maximize net benefits presented in the July 2007 final rule for medical instrument industries that
would be considered to be small entities 4. Unfunded Mandates January 1, 2006, through December 31,
according to the SBA size standards. For Section 202 of the Unfunded 2006, and updated cost report
the pharmaceutical preparation Mandates Reform Act of 1995 (Pub. L. information. In response to a provision
manufacturing industry (NAICS 104–4) also requires that agencies assess in Pub. L. 108–173 that we analyze the
325412), the size standard is 750 or anticipated costs and benefits before cost of outpatient services in rural
fewer employees. For biological issuing any rule whose mandates hospitals relative to urban hospitals, we
products (except diagnostic) (NAICS require spending in any 1 year of $100 are proposing to continue increased
325414), the standard size is 500 or million in 1995 dollars, updated payments to rural SCHs, including
fewer employees, and for surgical and annually for inflation. That threshold EACHs. Section II.F. of this proposed
medical instrument manufacturing level is currently approximately $120 rule provides greater detail on this rural
(NAICS 339112), the standard is 500 or million. This proposed rule would not adjustment. Finally, we are proposing to
fewer employees (see the standards Web mandate any requirements for State, remove one device category, HCPCS
site at: http//www.sba.gov/idc/groups/ local, or tribal government, nor would it code C1820 (Generator, neurostimulator,
public/documents/ affect private sector costs. (implantable), with rechargeable battery
serv_sstd_tablepdf.pdf). Individuals and and charging system), from pass-through
States are not included in the definition 5. Federalism payment status in CY 2008.
of a small entity. Executive Order 13132 establishes Under this proposed rule, the update
Not-for-profit organizations are also certain requirements that an agency change to the conversion factor as
considered to be small entities under must meet when it publishes any rule provided by statute would increase total
the RFA. There are 2,146 voluntary (proposed or final) that imposes OPPS payments by 3.3 percent in CY
hospitals that we consider to be not for- substantial direct costs on State and 2008. The one-time wage
profit organizations to which this local governments, preempts State law, reclassification under section 508
proposed rule applies. or otherwise has Federalism expires September 30, 2007, and
implications. therefore is not contemplated in this
3. Small Rural Hospitals
We have examined this proposed rule proposed rule. The proposed changes to
In addition, section 1102(b) of the Act in accordance with Executive Order the APC weights including the changes
requires us to prepare a regulatory 13132, Federalism, and have that would result from the proposal to
impact analysis if a rule may have a determined that it would not have an expand packaging, changes to the wage
significant impact on the operations of impact on the rights, roles, and indices, the continuation of a payment
a substantial number of small rural responsibilities of State, local or tribal adjustment for rural SCHs and EACHs
hospitals. This analysis must conform to governments. As reflected in Table 67, would not increase OPPS payments
the provisions of section 604 of the we estimate that OPPS payments to because these changes to the OPPS are
RFA. With the exception of hospitals governmental hospitals (including State budget neutral. However, these
located in certain New England and local governmental hospitals) proposed updates do change the
counties, for purposes of section 1102(b) would increase by 3.6 percent under distribution of payments within the
of the Act, we previously defined a this proposed rule. The provisions budget neutral system as shown in
small rural hospital as a hospital with related to payments to ASCs in CY 2008 Table 67 and described in more detail
fewer than 100 beds that is located would not affect payments to in this section.
outside of a Metropolitan Statistical government hospitals. 1. Alternatives Considered
Area (MSA) (or New England County
Metropolitan Area (NECMA)). However, B. Effects of OPPS Changes in This Alternatives to the changes we are
under the new labor market definitions Proposed Rule proposing to make and the reasons that
that we adopted in the CY 2005 final (If you choose to comment on issues we have chosen the options are
rule with comment period (consistent in this section, please include the discussed throughout this proposed
with the FY 2005 IPPS final rule), we no comment ‘‘OPPS Impact’’ at the rule. Some of the major issues discussed
longer employ NECMAs to define urban beginning of your comment.) in this proposed rule and the options
areas in New England. Therefore, we We are proposing to make several considered are discussed below.
now define a small rural hospital as a changes to the OPPS that are required
a. Alternatives Considered for the
hospital with fewer than 100 beds that by the statute. We are required under
Packaging Proposals for CY 2008 OPPS
is located outside of an MSA. Section section 1833(t)(3)(C)(ii) of the Act to
601(g) of the Social Security update annually the conversion factor In section II.A.4.c. of this proposed
Amendments of 1983 (Pub. L. 98–21) used to determine the APC payment rule, we are proposing to package
designated hospitals in certain New rates. We are also required under payment for the following seven
England counties as belonging to the section 1833(t)(9)(A) of the Act to revise, categories of ancillary supportive
adjacent NECMA. Thus, for purposes of not less often than annually, the wage services into payment for the
the OPPS, we classify these hospitals as index and other adjustments. In independent service with which they
urban hospitals. We believe that the addition, we must review the clinical are billed. We are also proposing to pay
changes to the OPPS in this proposed integrity of payment groups and weights for low dose rate prostate brachytherapy
rule would affect both a substantial at least annually. Accordingly, in this and cardiac electrophysiology
number of rural hospitals as well as proposed rule, we are proposing to evaluation and ablation services under
other classes of hospitals and that the update the conversion factor and the composite APCs in which a single
effects on some may be significant. The wage index adjustment for hospital payment is made for multiple major
changes to the ASC payment system for outpatient services furnished beginning services that are commonly performed
CY 2008 will have no effect on small January 1, 2008, as we discuss in on the same date. We discuss each
rural hospitals. Therefore, we conclude sections II.C. and II.D., respectively, of category of services that we propose to
that this proposed rule would have a this proposed rule. We also are package and each set of services for
significant impact on a substantial proposing to revise the relative APC which we propose a composite APC
number of small rural hospitals. payment weights using claims data from below:
(1) Guidance Services always package payment for most cost-effective and clinically
We are proposing to package payment supportive guidance services, while advantageous manner.
for supportive guidance services into allowing separate payment for one The third alternative we considered,
particular guidance service when that and ultimately selected, was to package
the payment for the independent
guidance service is furnished without payment for the costs of image
procedure to which the guidance service
an independent service. When guidance processing services in all cases, without
is ancillary and supportive. In the case
services are furnished as an ancillary regard to the possibility of the service
of one particular guidance procedure,
and supportive adjunct to an being furnished without an independent
which would usually be provided in
independent procedure, we are service on the same date of service.
conjunction with another independent
proposing to package payment for all While an image processing service is not
procedure but may occasionally be
guidance procedures. When one specific necessarily provided on the same date
provided without another independent
guidance service (which is occasionally of service as the independent procedure
service on the same date of service, we
not provided in conjunction with an to which it is ancillary and supportive,
propose to permit separate payment if providing separate payment for each
the service is billed without an independent procedure on the same
date of service) is not provided on the imaging processing service whenever it
independent procedure on the same is performed is not consistent with
date of service. We refer readers to same date as an independent procedure,
we would pay separately for that encouraging value-based purchasing
section II.A.4.c.(1) of this proposed rule under the OPPS. We believe it is
for the complete discussion of this service. We believe that this alternative
would provide the most appropriate important to package payment for
proposal. We considered several policy supportive dependent services that
options for the payment of guidance incentives to control volume and
spending for these services, without accompany independent procedures but
services in CY 2008. that may not need to be provided face-
The first alternative we considered discouraging the performance of the
service in those infrequent cases when to-face with the patient in the same
was to propose no changes to packaging encounter as the independent service.
for the CY 2008 OPPS. Under this one particular guidance service is
provided without an independent Packaging encourages hospitals to
alternative, codes that were packaged establish protocols that ensure that
for CY 2007 would remain packaged for procedure.
services are furnished only when they
CY 2008 and codes that were separately (2) Image Processing are medically necessary and to carefully
paid for CY 2007 would remain scrutinize the services ordered by
separately paid for CY 2008. There are We are proposing to package payment
for image processing services into the practitioners to minimize unnecessary
a number of CPT codes that describe use of hospital resources. We also note
independent surgical procedures for payment for the major independent
service to which the image processing that our standard methodology to
which the code descriptors indicate that calculate median costs packages the
guidance is included in the code service is ancillary and supportive. We
refer readers to section II.A.4.(c)(2) of costs of dependent services with the
reported for the surgical procedure if it costs of independent services on
is used and, therefore, for which the this proposed rule for the complete
discussion of this proposal. We ‘‘natural’’ single claims across different
OPPS already makes packaged payment dates of service, so we are confident that
for the associated guidance service. considered several policy options for
the payment of image processing we would capture the costs of the
With a number of guidance services supportive image processing services for
already packaged, we did not select this services in CY 2008.
ratesetting, even if they were provided
option in part because we did not want The first alternative we considered on a different date than the independent
to create financial incentives for was to propose no changes to packaging procedure. Therefore, we believe that
hospitals to use one form of guidance for CY 2008 OPPS. Under this this alternative would provide
instead of another or to use guidance all alternative, codes that were packaged additional appropriate incentives to
the time, even if a procedure could be for CY 2007 would remain packaged for control volume and spending for these
safely provided without guidance. CY 2008 and codes that were separately services, without discouraging the use
Furthermore, we believe this alternative paid for CY 2007 would remain of the service in those infrequent cases
would not provide additional incentives separately paid for CY 2008. We did not when it is provided with an
for hospitals to utilize the most cost- select this alternative because we independent procedure but on a
effective and clinically advantageous believe it would not provide additional different date of service.
method of guidance that is appropriate incentives for hospitals to utilize the
in each situation. most cost-effective and clinically (3) Intraoperative Services
The second alternative we considered advantageous image processing services We are proposing to package payment
was to package the costs of guidance that are appropriate in each situation. for intraoperative services into the
services in all cases, without regard to The second alternative we considered payment for the independent procedure
the possibility of the service being was to package the costs of image to which the intraoperative service is
furnished without an independent processing services in cases in which ancillary and supportive. In the case of
service on the same date of service. We the image processing service is one intraoperative service, which would
did not select this alternative because furnished on the same date as an usually be provided in conjunction with
we believe that in the case of one independent service to which the image another independent procedure but may
particular guidance procedure, the processing service is ancillary and occasionally be provided without
procedure may sometimes be supportive but to pay separately for the another independent service on the
appropriately furnished without other image processing service when it is same date of service, we propose to
independent services on the same date furnished without an independent permit separate payment if the service is
and in these cases, we believe that there service on the same date of service. We billed without an independent
should be separate payment for the did not select this alternative because it procedure on the same date of service.
guidance service. would not have provided substantial We refer readers to section II.A.4.c.(3) of
The third alternative we considered, additional incentives for hospitals to this proposed rule for the complete
and the alternative we selected, was to utilize image processing in the most discussion of this proposal. We
considered several policy options for to control volume and spending for procedures that we believe are always
the payment of intraoperative services these services. integral to and dependent upon an
in CY 2008. independent separately payable
(4) Imaging Supervision and
The first alternative we considered procedure, but to conditionally package
Interpretation Services
was to propose no changes to packaging payment for those imaging supervision
for CY 2008 OPPS. Under this We are proposing to package payment and interpretation services that we
alternative, codes that were packaged for imaging supervision and believe are sometimes furnished
for CY 2007 would remain packaged for interpretation services into the payment without another separately payable
CY 2008 and codes that were separately for the independent service to which the service on the same date. We believe
paid for CY 2007 would remain imaging supervision and interpretation that this alternative is the most
separately paid for CY 2008. We did not service is ancillary and supportive. For appropriate choice because it creates
select this alternative because we some imaging supervision and additional incentives for hospitals to
believe it would not provide additional interpretation services, we are provide services only when medically
incentives for hospitals to utilize the proposing to permit separate payment if necessary to the individual patient
most cost-effective and clinically the service is the only separately paid when the supervision and interpretation
advantageous intraoperative services service billed for the date of service. We services is furnished as an ancillary and
that are appropriate in each situation. refer readers to section II.A.4.c.(4) of supportive adjunct to the independent
this proposed rule for the complete procedure. We would pay separately for
The second alternative we considered
discussion of this proposal. We some imaging supervision and
was to package payment for the costs of
considered several policy options for interpretation services in those cases,
intraoperative services in all cases,
the payment of imaging supervision and which our data show are limited, where
without regard to the possibility of the
interpretation services in CY 2008. they are not furnished on the same date
service being furnished without an The first alternative we considered
independent service on the same date of as another separately paid procedure.
was to propose no changes to packaging Therefore, we believe that this
service. We did not select this for CY 2008 OPPS. Under this
alternative because we believe that in alternative would provide the most
alternative, codes that were packaged appropriate incentives to control
the case of one particular intraoperative for CY 2007 would remain packaged
procedure, the procedure may volume and spending for these services,
and codes that were separately paid for without discouraging the performance
sometimes be appropriately furnished CY 2007 would remain separately paid
without other independent services on of the services in those relatively
for CY 2008. We did not select this infrequent cases when they are the only
the same date and in these cases, we alternative because we believe it would
believe that there should be separate services furnished.
not provide additional incentives for
payment for the intraoperative service. hospitals to utilize the most cost- (5) Diagnostic Radiopharmaceuticals
The third alternative we considered, effective and clinically advantageous We are proposing to package payment
and ultimately selected, was to radiological supervision and for diagnostic radiopharmaceuticals into
unconditionally package the costs of interpretation services that are the payment for their associated nuclear
intraoperative services in all cases appropriate in each situation. medicine procedures. We refer readers
except one, to allow for the possibility The second alternative we considered to section II.A.4.c.(5) of this proposed
of this one commonly intraoperative was to package the costs of imaging rule for the complete discussion of this
service being furnished without an supervision and interpretation services proposal. We considered several policy
independent service on the same date of in all cases, without regard to the options for the payment of diagnostic
service. We believe that there is some possibility of the service being radiopharmaceuticals in CY 2008.
possibility that this procedure could be furnished without an independent The first alternative we considered
appropriately performed without separately payable service on the same was to propose no changes to our
another independent procedure on the date of service. This alternative might packaging methodology for diagnostic
same date of service. We do not believe substantially reduce the financial radiopharmaceuticals in the CY 2008
this to be true of the other intraoperative incentive to furnish the service because OPPS. Under this alternative, diagnostic
services that we propose to separate payment would never be made radiopharmaceuticals with a mean per-
unconditionally package. We selected in any case for the service, even when day cost of $60 or under would be
this alternative because we thought it it was furnished without a separately packaged into the payment for
unlikely that intraoperative services payable service on the same date of associated procedures present on the
other than the one particular service service. We did not select this claim. Diagnostic radiopharmaceuticals
would ever be provided without an alternative because we believe that some with a per-day cost over $60 would
independent service. Packaging of the imaging supervision and receive separate payment. We did not
encourages hospitals to establish interpretation services may occasionally select this alternative because we
protocols that ensure that services are be furnished in conjunction with other believe it would not provide additional
furnished only when they are medically services that are currently packaged incentives for hospitals to utilize the
necessary and to carefully scrutinize the under the OPPS. In these circumstances, most cost-effective and clinically
services ordered by practitioners to if we were to unconditionally package advantageous diagnostic
minimize unnecessary use of hospital payment for these imaging supervision radiopharmaceuticals that are
resources. We believe that this is the and interpretation services, hospitals appropriate in each situation.
most appropriate alternative because, in would receive no payment at all for The second alternative we considered
general, it creates additional incentives providing the imaging supervision and was to package the costs of diagnostic
for hospitals to provide intraoperative interpretation service and the other radiopharmaceuticals in cases in which
services only when both medically minor procedure(s). the diagnostic radiopharmaceutical is
necessary and cost efficient for the The third alternative we considered, furnished on the same date as an
individual patient. Therefore, we and the alternative we selected, was to independent service to which the
believe that this alternative would unconditionally package imaging diagnostic radiopharmaceutical is
provide the most appropriate incentives supervision and interpretation ancillary and supportive but to pay
separately for the diagnostic threshold, this alternative would payable services provided by the
radiopharmaceutical when it is potentially maintain inconsistent hospital in the same encounter based on
furnished without an independent payment incentives across similar criteria discussed in more detail in
service on the same date of service. We products. section II.A.4.c.(7) of this proposed rule.
did not select this alternative because The second alternative we considered For CY 2007, we continued to apply the
diagnostic radiopharmaceuticals are was to package the costs of contrast criteria for separate payment for
always intended to be used with a media in cases in which the contrast observation care and the coding and
diagnostic nuclear medicine procedure. medium is furnished on the same date payment methodology for observation
Our claims data indicate that diagnostic as an independent service but to pay care that were implemented in CY 2006.
radiopharmaceuticals are infrequently separately for the contrast medium We did not select this alternative
provided on a different date of service when it is furnished without an because the current criteria for separate
from a nuclear medicine procedure. independent service on the same date of payment for observation services treat
Since our standard OPPS ratesetting service. We did not select this payment for observation care for various
methodology packages costs across alternative because we thought it clinical conditions differently and may
dates of service on ‘‘natural’’ single unlikely that contrast media would ever provide disincentives for efficiency. In
claims, we believe that our standard be provided without an independent addition, there has been substantial
methodology adequately captures the service on the same date of service. growth in program expenditures for
costs of diagnostic radiopharmaceuticals The third alternative we considered, hospital outpatient services under the
associated with diagnostic nuclear and the alternative we selected, was to OPPS in recent years, a trend that is
medicine procedures that are not unconditionally package the costs of reflected in the rapidly increasing
provided on the same date of service. contrast media with their associated volume of claims for separately payable
The third alternative we considered, independent diagnostic and therapeutic observation services. This alternative
and the alternative we selected, was to procedures. The vast majority of would not provide additional incentives
package the costs of diagnostic contrast media would currently be for hospitals to utilize observation
radiopharmaceuticals with their packaged under the proposed $60 services in the most cost-effective and
associated nuclear medicine procedures. packaging threshold. Given that most clinically advantageous manner.
Packaging the costs of supportive items contrast agents would already be The second alternative we considered
and services into the payment for the packaged under the OPPS in CY 2008, was to accept the APC Panel’s
independent procedure or service with we believe it would be desirable to recommendations to add syncope and
which they are associated encourages package payment for the remaining dehydration to the list of diagnoses
additional hospital efficiencies and contrast agents as this approach eligible for separate payment or to
enables hospitals to better manage their promotes additional efficiency and consider other clinical conditions for
resources with maximum flexibility. results in a more consistent payment separate payment for observation care.
Diagnostic radiopharmaceuticals are policy across products that may be used We believe that in certain circumstances
always intended to be used with a in many of the same independent observation could be appropriate for
diagnostic nuclear medicine procedure, procedures. patients with a range of diagnoses. Both
and are, therefore, particularly well (7) Observation Services the APC Panel and numerous
suited for packaging under the OPPS for commenters to prior OPPS proposed
the reasons identified in section We are proposing to package payment rules have confirmed their agreement
II.A.4.c.(5) of this proposed rule. for all observation care, reported under with this perspective. However, as
HCPCS code G0378 (Hospital packaging payment provides additional
(6) Contrast Media observation services, per hour) for CY desirable incentives for more efficient
We are proposing to package payment 2008. Payment for observation would be delivery of health care and provides
for contrast media into their associated packaged as part of the payment for the hospitals with significant flexibility to
independent diagnostic and therapeutic separately payable services with which manage their resources, we believe it is
procedures. We refer readers to section it is billed. We refer readers to section most appropriate to treat observation
II.A.4.c.(6) of this proposed rule for the II.A.4.c.(7) of this proposed rule for the care for all diagnoses similarly by
complete discussion of this proposal. complete discussion of this proposal. packaging its costs into payment for the
We considered several policy options We considered several policy options separately payable procedures with
for the payment of contrast media in CY for the payment of observation services which the observation is associated.
2008. in CY 2008. Consequently, we did not select this
The first alternative we considered The first alternative we considered alternative to expand separate
was to propose no changes to our was to propose no changes to payment observation payment to additional
packaging methodology for contrast of observation services for the CY 2008 diagnoses.
media in the CY 2008 OPPS. Under this OPPS. Since January 1, 2006, hospitals The third alternative we considered,
alternative, contrast media with a mean have reported observation services and the alternative we selected, was to
per-day cost of $60 or under would be based on an hourly unit of care using package payment for all observation
packaged into the payment for HCPCS code G0378. This code has a services reported with CPT code G0378
associated procedures present on the status indicator of ‘‘Q’’ under the CY under the CY 2008 OPPS. We believe
claim. Contrast media with a per-day 2007 OPPS, meaning that the OPPS this is the most appropriate alternative
cost over $60 would receive separate claims processing logic determines within the context of our proposed
payment. We did not select this whether the observation is packaged or packaging approach because observation
alternative because we believe it would separately payable. The OCE’s current is always provided as a supportive
not provide additional incentives for logic determines whether observation service in conjunction with other
hospitals to utilize contrast media in the care billed under G0378 is separately independent separately payable hospital
most cost-effective and clinically payable through APC 0339 outpatient services such as an
advantageous manner. With most (Observation), or whether payment for emergency department visit, surgical
contrast media already packaged based observation services would be packaged procedure, or another separately
on our proposed $60 packaging into the payment for other separately payable service, and thus its costs can
be packaged into the OPPS payment for payment rates would continue to be The first alternative we considered
such services. We believe that packaging based on single procedure claims, was to make no change to the current
payment into larger payment bundles which we have been told by policy. Under this alternative, Medicare
creates incentives for providers to stakeholders do not represent the and the beneficiary would continue to
furnish services in the most efficient typical treatment scenario. Interested pay the full APC rate, which is
way that meets the needs of the patient, parties have repeatedly told us, and our calculated using only claims for which
encouraging long-term cost examination of claims data supports, the full cost of a device is billed by the
containment. With approximately 70 that these services are typically hospital, even if the hospital received a
percent of the occurrences of furnished in combination with one substantial credit towards the cost of the
observation care billed under the OPPS another and, therefore, this may suggest replacement device. We did not select
currently packaged, this alternative that the use of single procedure claims this alternative because we believe that,
would extend the incentives for to establish the median costs that form as long as the APC payment amount is
efficiency already present for the vast the basis for payment for these services initially established to reflect the full
majority of observation care that is may result in our using clinically cost of the device when there is no
already packaged under the OPPS to the unusual or incorrectly coded claims as credit, there should be a reduction in
remaining 30 percent of observation the basis for payment. the Medicare payment amount when the
care for which we currently make The second alternative we considered, hospital receives a substantial credit
separate payment. (8) Composite APCs and the alternative we selected, is to toward cost of the replacement device.
We are proposing to establish two propose to create composite APCs for Similarly, we believe that the
composite APCs for CY 2008 OPPS. A these services which are commonly beneficiary cost sharing should be based
composite APC is an APC that provides furnished in combination with one on an amount that also reflects the
a single payment for several another and to make a single payment credit.
independent services when they are for the multiple services specified in the The second alternative we considered
furnished on the same date of service. composite APC at a prospectively
was to extend the current policy to cases
Composite APCs are intended to of partial credit without change. This
established rate based on the total cost
establish APC payment rates for would reduce the payment in all cases
of the combination of services
combinations of services that are in which the hospital received a credit
furnished. This alternative responds to
frequently furnished together so that the by the full offset amount for the APC,
public comments that multiple
multiple procedure claims on which that is, by 100 percent of the estimated
procedure claims for these services that
they are submitted may be used to set device cost contained in the APC. We
we have heretofore been unable to use
the payment rates for them and so that considered this alternative because, in
for ratesetting reflect the most common
the payment for the services provides our discussions with hospitals about
treatment scenarios. It also provides
greater incentives for efficient use of partial credits for devices, they advised
additional incentives for efficient
hospital resources. Specifically, we are us that hospitals generally charge the
proposing to establish composite APCs provision of services by bundling same amount for a device regardless of
for low dose rate prostate brachytherapy payment for multiple services into a whether they receive a significant
(which would be paid when CPT codes single payment. Composite APCs enable amount in credit towards the cost of that
55875 (Transperineal placement of us to use more of our claims data and device. Hence, in such a case the costs
needles or catheters into prostate for to use single procedure claims only to that are packaged into the APC payment
interstitial radioelement application, set payment rates for the uncommon for the applicable procedure contain the
with or without cystoscopy) and 77778 circumstances in which a particular same amount of device cost as if the
(Interstitial radiation source application; service is not furnished in combination hospital incurred the full cost of the
complex) are billed with the same date with other related independent services. device. We did not select this
of service) and for cardiac Therefore, we are proposing to establish alternative because we did not believe it
electrophysiology evaluation and two composite APCs for the CY 2008 was appropriate to reduce the payment
ablation services (which would be paid OPPS. to the hospital by the full cost of a
when at least one designated b. Partial Device Credits device if the hospital only received a
electrophysiology evaluation service is partial credit, and not a full credit,
billed on the same date as at least one We are proposing to reduce payment towards the cost of the device.
designated cardiac ablation service). We by 50 percent of the device offset The third alternative, which we are
refer readers to sections II.A.4.d.(2) and amount for specified APCs when proposing, is to reduce the APC
II.A.4.d.(3) of this proposed rule for a hospitals report that they have received payment by 50 percent of the offset
detailed discussion of the proposals for a credit for a replacement device of amount (that would be applied if the
these APCs. We note that we will greater than or equal to 20 percent of the hospital received full credit) in cases in
continue to pay individual services cost of the new replacement device which the hospital receives a partial
under their single procedure APCs as being implanted, if the device is on a credit of 20 percent or more of the cost
we have in the past, in recognition that list of specified devices. We refer of the new replacement device being
there are clinical circumstances in readers to section IV.A.3. of this implanted. Moreover, we are proposing
which the combinations of services proposed rule for a complete discussion to require hospitals to report a new
proposed for payment through the of this proposal. This is an extension of modifier when the hospital receives a
composite APCs are not furnished on the current policy that reduces the APC partial credit that is 20 percent or more
the same date. We considered two payment by the full device offset of the cost of the device being replaced.
alternatives with regard to the proposal amount when the hospital receives a We are proposing this alternative
to create composite APCs. replacement device without cost or because we believe that this approach
The first alternative we considered receives a credit for the full cost of the provides an appropriate and equitable
was to make no change to how we pay device being replaced. We considered payment to the hospital from Medicare
for these services. If we were to make no several alternatives in developing this and, depending on the service, may
change, we could continue to pay partial device credit proposal for CY reduce the beneficiary’s cost sharing for
separately for each service. The 2008. the service.
c. Brachytherapy Sources palladium–103 and cesium–131 would be made at charges reduced to cost
Pursuant to sections 1833(t)(2)(H) and deviate from the overall OPPS through December 31, 2007.
1833(t)(16)(C) of the Act, we paid for framework for prospective payment and
2. Limitations of Our Analysis
brachytherapy sources furnished from from the proposed prospective payment
of the non-stranded only sources The distributional impacts presented
January 1, 2004 through December 31,
specifically. This approach would here are the projected effects of the
2006 on a per source basis at an amount
subject similar items that are essential to policy changes on various hospital
equal to the hospital’s charge adjusted
brachytherapy treatments to different groups. We estimate the effects of
to cost by application of the hospital-
payment methodologies and could individual policy changes by estimating
specific overall CCR. Moreover,
potentially create financial incentives payments per service, while holding all
pursuant to section 107(a) of the MIEA– other payment policies constant. We use
TRHCA, which amended section for the use of some products over others.
The second alternative we considered the best data available but do not
1833(t)(16)(C) of the Act by extending attempt to predict behavioral responses
was to continue making payments for all
the payment period for brachytherapy to our policy changes. In addition, we
sources based on hospital charges
sources based on a hospital’s charges do not make adjustments for future
reduced to cost. Although hospitals are
adjusted to cost, we are paying for changes in variables such as service
familiar with this payment methodology
brachytherapy sources using the charges volume, service-mix, or number of
and this methodology would be
adjusted to cost methodology through encounters. As we have done in
consistent with the requirement that
December 31, 2007. Section 107(b)(1) of previous rules, we are soliciting
brachytherapy sources be paid
the MIEA–TRHCA amended section comments and information about the
separately, we believe that to continue
1833(t)(2)(H) of the Act, by adding a to pay on this basis would be anticipated effect of the proposed
requirement for the establishment of inconsistent with the general changes on hospitals and our
separate payment groups for ‘‘stranded methodology of a prospective payment methodology for estimating them. We
and non stranded’’ brachytherapy system and would provide no incentive discuss below several specific
devices beginning July 1, 2007. In for hospitals to provide brachytherapy limitations of our analysis.
section VII. B. of this proposed rule, we treatments in the most cost-effective and One limitation of our analysis is our
are proposing prospective payment for clinically advantageous manner. inability to estimate behavioral
all brachytherapy sources, including The third alternative we considered, responses to our proposal to increase
separate payment for stranded and non- and the alternative we selected, is to packaging and our proposal to pay for
stranded versions of sources currently propose prospective payment for each multiple procedures based on one
known to us, that is, iodine–125, brachytherapy source based on its composite payment rate. Specifically, it
palladium–103 and cesium–131. For median costs. For the sources which is possible that there could be a
each of the sources for which we have only have non-stranded versions, we are behavioral response to our proposals to
information that only non-stranded proposing to use our standard median package guidance services, image
source versions are marketed, we are cost methodology. For the three sources processing services, intraoperative
proposing to pay based on the median which have stranded and non-stranded services, imaging supervision and
cost per source based on our CY 2006 versions and for which we do not yet interpretation services, diagnostic
claims data. For sources for which we have separately reported stranded and radiopharmaceuticals, contrast agents,
have information that both stranded and non-stranded claims data, we are and observation services, and to pay
non-stranded versions are marketed and proposing to calculate the median costs some services using composite APCs
for which our CY 2006 billing codes do based on the assumption that the when the services are furnished in
not differentiate stranded and non- reportedly lower cost non-stranded specified combinations. However, we
stranded sources, we are proposing to sources would be unlikely to be in the are unable to estimate what the effect of
base payment for stranded and non- top 20 percent of the cost distribution of the behavioral response may be on
stranded brachytherapy sources on the our aggregate CY 2006 claims data for payment to hospitals. We refer readers
60th percentile and 40th percentile of each respective source, and on the to section II.A.4. of this proposed rule
our claims data, respectively, for CY assumption that the reportedly higher for further discussion of the proposed
2008. We discuss each option we cost stranded sources would be unlikely packaging approach. The purpose of
considered below. to be in the bottom 20 percent of the CY packaging these services and creating
The first alternative we considered 2006 cost distribution for each source. composite APCs is to remove financial
was to pay for each source of This approach to calculating median incentives to furnish additional services
brachytherapy based on our CY 2006 costs for stranded and non-stranded and, instead, to provide greater
median costs, with the exception of the iodine–125, palladium–103, and incentives for hospitals to assess the
3 sources for which we do not have cesium–131 sources results in proposed most cost-effective and appropriate
separately reported cost data for their Medicare payment rates based on the means to furnish necessary services. In
stranded and non-stranded versions, 60th percentile of our aggregate data for addition, we expect that hospitals will
i.e., iodine–125, palladium–103, and stranded sources and the 40th percentile negotiate for lower prices from suppliers
cesium–131. Under this option, for of our aggregate data for non-stranded to maximize the margin between their
these six stranded and non-stranded sources. This methodology provides for cost of providing services and the
sources, we considered payment based separate payment of all sources, Medicare payment for the services. We
on hospital charges reduced to cost for including stranded and non-stranded recognize that it is also possible that
CY 2008. This approach would be a step sources, recognizes a cost differential hospitals could change behavior in a
toward prospective payment for between stranded and non-stranded manner that seeks to overcome any
brachytherapy sources, as the sources sources, is consistent with our reductions in total payments by ceasing
that only have non-stranded versions prospective payment methodology for to provide certain packaged services on
would receive prospective payment setting payment rates for other services, the same date of service and instead
consistent with the overall OPPS and is consistent with the expiration of requiring patients to receive those
methodology. However, payment for the requirement of the MIEA–TRHCA services on different dates of service or
stranded and non-stranded iodine–125, that payment for brachytherapy sources at different locations, so as to either
receive separate additional payment for same frequency at which it occurred in referencing payment for APC 0033 in
services that would otherwise be CY 2006, and hence we have made no Addendum A to this proposed rule.
packaged or to not incur the additional estimates of how such activity may The estimated increase in the total
costs of those services. We believe that impact payments to hospitals. payments made under the OPPS is
this will be uncommon for several Fourth, for purposes of this impact limited by the increase to the
reasons. We anticipate that hospitals analysis, for those brachytherapy conversion factor set under the
would continue to provide care that is sources with proposed new codes to methodology in the statute. The
aligned with the best interests of the distinguish between stranded and non- distributional impacts presented do not
patient. In the vast majority of cases for stranded version, we assumed that half include assumptions about changes in
the services that are newly proposed for of the brachytherapy sources that volume and service-mix. The enactment
unconditional packaging in CY 2008, hospitals will use in CY 2008 will be of Pub. L. 108–173 on December 8,
the services would need to be provided stranded sources and that half of them 2003, provided for the additional
in the same facility and during the same will be non-stranded sources. The payment outside of the budget
encounter as the independent procedure statute requires us to pay for stranded neutrality requirement for wage indices
they support. Furthermore, in the case and non stranded sources through for specific hospitals reclassified under
of conditionally packaged services, we different APC groups, but given the lack section 508. The amounts attributable to
note that the supportive services that we of separately reported claims data for this reclassification are incorporated
have included in our packaging stranded and non-stranded sources, for into the CY 2007 estimates but because
proposals are typically services that are the purposes of this impact analysis, we section 508 expires for CY 2008 rates,
provided during or shortly preceding made this assumption. We welcome no additional payments under section
the independent procedure to which data that would provide the expected 508 are considered for CY 2008 in this
they are ancillary and supportive, and CY 2008 ratio of stranded sources to impact analysis.
thus it is unlikely that the supportive non-stranded sources for purposes of Table 67 shows the estimated
service that is packaged and the the CY 2008 final rule impact analysis. redistribution of hospital and CMHC
independent procedure would be The final limitation of our analysis is payments among providers as a result of
performed in different locations. that we cannot predict the utilization of APC reconfiguration and recalibration
However, we are unable to quantify the new CY 2007 CPT codes that replace without the proposal to expand
extent to which such behavioral change existing CY 2006 CPT codes for which packaging; APC reconfiguration and
may impact Medicare payments to we have cost data on which we base the recalibration including the proposal to
hospitals. proposed CY 2008 OPPS payment rates. expand packaging; wage indices and
Secondly, we are not able to estimate In years past, we have estimated the continuation of the adjustment for rural
the impact on hospitals of our proposal impact of these code changes as if the SCHs and EACHs with extension to
to reduce payment when a hospital deleted codes would continue to exist brachytherapy sources in CY 2008; the
receives a partial credit for a medical for the applicable year for which we estimated distribution of increased
device that fails while under warranty were estimating impacts. For this payments in CY 2008 resulting from the
or otherwise. We do not currently proposed rule, we applied the AMA’s combined impact of the APC
require hospitals to notify us when they estimates of new code utilization which recalibration with the proposal to
received a partial credit for a device for are used for the MPFS proposed rule. expand packaging, wage effects, the
which they are billing. In addition, However, we do not know whether rural SCH and EACH adjustment, and
hospitals have informed us that these estimates of physician utilization the market basket update to the
hospitals generally do not currently are equally applicable to outpatient conversion factor; and, finally,
reduce the charge for a device when hospital services. We request comments estimated payments considering all
they receive a partial credit toward the regarding whether it is appropriate for payments for CY 2008 relative to all
device for which they are billing us to use the AMA estimates of payments for CY 2007, including the
Medicare. Therefore, we have no means utilization for new codes in the impact of expiring wage provisions of
of knowing the frequency with which estimation of the impact of proposed CY section 508, changes in the outlier
this happens or the extent to which 2008 payments on hospitals. threshold, and changes to the pass-
hospitals’ costs for the devices being through estimate. Because updates to
3. Estimated Impacts of This Proposed
replaced are reduced as a result of the the conversion factor, including the
Rule on Hospitals and CMHCs
partial credits and cannot estimate the update of the market basket and the
impact of the proposed policy on Table 67 below shows the estimated addition of money not dedicated to
hospital payments under OPPS in CY impacts of this proposed rule on pass-through payments, are applied
2008. hospitals. Historically, the first line of uniformly, observed redistributions of
Third, we are unable to estimate the the impact table, which estimates the payments in the impact table for
extent to which hospitals will incur no change in payments to all hospitals, has hospitals largely depend on the mix of
cost for devices or will receive full always included cancer and children’s services furnished by a hospital (for
credits for devices being replaced as a hospitals, which are held harmless to example, how the APCs for the
result of the failure of the device. In CY their pre–BBA payment to cost ratio. hospital’s most frequently furnished
2006, hospitals reported the ‘‘FB’’ This year, for the first time, we are also services would change), the impact of
modifier on codes for devices that they including CMHCs in the first line that the wage index changes on the hospital,
received without cost or for which they includes all providers because we and the impact of the payment
received a full credit. However, we are included CMHCs in our weight scaler adjustment for rural SCHs, including
unable to forecast the extent to which estimate. We are not showing the EACHs. However, total payments made
the frequency or the type of device for estimated impact of the proposed under this system and the extent to
which this occurred in CY 2006 will changes on CMHCs alone because which this proposed rule would
recur for CY 2008. We believe that most CMHCs bill only one service under the redistribute money during
of these occurrences were the result of OPPS, partial hospitalization, and each implementation also would depend on
specific activity that we have no reason CMHC can, therefore easily estimate the changes in volume, practice patterns,
to believe will occur in CY 2008 at the impact of the proposed changes by and the mix of services billed between
CY 2007 and CY 2008, which CMS and resource characteristics). The neutrality adjustments for differences in
cannot forecast. placement of the HCPCS code in a new wages and the adjustment for rural
Overall, the proposed OPPS rates for APC as a result of the effect of the SCHs and EACHs.
CY 2008 would have a positive effect for proposed packaging approach often Finally, Column 5 depicts the full
providers paid under the OPPS, changed the APC median cost. impact of the proposed CY 2008 policy
resulting in a 3.3 percent increase in Furthermore, changing the cost of a on each hospital group by including the
Medicare payments. Removing cancer service subject to the multiple effect of all the proposed changes for CY
and children’s hospitals because their procedure discount policy, as well as 2008 (including the APC reconfiguration
payments are held harmless to the pre– packaging some services previously and recalibration with the packaging
BBA ratio between payment and cost, subject to the multiple procedure changes shown in Column 2) and
and CMHCs, suggests that changes discount policy, changed the relative comparing them to all estimated
would result in a 3.5 percent increase in weight ranking of services on a claim payments in CY 2007, including
Medicare payments to all other subject to the multiple procedure changes to the wage index under section
hospitals, exclusive of transitional pass- discount policy, significantly changing 508 of Pub. L. 108–173 and expiring in
through payments. discounting patterns in some cases. September 2007. Column 5 shows the
To illustrate the impact of the Column 2 reflects the combined combined budget neutral effects of
proposed CY 2008 changes, our analysis effects of APC reclassification and Columns 2 through 4, plus the impact
begins with a baseline simulation model recalibration changes attributable to of the proposed change to the fixed
that uses the final CY 2007 weights, the changes resulting from the proposed outlier threshold from $1,825 to $2,000,
FY 2007 final post-reclassification IPPS reclassification of services codes among expiring section 508 reclassification
wage indices, and the final CY 2007 APC groups and the proposed wage index increases, and the impact of
conversion factor. Column 2A in Table recalibration of APC weights without changing the percentage of total
67 shows the independent effect of the proposed packaging approach in payments dedicated to transitional pass
changes resulting from the proposed addition to all APC reclassification and through payments. We estimate that
reclassification of services among APC recalibration changes attributable to the these cumulative changes increase
groups and the proposed recalibration of proposed packaging approach. We payments by 3.3 percent.
APC weights without the proposed modeled the independent effect of all We modeled the independent effect of
changes to packaging, based on 12 APC recalibration by varying only the all changes in Column 5 using the final
months of CY 2006 hospital OPPS weights in the baseline model, the final weights for CY 2007 and the proposed
claims data and more recent cost report CY 2007 weights versus the proposed weights for CY 2008. We used the final
data. We modeled the independent CY 2008 weights, and calculating the conversion factor for CY 2007 of
effect of APC recalibration by varying percent difference in payments. $61.468 and the proposed CY 2008
only the weights, the final CY 2007 Column 3 reflects the independent conversion factor of $63.693. Column 5
weights versus the estimated CY 2008 effects of updated wage indices, also contains simulated outlier
weights without expanded packaging in including the new occupational mix payments for each year. We used the
our baseline model, and calculating the data described in the FY 2008 IPPS final charge inflation factor used in the FY
percent difference in payments. Column rule, and the proposed 7.1 percent rural 2008 IPPS proposed rule of 7.26 percent
2B in Table 67 shows the independent adjustment for SCHs and EACHs with (1.0726) to increase individual costs on
effect of changes resulting from the extension to brachytherapy sources. The the CY 2006 claims to reflect CY 2007
proposed packaging approach, OPPS wage index for CY 2008 includes dollars, and we used the most recent
including the proposed creation of the budget neutrality adjustment for the overall CCR in the April Outpatient
composite APCs 8000 and 8001, based rural floor, as discussed in section II.D. Provider-Specific File. Using the CY
on 12 months of CY 2006 hospital OPPS of this proposed rule. We modeled the 2006 claims and a 7.26 percent charge
claims data and more recent cost report independent effect of updating the wage inflation factor, we currently estimate
data. We modeled the independent index and the rural adjustment by that actual outlier payments for CY
effect of APC recalibration by varying varying only the wage index, using the 2007, using a multiple threshold of 1.75
only the weights in the baseline model, proposed CY 2008 scaled weights, and and a fixed-dollar threshold of $1,825
the proposed CY 2008 weights without a CY 2007 conversion factor that would be approximately 1.0 (0.96)
packaging and CY 2008 weights with included a budget neutrality adjustment percent of total payments. Outlier
expanded packaging, and calculating for changes in wage effects and the rural payments of 0.96 percent appear in the
the percent difference in payments adjustment between CY 2007 and CY CY 2007 comparison in Column 5. We
relative to the CY 2007 base used in 2008. used the same set of claims and a charge
Column 2A in order to show the Column 4 demonstrates the combined inflation factor of 15.04 percent (1.1504)
packaging proposal’s additive effect. ‘‘budget neutral’’ impact of proposed and the CCRs on the April Outpatient
Column 2B also reflects the APC recalibration with the packaging Provider-Specific File with an
independent effect of changes resulting proposal (that is, Column 2), the wage adjustment of 0.9912 to reflect relative
from APC reclassification and index update and the proposed changes in cost and charge inflation
recalibration changes and changes in adjustment for rural SCHs and EACHs between CY 2007 and CY 2008 to model
multiple procedure discount patterns on various classes of hospitals (that is, the CY 2008 outliers at 1.0 percent of
that occur as a result of the proposed Column 3), as well as the impact of total payments using a multiple
changes to packaging. When services updating the conversion factor with the threshold of 1.75 and a fixed dollar
were packaged as proposed, the market basket update. We modeled the threshold of $2,000.
resulting median costs at the HCPCS independent effect of the proposed

code level often changed, requiring budget neutrality adjustments and the Column 1: Total Number of Hospitals
migration of HCPCS codes to different proposed market basket update by using The first line in Column 1 in Table 67
APCs to address violations of the two the weights and wage indices for each shows the total number of providers
times rule (that is, to ensure that the year, and using a CY 2007 conversion (4,171), including cancer and children’s
HCPCS codes within the APC remained factor that included the proposed hospitals and CMHCs for which we
homogeneous with regard to clinical market basket update and budget were able to use CY 2006 hospital
outpatient claims to model CY 2007 and ‘‘other’’ urban hospitals experience an of proposed changes to packaging. Rural
CY 2008 payments by classes of increase of 0.5 percent. hospitals with 150 or more beds would
hospitals. We excluded all hospitals for Overall, rural hospitals would show a experience decreases while smaller
which we could not accurately estimate modest 0.2 percent increase as a result rural hospitals would experience
CY 2007 or CY 2008 payment and of proposed changes to the APC increases in payment.
entities that are not paid under the structure that would occur without the Among teaching hospitals, the largest
OPPS. The latter entities include CAHs, proposed changes in packaging. In observed impacts resulting from the
all-inclusive hospitals, and hospitals general, rural hospitals with 101 or proposed packaging include a decrease
located in Guam, the U.S. Virgin more beds would experience increases of 0.4 percent for minor teaching
Islands, Northern Mariana Islands, greater than rural hospitals with 100 hospitals and an increase of 0.3 percent
American Samoa, and the State of beds or fewer. Similarly, rural hospitals for major teaching hospitals.
Maryland. This process is discussed in that bill greater than 10,999 lines (that Classifying hospitals by type of
greater detail in section II.A. of this is, total payable claim lines in CY 2006) ownership suggests that proprietary
proposed rule. At this time, we are would experience increases greater than hospitals would decrease 0.2 percent,
unable to calculate a disproportionate rural hospitals that bill 10,999 lines and and governmental and voluntary
share (DSH) variable for hospitals not fewer. Urban and rural hospitals that hospitals would experience no change.
participating in the IPPS. Hospitals for bill Medicare fewer than 5,000 lines
would see reductions of 10.7 percent Column 2: Combination of Columns 2A
which we do not have a DSH variable and 2B
are grouped separately and generally and 8.1 percent respectively, due to the
include psychiatric hospitals, proposed reduction in payment for This column shows the combined
rehabilitation hospitals, and LTCHs. We partial hospitalization (APC 0033) for effects of proposed policies other than
show the total number (3,911) of OPPS CY 2008 and due to the limitation on the proposed changes to packaging (for
hospitals, excluding the hold-harmless the aggregate total OPPS payment per example, changes to payment for
cancer and children’s hospitals, and day for mental health services to the per brachytherapy sources and therapeutic
CMHCs, on the second line of the table. diem payment for partial hospitalization radiopharmaceuticals), which are
We excluded cancer and children’s (APC 0034). reflected in part in column 2A with the
hospitals because section 1833(t)(7)(D) Among teaching hospitals, the largest additional changes to reconfiguration
of the Act permanently holds harmless observed impacts resulting from and recalibration that would be made if
cancer hospitals and children’s proposed APC recalibration include an we were to finalize the packaging
hospitals to a proportion of their pre- increase of 0.5 percent for minor proposal (Column 2B). In many cases,
BBA payment relative to their pre-BBA teaching hospitals and an increase of 0.1 the redistribution created by the
costs and, therefore, we removed them percent for major teaching hospitals. reduction in the partial hospitalization
Classifying hospitals by type of payment offsets other recalibration
from our impact analyses. We excluded
ownership suggests that proprietary losses. Overall, these changes would
CMHCs, because they only bill one
hospitals would not experience any increase payments to urban hospitals by
service under the OPPS, and thus they
change in payment, governmental 0.2 percent. We estimate that both large
can easily determine the impact of the
hospitals would experience an increase urban hospitals and other urban
proposed changes.
of 0.2 percent, and voluntary hospitals hospitals would see a 0.2 percent
Column 2A: APC Recalibration Prior to would experience an increase of 0.4 increase in payments attributable to all
the Packaging Proposal percent. recalibration.
Column 2B: APC Recalibration and Overall, rural hospitals would show a
This column estimates what the modest 0.6 percent increase as a result
effects of APC reconfiguration and Addition of the Packaging Proposal
of proposed changes to the APC
recalibration would be if we were not to This column estimates what the structure and the packaging proposal.
finalize the proposed packaging additional, independent effects of APC Rural hospitals with 200 or more beds
changes. The effects described in this reconfiguration and recalibration, and would experience decreases while
column reflect updated cost report and resulting changes in discounting smaller rural hospitals would
claims data, as well as policy changes patterns, would be with the expanded experience increases in payment.
not related to proposed additional packaging and all other changes that we Among teaching hospitals, the largest
packaging, including APC Panel propose for CY 2008. Significant observed impacts resulting from
recommendations and proposed changes not related to packaging were proposed APC recalibration and the
payment for brachytherapy sources. We addressed in column 2A. In general, the packaging proposal include an increase
assumed that radiopharmaceuticals packaging proposal redistributes of 0.5 percent for major teaching
would be paid prospectively based on payments from larger and urban hospitals and an increase of 0.1 percent
their mean unit cost. In general, the hospitals to smaller and rural hospitals for minor teaching hospitals.
combined effects of the APC that provide fewer packaged services Classifying hospitals by type of
reclassification and recalibration and fewer of the independent services ownership suggests that proprietary
without the packaging proposal for into which the supportive services were hospitals would decrease 0.2 percent,
hospitals in Column 2A are similar to packaged. Overall, these additional governmental hospitals would increase
the effects of APC recalibration in recent changes would decrease payments to by 0.2 percent, and voluntary hospitals
years. The 0.3 percent increase for all urban hospitals by 0.1 percent. We would increase by 0.4 percent.
hospitals reflects the redistribution of estimate that urban hospitals that bill
lost partial hospitalization per diem less than 11,000 lines would see an Column 3: New Wage Indices and the
payment from CMHCs to other increase of slightly over 1 percent, while Effect of the Rural Adjustment
hospitals. For example, overall, these urban hospitals that bill at least 11,000 This column estimates impact of
changes would increase payments to lines or more would experience less of applying the proposed IPPS FY 2008
urban hospitals by 0.3 percent. We an increase or a small decrease. wage indices for CY 2008, continuing
estimate that large urban hospitals Overall, rural hospitals would show a the rural adjustment for CY 2008, and
would see a 0.2 percent increase, while modest 0.4 percent increase as a result extending the rural adjustment to
include brachytherapy sources. Overall, of the proposed decreases in payment CY 2008, plus 0.04 percent for the
these changes would not change the for partial hospitalization and mental difference in estimated outlier payments
payments to urban hospitals. Overall, health services appearing in Column between CY 2007 and CY 2008, less 0.14
rural hospitals would show no change 2A. percent for expiring 508 wage payments.
as a result of proposed changes to the Overall, rural hospitals would show a When we exclude cancer and children’s
wage indices and the continuation of 3.9 percent increase as a result of hospitals (which are held harmless to
the rural adjustment. proposed market basket update. Rural their pre-OPPS costs), and CMHCs, the
Among teaching hospitals, the largest hospitals that bill less than 5,000 lines gain becomes 3.5 percent.
observed impacts resulting from would see a 4.2 percent decrease, also
The combined effect of all proposed
proposed changes to the wage indices as a result of proposed decreases in
changes for CY 2008 would increase
and the continuation of the rural payment for partial hospitalization
payments to urban hospitals by 3.5
adjustment include a decrease of 0.2 appearing in Column 2A. Rural
percent. We estimate that large urban
percent for major teaching hospitals and hospitals that bill more than 5,000 lines
hospitals would see a 3.5 percent
no change for minor teaching hospitals. would experience increases.
Classifying hospitals by type of Among teaching hospitals, the largest increase, while ‘‘other’’ urban hospitals
ownership suggests that proprietary observed impacts resulting from the experience an increase of 3.4 percent.
hospitals would gain 0.2 percent, proposed market basket update include Urban hospitals that bill less than 5,000
government hospitals would experience an increase of 3.6 percent for major lines experience a decrease of 5.4
an increase of 0.1 percent, and teaching hospitals and an increase of 3.4 percent, up from 6.0 percent in column
voluntary hospitals would experience percent for minor teaching hospitals. 4 due to increases in outlier payments
no change. Classifying hospitals by type of for partial hospitalization.
ownership suggests that proprietary Overall, rural hospitals would show a
Column 4: All Budget Neutrality hospitals would gain 3.3 percent, 3.8 percent increase as a result of the
Changes and Market Basket Update government hospitals would experience combined effects of all proposed
The addition of the proposed market an increase of 3.6 percent, and changes for CY 2008. Rural hospitals
update alleviates any negative impacts voluntary hospitals would experience that bill less than 5,000 lines experience
on payments for CY 2008 created by the an increase of 3.6 percent. a decrease of 3.0 percent, which is less
proposed budget neutrality adjustments than the 4.2 percent in column 4 due to
made in Columns 2 and 3, with the Column 5: All Proposed Changes for CY
2008 an increase in outlier payments for
exception of urban and rural hospitals partial hospitalization. All rural
with the lowest volume of services and Column 5 compares all proposed hospitals that bill greater than 5,000
hospitals not paid under the IPPS, changes for CY 2008 to final payment lines experience increases ranging from
including psychiatric hospitals, for CY 2007 and includes the expiring 3.3 percent to 4.9 percent.
rehabilitation hospitals, and LTCHs section 508 reclassification wage
(DSH not available). In many instances, indices, the proposed change in the Among teaching hospitals, the largest
the redistribution of payments created outlier threshold, and the difference in observed impacts resulting from the
by APC recalibration offsets those pass through estimates which are not combined effects of all proposed
introduced by updating the wage included in the combined percentages changes include an increase of 3.5
indices. shown in Column 4. Overall, we percent for major teaching hospitals and
Overall, these changes would increase estimate that providers would gain 3.3 an increase of 3.3 percent for minor
payments to urban hospitals by 3.5 percent under this proposed rule in CY teaching hospitals.
percent. We estimate that both large 2008 relative to total spending in CY Classifying hospitals by type of
urban hospitals and other urban 2007. The 3.3 percent for all providers ownership suggests that proprietary
hospitals would see a 3.5 percent in Column 5 is rounded from 3.26 hospitals would gain 3.4 percent,
increase. In contrast, small urban percent, which reflects the 3.3 percent government hospitals would experience
hospitals that bill fewer than 5000 lines market basket increase, plus 0.06 an increase of 3.6 percent, and
per year would experience a decrease in percent for the change in the pass- voluntary hospitals would experience
payment of 6 percent, largely as a result through estimate between CY 2007 and an increase of 3.5 percent.
TABLE 67.—PROPOSED IMPACT OF CHANGES FOR CY 2008 HOSPITAL OUTPATIENT PROSPECTIVE PAYMENT SYSTEM
APC changes New wage Comb (cols
Number of index and
Prior to pack- 2,3) with up- All changes
hospitals Packaging Comb (cols rural adjust-
aging pro- date
proposal 2A,2B) ment
posal
(1) (2A) (2B) (2) (3) (4) (5)
Proposed Impact of CY 2008 Hospital Outpatient Prospective Payment System Changes
ALL PROVIDERS* ..................... 4171 0.0 0.0 0.0 0.0 3.3 3.3
ALL HOSPITALS ....................... 3911 0.3 0.0 0.3 0.0 3.6 3.5
(excludes hospitals held harm-
less and CMHCs)

URBAN HOSPITALS ................. 2916 0.3 ¥0.1 0.2 0.0 3.5 3.5
LARGE URBAN (GT 1
MILL.) .............................. 1591 0.2 0.1 0.2 0.0 3.5 3.5
OTHER URBAN (LE 1
MILL.) .............................. 1325 0.5 ¥0.3 0.2 0.0 3.5 3.4
RURAL HOSPITALS .................. 995 0.2 0.4 0.6 0.0 3.9 3.8
SOLE COMMUNITY ........... 410 0.3 0.4 0.7 0.2 4.2 3.9
TABLE 67.—PROPOSED IMPACT OF CHANGES FOR CY 2008 HOSPITAL OUTPATIENT PROSPECTIVE PAYMENT SYSTEM—
Continued
Number of index and
aging pro- date
posal
(1) (2A) (2B) (2) (3) (4) (5)
OTHER RURAL .................. 585 0.2 0.4 0.5 ¥0.2 3.7 3.8
BEDS (URBAN):
0–99 BEDS ......................... 947 ¥0.2 0.5 0.3 0.1 3.7 3.7
100–199 BEDS ................... 917 0.1 0.1 0.2 0.0 3.5 3.4
200–299 BEDS ................... 469 0.5 ¥0.2 0.3 ¥0.1 3.6 3.5
300–499 BEDS ................... 409 0.4 ¥0.2 0.2 0.1 3.6 3.6
500 + BEDS ........................ 174 0.4 ¥0.3 0.1 0.0 3.4 3.3
BEDS (RURAL):
0–49 BEDS*** ..................... 345 0.1 1.2 1.4 ¥0.1 4.6 4.5
50–100 BEDS*** ................. 383 0.1 0.9 1.0 0.2 4.5 4.5
101–149 BEDS ................... 159 0.3 0.4 0.7 0.0 4.0 4.0
150–199 BEDS ................... 64 0.4 ¥0.3 0.1 ¥0.6 2.7 2.7
200 + BEDS ........................ 44 0.3 ¥0.7 ¥0.5 0.1 2.9 2.6
VOLUME (URBAN):
LT 5,000 Lines .................... 591 ¥10.7 1.4 ¥9.3 0.0 ¥6.0 ¥5.4
5,000–10,999 Lines ............ 165 ¥1.6 1.2 ¥0.3 0.1 3.1 3.0
11,000–20,999 Lines .......... 269 ¥0.5 0.6 0.1 0.1 3.6 3.7
21,000–42,999 Lines .......... 545 0.3 0.3 0.6 0.2 4.0 4.0
GT 42,999 Lines ................. 1346 0.4 ¥0.2 0.2 0.0 3.5 3.5
VOLUME (RURAL):
LT 5,000 Lines .................... 82 ¥8.1 1.3 ¥6.8 ¥0.6 ¥4.2 ¥3.0
5,000–10,999 Lines ............ 104 0.0 1.2 1.2 0.3 4.9 4.8
11,000–20,999 Lines .......... 208 0.3 1.3 1.6 0.1 5.0 4.8
21,000–42,999 Lines .......... 310 0.3 1.1 1.4 0.2 4.9 4.9
GT 42,999 Lines ................. 291 0.2 0.0 0.2 ¥0.1 3.4 3.3
REGION (URBAN):
NEW ENGLAND ................. 157 0.0 0.8 0.8 ¥0.1 4.0 3.8
MIDDLE ATLANTIC ............ 378 0.4 0.6 1.0 ¥0.4 3.9 3.5
SOUTH ATLANTIC ............. 454 0.4 ¥0.4 0.0 0.1 3.5 3.5
EAST NORTH CENT .......... 461 0.5 ¥0.2 0.3 ¥0.2 3.4 3.2
EAST SOUTH CENT .......... 195 0.7 ¥0.6 0.1 0.1 3.4 3.5
WEST NORTH CENT ......... 187 0.4 ¥0.2 0.2 0.3 3.8 3.8
WEST SOUTH CENT ......... 464 0.5 ¥0.8 ¥0.3 ¥0.2 2.8 2.9
MOUNTAIN ......................... 181 0.6 ¥0.1 0.5 0.0 3.8 3.9
PACIFIC .............................. 388 ¥0.4 0.2 ¥0.3 0.6 3.6 3.7
PUERTO RICO ................... 51 1.0 0.3 1.2 ¥0.2 4.4 4.4
REGION (RURAL):
NEW ENGLAND ................. 21 0.0 0.9 0.8 ¥0.5 3.6 3.7
MIDDLE ATLANTIC ............ 70 0.1 0.8 0.8 0.0 4.2 4.2
SOUTH ATLANTIC ............. 171 0.2 0.4 0.6 ¥0.2 3.7 3.8
EAST NORTH CENT .......... 126 0.2 0.3 0.5 0.0 3.8 3.4
EAST SOUTH CENT .......... 177 0.2 ¥0.1 0.1 ¥0.1 3.3 3.4
WEST NORTH CENT ......... 116 0.3 0.2 0.5 0.1 3.9 3.6
WEST SOUTH CENT ......... 198 0.2 0.1 0.4 ¥0.6 3.0 3.2
MOUNTAIN ......................... 78 0.4 1.3 1.7 0.7 5.7 5.5
PACIFIC .............................. 38 0.4 0.9 1.3 1.8 6.4 6.0
TEACHING STATUS:
NON-TEACHING ................ 2889 0.3 0.0 0.3 0.1 3.7 3.7
MINOR ................................ 739 0.5 ¥0.4 0.1 0.0 3.4 3.3
MAJOR ............................... 283 0.1 0.3 0.5 ¥0.2 3.6 3.5
DSH PATIENT PERCENT:
.0 ......................................... 10 2.8 2.2 5.0 0.0 8.4 8.3
GT 0–0.10 ........................... 394 0.6 0.1 0.6 ¥0.1 3.8 3.8
0.10–0.16 ............................ 467 0.5 ¥0.1 0.4 ¥0.1 3.6 3.4
0.16–0.23 ............................ 764 0.4 ¥0.1 0.3 0.1 3.7 3.6
0.23–0.35 ............................ 955 0.4 ¥0.1 0.3 0.0 3.6 3.6
GE 0.35 ............................... 757 0.0 0.1 0.1 0.1 3.5 3.6
DSH NOT AVAILABLE** .... 564 ¥10.7 0.8 ¥9.9 0.2 ¥6.4 ¥6.0
URBAN TEACHING/DSH:
TEACHING & DSH ............. 916 0.4 ¥0.1 0.3 ¥0.1 3.5 3.4
NO TEACHING/DSH .......... 1455 0.4 ¥0.1 0.3 0.1 3.7 3.7
NO TEACHING/NO DSH .... 9 2.8 2.2 5.0 0.0 8.4 8.3
DSH NOT AVAILABLE2 ..... 536 ¥10.7 0.8 ¥9.9 0.3 ¥6.4 ¥5.9
TYPE OF OWNERSHIP:
VOLUNTARY ...................... 2146 0.4 0.0 0.4 0.0 3.6 3.5
TABLE 67.—PROPOSED IMPACT OF CHANGES FOR CY 2008 HOSPITAL OUTPATIENT PROSPECTIVE PAYMENT SYSTEM—
Continued
Number of index and
aging pro- date
posal
(1) (2A) (2B) (2) (3) (4) (5)
PROPRIETARY .................. 1179 0.0 ¥0.2 ¥0.2 0.2 3.3 3.4

GOVERNMENT .................. 586 0.2 0.0 0.2 0.1 3.6 3.6
Column (1) shows total providers.
Column (2A) shows the impact of changes resulting from the reclassification of HCPCS codes among APC groups resulting from updated
2006 claims data and implementation of policies not related to packaging, such as proposed payment for brachytherapy sources.
Column (2B) shows the impact of changes resulting from the packaging proposal and any resulting changes to APC recalibration and dis-
counting patterns.
Column (2) shows the combined impact of all APC reconfiguration and recalibration changes in columns 2A and 2B.
Column (3) shows the budget neutral impact of updating the wage index and rural adjustment by applying the FY 2008 hospital inpatient wage
index and extending the rural adjustment to brachytherapy sources.
Column (4) shows the impact of all budget neutrality adjustments and the addition of the market basket update.
Column (5) shows the additional adjustments to the conversion factor resulting from the change in the pass-through estimate and outlier pay-
ments. This column also shows the impact of the expiring 508 wage reclassification, which ends in September 2007
* These 4,171 providers include children and cancer hospitals, which are held harmless to pre-BBA payment to cost ratios, and Community
Mental Health Centers.
** Complete DSH numbers are not available for providers that are not paid under IPPS, including rehabilitation, psychiatric, and long-term care
hospitals.
*** Section 1833(t)(7)(D) of the Act specifies that rural hospitals with 100 or fewer beds (that are not also sole community hospitals) receive ad-
ditional payment for covered hospital outpatient services furnished during CY 2008 for which the prospective payment system amount is less
than the pre-BBA amount. The amount of payment is increased by 85 percent of that difference for CY 2008.
4. Estimated Effect of This Proposed In order to better understand the additional 3.3 percent increase in
Rule on Beneficiaries impact of changes in copayment on payments for CY 2008, after considering
beneficiaries, we modeled the percent all proposed changes to APC
For services for which the beneficiary change in total copayment liability reconfiguration and recalibration,
pays a copayment of 20 percent of the using CY 2006 claims. We estimate, including those resulting from the
payment rate, the beneficiary share of using the claims of the 4,171 hospitals proposal to expand packaging and the
payment would increase for services for and CMHCs on which our modeling is proposal to pay for brachytherapy
which the OPPS payments would rise based, that total beneficiary liability for sources on a prospective payment basis,
and would decrease for services for copayments would decline as an overall as well as the proposed market basket
which the OPPS payments would fall. percentage of total payments from 26.6 increase, and the estimated cost of
For example, for an electrocardiogram percent in CY 2007 to 25.6 percent in outliers and proposed changes to the
(APC 0099), the minimum unadjusted CY 2008. This estimated decline in pass through estimate. The
copayment in CY 2007 was $4.66. In beneficiary liability is a consequence of accompanying discussion, in
this proposed rule, the minimum the APC recalibration and combination with the rest of this
unadjusted copayment for APC 0099 is reconfiguration we are proposing to proposed rule constitutes a regulatory
$4.98 because the OPPS payment for the make for CY 2008. impact analysis.
service would increase under this With respect to partial
proposed rule. In another example, for 6. Accounting Statement
hospitalization, the copayment in CY
a Level IV Needle Biopsy (APC 0037), in 2007 of $46.95 would decline to $35.98 As required by OMB Circular A–4
the CY 2007 OPPS, the national under this proposed rule as a result of (available at http://
unadjusted copayment was $228.76, and the proposed decline in the per diem www.whitehouse.gov/omb/circulars/
the minimum unadjusted copayment payment for partial hospitalization from a004/a-4.pdf), in Table 68, we have
was $126.20. In this proposed rule, the $234.73 in CY 2007 to $179.88 for CY prepared an accounting statement
national unadjusted copayment for APC 2008. showing the CY 2008 estimated hospital
0037 is $228.70. The minimum OPPS incurred benefit impact
unadjusted copayment for APC 0037 is 5. Conclusion associated with the estimated CY 2008
$177.83, or 20 percent of the payment The changes in this proposed rule outpatient hospital market basket
for APC 0037. The minimum unadjusted would affect all classes of hospitals. update shown in this proposed rule,
copayment would rise because the Some classes of hospitals experience based on the 2007 Trustees’ Report
payment rate for APC 0037 would rise. significant gains and others less baseline. This estimate only reflects the
In all cases, the statute limits significant gains, but almost all classes effect of the statutorily required market
beneficiary liability for copayment for a of hospitals would experience positive basket update and does not take into
service to the inpatient hospital updates in OPPS payments in CY 2008. account potential enrollment,
deductible for the applicable year. For Table 67 demonstrates the estimated utilization, or case-mix changes. All
CY 2007, the inpatient deductible is distributional impact of the OPPS estimated impacts are classified as
$992. budget neutrality requirements and an transfers.
TABLE 68.—ACCOUNTING STATEMENT: CY 2008 ESTIMATED HOSPITAL OPPS INCURRED BENEFIT IMPACT ASSOCIATED
WITH THE ESTIMATED CY 2008 OUTPATIENT HOSPITAL MARKET BASKET UPDATE
[in billions]
Category Transfers
Annualized Monetized Transfers ........................ $0.8

From Whom To Whom? ..................................... Federal Government to outpatient hospitals and other providers who receive payment under
the hospital OPPS.
C. Effects of ASC Payment System based on the MPFS facility PE RVUs In the July 2007 final rule for the
Changes in This Proposed Rule and to exclude covered ancillary revised ASC payment system, we
(If you choose to comment on issues radiology services and covered ancillary estimated the CY 2008 ASC payment
in this section, please include the drugs and biologicals from the rates, budget neutrality factor, and
caption ‘‘ASC Impact’’ at the beginning categories of DHS that are subject to the impacts using the CY 2007 OPPS
of your comment.) physician self-referral prohibition. relative payment weights with an
We are publishing elsewhere in this The revised Medicare ASC payment estimated update factor for CY 2008, the
issue of the Federal Register the final system that we are implementing CY 2007 MPFS PE RVUs trended
rule for the revised ASC payment beginning January 1, 2008 could have a forward to CY 2008, and CY 2005
system, effective January 1, 2008. In the far-reaching effect on the provision of utilization data projected forward to CY
July 2007 final rule for the revised ASC outpatient surgical services for a 2008. In that final rule, we indicated
payment system, we adopted the number of years to come for several that these estimates were illustrative
method we will use to set payment rates reasons. First, the list of procedures that and that the CY 2008 ASC payment
for ASC services furnished in will be eligible for payment under the rates and budget neutrality factor would
association with covered surgical revised ASC payment system is greatly be proposed in the CY 2008 OPPS/ASC
procedures and covered ancillary expanded from the list of surgical proposed rule based on the
procedures beginning January 1, 2008. procedures eligible for payment under methodology for calculating budget
In that final rule, we established that the the ASC payment system in CY 2007 neutrality established in the July 2007
OPPS relative payment weights and and earlier years. In addition, we are final rule and incorporating the
payment rates will be used as the basis moving from a limited fee schedule proposed CY 2008 OPPS relative
for the payment of most covered based on nine disparate payment groups payment weights, the proposed CY 2008
surgical procedures and covered to a payment system incorporating MPFS PE RVUs, and CY 2006 utilization
ancillary services under the revised ASC relative payment weights for groups of information projected forward to CY
payment system. procedures with similar clinical and 2008. The final CY 2008 ASC payment
In the July 2007 final rule for the resource characteristics, that is, the APC rates and budget neutrality factor will be
revised ASC payment system, we also groups that are the unit of payment in established in the CY 2008 OPPS/ASC
established that we would update the the OPPS. final rule with comment period, in
ASC payment system annually as part of accord with the methodology for
the OPPS rulemaking cycle. As part of Implementation by January 1, 2008 of calculating budget neutrality established
the annual OPPS rulemaking cycle, we a revised ASC payment system designed in the July 2007 final rule and based on
indicated we would update the ASC to result in budget neutrality is the final CY 2008 OPPS payment
covered surgical procedures and mandated by section 626 of Pub. L. 108– weights, the final CY 2008 MPFS RVUs,
covered ancillary services, as well as 173. To set ASC payment rates for CY and updated CY 2006 utilization data
their payment rates. Such an update is 2008 under the revised payment system, projected forward to CY 2008.
very important because the OPPS we are multiplying ASC relative Our final methodology for calculating
relative payment weights and rates will payment weights for surgical procedures the budget neutrality adjustment factor
be used as the basis for the payment of by an ASC conversion factor that we established in the July 2007 final rule
most covered surgical procedures and calculated to result in the same amount considered not only the effects of the
covered ancillary services under the of aggregate Medicare expenditures in new payment rates to be implemented
revised ASC payment system. This joint CY 2008 as we estimate would have under the revised payment system, but
update process will ensure that the ASC been made if the revised payment also the estimated net effect of migration
updates occur in a regular, predictable, system were not implemented. of new ASC procedures across
and timely manner, and that the ASC The effects of the expanded number ambulatory care settings. Both the
payment rates immediately reflect the and types of procedures for which an estimated budget neutrality adjustment
updated OPPS relative payment ASC payment may be made and other factor presented in the July 2007 final
weights. policy changes that affect the revised rule and the budget neutrality
In this CY 2008 OPPS/ASC proposed payment system, combined with adjustment factor proposed in this rule
rule, we are proposing to update the significant changes in payment rates for are based on that methodology, which
revised ASC payment system for CY covered surgical procedures, will vary takes into account projected migration.
2008 to reflect the proposed CY 2008 across ASCs, depending on whether or In the final model, we assume that over
OPPS relative payment weights and not the ASC limits its services to those the first 2 years of the revised payment
rates, as well as update the list of in a particular surgical specialty area, system, approximately 25 percent of the
covered surgical and covered ancillary the volume of specific services provided HOPD volume of new ASC procedures
services. We are also proposing to revise by the ASC, the extent to which ASCs would migrate from the HOPD service
the regulations to make practice expense will offer different services, and the setting to ASCs, and that over the 4-year
payment to physicians who perform percentage of its patients that are transition period, approximately 15
noncovered ASC procedures in ASCs Medicare beneficiaries. percent of the physicians’ office volume
of new ASC procedures would migrate a. Office-Based Procedures predominantly performed in physicians’
to ASCs. According to our final policy for the offices. We believe that designating
We estimate that the revised ASC revised ASC payment system, we these procedures as office-based, which
payment system will result in neither designate as office-based those results in the ASC payment rate for
procedures that are added to the ASC these procedures being capped at the
savings nor costs to the Medicare
list of covered surgical procedures in CY physician office rate (that is, the MPFS
program in CY 2008. That is, because it
2008 or later years and that we nonfacility practice PE RVU amount), if
is designed to be budget neutral, in CY
determine are predominantly performed applicable, is an appropriate step to
2008, the revised ASC payment system ensure that Medicare payment policy
will neither increase nor decrease in physicians’ offices based on
consideration of the most recent does not create financial incentives for
expenditures under Part B of Medicare. such procedures to shift unnecessarily
We further estimate that beneficiaries available volume and utilization data for
each individual procedure code and/or, from physicians’ offices to ASCs.
will save approximately $20 million
under the revised ASC payment system if appropriate, the clinical b. Partial Device Credits
in CY 2008, because ASC payment rates characteristics, utilization, and volume We are proposing to reduce the ASC
will, in most cases, be lower than OPPS of related codes. We establish payment payment by one half of the device offset
payment rates for the same services and for procedures designated as office- amount for certain surgical procedures
because, except for screening flexible based at the lesser of the MPFS into which the device cost is packaged,
nonfacility PE RVU amount or the ASC when an ASC receives a partial credit
sigmoidoscopy and screening
rate developed according to the toward replacement of specific
colonoscopy procedures, beneficiary
standard methodology of the revised implantable devices. This partial
coinsurance for ASC services is 20
ASC payment system. In the July 2007 payment reduction would apply when
percent rather than 20 to 40 percent as final rule for the revised ASC payment
is the case under the OPPS. (The only the amount of the device credit is
system, we designated a number of greater than or equal to 20 percent of the
possible instance in which an ASC procedures as office-based, based on our
coinsurance amount could exceed the cost of the new replacement device
evaluation of the most recent available being implanted. Under this proposed
OPPS copayment amount would be CY 2005 volume and utilization data for policy, both the Medicare payment to
when the coinsurance amount for a each individual procedure code and/or the ASC and the beneficiary
procedure under the revised ASC related codes. In developing this coinsurance liability would be reduced
payment system exceeds the hospital proposed rule, we reviewed the newly when an ASC receives a partial device
inpatient deductible. Section available CY 2006 utilization data for all credit. This proposal is an extension of
1833(t)(8)(C)(i) of the Act provides that those surgical procedures newly added the policy established in the final rule
the copayment amount for a procedure for ASC payment in CY 2008 that were for the revised ASC payment system,
paid under the OPPS cannot exceed the assigned payment indicator ‘‘G2’’ as which reduces the ASC payment by the
inpatient deductible established for the non-office-based additions in the July full device offset amount for certain
year in which the procedure is 2007 final rule for the revised ASC devices when the ASC receives a
performed, but there is no such payment system. Based on this analysis, replacement device without cost or
requirement related to the ASC we are proposing to designate 19 receives a credit for the full cost of the
coinsurance amount.) Beneficiary additional procedures as office-based for device being replaced. This partial
coinsurance for services migrating from CY 2008. We considered two device credit proposal for ASCs mirrors
physicians’ offices to ASCs may alternatives in developing this proposal. the partial device credit proposal for the
decrease or increase under the revised The first alternative we considered OPPS in this proposed rule. We
ASC payment system, depending on the was to make no change to the current considered several alternatives in
particular service and whether the policy for these 19 procedures. This developing this partial device credit
Medicare payment to the physician for would mean that we would continue to proposal for CY 2008.
providing that service in his or her pay these procedures at the standard The first alternative we considered
office is higher or lower than the sum ASC payment rate developed according was to make no change to the current
of the Medicare payment to the ASC for to the standard methodology of the policy. Under this alternative, Medicare
providing the facility portion of that revised ASC payment system. We did and the beneficiary would continue to
service and the Medicare payment to the not select this alternative because our pay the ASC the full payment rate for
physician for providing that service in analysis of the most recently available the device implantation procedure even
a facility (non-office) setting. As noted utilization data for these services and if the ASC received a substantial credit
previously, the net effect of the revised related procedures indicates that these towards the cost of the replacement
19 procedures could be considered to be device. The ASC payment for the device
ASC payment system on beneficiary
predominantly performed in physicians’ implantation procedure is based on the
coinsurance, taking into account the
offices. We were concerned that if these OPPS relative weight for the procedure,
migration of services from HOPDs and
services were not designated as office- which is calculated using only OPPS
physicians’ offices, is estimated to be
based, it could create financial claims for which the full cost of a device
$20 million in beneficiary savings in CY is billed. We did not select this
incentives for these procedures to shift
2008. alternative because we believe that, as
from physicians’ offices to ASCs for
1. Alternatives Considered reasons unrelated to the most long as the ASC payment amount is
appropriate setting for surgical care. established based on an OPPS relative
Alternatives to the changes we are The second alternative we considered, weight that is calculated using only
making and the reasons that we have and the alternative we selected, is to claims that reflect the full cost of the
chosen the options are discussed propose to designate 19 additional device when there is no credit, there
throughout this proposed rule. Some of procedures as office-based for CY 2008. should be a reduction in the Medicare
the major issues discussed in this We selected this alternative because our payment amount when the ASC receives
proposed rule and the options claims data indicate that these a substantial credit toward cost of the
considered are discussed below. procedures could be considered to be replacement device. Similarly, we
believe that the beneficiary cost sharing The first alternative we considered higher nonfacility rate to physicians
should be based on an amount that also was to make no change to the current who furnish excluded ASC procedures.
reflects the credit. policy concerning physician payment
The second alternative we considered 2. Limitations of Our Analysis
for services performed in ASCs that are
was to extend the current no cost/full not on the ASC list of covered surgical Presented here are the projected
credit reduction policy to cases of procedures. Under current policy, the effects of the policy and statutory
partial credit without change. This physician is paid the higher nonfacility changes that will be effective for CY
would reduce the payment in all cases PE amount when the physician 2008 on aggregate ASC utilization and
in which the ASC received a credit by performs a service in an ASC that is not Medicare payments. One limitation of
the full offset amount for the device on the ASC list of covered surgical this analysis is that we could only infer
implantation procedure, that is, by 100 the effects of the revised payment
procedures (unless a nonfacility rate
percent of the estimated device cost system on different types of ASCs, for
does not exist in which case Medicare
included in the procedure payment rate. example, single or multispecialty, high
pays the facility rate). In the final rule
We did not select this alternative or low volume, and urban or nonurban
for the revised ASC payment system, we ASCs, based on an overall comparison
because we did not believe it was
adopted a final policy that identifies of procedure volumes and facility
appropriate to reduce the payment to
and excludes from ASC payment only payments between the current and the
the ASC by the full cost of a device if
the ASC only received a partial credit, those procedures that could pose a revised payment system. At this time,
and not a full credit, towards the cost of significant risk to beneficiary safety or we do not have a provider-level dataset
the device. would be expected to require an of CY 2006 ASC utilization that
The third alternative, which we are overnight stay. Because these excluded accurately identifies unique ASCs and
proposing, is to reduce the ASC procedures have been specifically their geographic information that would
procedure payment by 50 percent of the identified by CMS as procedures that allow us to compare estimated
offset amount (that would be applied if could pose a significant risk to payments and geographic adjustment
the ASC received full credit) in cases in beneficiary safety or would be expected among classes of ASCs based on a
which the ASC receives a partial credit to require an overnight stay, we do not provider-level analysis.
greater than or equal to 20 percent of the believe it would be appropriate to A second limitation is our lack of
cost of the new replacement device provide payment based on the higher information on ASC resource use. ASCs
being implanted. Moreover, we are nonfacility PE RVUs to physicians who are not required to file Medicare cost
proposing to require the ASC to report furnish them as we do not believe these reports and, therefore, we do not have
a new modifier when the ASC receives procedures are safe for performance in cost information to evaluate whether or
a partial credit that is equal to or greater an ASC. Consequently, we did not select not the proposed payments for ASC
than 20 percent of the cost of the device this alternative. services coincide with the resources
being replaced. We are proposing this The second alternative that we required by ASCs to provide those
alternative because we believe that this services.
considered, and that we selected, was to
approach provides an appropriate and A third limitation of our analysis is
propose that a physician performing a our inability to predict changes in
equitable payment to the ASC from procedure in an ASC would receive
Medicare and will reduce the service mix between CY 2006 and CY
payment based on the facility PE RVUs 2008 with precision. The aggregated
beneficiary’s cost sharing for the service. and excluding the TC payment, if impact tables below are based upon a
c. Payment to Physicians for Services applicable, regardless of whether a methodology that assumes no changes
Not on the ASC List of Covered Surgical procedure is on the ASC list of covered in service mix with respect to the CY
Procedures surgical procedures. We selected this 2006 ASC data used for this proposed
Under current policy, when alternative for several reasons. We rule. We believe that the net effect on
physicians perform surgical procedures believe ASCs are facilities that are Medicare expenditures of changes in
in ASCs that are included on the ASC similar, insofar as the delivery of service mix for current ASC covered
list of covered surgical procedures, they surgical and related nonsurgical surgical procedures will be negligible in
are paid under the MPFS for the PE services, to HOPDs. Specifically, when the aggregate. Such changes may have
component using the facility PE RVUs. services are provided in ASCs, the ASC, differential effects across surgical
When physicians perform surgical not the physician, bears responsibility specialties as ASCs adjust to proposed
procedures in ASCs that are not for the facility costs associated with the payment rates. However, we are unable
included on the ASC list of covered service. This situation parallels the to accurately project such changes at a
surgical procedures and for which hospital facility resource responsibility disaggregated level. Clearly, individual
Medicare does not allow facility for hospital outpatient services. ASCs will experience changes in
payments to ASCs, physicians currently Therefore, we believe it would be more payment that differ from the aggregated
are paid for the PE component at the appropriate for physicians to be paid for estimated changes presented below.
higher nonfacility rate (unless a all services furnished in ASCs just as Because we do not have experience
nonfacility rate does not exist in which they would be paid for all services with ASC payment under the revised
case Medicare pays the facility rate). In furnished in the hospital outpatient payment system, we have relied on
this proposed rule, we are proposing setting. In addition, because we have comments and information from
that regardless of whether a procedure adopted a final policy for the revised stakeholders in response to our August
is on the ASC list of covered surgical ASC payment system that identifies and 2006 proposed rule for the revised ASC
procedures, a physician performing that excludes from ASC payment only those payment system to mitigate the
procedure in an ASC would receive procedures that could pose a significant limitations in the data available to us for
payment based on the facility PE RVUs risk to beneficiary safety or would be analysis of the impact of the changes on
and excluding the technical component expected to require an overnight stay, classes of specialty ASCs, on
(TC) payment, if applicable. We we believe that it would be incongruous physicians, and on beneficiaries. We
considered two alternatives in with the revised ASC payment system anticipate improving the accuracy of
developing this proposal. methodology to continue to pay the estimated impacts over time.
3. Estimated Effects of This Proposed will transition the blend first to 50/50 • Column 3—Estimated CY 2008
Rule on ASCs and then to a 25/75 blend of the CY Percent Change with Transition (75/25
a. Payment to ASCs 2007 ASC rate and the revised ASC Blend) is the aggregate percentage
payment rate. Beginning in CY 2011, we increase or decrease in Medicare
Some ASCs are multispecialty will pay ASCs for covered surgical program payment to ASCs for each
facilities that perform the gamut of procedures on the CY 2007 ASC list at surgical specialty group that is
surgical procedures, from excision of the fully implemented revised ASC attributable to proposed changes in the
lesions to hernia repair to cataract payment rates. We will not transition
extraction; others focus on a single ASC payment rates for CY 2008 under
payment for procedures that were not the 75/25 blend of the CY 2007 ASC
specialty and perform only a limited included on the ASC list of covered
range of surgical procedures, such as payment rate and the CY 2008 revised
surgical procedures in CY 2007; we will ASC payment rate.
eye procedures, gastrointestinal pay these procedures as at the fully
procedures, or orthopedic surgery. The implemented ASC rate, beginning in CY • Column 4—Estimated CY 2008
combined effect on an individual ASC 2008. Percent Change without Transition
of the CY 2008 revised payment system Table 69 shows the impact of the (Fully Implemented) is the aggregate
and the expanded ASC list of covered percentage increase or decrease in
revised payment system by surgical
surgical procedures will depend on a Medicare program payment to ASCs for
specialty group. We have aggregated the
number of factors, including, but not each surgical specialty group that is
surgical HCPCS codes by specialty
limited to, the mix of services the ASC attributable to proposed changes in the
group and estimated the effect on
provides, the volume of specific services ASC payment rates for CY 2008 if there
aggregated payment for surgical
provided by the ASC, the percentage of were no transition period to the revised
specialty groups, considering separately
its patients who are Medicare payment rates. The percentages
the proposed CY 2008 transitional rate
beneficiaries, and the extent to which an appearing in column 4 are presented as
and the proposed fully implemented
ASC will choose to provide different a comparison for the transition policy in
revised payment rate discussed above.
services. The following discussion
The groups are sorted for display in column 3 and do not depict the impact
presents two tables that provide
descending order by estimated Medicare of the fully implemented proposal in
estimates of the impact of the revised
ASC payment system on Medicare program payment to ASCs for CY 2008 2011.
payments to ASC for current ASC in the absence of the revised ASC Table 69 depicts estimated proposed
services, assuming the same mix of payment system. The following is an changes to ASCs’ payments at the
services as offered by ASCs in our CY explanation of the information surgical specialty group level. For all
2006 claims data. The first table depicts presented in Table 69. but gastrointestinal procedures, if an
aggregate percent change in payment by • Column 1—Surgical Specialty ASC offers the same mix of services in
surgical specialty group and the other Group indicates the surgical specialties CY 2008 that is reflected in our national
compares payment for procedures into which ASC procedures are
CY 2006 claims data, proposed
estimated to receive the most payment grouped. We used the CPT code range
Medicare payments to the ASC for
in CY 2008 under the current payment definitions and Level II HCPCS codes
services in that surgical specialty group
system. A third table highlights changes and Category III CPT codes, as
appropriate, to account for all surgical are expected to increase under the
in payment rates between this CY 2008 revised payment system. If the revised
proposed rule and those in the July 2007 procedures to which the proposed
Medicare program payments are payment system was fully implemented
final rule for the revised ASC payment in CY 2008, we would expect all but
system for procedures estimated to attributed.
• Column 2—Estimated CY 2008 ASC gastrointestinal procedures and nervous
receive the most payment in CY 2008
Payments in the absence of the revised system procedures to receive greater
under the existing payment system.
In section XVI.C. of this proposed ASC payment system were calculated by Medicare payment. In addition to the
rule, we reiterate the transition of 4 multiplying the CY 2007 ASC payment impacts on Medicare payments for
years, where payments will generally be rate by CY 2008 ASC utilization (which current ASC procedures shown in Table
made using a blend of the rates based on is based on CY 2006 ASC utilization 69, it is important to note that estimated
the CY 2007 ASC payment rate and the multiplied by a factor of 1.176 to take CY 2008 payments to ASCs are
revised ASC payment rate. In CY 2008, into account expected volume growth estimated to increase by more than $240
we will pay ASCs using a 75/25 blend, with volume adjustment, as appropriate, million in CY 2008 due to projected
in which payment will be calculated by for the multiple procedure discount). migration of new ASC services from
adding 75 percent of the CY 2007 ASC The resulting amount was then HOPDs and physician offices to ASC.
rate for a surgical procedure on the CY multiplied by 0.8 to estimate the This increased spending in ASCs is
2007 ASC list of covered surgical Medicare program’s share of the total projected to be fully offset by savings
procedures and 25 percent of the payments to the ASC. The estimated CY from reduced spending in HOPDs and
revised CY 2008 ASC rate for the same 2008 payment amounts are expressed in physicians’ offices due to service
procedure. For CYs 2009 and 2010, we millions of dollars. migration.
TABLE 69.—ESTIMATED CY 2008 IMPACT OF THE REVISED ASC PAYMENT SYSTEM ON ESTIMATED AGGREGATE PRO-
POSED CY 2008 MEDICARE PROGRAM PAYMENTS UNDER THE 75/25 TRANSITION BLEND AND WITHOUT A TRANSI-
TION, BY SURGICAL SPECIALTY GROUP
Estimated CY
Estimated CY
Estimated CY 2008 percent
2008 percent
2008 ASC change with-
Surgical specialty group change with
payments (in out transition
transition (75/
millions) (fully imple-
25 blend) mented)
(1) (2) (3) (4)
Eye and ocular adnexa ................................................................................................................ $1,205 1 5

Digestive system .......................................................................................................................... 661 ¥4 ¥14
Nervous system ........................................................................................................................... 251 3 ¥2
Musculoskeletal system ............................................................................................................... 148 25 100
Integumentary system ................................................................................................................. 81 8 34
Genitourinary system ................................................................................................................... 68 12 46
Respiratory system ...................................................................................................................... 19 18 72
Cardiovascular system ................................................................................................................ 7 25 98
Auditory system ........................................................................................................................... 4 24 83
Hemic and lymphatic systems ..................................................................................................... 2 32 129
Other systems .............................................................................................................................. 0.1 29 116
Table 70 below shows the estimated rate by CY 2008 ASC utilization (which incorporating a 75/25 blend of the
impact of the revised payment system is based on CY 2006 ASC utilization estimated ASC payment using the CY
on proposed aggregate ASC payments multiplied by a factor of 1.176 to take 2007 ASC payment rate and the CY
for selected procedures during the first into account expected volume growth 2008 revised ASC payment rate.
year of implementation (CY 2008) with with volume adjustment, as appropriate, • Column 5—CY 2008 Proposed
and without the transitional blended for the multiple procedure discount). Percent Change without Transition
rate. The table displays 30 of the The resulting amount was then (Fully Implemented) reflects the percent
procedures receiving the highest multiplied by 0.8 to estimate the differences between the estimated ASC
estimated CY 2008 ASC payments under Medicare program’s share of the total payment rates for CY 2008 under the
the existing Medicare payment system. payments to the ASC. The estimated CY
The HCPCS codes are sorted in current system and the proposed
2008 payment amounts are expressed in estimated payment rates for CY 2008
descending order by estimated program millions of dollars.
payment. under the revised payment system if
• Column 1—HCPCS code • Column 4—CY 2008 Proposed there were no transition period to the
• Column 2—Short Descriptor of the Percent Change with Transition (75/25 revised payment rates. The percentages
HCPCS code Blend) reflects the percent differences appearing in column 5 are presented as
• Column 3—Estimated CY 2008 ASC between the estimated ASC payment a comparison for the transition policy in
Payments in the absence of the revised rates for CY 2008 under the current column 4 and do not depict the impact
payment system were calculated by system and the proposed payment rates of the fully implemented proposal in
multiplying the CY 2007 ASC payment for CY 2008 under the revised system, 2011.
TABLE 70.—ESTIMATED CY 2008 IMPACT OF PROPOSED REVISED ASC PAYMENT SYSTEM ON AGGREGATE PAYMENTS
FOR PROCEDURES WITH THE HIGHEST ESTIMATED CY 2008 PAYMENTS UNDER THE CURRENT SYSTEM
Estimated CY
Estimated CY Estimated CY 2008 percent
2008 ASC 2008 percent changes with-
HCPCS code Short Descriptor payments change out transition
(in millions) (75/25 blend) (fully imple-
mented)
(1) (2) (3) (4) (5)
66984 .......... Cataract surg w/iol, 1 stage ............................................................................... $981 1 3

43239 .......... Upper GI endoscopy, biopsy ............................................................................. 143 ¥5 ¥19
45378 .......... Diagnostic colonoscopy ..................................................................................... 133 ¥4 ¥16
45380 .......... Colonoscopy and biopsy .................................................................................... 110 ¥4 ¥16
66821 .......... After cataract laser surgery ............................................................................... 87 ¥8 ¥31
45385 .......... Lesion removal colonoscopy ............................................................................. 87 ¥4 ¥16
62311 .......... Inject spine l/s (cd) ............................................................................................. 70 ¥3 ¥11
64483 .......... Inj foramen epidural l/s ...................................................................................... 42 ¥3 ¥11

66982 .......... Cataract surgery, complex ................................................................................. 37 1 3
45384 .......... Lesion remove colonoscopy .............................................................................. 36 ¥4 ¥16
15823 .......... Revision of upper eyelid .................................................................................... 35 5 21
G0121 .......... Colon ca scrn not hi rsk ind ............................................................................... 34 ¥6 ¥26
G0105 .......... Colorectal scrn; hi risk ind ................................................................................. 27 ¥6 ¥26
64476 .......... Inj paravertebral l/s ADD-on .............................................................................. 24 ¥12 ¥48
64475 .......... Inj paravertebral l/s ............................................................................................ 24 ¥3 ¥11
TABLE 70.—ESTIMATED CY 2008 IMPACT OF PROPOSED REVISED ASC PAYMENT SYSTEM ON AGGREGATE PAYMENTS
FOR PROCEDURES WITH THE HIGHEST ESTIMATED CY 2008 PAYMENTS UNDER THE CURRENT SYSTEM—Continued
Estimated CY
Estimated CY Estimated CY 2008 percent
2008 ASC 2008 percent changes with-
HCPCS code Short Descriptor payments change out transition
(in millions) (75/25 blend) (fully imple-
mented)
(1) (2) (3) (4) (5)
43235 .......... Uppr gi endoscopy, diagnosis ........................................................................... 23 2 8

52000 .......... Cystoscopy ......................................................................................................... 21 ¥6 ¥24
67904 .......... Repair eyelid defect ........................................................................................... 16 7 26
64721 .......... Carpal tunnel surgery ........................................................................................ 15 18 72
29881 .......... Knee arthroscopy/surgery .................................................................................. 15 23 94
43248 .......... Uppr gi endoscopy/guide wire ........................................................................... 14 ¥5 ¥19
62310 .......... Inject spine c/t .................................................................................................... 12 ¥3 ¥11
64484 .......... Inj foramen epidural ADD-on ............................................................................. 11 ¥3 ¥11
29880 .......... Knee arthroscopy/surgery .................................................................................. 11 23 94
G0260 .......... Inj for sacroiliac jt anesth ................................................................................... 9 ¥3 ¥11
28285 .......... Repair of hammertoe ......................................................................................... 9 18 72
67038 .......... Strip retinal membrane ...................................................................................... 9 30 120
29848 .......... Wrist endoscopy/surgery ................................................................................... 9 ¥2 ¥9
64623 .......... Destr paravertebral n ADD-on ........................................................................... 9 ¥3 ¥11
45383 .......... Lesion removal colonoscopy ............................................................................. 8 ¥4 ¥16
Over time, we believe that the current the first year under the revised ASC the group of genitourinary procedures
ASC payment system has served as an payment system, and only two groups currently performed in ASCs is
incentive to ASCs to focus on providing for which a decrease would be expected expected to increase by 12 percent.
procedures for which they determine if there were no transition period to the Although a urology specialty ASC may
Medicare payments would support the revised CY 2008 payment rates. The currently perform more cystoscopy
ASC’s continued operation. We would estimated increased payments at the full procedures than any other genitourinary
expect that, under the existing payment group level are due to the moderating procedure, we believe that under the
system, the ASC payment rates for many effect of the proposed payment revised ASC payment system, each ASC
of the most frequently performed increases for the less frequently has the opportunity to adapt to the
procedures in ASCs are similar to the performed procedures within the payment decrease for its most frequently
OPPS payment rates for the same surgical specialty group. The exception performed procedures by offering an
procedures. Conversely, we would to this is the surgical specialty group of increased breadth of procedures, still
expect that procedures with existing eye and ocular adnexa where the within the clinical specialty area, and
ASC payment rates that are substantially projected aggregate increase in CY 2008 receive payments that are adequate to
lower than the OPPS rates would be under the revised system is driven by a support continued operations.
performed least often in ASCs. We small proposed increase, 1 percent, in Similarly, proposed payment for all of
believe the revised ASC payment system payment for the highest volume the highest volume pain management
represents a major stride towards procedure (CPT code 66984, injection procedures are expected to
encouraging greater efficiency in ASCs Extracapsular cataract removal with decrease in CY 2008, although payment
and promoting a significant increase in insertion of intraocular lens prosthesis for nervous system procedures overall
the breadth of surgical procedures (one stage procedures), manual or are expected to increase. However,
performed in ASCs, because it mechanical technique (e.g., irrigation without a transition for CY 2008, we
distributes payments across the entire and aspiration or phacoemulsification)). estimate that payments also would
spectrum of covered surgical As a result of the redistribution of decrease slightly for the nervous system
procedures, based on a coherent system payments across the expanded breadth surgical specialty group.
of relative payment weights that are of surgical procedures for which For those procedures that will be paid
related to the clinical and facility Medicare will provide an ASC payment, a significantly lower amount under the
resource characteristics of those we believe that ASCs may change the revised payment system than they are
procedures. mix of services they provide over the currently paid, we believe that their
Table 70 identifies a number of ASC next several years. The revised ASC current payment rates, which are closer
procedures receiving the highest payment system should encourage ASCs to the OPPS payment rates than other
estimated CY 2008 payment under the to expand their service mix beyond the ASC procedures, are likely to be
current system and shows that most of handful of the highest paying generous relative to ASC costs, so ASCs
them will experience payment decreases procedures which comprise the majority would, in all likelihood, continue
in CY 2008 under the revised ASC of ASC utilization under the existing performing those procedures under the
payment system. This contrasts with the ASC payment system. For example, revised payment system. We also note
estimated aggregate payment increases although the proposed payment rate for that the majority of the most frequently
at the surgical specialty group level cystoscopy (CPT code 52000), the performed ASC procedures specifically
displayed in Table 69. In fact, Table 69 highest volume ASC genitourinary studied by the GAO, as described in the
shows only one surgical specialty group procedure, is 6 percent less for CY 2008 July 2007 final rule for the revised ASC
of procedures for which the proposed than under the existing payment system, payment system, appear in Table 70
payments are expected to decrease in overall proposed payment to ASCs for with proposed payment decreases under
the revised ASC payment system. The surgical procedures discussed above, in for the multiple procedure discount).
GAO concluded that for these CY 2008 we also are adding hundreds The resulting amount was then
procedures the OPPS APC groups of surgical procedures to the already multiplied by 0.8 to estimate the
accurately reflect the relative costs of extensive list of procedures for which Medicare program’s share of the total
procedures performed at ASCs and that Medicare allows payment to ASCs, payments to the ASC. The estimated CY
ASCs have substantially lower costs. creating new opportunities for ASCs to 2008 payment amounts are expressed in
For some procedures the proposed expand their range of covered surgical millions of dollars.
payment amounts in CY 2008 are much procedures. For the first time, ASCs will • Column 4—Final Rule Estimated
higher than the CY 2007 rates currently be paid separately for covered ancillary CY 2008 Payment Rate with Transition
paid to ASCs. For example, payment for services that are integral to covered (75/25 Blend) presents the estimated CY
CPT code 67038 (Vitrectomy, surgical procedures, including certain 2008 payment rate from the July 2007
mechanical, pars plana approach; with radiology procedures, costly drugs and final rule for the revised ASC payment
epiretinal membrane stripping) biologicals, devices with pass-through system.
increases by 30 percent compared to status under the OPPS, and • Column 5—Proposed Rule
estimated CY 2008 payments under the brachytherapy sources. While separately Estimated CY 2008 Payment Rate
current system. Similarly, the proposed paid radiology services will be paid presents the proposed CY 2008 payment
CY 2008 ASC payment for CPT code based on their ASC relative payment rate in this proposed rule.
29880 (Arthroscopy, knee, surgical; with weight calculated according to the
meniscetomy (medial AND lateral, • Column 6—Estimated Percent
standard rate-setting methodology of the
including any meniscal shaving)) Change from Final Rule to Proposed
revised ASC payment system or to the
increases by 23 percent. For these two Rule presents the percent change in the
MPFS nonfacility practice expense
procedures and the other procedures payment rate from the final rule to this
amount, whichever is lower, the other
with estimated payment increases proposed rule.
items newly eligible for separate
greater than 10 percent, the increases payment in ASCs will be paid Table 71 shows that although the
are due to the comparatively higher comparably to their OPPS rates because estimated ASC budget neutrality
OPPS rates which, when adjusted by the we would not expect ASCs to percentage has changed from the July
ASC budget neutrality factor and experience efficiencies in providing 2007 final rule for the revised ASC
blended with the CY 2007 ASC payment them. Lastly, the July 2007 final rule for payment system (67 percent) to this CY
amounts, generate CY 2008 ASC the revised ASC payment system 2008 OPPS/ASC proposed rule (65
payment rates that are substantially established a specific payment percent), payment rates for individual
above the current CY 2007 ASC methodology for device-intensive procedures generally change very little
payment amounts. procedures that provides the same from the final rule to this proposed rule.
As proposed in this rule, payments for packaged payment for the device as Due to the proposed OPPS APC
most of the highest volume colonoscopy under the OPPS, while providing a recalibration for CY 2008, including the
and upper gastrointestinal endoscopy reduced service payment that is subject OPPS packaging proposal, the CY 2008
procedures will decrease under the to the 4-year transition if the device- OPPS payment rates are typically
revised payment system. Table 69 intensive procedure is on the CY 2007 increasing slightly for many surgical
estimates that payment decreases also ASC list of covered surgical procedures. procedures compared to the CY 2007
are expected for the gastrointestinal We expect that this final methodology OPPS payment rates. Because the
surgical specialty group overall. We will allow ASCs to continue to expand proposed CY 2008 ASC payment rates
believe that decreased payments for so their provision of device-intensive in this proposed rule are a product of
many of the gastrointestinal procedures services and to begin performing new typically higher OPPS payment rates
are because current ASC payment rates device intensive ASC procedures. and a slightly lower budget neutrality
are close to the OPPS rates. Procedures Table 71 displays a comparison of the factor (as compared to the final rule on
with current payment rates that are Medicare payment rates for ASC the revised ASC payment system), these
nearly as high as their OPPS rates are procedures receiving the highest two forces in many cases balance each
negatively affected under the revised estimated CY 2008 payment under the other, and the resulting ASC payment
payment system while procedures for current ASC payment system, based on rates estimated in this proposed rule for
which ASC rates have historically been the estimates provided in the July 2007 many procedures change little
much lower than the comparable OPPS ASC final rule for illustrative purposes, compared with the final rule for the
rates are positively affected. The and the proposed payment rates revised ASC payment system. Because
payment decreases expected in the first presented in this CY 2008 OPPS/ASC we have not revised our budget
year under the revised ASC payment proposed rule. neutrality methodology nor other ASC
system for some of the high volume • Column 1—HCPCS code. ratesetting policies from the July 2007
gastrointestinal procedures are not large • Column 2—Short Descriptor of the final rule, to the extent that there are
(all less than 7 percent). We believe that HCPCS code. significant observed changes for
ASCs can generally continue to cover • Column 3—Estimated CY 2008 ASC particular surgical procedures in
their costs for these procedures, and that Payments in the absence of the revised estimated payment rates between the
ASCs specializing in providing those payment system were calculated by final rule and this proposed rule, these
services will be able to adapt their multiplying the CY 2007 ASC payment reflect more specific changes in the
business practices and case mix to rate by CY 2008 ASC utilization (which OPPS payment rates stemming from the
is based on CY 2006 ASC utilization proposed APC recalibration, including
manage declines for individual

procedures. multiplied by a factor of 1.176 to take the effects of the OPPS packaging
In addition to the procedures into account expected volume growth proposal, under the proposed CY 2008
currently on the ASC list of covered with volume adjustment, as appropriate, OPPS.
TABLE 71.—COMPARISON OF ESTIMATED CY 2008 MEDICARE PAYMENT RATES IN THE JULY 2007 FINAL RULE FOR THE
REVISED ASC PAYMENT SYSTEM AND CY 2008 OPPS/ASC PROPOSED RULE FOR PROCEDURES WITH THE HIGHEST
ESTIMATED CY 2008 PAYMENTS UNDER THE CURRENT SYSTEM
July 2007 ASC Estimated per-
Proposed rule
Estimated CY final rule esti- cent change
estimated CY
2008 ASC mated CY from July 2007
HCPCS code Short Descriptor 2008 payment
payments 2008 payment ASC final rule
rate
(in millions) rate to proposed
(75/25 blend)
(75/25 blend) rule
66984 ........... Cataract surg w/iol, 1 stage ................................................... $981 $981.09 $980.43 0
43239 ........... Upper GI endoscopy, biopsy ................................................. 143 422.96 424.27 0
45378 ........... Diagnostic colonoscopy ......................................................... 133 427.76 428.0 2
45380 ........... Colonoscopy and biopsy ........................................................ 110 427.76 428.02 0
66821 ........... After cataract laser surgery ................................................... 87 288.45 288.60 0
45385 ........... Lesion removal colonoscopy ................................................. 87 427.76 428.02 0
62311 ........... Inject spine l/s (cd) ................................................................. 70 317.40 323.62 2
64483 ........... Inj foramen epidural l/s .......................................................... 42 317.40 323.62 2
66982 ........... Cataract surgery, complex ..................................................... 37 981.09 980.43 0
45384 ........... Lesion remove colonoscopy .................................................. 36 427.76 428.02 0
15823 ........... Revision of upper eyelid ........................................................ 35 687.02 754.42 10
G0121 .......... Colon ca scrn not hi rsk ind ................................................... 34 417.98 417.44 0
G0105 .......... Colorectal scrn; hi risk ind ..................................................... 27 417.98 417.44 0
64476 ........... Inj paravertebral l/s ADD-on .................................................. 24 310.64 292.80 ¥6
64475 ........... Inj paravertebral l/s ................................................................ 24 317.40 323.62 2
43235 ........... Uppr gi endoscopy, diagnosis ............................................... 23 338.21 339.52 0
52000 ........... Cystoscopy ............................................................................. 21 318.83 312.97 ¥2
67904 ........... Repair eyelid defect ............................................................... 16 654.63 671.51 3
64721 ........... Carpal tunnel surgery ............................................................ 15 524.35 526.05 0
29881 ........... Knee arthroscopy/surgery ...................................................... 15 776.94 777.27 0
43248 ........... Uppr gi endoscopy/guide wire ............................................... 14 422.96 424.27 0
62310 ........... Inject spine c/t ........................................................................ 12 317.40 323.62 2
64484 ........... Inj foramen epidural ADD-on ................................................. 11 317.40 323.62 2
29880 ........... Knee arthroscopy/surgery ...................................................... 11 776.94 777.27 0
G0260 .......... Inj for sacroiliac jt anesth ....................................................... 9 310.64 323.62 4
28285 ........... Repair of hammertoe ............................................................. 9 599.75 601.67 0
67038 ........... Strip retinal membrane .......................................................... 9 935.83 932.21 0
29848 ........... Wrist endoscopy/surgery ....................................................... 9 1,308.69 1,309.02 0
64623 ........... Destr paravertebral n ADD-on ............................................... 9 317.40 323.62 2
45383 ........... Lesion removal colonoscopy ................................................. 8 427.76 428.02 0
b. Payment to Physicians for Performing more complex than procedures screening colonoscopy and flexible
Excluded ASC Procedures in an ASC furnished in physicians’ offices. sigmoidoscopy procedures, the ASC
Consequently, most surgical procedures coinsurance rate for all procedures is 20
As discussed in section XVI.G. of this that will be excluded from the list of percent. This contrasts with procedures
proposed rule, we are proposing to pay ASC covered surgical procedures in CY performed in HOPDs where the
physicians at the facility rate for 2008 do not have nonfacility PE RVUs. beneficiary is responsible for
furnishing procedures in ASCs that are Specifically, only 25 of approximately copayments that range from 20 percent
excluded from the ASC list of covered 280 excluded ASC procedures for CY to 40 percent. In addition, ASC payment
procedures. This policy reduces site of 2008 have nonfacility PE RVUs. As a rates under the revised payment system
service (facility versus nonfacility) result, even under our current policy, are lower than payment rates for the
differentials that currently exist and same procedures under the OPPS, so the
physicians performing an excluded ASC
aligns physician payment policies for beneficiary coinsurance amount under
procedure in an ASC would be paid for
services furnished in ASCs and hospital the ASC payment system almost always
most excluded procedures based on the
outpatient departments. will be less than the OPPS copayment
facility PE RVUs. Thus, our proposed
We believe that the effect of the policy to pay physicians for excluded amount for the same services. (The only
proposed change will be small. ASC procedures performed in ASCs exceptions will be when the ASC
Currently, physicians are paid for based on the facility PE RVUs would coinsurance amount exceeds the
procedures performed in ASCs that are only impact Medicare payment rates for inpatient deductible. The statute
not on the list of ASC covered surgical the small proportion of excluded requires that copayment amounts under
procedures based on the nonfacility PE procedures that have nonfacility PE the OPPS not exceed the inpatient
RVUs, unless a nonfacility rate does not RVUs. deductible.) Beneficiary coinsurance for
exist in which case they are paid based services migrating from physicians’
on the facility rate. For CY 2008, we 4. Estimated Effects of This Proposed offices to ASCs may decrease or increase
excluded procedures from the ASC list Rule on Beneficiaries under the revised ASC payment system,
of covered surgical procedures because a. Payment to ASCs depending on the particular service and
they could pose a significant risk to the relative payment amounts for that
beneficiary safety or would be expected We estimate that the changes for CY service in the physician’s office
to require an overnight stay and, as 2008 will be positive for beneficiaries in compared with the ASC. As noted
such, these procedures are generally at least two respects. Except for previously, the net effect of the revised
ASC payment system on beneficiary not expect that the proposed change a total increase in Medicare payments to
coinsurance, taking into account the would result in a meaningful increase in ASCs for CY 2008 of approximately
migration of services from HOPDs and beneficiary liability because we do not $240 million as a result of the revised
physicians’ offices, is estimated to be expect that these excluded services, ASC payment system, which will be
$20 million in beneficiary savings in CY which we have determined could pose fully offset by savings from reduced
2008. a significant risk to beneficiary safety or Medicare spending in HOPDs and
In addition to the lower out-of-pocket would be expected to require an physicians’ offices on services that
expenses, we believe that beneficiaries overnight stay, will be furnished to migrate from these settings to ASCs (as
also will have access to more services in Medicare beneficiaries in ASCs. We discussed in detail in section XVI.L. of
ASCs as a result of the addition of expect further that physicians and ASCs this proposed rule). Furthermore, we
approximately 790 surgical procedures would advise beneficiaries of all of the estimate that the revised ASC payment
to the ASC list of covered surgical possible consequences (including denial system will result in Medicare savings
services eligible for Medicare payment. of Medicare payment with concomitant of $200 million over 5 years due to
We expect that ASCs will provide a beneficiary liability and significant migration of new ASC services from
broader range of surgical services under surgical risk) if surgical procedures HOPDs and physicians’ offices to ASCs
the revised payment system and that excluded from ASC payment were over time. We anticipate that this
beneficiaries will benefit from having provided in ASCs. proposed rule will have a significant
access to a greater variety of surgical economic impact on a substantial
procedures in ASCs. 5. Conclusion
number of small entities.
The changes to the ASC payment
b. Payment to ASCs for Excluded system for CY 2008 will affect each of 6. Accounting Statement
Procedures Performed in an ASC the approximately 4,600 ASCs currently
In addition, the proposed revision to approved for participation in the As required by OMB Circular A–4
§ 414.22(b)(5)(i) (A) and (B) would Medicare program. The effect on an (available at http://www.whitehousegov/
impose beneficiary liability for facility individual ASC will depend on the omb/circulars/a004/a-4.pdf), in Table
costs associated with surgical ASC’s mix of patients, the proportion of 72 below, we have prepared an
procedures that are not Medicare the ASC’s patients that are Medicare accounting statement showing the
covered surgical procedures in ASCs. In beneficiaries, the degree to which the classification of the expenditures
the July 2007 final rule for the revised payments for the procedures offered by associated with the implementation of
ASC payment system, CMS determined the ASC are changed under the revised the CY 2008 revised ASC payment
that the only surgical procedures that payment system, and the degree to system, based on the provisions of this
will be excluded from ASC payment in which the ASC chooses to provide a final rule. As explained above, we
CY 2008 are those that could pose a different set of procedures. estimate that Medicare payments to
significant safety risk to beneficiaries The revised ASC payment system is ASCs for CY 2008 will be about $240
when furnished in an ASC or are designed to result in the same aggregate million higher than they otherwise
expected to require an overnight stay amount of Medicare expenditures in CY would be in the absence of the revised
when furnished in ASCs and, therefore, 2008 that would be made in the absence ASC payment system. This $240 million
Medicare provides no payment to ASCs of the revised ASC payment system. As in additional payments to ASCs will be
for these procedures. The proposed mentioned previously, we estimate that fully offset by savings from reduced
revision to § 414.22(b)(5)(i)(A) and (B) the revised ASC payment system and Medicare spending in HOPDs and
would also provide for no payment to the expanded ASC list of covered physicians’ offices on services that
physicians for the facility resources surgical procedures that we are migrate from these settings to ASCs.
required to furnish these services, implementing in CY 2008 will have no This table provides our best estimate of
leaving the beneficiary liable for the net effect on Medicare expenditures Medicare payments to providers and
facility payment if a surgical procedure compared to the level of Medicare suppliers as a result of the CY 2008
excluded by Medicare from ASC expenditures that would have occurred revised ASC payment system, as
payment is, in fact, performed in the in CY 2008 in the absence of the revised presented in this proposed rule. All
ASC setting. In reality, however, we do payment system. However, there will be expenditures are classified as transfers.
TABLE 72.—ACCOUNTING STATEMENT: CLASSIFICATION OF ESTIMATED EXPENDITURES FROM CY 2007 TO CY 2008 AS A

RESULT OF THE CY 2008 REVISED ASC PAYMENT SYSTEM
Category Transfers
Annualized Monetized Transfers .............................................................. $0 Million.

From Whom to Whom .............................................................................. Federal Government to Medicare Providers and Suppliers.
Annualized Monetized Transfer ................................................................ 0 Million.
From Whom to Whom .............................................................................. Premium Payments from Beneficiaries to Federal Government.
Total ................................................................................................... 0 Million.
D. Effects of the Proposed Requirements hospital outpatient settings under the by May 31, 2008. CMS and its
for Reporting of Quality Data for HOP QDRP. We also note that, for the contractors will provide assistance to all
Hospital Outpatient Settings CY 2009 payment update, hospitals hospitals that wish to submit data. As
must pass our validation requirement of noted in section XVIII of this proposed
In section XVII. of this proposed rule, a minimum of 80 percent reliability, rule, we are also providing additional
we discuss our proposed measures and based upon our chart-audit validation validation criteria to ensure that the
requirements for reporting of quality process, for January 2008. These data quality data being sent to CMS are
data to CMS for services furnished in are due to the OPPS Clinical Warehouse accurate. The requirement of 5 charts
per hospital will result in the beneficiaries. We believe that these 42 CFR Part 419
submission of approximately 21,500 proposed revisions would impose Hospitals, Medicare, Reporting and
charts for services furnished in January minimal additional costs on hospitals. recordkeeping requirements.
2008 to the agency. We reimburse In fact, hospitals may realize some
hospitals for the cost of sending charts minimal cost savings. The cost of 42 CFR Part 482
to the Clinical Data Abstraction Center implementing these proposed changes Grant program-health, Hospitals,
(CDAC) at the rate of 12 cents per page would largely be limited to the one-time Medicaid, Medicare, Reporting and
for copying and approximately $4.00 cost related to the revision of a recordkeeping requirements.
per chart for postage. Our experience hospital’s medical staff bylaws and its
shows that the average inpatient chart policies and procedures as they relate to 42 CFR Part 485
received at the CDAC is approximately the proposed requirements for medical Grant program-health, Health
150 pages, and we estimate outpatient history and physical examinations and facilities, Medicaid, Medicare,
charts will contain a similar number of for preanesthesia and postanesthesia Reporting and recordkeeping
pages. Thus, the agency estimates that it evaluations. There also may be some requirements.
will have expenditures of approximately minimal cost associated with For reasons stated in the preamble of
$473,200 to collect the January 2008 communicating these changes to this proposed rule, the Centers for
charts. Given that we reimburse for the affected hospital staff. However, we Medicare & Medicaid Services is
copying and mailing related to this data believe that these costs would be offset proposing to amend 42 CFR Chapter IV
collection effort, we believe that a by the benefits derived from the overall as set forth below:
requirement for five charts per hospital intent of these proposed revisions to
for services furnished in January 2008 require that the most current PART 410—SUPPLEMENTARY
represents a minimal burden to the information regarding a patient’s MEDICAL INSURANCE (SMI)
participating hospital. condition be available to hospital staff BENEFITS
E. Effects of the Proposed Policy on CAH so that risks to patient safety can be 1. The authority citation for Part 410
Off-Campus and Co-Location minimized and potential adverse continues to read as follows:
Requirements outcomes can be avoided. Furthermore, Authority: Secs. 1102 and 1871 of the
the proposed changes would clarify Social Security Act (42 U.S.C. 1302 and
In section XVIII.A. of this proposed existing hospital CoPs to make them
rule, we discuss our proposed changes 1395hh).
more consistent with current practice,
regarding a CAH’s ability to co-locate 2. Section 410.27 is amended by—
while still retaining the flexibility and a. Revising paragraph (a)(1)(iii).
with another acute care hospital or
reduction in burden that hospitals are b. Revising paragraph (f).
establish an off-campus location that
currently provided in meeting those The revisions read as follows:
does not comply with the location
CoPs. Therefore, no burden is being
requirements (more than a 35-mile § 410.27 Outpatient hospital services and
assessed on the revision of medical staff
drive, or in the case of mountainous supplies incident to a physician service:
bylaws and hospital policies and
terrain or in areas with only secondary Conditions.
procedures or on the communication of
roads available, a 15-mile drive) for (a) * * *
these revisions to staff that would be
CAHs. We are proposing to clarify in (1) * * *
required by these proposed revisions as
this proposed rule that if a CAH with a (iii) In the hospital or at a department
necessary provider designation has a co- these practices are usual and customary
business practices. of a provider, as defined in
location arrangement with another § 413.65(a)(2) of this subchapter, that
hospital or CAH that was in effect before G. Executive Order 12866 has provider-based status in relation to
January 1, 2008, and the type and scope a hospital under § 413.65 of this
In accordance with the provisions of
of services offered by the facilities co- subchapter; and
Executive Order 12866, this proposed
located with the necessary provider * * * * *
rule was reviewed by the OMB.
CAH do not change, the CAH can (f) Services furnished at a department
continue those arrangements. In List of Subjects of a provider, as defined in
addition, if a CAH (including one with § 413.65(a)(2) of this subchapter, that
42 CFR Part 410
a necessary provider designation) has provider-based status in relation to
operates a provider-based location or an Health facilities, Health professions, a hospital under § 413.65 of this
off-campus distinct part psychiatric or Laboratories, Medicare, Rural areas, X subchapter, must be under the direct
rehabilitation unit after January 1, 2008, rays. supervision of a physician. ‘‘Direct
the CAH must comply with the location supervision’’ means the physician must
42 CFR Part 411
requirements. We have proposed that be present and on the premises of the
CAHs can continue current co-location Kidney diseases, Medicare, Physician location and immediately available to
and off-campus arrangements that are in referral, Reporting and recordkeeping furnish assistance and direction
place as of January 1, 2008. We believe requirements. throughout the performance of the
there is no burden associated with this 42 CFR Part 414 procedure. It does not mean that the
proposed clarifying regulation. physician must be present in the room
Administrative practice and
F. Effects of Proposed Policy Revisions when the procedure is performed.
procedure, Health facilities, Health
to the Hospital CoPs professions, Kidney diseases, Medicare, PART 411—EXCLUSIONS FROM
In section XVIII.B. of this proposed Reporting and recordkeeping MEDICARE AND LIMITATIONS ON
rule, we discuss proposed changes to requirements. MEDICARE PAYMENT
the hospital CoPs relating to timeframes
for completion of medical history and 42 CFR Part 416 3. The authority citation for Part 411
physical examination and proposed Health facilities, Kidney diseases, continues to read as follows:
requirements for preanesthesia and Medicare, Reporting and recordkeeping Authority: Secs. 1102, 1860D–1 through
postanesthesia evaluations of Medicare requirements. 1860D–42, 1871, and 1877 of the Social
Security Act (42 U.S.C. 1302, 1395w-101 PART 414—PAYMENT FOR PART B (2) The ASC receives full credit for
through 1395w-152, and 1395nn. MEDICAL AND OTHER HEALTH the cost of a replaced device; or
4. Section 411.351 is amended by SERVICES (3) The ASC receives partial credit for
revising the definitions of ‘‘outpatient the cost of a replaced device but only
5. The authority citation for Part 414 where the amount of the device credit
prescription drugs’’ and ‘‘radiology and continues to read as follows:
certain other imaging services’’ to read is greater than or equal to 20 percent of
as follows: Authority: Secs. 1102, 1871, and 1881(b)(1) the cost of the new replacement device
of the Social Security Act (42 U.S.C. 1302, being implanted.
§ 411.351 Definitions. 1395hh, and 1395rr(b)(1)). (b) Amount of reduction to the ASC
* * * * * 6. Section 414.22 is amended by payment for the covered surgical
Outpatient prescription drugs means revising paragraphs (b)(5)(i)(A) and (B) procedure. (1) The amount of the
to read as follows: reduction to the ASC payment made
all drugs covered by Medicare Part B or
under paragraphs (a)(1) and (a)(2) of this
D, except for those drugs that are
§ 414.22 Relative value units (RVUs). section is calculated in the same manner
‘‘covered ancillary services,’’ as defined
* * * * * as the device payment reduction that
at § 416.164(b) of this chapter, for which
(b) * * * would be applied to the ASC payment
separate payment is made to an
(5) * * * for the covered surgical procedure in
ambulatory surgical center.
(i) * * * order to remove predecessor device
* * * * * (A) Facility practice expense RVUs. costs so that the ASC payment amount
Radiology and certain other imaging The lower facility practice expense for a device with pass-through status
services means those particular services RVUs apply to services furnished to under § 419.66 of this subchapter
so identified on the List of CPT/HCPCS patients in the hospital, skilled nursing represents the full cost of the device,
Codes. All services identified on the List facility, community mental health and no packaged device payment is
of CPT/HCPCS Codes are radiology and center, or in an ambulatory surgical provided through the ASC payment for
certain other imaging services for center. (The facility practice expense the covered surgical procedure.
purposes of this subpart. Any service RVUs for a particular code may not be (2) The amount of the reduction to the
not specifically identified as radiology greater than the nonfacility RVUs for the ASC payment made under paragraph
and certain other imaging services on code.) (a)(3) of this section is 50 percent of the
the List of CPT/HCPCS Codes is not a (B) Nonfacility practice expense payment reduction that would be
radiology or certain other imaging RVUs. The higher nonfacility practice calculated under paragraph (b)(1) of this
service for purposes of this subpart. The expense RVUs apply to services section.
list of codes identifying radiology and performed in a physician’s office, a * * * * *
certain other imaging services includes patient’s home, a nursing facility, or a
the professional and technical facility or institution other than a PART 419—PROSPECTIVE PAYMENT
components of any diagnostic test or hospital or skilled nursing facility, SYSTEM FOR HOSPITAL OUTPATIENT
procedure using x-rays, ultrasound, community mental health center, or DEPARTMENT SERVICES
computerized axial tomography, ASC. 9. The authority citation for Part 419
magnetic resonance imaging, nuclear
* * * * * continues to read as follows:
medicine (effective January 1, 2007), or
other imaging services. All codes Authority: Secs. 1102, 1833(t), and 1871 of
PART 416—AMBULATORY SURGICAL the Social Security Act (42 U.S.C. 1302,
identified as radiology and certain other SERVICES 1395l(t), and 1395hh).
imaging services are covered under
section 1861(s)(3) of the Act and 7. The authority citation for Part 416 10. Section 419.43 is amended by
§ 410.32 and § 410.34 of this chapter, continues to read as follows: revising paragraph (g)(4) to read as
but do not include— Authority: Secs. 1102 and 1871 of the follows:
(1) X ray, fluoroscopy, or ultrasound Social Security Act (42 U.S.C. 1302 and § 419.43 Adjustments to national program
procedures that require the insertion of 1395hh). payment and beneficiary copayment
a needle, catheter, tube, or probe 8. Added in a separate final rule amounts.
through the skin or into a body orifice; published elsewhere in this issue of the * * * * *
(2) Radiology or certain other imaging Federal Register, § 416.179 is amended (g) * * *
services that are integral to the by— (4) Excluded services and groups.
performance of a medical procedure that a. Revising the section heading. Drugs and biologicals that are paid
is not identified on the list of CPT/ b. Revising paragraphs (a)(1) and under a separate APC and devices paid
HCPCS codes as a radiology or certain (a)(2) under § 419.66 are excluded from
other imaging service and is c. Adding new paragraph (a)(3). qualification for the payment
performed— d. Redesignating the text of paragraph adjustment in paragraph (g)(2) of this
(i) Immediately prior to or during the (b) as paragraph (b)(1). section.
medical procedure; or e. Revising newly redesignated * * * * *
(ii) Immediately following the paragraph (b)(1). 11. Section 419.44 is amended by—
medical procedure when necessary to f. Adding new paragraph (b)(2). a. Revising the section heading.
confirm placement of an item placed The revisions and additions read as b. Revising paragraph (b).
follows: The revisions and addition read as
during the medical procedure.

(3) Radiology and certain other follows:
§ 416.179 Payment and coinsurance
imaging services that are ‘‘covered reduction for devices replaced without cost § 419.44 Payment reductions for
ancillary services,’’ as defined at or when full or partial credit is received. procedures.
§ 416.164(b), for which separate (a) * * * * * * * *
payment is made to an ASC. (1) The device is replaced without (b) Interrupted procedures. When a
* * * * * cost to the ASC or the beneficiary; procedure is terminated prior to
completion due to extenuating § 419.70 [Amended] and the cross-reference ‘‘§ 488.54(c)’’ is
circumstances or circumstances that 13. Section 419.70 is amended by— added in its place.
threaten the well-being of the patient, a. In paragraph (d)(1)(i), removing the 17. Section 482.24 is amended by
the Medicare program payment amount cross-reference ‘‘§ 412.63(b)’’ and revising paragraph (c)(2)(i) to read as
and the beneficiary copayment amount adding the cross-reference ‘‘§ 412.64(b)’’ follows:
are based on— in its place.
(1) The full program and beneficiary b. In paragraph (d)(2)(i), removing the § 482.24 Condition of participation:
copayment amounts if the procedure for cross-reference ‘‘§ 412.63(b)’’ and Medical record services.
which anesthesia is planned is adding the cross-reference ‘‘§ 412.64(b)’’ * * * * *
discontinued after the induction of in its place. (c) * * *
anesthesia or after the procedure is c. In paragraph (d)(4)(ii), removing the (2) * * *
started; cross-reference ‘‘§ 412.63(b)’’ and (i) Evidence of—
(2) One-half the full program and the adding the phrase ‘‘§ 412.63(b) or (A) A medical history and physical
beneficiary copayment amounts if the § 412.64(b), as applicable,’’ in its place. examination completed and
procedure for which anesthesia is documented no more than 30 days
planned is discontinued after the PART 482—CONDITIONS OF before or 24 hours after admission or
patient is prepared and taken to the PARTICIPATION FOR HOSPITALS registration, but prior to surgery or a
room where the procedure is to be
14. The authority citation for Part 482 procedure requiring anesthesia services.
performed but before anesthesia is
continues to read as follows: The medical history and physical
induced; or
(3) One-half of the full program and Authority: Secs. 1102 and 1871 of the
examination must be placed in the
beneficiary copayment amounts if a Social Security Act (42 U.S.C. 1302 and patient’s medical record within 24
procedure for which anesthesia is not 1395hh). hours after admission or registration,
planned is discontinued after the but prior to surgery or a procedure
15. Section 482.22 is amended by requiring anesthesia services.
patient is prepared and taken to the revising paragraph (c)(5) to read as
room where the procedure is to be (B) An updated examination of the
follows:
performed. patient, including any changes in the
12. Section 419.45 is amended by— § 482.22 Condition of participation: patient’s condition, when the medical
a. Revising the section heading. Medical staff. history and physical examination are
b. Revising paragraph (a)(1). * * * * * completed within 30 days before
c. Revising paragraph (a)(2). (c) * * * admission or registration.
d. Adding new paragraph (a)(3). (5) Include a requirement that— Documentation of the updated
e. Revising paragraph (b). (i) A medical history and physical examination must be placed in the
The revisions and additions read as examination be completed and patient’s medical record within 24
follows: documented for each patient no more hours after admission or registration,
§ 419.45 Payment and copayment than 30 days before or 24 hours after but prior to surgery or a procedure
reduction for devices replaced without cost admission or registration, but prior to requiring anesthesia services.
or when full or partial credit is received. surgery or a procedure requiring * * * * *
(a) * * * anesthesia services. The medical history 18. Section 482.51 is amended by
(1) The device is replaced without and physical examination must be revising paragraph (b)(1) to read as
cost to the provider or the beneficiary; completed and documented by a follows:
(2) The provider receives full credit physician (as defined in section 1861(r)
for the cost of a replaced device; or of the Act), an oromaxillofacial surgeon, § 482.51 Condition of participation:
(3) The provider receives partial or other qualified licensed individual in Surgical services.
credit for the cost of a replaced device accordance with State law and hospital * * * * *
but only where the amount of the device policy. (b) * * *
credit is greater than or equal to 20 (ii) An updated examination of the (1) Prior to surgery or a procedure
percent of the cost of the new patient, including any changes in the requiring anesthesia services and except
replacement device being implanted. patient’s condition, be completed and in the case of emergencies:
(b) Amount of reduction to the APC documented within 24 hours after (i) A medical history and physical
payment. admission or registration, but prior to examination must be completed and
(1) The amount of the reduction to the surgery or a procedure requiring documented no more than 30 days
APC payment made under paragraphs anesthesia services, when the medical before or 24 hours after admission or
(a)(1) and (a)(2) of this section is history and physical examination are registration.
calculated in the same manner as the completed within 30 days before (ii) An updated examination of the
offset amount that would be applied if admission or registration. The updated patient, including any changes in the
the device implanted during a examination of the patient, including patient’s condition, must be completed
procedure assigned to the APC had any changes in the patient’s condition, and documented within 24 hours after
transitional pass-through status under must be completed and documented by admission or registration when the
§ 419.66. a physician (as defined in section
(2) The amount of the reduction to the medical history and physical
1861(r) of the Act), an oromaxillofacial examination are completed within 30
APC payment made under paragraph surgeon, or other qualified licensed days before admission or registration.
(a)(3) of this section is 50 percent of the individual in accordance with State law
offset amount that would be applied if * * * * *
and hospital policy.
the device implanted during a 19. Section 482.52 is amended by—
* * * * *
procedure assigned to the APC had a. Revising paragraph (b)(1).
transitional pass-through status under § 482.23 [Amended] b. Revising paragraph (b)(3).
§ 419.66. 16. In § 482.23(b)(1), the cross- c. Removing paragraph (b)(4).
* * * * * reference ‘‘§ 405.1910(c)’’ is removed The revisions read as follows:
§ 482.52 Condition of participation: (e) Standard: Off-campus and co- in the case of mountainous terrain or in
Anesthesia services. location requirements for CAHs. A CAH areas with only secondary roads
* * * * * may continue to meet the location available, a 15-mile drive) from a
(b) * * * requirement of paragraph (c) of this hospital or another CAH.
(1) A preanesthesia evaluation section based only if the CAH meets the
completed and documented by an (3) If either a CAH or a CAH that has
following:
individual qualified to administer (1) If a CAH with a necessary provider been designated as a necessary provider
anesthesia, as specified in paragraph (a) designation is co-located (that is, it by the State does not meet the
of this section, performed within 48 shares a campus, as defined in requirements in paragraph (e)(1) of this
hours prior to surgery or a procedure § 413.65(a)(2) of this chapter, with section, by co locating with another
requiring anesthesia services. another hospital or CAH), the necessary hospital or CAH after January 1, 2008,
* * * * * provider CAH can continue to meet the or creates or acquires a provider-based
(3) A postanesthesia evaluation location requirement of paragraph (c) of location or off-campus distinct part unit
completed and documented by an this section only if the co-location after January 1, 2008, that does not meet
individual qualified to administer arrangement was in effect before January the requirements in paragraph (e)(2) of
anesthesia, as specified in paragraph (a) 1, 2008, and the type and scope of this section, the CAH’s provider
of this section, after surgery or a services offered by the facility co- agreement will be subject to termination
procedure requiring anesthesia services, located with the necessary provider in accordance with the provisions of
but before discharge or transfer from the CAH do not change. A change of § 489.53(a)(3), unless the CAH
postanesthesia recovery area. ownership of any of the facilities with terminates the off-campus arrangement
* * * * * a co-location arrangement that was in or the co-location arrangement, or both.
effect before January 1, 2008 will not be
PART 485—CONDITIONS OF (Catalog of Federal Domestic Assistance
considered to be a new co-location
PARTICIPATION: SPECIALIZED Program No. 93.773, Medicare—Hospital
arrangement.
PROVIDERS Insurance; and Program No. 93.774, Medicare
(2) If a CAH or a necessary provider
Supplementary Medical Insurance Program)
20, The authority citation for Part 485 CAH operates a provider-based location,
including a department or remote (Catalog of Federal Domestic Assistance
continues to read as follows: Program No. 93.778, Medical Assistance
location, as defined in § 413.65(a)(2) of
Authority: Secs. 1102 and 1871 of the this chapter, or an off-campus distinct Program)
Social Security Act (42 U.S.C. 1302 and
1395hh).
part psychiatric or rehabilitation unit, as Dated: July 5, 2007.
21. Section 485.610 is amended by defined in § 485.647, that was created or Leslie V. Norwalk,
adding new paragraph (e) to read as acquired by the CAH after January 1, Acting Administrator, Centers for Medicare
follows: 2008, the CAH can continue to meet the & Medicaid Services.
location requirement of paragraph (c) of
Approved: July 10, 2007.
§ 485.610 Condition of participation: this section only if the provider-based
Status and location. location or off-campus distinct part unit Michael O. Leavitt,
* * * * * is located more than a 35-mile drive (or, Secretary.
ADDENDUM A.—PROPOSED OPPS APCS FOR CY 2008

National Minimum
Relative Payment
APC Group Title SI unadjusted unadjusted
weight rate copayment copayment
0001 ........... Level I Photochemotherapy ............................................................................. S ................. 0.5204 $33.15 $7.00 $6.63
0002 ........... Level I Fine Needle Biopsy/Aspiration ............................................................ T ................. 1.1915 $75.89 .................... $15.18
0003 ........... Bone Marrow Biopsy/Aspiration ...................................................................... T ................. 3.2390 $206.30 .................... $41.26
0004 ........... Level I Needle Biopsy/Aspiration Except Bone Marrow .................................. T ................. 4.5062 $287.01 .................... $57.40
0005 ........... Level II Needle Biopsy/Aspiration Except Bone Marrow ................................. T ................. 7.3012 $465.04 .................... $93.01
0006 ........... Level I Incision & Drainage ............................................................................. T ................. 1.4630 $93.18 .................... $18.64
0007 ........... Level II Incision & Drainage ............................................................................ T ................. 12.5792 $801.21 .................... $160.24
0008 ........... Level III Incision and Drainage ........................................................................ T ................. 19.0457 $1,213.08 .................... $242.62
0012 ........... Level I Debridement & Destruction ................................................................. T ................. 0.2682 $17.08 .................... $3.42
0013 ........... Level II Debridement & Destruction ................................................................ T ................. 0.8046 $51.25 .................... $10.25
0015 ........... Level III Debridement & Destruction ............................................................... T ................. 1.5119 $96.30 .................... $19.26
0016 ........... Level IV Debridement & Destruction ............................................................... T ................. 2.7493 $175.11 .................... $35.02
0017 ........... Level VI Debridement & Destruction ............................................................... T ................. 20.0977 $1,280.08 .................... $256.02
0019 ........... Level I Excision/Biopsy .................................................................................... T ................. 4.4463 $283.20 $71.80 $56.64
0020 ........... Level II Excision/Biopsy ................................................................................... T ................. 8.7155 $555.12 .................... $111.02
0021 ........... Level III Excision/Biopsy .................................................................................. T ................. 16.5832 $1,056.23 $219.40 $211.25
0022 ........... Level IV Excision/Biopsy ................................................................................. T ................. 21.4534 $1,366.43 $354.40 $273.29
0023 ........... Exploration Penetrating Wound ....................................................................... T ................. 9.5721 $609.68 .................... $121.94
0028 ........... Level I Breast Surgery ..................................................................................... T ................. 20.9980 $1,337.43 $303.70 $267.49
0029 ........... Level II Breast Surgery .................................................................................... T ................. 32.4940 $2,069.64 $581.50 $413.93
0030 ........... Level III Breast Surgery ................................................................................... T ................. 40.4634 $2,577.24 $747.00 $515.45
0031 ........... Smoking Cessation Services ........................................................................... X ................. 0.1660 $10.57 .................... $2.11
0033 ........... Partial Hospitalization ...................................................................................... P ................. 2.8241 $179.88 .................... $35.98
0034 ........... Mental Health Services Composite ................................................................. P ................. 2.8241 $179.88 .................... $35.98
0035 ........... Arterial/Venous Puncture ................................................................................. T ................. 0.2091 $13.32 .................... $2.66
0037 ........... Level IV Needle Biopsy/Aspiration Except Bone Marrow ............................... T ................. 13.9599 $889.15 $228.70 $177.83
0039 ........... Level I Implantation of Neurostimulator .......................................................... S ................. 197.4688 $12,577.38 .................... $2,515.48
0040 ........... Percutaneous Implantation of Neurostimulator Electrodes, Excluding Cranial S ................. 63.7536 $4,060.66 .................... $812.13
Nerve.
0041 ........... Level I Arthroscopy .......................................................................................... T ................. 29.4467 $1,875.55 .................... $375.11
0042 ........... Level II Arthroscopy ......................................................................................... T ................. 47.7765 $3,043.03 $804.70 $608.61
0043 ........... Closed Treatment Fracture Finger/Toe/Trunk ................................................. T ................. 1.8742 $119.37 .................... $23.87
0045 ........... Bone/Joint Manipulation Under Anesthesia .................................................... T ................. 15.0176 $956.52 $268.40 $191.30
ADDENDUM A.—PROPOSED OPPS APCS FOR CY 2008—Continued

National Minimum
Relative Payment
0047 ........... Arthroplasty without Prosthesis ....................................................................... T ................. 35.9249 $2,288.16 $537.00 $457.63
0048 ........... Level I Arthroplasty with Prosthesis ................................................................ T ................. 51.0431 $3,251.09 .................... $650.22
0049 ........... Level I Musculoskeletal Procedures Except Hand and Foot .......................... T ................. 21.5761 $1,374.25 .................... $274.85
0050 ........... Level II Musculoskeletal Procedures Except Hand and Foot ......................... T ................. 29.3263 $1,867.88 .................... $373.58
0051 ........... Level III Musculoskeletal Procedures Except Hand and Foot ........................ T ................. 43.5953 $2,776.72 .................... $555.34
0052 ........... Level IV Musculoskeletal Procedures Except Hand and Foot ........................ T ................. 78.6518 $5,009.57 .................... $1,001.91
0053 ........... Level I Hand Musculoskeletal Procedures ...................................................... T ................. 16.8220 $1,071.44 $253.40 $214.29
0054 ........... Level II Hand Musculoskeletal Procedures ..................................................... T ................. 26.7322 $1,702.65 .................... $340.53
0055 ........... Level I Foot Musculoskeletal Procedures ....................................................... T ................. 21.1762 $1,348.78 $355.30 $269.76
0056 ........... Level II Foot Musculoskeletal Procedures ...................................................... T ................. 44.4710 $2,832.49 .................... $566.50
0057 ........... Bunion Procedures .......................................................................................... T ................. 29.8356 $1,900.32 $475.90 $380.06
0058 ........... Level I Strapping and Cast Application ........................................................... S ................. 1.1272 $71.79 .................... $14.36
0060 ........... Manipulation Therapy ...................................................................................... S ................. 0.4877 $31.06 .................... $6.21
0061 ........... Laminectomy or Incision for Implantation of Neurostimulator Electrodes, Ex- S ................. 81.3252 $5,179.85 .................... $1,035.97
cluding Cranial Nerve.
0062 ........... Level I Treatment Fracture/Dislocation ........................................................... T ................. 26.3092 $1,675.71 $372.80 $335.14
0063 ........... Level II Treatment Fracture/Dislocation .......................................................... T ................. 40.3466 $2,569.80 $548.30 $513.96
0064 ........... Level III Treatment Fracture/Dislocation ......................................................... T ................. 60.0595 $3,825.37 $835.70 $765.07
0065 ........... Level I Stereotactic Radiosurgery, MRgFUS, and MEG ................................. S ................. 17.1992 $1,095.47 .................... $219.09
0066 ........... Level II Stereotactic Radiosurgery, MRgFUS, and MEG ................................ S ................. 47.3767 $3,017.56 .................... $603.51
0067 ........... Level III Stereotactic Radiosurgery, MRgFUS, and MEG ............................... S ................. 61.5205 $3,918.43 .................... $783.69
0069 ........... Thoracoscopy .................................................................................................. T ................. 33.1688 $2,112.62 $591.60 $422.52
0070 ........... Thoracentesis/Lavage Procedures .................................................................. T ................. 5.3095 $338.18 .................... $67.64
0071 ........... Level I Endoscopy Upper Airway .................................................................... T ................. 0.8256 $52.58 $11.20 $10.52
0072 ........... Level II Endoscopy Upper Airway ................................................................... T ................. 1.5730 $100.19 $21.20 $20.04
0073 ........... Level III Endoscopy Upper Airway .................................................................. T ................. 4.2060 $267.89 $69.10 $53.58
0074 ........... Level IV Endoscopy Upper Airway .................................................................. T ................. 17.4546 $1,111.74 $292.20 $222.35
0075 ........... Level V Endoscopy Upper Airway ................................................................... T ................. 23.2819 $1,482.89 $445.90 $296.58
0076 ........... Level I Endoscopy Lower Airway .................................................................... T ................. 10.1732 $647.96 $189.80 $129.59
0077 ........... Level I Pulmonary Treatment .......................................................................... S ................. 0.3904 $24.87 $7.70 $4.97
0078 ........... Level II Pulmonary Treatment ......................................................................... S ................. 1.3636 $86.85 .................... $17.37
0079 ........... Ventilation Initiation and Management ............................................................ S ................. 2.6745 $170.35 .................... $34.07
0080 ........... Diagnostic Cardiac Catheterization ................................................................. T ................. 39.8631 $2,539.00 $838.90 $507.80
0082 ........... Coronary or Non-Coronary Atherectomy ......................................................... T ................. 88.7717 $5,654.14 .................... $1,130.83
0083 ........... Coronary or Non-Coronary Angioplasty and Percutaneous Valvuloplasty ..... T ................. 46.0685 $2,934.24 .................... $586.85
0084 ........... Level I Electrophysiologic Procedures ............................................................ S ................. 10.2918 $655.52 .................... $131.10
0085 ........... Level II Electrophysiologic Procedures ........................................................... T ................. 48.6296 $3,097.37 .................... $619.47
0086 ........... Level III Electrophysiologic Procedures .......................................................... T ................. 90.7639 $5,781.03 .................... $1,156.21
0088 ........... Thrombectomy ................................................................................................. T ................. 39.8001 $2,534.99 $655.20 $507.00
0089 ........... Insertion/Replacement of Permanent Pacemaker and Electrodes ................. T ................. 122.5662 $7,806.61 $1,682.20 $1,561.32
0090 ........... Insertion/Replacement of Pacemaker Pulse Generator .................................. T ................. 99.8268 $6,358.27 $1,612.80 $1,271.65
0091 ........... Level II Vascular Ligation ................................................................................ T ................. 43.6609 $2,780.89 .................... $556.18
0092 ........... Level I Vascular Ligation ................................................................................. T ................. 26.4396 $1,684.02 .................... $336.80
0093 ........... Vascular Reconstruction/Fistula Repair without Device .................................. T ................. 30.8639 $1,965.81 .................... $393.16
0094 ........... Level I Resuscitation and Cardioversion ......................................................... S ................. 2.5547 $162.72 $46.20 $32.54
0095 ........... Cardiac Rehabilitation ..................................................................................... S ................. 0.5868 $37.38 $13.80 $7.48
0096 ........... Non-Invasive Vascular Studies ....................................................................... S ................. 1.5254 $97.16 $37.60 $19.43
0097 ........... Prolonged Physiologic and Ambulatory Monitoring ......................................... X ................. 1.0396 $66.22 $23.70 $13.24
0099 ........... Electrocardiograms .......................................................................................... S ................. 0.3912 $24.92 .................... $4.98
0100 ........... Cardiac Stress Tests ....................................................................................... X ................. 2.8631 $182.36 $41.40 $36.47
0101 ........... Tilt Table Evaluation ........................................................................................ S ................. 4.4249 $281.84 $100.20 $56.37
0103 ........... Miscellaneous Vascular Procedures ............................................................... T ................. 15.2572 $971.78 .................... $194.36
0104 ........... Transcatheter Placement of Intracoronary Stents .......................................... T ................. 89.0212 $5,670.03 .................... $1,134.01
0105 ........... Repair/Revision/Removal of Pacemakers, AICDs, or Vascular Devices ........ T ................. 24.7274 $1,574.96 $370.40 $314.99
0106 ........... Insertion/Replacement of Pacemaker Leads and/or Electrodes ..................... T ................. 75.0068 $4,777.41 .................... $955.48
0107 ........... Insertion of Cardioverter-Defibrillator .............................................................. T ................. 353.1242 $22,491.54 .................... $4,498.31
0108 ........... Insertion/Replacement/Repair of Cardioverter-Defibrillator Leads .................. T ................. 403.0232 $25,669.76 .................... $5,133.95
0109 ........... Removal/Repair of Implanted Devices ............................................................ T ................. 6.1077 $389.02 .................... $77.80
0110 ........... Transfusion ...................................................................................................... S ................. 3.4924 $222.44 .................... $44.49
0111 ........... Blood Product Exchange ................................................................................. S ................. 12.1982 $776.94 $198.40 $155.39
0112 ........... Apheresis and Stem Cell Procedures ............................................................. S ................. 31.9648 $2,035.93 $433.20 $407.19
0113 ........... Excision Lymphatic System ............................................................................. T ................. 23.5105 $1,497.45 .................... $299.49
0114 ........... Thyroid/Lymphadenectomy Procedures .......................................................... T ................. 45.1729 $2,877.20 .................... $575.44
0115 ........... Cannula/Access Device Procedures ............................................................... T ................. 30.5379 $1,945.05 .................... $389.01
0121 ........... Level I Tube changes and Repositioning ........................................................ T ................. 3.2914 $209.64 $43.80 $41.93
0125 ........... Refilling of Infusion Pump ............................................................................... T ................. 2.3262 $148.16 .................... $29.63
0126 ........... Level I Urinary and Anal Procedures .............................................................. T ................. 1.0850 $69.11 $16.40 $13.82
0127 ........... Level IV Stereotactic Radiosurgery, MRgFUS, and MEG .............................. S ................. 123.4696 $7,864.15 .................... $1,572.83
0130 ........... Level I Laparoscopy ........................................................................................ T ................. 34.8153 $2,217.49 $659.50 $443.50
0131 ........... Level II Laparoscopy ....................................................................................... T ................. 46.1201 $2,937.53 $1,001.80 $587.51
0132 ........... Level III Laparoscopy ...................................................................................... T ................. 71.0022 $4,522.34 $1,239.20 $904.47
0133 ........... Level I Skin Repair .......................................................................................... T ................. 1.3340 $84.97 $26.76 $16.99
0134 ........... Level II Skin Repair ......................................................................................... T ................. 2.1114 $134.48 $42.36 $26.90
0135 ........... Level III Skin Repair ........................................................................................ T ................. 4.6816 $298.19 .................... $59.64
0136 ........... Level IV Skin Repair ........................................................................................ T ................. 15.4399 $983.41 .................... $196.68
0137 ........... Level V Skin Repair ......................................................................................... T ................. 20.9338 $1,333.34 .................... $266.67
0140 ........... Esophageal Dilation without Endoscopy ......................................................... T ................. 6.0867 $387.68 $91.40 $77.54
0141 ........... Level I Upper GI Procedures .......................................................................... T ................. 8.6730 $552.41 $143.30 $110.48
0142 ........... Small Intestine Endoscopy .............................................................................. T ................. 9.6264 $613.13 $152.70 $122.63
0143 ........... Lower GI Endoscopy ....................................................................................... T ................. 9.0360 $575.53 $186.00 $115.11

National Minimum
Relative Payment
0146 ........... Level I Sigmoidoscopy and Anoscopy ............................................................ T ................. 5.1441 $327.64 .................... $65.53
0147 ........... Level II Sigmoidoscopy and Anoscopy ........................................................... T ................. 8.8611 $564.39 .................... $112.88
0148 ........... Level I Anal/Rectal Procedures ....................................................................... T ................. 4.5189 $287.82 .................... $57.56
0149 ........... Level III Anal/Rectal Procedures ..................................................................... T ................. 23.2282 $1,479.47 .................... $295.89
0150 ........... Level IV Anal/Rectal Procedures .................................................................... T ................. 30.5544 $1,946.10 $437.10 $389.22
0151 ........... Endoscopic Retrograde Cholangio-Pancreatography (ERCP) ........................ T ................. 21.2820 $1,355.51 .................... $271.10
0152 ........... Level I Percutaneous Abdominal and Biliary Procedures ............................... T ................. 28.7304 $1,829.93 .................... $365.99
0153 ........... Peritoneal and Abdominal Procedures ............................................................ T ................. 25.4636 $1,621.85 $397.90 $324.37
0154 ........... Hernia/Hydrocele Procedures ......................................................................... T ................. 31.1722 $1,985.45 $464.80 $397.09
0155 ........... Level II Anal/Rectal Procedures ...................................................................... T ................. 11.6524 $742.18 .................... $148.44
0156 ........... Level III Urinary and Anal Procedures ............................................................ T ................. 3.0601 $194.91 .................... $38.98
0157 ........... Colorectal Cancer Screening: Barium Enema ................................................ S ................. 2.2613 $144.03 .................... $28.81
0158 ........... Colorectal Cancer Screening: Colonoscopy ................................................... T ................. 8.0134 $510.40 .................... $127.60
0159 ........... Colorectal Cancer Screening: Flexible Sigmoidoscopy .................................. S ................. 4.7799 $304.45 .................... $76.11
0160 ........... Level I Cystourethroscopy and other Genitourinary Procedures .................... T ................. 6.1077 $389.02 .................... $77.80
0161 ........... Level II Cystourethroscopy and other Genitourinary Procedures ................... T ................. 18.1376 $1,155.24 $243.72 $231.05
0162 ........... Level III Cystourethroscopy and other Genitourinary Procedures .................. T ................. 25.2775 $1,610.00 .................... $322.00
0163 ........... Level IV Cystourethroscopy and other Genitourinary Procedures .................. T ................. 36.9175 $2,351.39 .................... $470.28
0164 ........... Level II Urinary and Anal Procedures ............................................................. T ................. 2.1659 $137.95 .................... $27.59
0165 ........... Level IV Urinary and Anal Procedures ............................................................ T ................. 19.6126 $1,249.19 .................... $249.84
0166 ........... Level I Urethral Procedures ............................................................................ T ................. 19.6570 $1,252.01 .................... $250.40
0168 ........... Level II Urethral Procedures ........................................................................... T ................. 30.1994 $1,923.49 $388.10 $384.70
0169 ........... Lithotripsy ........................................................................................................ T ................. 43.0352 $2,741.04 $1,009.40 $548.21
0170 ........... Dialysis ............................................................................................................ S ................. 6.7915 $432.57 .................... $86.51
0181 ........... Level II Male Genital Procedures .................................................................... T ................. 35.1574 $2,239.28 $621.80 $447.86
0183 ........... Level I Male Genital Procedures ..................................................................... T ................. 22.7802 $1,450.94 .................... $290.19
0184 ........... Prostate Biopsy ............................................................................................... T ................. 11.3168 $720.80 .................... $144.16
0188 ........... Level II Female Reproductive Proc ................................................................. T ................. 1.4138 $90.05 .................... $18.01
0189 ........... Level III Female Reproductive Proc ................................................................ T ................. 3.0466 $194.05 .................... $38.81
0190 ........... Level I Hysteroscopy ....................................................................................... T ................. 22.1171 $1,408.70 $424.20 $281.74
0191 ........... Level I Female Reproductive Proc .................................................................. T ................. 0.1414 $9.01 $2.50 $1.80
0192 ........... Level IV Female Reproductive Proc ............................................................... T ................. 7.4497 $474.49 .................... $94.90
0193 ........... Level V Female Reproductive Proc ................................................................ T ................. 19.2052 $1,223.24 .................... $244.65
0195 ........... Level VI Female Reproductive Procedures .................................................... T ................. 32.9713 $2,100.04 $483.80 $420.01
0202 ........... Level VII Female Reproductive Procedures ................................................... T ................. 43.2255 $2,753.16 $981.50 $550.63
0203 ........... Level IV Nerve Injections ................................................................................ T ................. 15.5687 $991.62 $240.30 $198.32
0204 ........... Level I Nerve Injections ................................................................................... T ................. 2.3254 $148.11 $40.10 $29.62
0206 ........... Level II Nerve Injections .................................................................................. T ................. 4.1589 $264.89 $56.83 $52.98
0207 ........... Level III Nerve Injections ................................................................................. T ................. 7.1370 $454.58 .................... $90.92
0208 ........... Laminotomies and Laminectomies .................................................................. T ................. 47.6714 $3,036.33 .................... $607.27
0209 ........... Level II Extended EEG and Sleep Studies ..................................................... S ................. 11.5647 $736.59 $268.70 $147.32
0212 ........... Nervous System Injections .............................................................................. T ................. 8.6797 $552.84 .................... $110.57
0213 ........... Level I Extended EEG and Sleep Studies ...................................................... S ................. 2.3476 $149.53 $53.50 $29.91
0215 ........... Level I Nerve and Muscle Tests ..................................................................... S ................. 0.5746 $36.60 .................... $7.32
0216 ........... Level III Nerve and Muscle Tests ................................................................... S ................. 2.7680 $176.30 .................... $35.26
0218 ........... Level II Nerve and Muscle Tests .................................................................... S ................. 1.1861 $75.55 .................... $15.11
0220 ........... Level I Nerve Procedures ................................................................................ T ................. 18.5069 $1,178.76 .................... $235.75
0221 ........... Level II Nerve Procedures ............................................................................... T ................. 32.0518 $2,041.48 $463.60 $408.30
0222 ........... Implantation of Neurological Device ................................................................ T ................. 193.3327 $12,313.94 .................... $2,462.79
0224 ........... Implantation of Catheter/Reservoir/Shunt ....................................................... T ................. 37.1117 $2,363.76 .................... $472.75
0225 ........... Implantation of Neurostimulator Electrodes, Cranial Nerve ............................ S ................. 221.4181 $14,102.78 .................... $2,820.56
0227 ........... Implantation of Drug Infusion Device .............................................................. T ................. 178.7228 $11,383.39 .................... $2,276.68
0229 ........... Transcatherter Placement of Intravascular Shunts ......................................... T ................. 89.7027 $5,713.43 .................... $1,142.69
0230 ........... Level I Eye Tests & Treatments ...................................................................... S ................. 0.7379 $47.00 .................... $9.40
0231 ........... Level III Eye Tests & Treatments .................................................................... S ................. 2.3117 $147.24 .................... $29.45
0232 ........... Level I Anterior Segment Eye Procedures ...................................................... T ................. 5.1145 $325.76 $81.59 $65.15
0233 ........... Level II Anterior Segment Eye Procedures ..................................................... T ................. 16.5252 $1,052.54 $266.30 $210.51
0234 ........... Level III Anterior Segment Eye Procedures .................................................... T ................. 24.0821 $1,533.86 $511.30 $306.77
0235 ........... Level I Posterior Segment Eye Procedures .................................................... T ................. 4.0100 $255.41 $58.90 $51.08
0236 ........... Level II Posterior Segment Eye Procedures ................................................... T ................. 18.8779 $1,202.39 .................... $240.48
0237 ........... Level III Posterior Segment Eye Procedures .................................................. T ................. 29.0019 $1,847.22 .................... $369.44
0238 ........... Level I Repair and Plastic Eye Procedures .................................................... T ................. 2.8636 $182.39 .................... $36.48
0239 ........... Level II Repair and Plastic Eye Procedures ................................................... T ................. 7.1099 $452.85 .................... $90.57
0240 ........... Level III Repair and Plastic Eye Procedures .................................................. T ................. 19.2280 $1,224.69 $309.50 $244.94
0241 ........... Level IV Repair and Plastic Eye Procedures .................................................. T ................. 24.8916 $1,585.42 $384.40 $317.08
0242 ........... Level V Repair and Plastic Eye Procedures ................................................... T ................. 37.3504 $2,378.96 $597.30 $475.79
0243 ........... Strabismus/Muscle Procedures ....................................................................... T ................. 24.3920 $1,553.60 $430.30 $310.72
0244 ........... Corneal Transplant .......................................................................................... T ................. 38.2919 $2,438.93 $803.20 $487.79
0245 ........... Level I Cataract Procedures without IOL Insert .............................................. T ................. 14.9022 $949.17 $217.00 $189.83
0246 ........... Cataract Procedures with IOL Insert ............................................................... T ................. 24.2197 $1,542.63 $495.90 $308.53
0247 ........... Laser Eye Procedures ..................................................................................... T ................. 5.2389 $333.68 $104.30 $66.74
0249 ........... Level II Cataract Procedures without IOL Insert ............................................. T ................. 29.7487 $1,894.78 $524.60 $378.96
0250 ........... Nasal Cauterization/Packing ........................................................................... T ................. 1.1708 $74.57 $25.30 $14.91
0251 ........... Level I ENT Procedures .................................................................................. T ................. 2.5765 $164.11 .................... $32.82
0252 ........... Level II ENT Procedures ................................................................................. T ................. 7.6539 $487.50 $109.10 $97.50
0253 ........... Level III ENT Procedures ................................................................................ T ................. 16.6341 $1,059.48 $282.20 $211.90
0254 ........... Level IV ENT Procedures ................................................................................ T ................. 24.3535 $1,551.15 $321.30 $310.23
0256 ........... Level V ENT Procedures ................................................................................. T ................. 40.5598 $2,583.38 .................... $516.68
0258 ........... Tonsil and Adenoid Procedures ...................................................................... T ................. 22.9075 $1,459.05 $437.20 $291.81
0259 ........... Level VI ENT Procedures ................................................................................ T ................. 404.3379 $25,753.49 $8,698.40 $5,150.70

National Minimum
Relative Payment
0260 ........... Level I Plain Film Except Teeth ...................................................................... X ................. 0.7259 $46.23 .................... $9.25
0261 ........... Level II Plain Film Except Teeth Including Bone Density Measurement ........ X ................. 1.2024 $76.58 .................... $15.32
0262 ........... Plain Film of Teeth .......................................................................................... X ................. 0.5739 $36.55 .................... $7.31
0263 ........... Miscellaneous Radiology Procedures ............................................................. X ................. 1.4802 $94.28 $21.44 $18.86
0265 ........... Level I Diagnostic and Screening Ultrasound ................................................. S ................. 0.9925 $63.22 $23.60 $12.64
0266 ........... Level II Diagnostic and Screening Ultrasound ................................................ S ................. 1.5657 $99.72 $37.80 $19.94
0267 ........... Level III Diagnostic and Screening Ultrasound ............................................... S ................. 2.4859 $158.33 $60.50 $31.67
0269 ........... Level II Echocardiogram Except Transesophageal ......................................... S ................. 6.5908 $419.79 .................... $83.96
0270 ........... Transesophageal Echocardiogram .................................................................. S ................. 8.4200 $536.30 $141.30 $107.26
0272 ........... Fluoroscopy ..................................................................................................... X ................. 1.3270 $84.52 $31.60 $16.90
0274 ........... Myelography .................................................................................................... S ................. 3.9008 $248.45 $62.80 $49.69
0275 ........... Arthrography .................................................................................................... S ................. 2.2785 $145.12 $44.13 $29.02
0276 ........... Level I Digestive Radiology ............................................................................. S ................. 1.4387 $91.64 $34.90 $18.33
0277 ........... Level II Digestive Radiology ............................................................................ S ................. 2.2875 $145.70 $54.50 $29.14
0278 ........... Diagnostic Urography ...................................................................................... S ................. 2.6114 $166.33 $59.40 $33.27
0279 ........... Level II Angiography and Venography ............................................................ S ................. 5.9365 $378.11 $97.07 $75.62
0280 ........... Level III Angiography and Venography ........................................................... S ................. 11.3221 $721.14 $199.34 $144.23
0282 ........... Miscellaneous Computed Axial Tomography .................................................. S ................. 1.6768 $106.80 $37.80 $21.36
0283 ........... Level I Computed Tomography with Contrast ................................................. S ................. 4.5485 $289.71 $100.30 $57.94
0284 ........... Magnetic Resonance Imaging and Magnetic Resonance Angiography with S ................. 6.7963 $432.88 $148.40 $86.58
Contrast.
0288 ........... Bone Density:Axial Skeleton ........................................................................... S ................. 1.1920 $75.92 $28.90 $15.18
0293 ........... Level V Anterior Segment Eye Procedures .................................................... T ................. 83.0605 $5,290.37 $1,128.20 $1,058.07
0299 ........... Hyperthermia and Radiation Treatment Procedures ....................................... S ................. 6.0275 $383.91 .................... $76.78
0300 ........... Level I Radiation Therapy ............................................................................... S ................. 1.5000 $95.54 .................... $19.11
0301 ........... Level II Radiation Therapy .............................................................................. S ................. 2.2933 $146.07 .................... $29.21
0303 ........... Treatment Device Construction ....................................................................... X ................. 3.0657 $195.26 $66.90 $39.05
0304 ........... Level I Therapeutic Radiation Treatment Preparation .................................... X ................. 1.6409 $104.51 $38.60 $20.90
0305 ........... Level II Therapeutic Radiation Treatment Preparation ................................... X ................. 4.1775 $266.08 $91.30 $53.22
0307 ........... Myocardial Positron Emission Tomography (PET) imaging ............................ S ................. 42.5674 $2,711.25 .................... $542.25
0308 ........... Non-Myocardial Positron Emission Tomography (PET) imaging .................... S ................. 17.3837 $1,107.22 .................... $221.44
0310 ........... Level III Therapeutic Radiation Treatment Preparation .................................. X ................. 14.0797 $896.78 $325.20 $179.36
0312 ........... Radioelement Applications .............................................................................. S ................. 8.3915 $534.48 .................... $106.90
0313 ........... Brachytherapy .................................................................................................. S ................. 11.6098 $739.46 .................... $147.89
0315 ........... Level II Implantation of Neurostimulator ......................................................... T ................. 262.8116 $16,739.26 .................... $3,347.85
0316 ........... Level II Computed Tomography with Contrast ............................................... S ................. 11.7923 $751.09 $300.26 $150.22
0320 ........... Electroconvulsive Therapy .............................................................................. S ................. 5.9448 $378.64 $80.00 $75.73
0322 ........... Brief Individual Psychotherapy ........................................................................ S ................. 1.2454 $79.32 .................... $15.86
0323 ........... Extended Individual Psychotherapy ................................................................ S ................. 1.6720 $106.49 .................... $21.30
0324 ........... Family Psychotherapy ..................................................................................... S ................. 2.2233 $141.61 .................... $28.32
0325 ........... Group Psychotherapy ...................................................................................... S ................. 1.0119 $64.45 $14.04 $12.89
0330 ........... Dental Procedures ........................................................................................... S ................. 9.2780 $590.94 .................... $118.19
0332 ........... Computed Tomography without Contrast ....................................................... S ................. 3.1487 $200.55 $75.20 $40.11
0333 ........... Computed Tomography without Contrast followed by Contrast) .................... S ................. 5.3374 $339.96 $119.00 $67.99
0335 ........... Magnetic Resonance Imaging, Miscellaneous ................................................ S ................. 5.0067 $318.89 $111.90 $63.78
0336 ........... Magnetic Resonance Imaging and Magnetic Resonance Angiography with- S ................. 5.7101 $363.69 $139.50 $72.74
out Contrast.
0337 ........... Magnetic Resonance Imaging and Magnetic Resonance Angiography with- S ................. 8.6689 $552.15 $199.50 $110.43
out Contrast followed by Contrast.
0340 ........... Minor Ancillary Procedures ............................................................................. X ................. 0.6416 $40.87 .................... $8.17
0341 ........... Skin Tests ........................................................................................................ X ................. 0.0879 $5.60 $2.20 $1.12
0342 ........... Level I Pathology ............................................................................................. X ................. 0.0928 $5.91 $2.00 $1.18
0343 ........... Level III Pathology ........................................................................................... X ................. 0.5372 $34.22 $10.80 $6.84
0344 ........... Level IV Pathology .......................................................................................... X ................. 0.8586 $54.69 $15.60 $10.94
0345 ........... Level I Transfusion Laboratory Procedures .................................................... X ................. 0.2211 $14.08 .................... $2.82
0346 ........... Level II Transfusion Laboratory Procedures ................................................... X ................. 0.3464 $22.06 .................... $4.41
0347 ........... Level III Transfusion Laboratory Procedures .................................................. X ................. 0.8166 $52.01 $11.20 $10.40
0350 ........... Administration of flu and PPV vaccine ............................................................ S ................. 0.4037 $25.71 .................... $0.00
0360 ........... Level I Alimentary Tests .................................................................................. X ................. 1.6383 $104.35 $33.80 $20.87
0361 ........... Level II Alimentary Tests ................................................................................. X ................. 4.0867 $260.29 $83.20 $52.06
0363 ........... Level I Otorhinolaryngologic Function Tests ................................................... X ................. 0.8542 $54.41 $17.40 $10.88
0364 ........... Level I Audiometry ........................................................................................... X ................. 0.4448 $28.33 $6.98 $5.67
0365 ........... Level II Audiometry .......................................................................................... X ................. 1.2810 $81.59 $18.50 $16.32
0366 ........... Level III Audiometry ......................................................................................... X ................. 1.8646 $118.76 $26.10 $23.75
0367 ........... Level I Pulmonary Test ................................................................................... X ................. 0.5955 $37.93 $14.38 $7.59
0368 ........... Level II Pulmonary Tests ................................................................................. X ................. 0.9541 $60.77 $22.70 $12.15
0369 ........... Level III Pulmonary Tests ................................................................................ X ................. 2.7874 $177.54 $44.10 $35.51
0370 ........... Allergy Tests .................................................................................................... X ................. 1.1024 $70.22 .................... $14.04
0373 ........... Level I Neuropsychological Testing ................................................................ X ................. 1.8183 $115.81 .................... $23.16
0375 ........... Ancillary Outpatient Services When Patient Expires ...................................... S ................. 73.4077 $4,675.56 .................... $935.11
0377 ........... Level II Cardiac Imaging ................................................................................. S ................. 12.0147 $765.25 $158.80 $153.05
0378 ........... Level II Pulmonary Imaging ............................................................................. S ................. 5.1617 $328.76 $125.30 $65.75
0379 ........... Injection adenosine 6 MG ............................................................................... K ................. .................... $22.65 .................... $4.53
0381 ........... Single Allergy Tests ......................................................................................... X ................. 0.3014 $19.20 .................... $3.84
0382 ........... Level II Neuropsychological Testing ............................................................... X ................. 2.6763 $170.46 .................... $34.09
0383 ........... Cardiac Computed Tomographic Imaging ...................................................... S ................. 4.9887 $317.75 $124.17 $63.55
0384 ........... GI Procedures with Stents .............................................................................. T ................. 25.2289 $1,606.90 .................... $321.38
0385 ........... Level I Prosthetic Urological Procedures ........................................................ S ................. 85.3372 $5,435.38 .................... $1,087.08
0386 ........... Level II Prosthetic Urological Procedures ....................................................... S ................. 143.8001 $9,159.06 .................... $1,831.81
0387 ........... Level II Hysteroscopy ...................................................................................... T ................. 34.8162 $2,217.55 $655.50 $443.51

National Minimum
Relative Payment
0388 ........... Discography ..................................................................................................... S ................. 9.0300 $575.15 $169.68 $115.03

0389 ........... Level I Non-imaging Nuclear Medicine ........................................................... S ................. 1.5806 $100.67 $33.80 $20.13
0390 ........... Level I Endocrine Imaging ............................................................................... S ................. 2.8272 $180.07 $57.60 $36.01
0391 ........... Level II Endocrine Imaging .............................................................................. S ................. 3.6540 $232.73 $66.10 $46.55
0392 ........... Level II Non-imaging Nuclear Medicine .......................................................... S ................. 3.2810 $208.98 $49.30 $41.80
0393 ........... Red Cell/Plasma Studies ................................................................................. S ................. 5.5260 $351.97 $82.00 $70.39
0394 ........... Hepatobiliary Imaging ...................................................................................... S ................. 4.5297 $288.51 $102.60 $57.70
0395 ........... GI Tract Imaging .............................................................................................. S ................. 3.8546 $245.51 $89.70 $49.10
0396 ........... Bone Imaging .................................................................................................. S ................. 3.9566 $252.01 $95.00 $50.40
0397 ........... Vascular Imaging ............................................................................................. S ................. 3.0424 $193.78 $49.50 $38.76
0398 ........... Level I Cardiac Imaging .................................................................................. S ................. 5.4404 $346.52 $100.00 $69.30
0400 ........... Hematopoietic Imaging .................................................................................... S ................. 4.1916 $266.98 $93.20 $53.40
0401 ........... Level I Pulmonary Imaging .............................................................................. S ................. 3.2976 $210.03 $78.10 $42.01
0402 ........... Level II Nervous System Imaging ................................................................... S ................. 8.8414 $563.14 $114.10 $112.63
0403 ........... Level I Nervous System Imaging .................................................................... S ................. 3.3325 $212.26 $82.39 $42.45
0404 ........... Renal and Genitourinary Studies .................................................................... S ................. 5.0935 $324.42 $84.10 $64.88
0406 ........... Level I Tumor/Infection Imaging ...................................................................... S ................. 4.4988 $286.54 $98.10 $57.31
0407 ........... Level I Radionuclide Therapy .......................................................................... S ................. 3.4563 $220.14 $78.10 $44.03
0408 ........... Level III Tumor/Infection Imaging .................................................................... S ................. 16.0595 $1,022.88 .................... $204.58
0409 ........... Red Blood Cell Tests ...................................................................................... X ................. 0.1246 $7.94 $2.20 $1.59
0412 ........... IMRT Treatment Delivery ................................................................................ S ................. 5.7275 $364.80 .................... $72.96
0413 ........... Level II Radionuclide Therapy ......................................................................... S ................. 5.4891 $349.62 .................... $69.92
0414 ........... Level II Tumor/Infection Imaging ..................................................................... S ................. 7.4985 $477.60 $190.92 $95.52
0415 ........... Level II Endoscopy Lower Airway ................................................................... T ................. 24.2882 $1,546.99 $459.90 $309.40
0417 ........... Computerized Reconstruction ......................................................................... S ................. 2.3401 $149.05 .................... $29.81
0418 ........... Insertion of Left Ventricular Pacing Elect. ....................................................... T ................. 250.5383 $15,957.54 .................... $3,191.51
0422 ........... Level II Upper GI Procedures ......................................................................... T ................. 24.6480 $1,569.91 $445.06 $313.98
0423 ........... Level II Percutaneous Abdominal and Biliary Procedures .............................. T ................. 44.1192 $2,810.08 .................... $562.02
0425 ........... Level II Arthroplasty with Prosthesis ............................................................... T ................. 113.6713 $7,240.07 .................... $1,448.01
0426 ........... Level II Strapping and Cast Application .......................................................... S ................. 2.2383 $142.56 .................... $28.51
0427 ........... Level II Tube Changes and Repositioning ...................................................... T ................. 14.8912 $948.47 .................... $189.69
0428 ........... Level III Sigmoidoscopy and Anoscopy .......................................................... T ................. 21.8923 $1,394.39 .................... $278.88
0429 ........... Level V Cystourethroscopy and other Genitourinary Procedures ................... T ................. 45.9021 $2,923.64 .................... $584.73
0430 ........... Drug Preadministration-Related Services ....................................................... S ................. 0.6123 $39.00 .................... $7.80
0432 ........... Health and Behavior Services ......................................................................... S ................. 0.3020 $19.24 .................... $3.85
0433 ........... Level II Pathology ............................................................................................ X ................. 0.2482 $15.81 $5.90 $3.16
0434 ........... Cardiac Defect Repair ..................................................................................... T ................. 141.9601 $9,041.86 .................... $1,808.37
0436 ........... Level I Drug Administration ............................................................................. S ................. 0.2201 $14.02 .................... $2.80
0437 ........... Level II Drug Administration ............................................................................ S ................. 0.4037 $25.71 .................... $5.14
0438 ........... Level III Drug Administration ........................................................................... S ................. 0.8310 $52.93 .................... $10.59
0439 ........... Level IV Drug Administration ........................................................................... S ................. 1.7152 $109.25 .................... $21.85
0440 ........... Level V Drug Administration ............................................................................ S ................. 1.8310 $116.62 .................... $23.32
0441 ........... Level VI Drug Administration ........................................................................... S ................. 2.4378 $155.27 .................... $31.05
0442 ........... Dosimetric Drug Administration ....................................................................... S ................. 30.2249 $1,925.11 .................... $385.02
0604 ........... Level 1 Hospital Clinic Visits ........................................................................... V ................. 0.8381 $53.38 .................... $10.68
0609 ........... Level 1 Emergency Visits ................................................................................ V ................. 0.8271 $52.68 $12.70 $10.54
0617 ........... Critical Care ..................................................................................................... S ................. 6.8478 $436.16 $111.50 $87.23
0618 ........... Trauma Response with Critical Care .............................................................. S ................. 5.6539 $360.11 $144.04 $72.02
0621 ........... Level I Vascular Access Procedures .............................................................. T ................. 11.0043 $700.90 .................... $140.18
0622 ........... Level II Vascular Access Procedures ............................................................. T ................. 24.5273 $1,562.22 .................... $312.44
0623 ........... Level III Vascular Access Procedures ............................................................ T ................. 29.3210 $1,867.54 .................... $373.51
0624 ........... Phlebotomy and Minor Vascular Access Device Procedures ......................... X ................. 0.5763 $36.71 $12.60 $7.34
0625 ........... Level IV Vascular Access Procedures ............................................................ T ................. 87.3200 $5,561.67 .................... $1,112.33
0648 ........... Level IV Breast Surgery .................................................................................. T ................. 52.9438 $3,372.15 .................... $674.43
0651 ........... Complex Interstitial Radiation Source Application .......................................... S ................. 15.4158 $981.88 .................... $196.38
0652 ........... Insertion of Intraperitoneal and Pleural Catheters .......................................... T ................. 31.7598 $2,022.88 .................... $404.58
0653 ........... Vascular Reconstruction/Fistula Repair with Device ....................................... T ................. 41.0875 $2,616.99 .................... $523.40
0654 ........... Insertion/Replacement of a permanent dual chamber pacemaker ................. T ................. 106.9053 $6,809.12 .................... $1,361.82
0655 ........... Insertion/Replacement/Conversion of a permanent dual chamber pace- T ................. 144.2764 $9,189.40 .................... $1,837.88
maker.
0656 ........... Transcatheter Placement of Intracoronary Drug-Eluting Stents ..................... T ................. 118.8818 $7,571.94 .................... $1,514.39
0659 ........... Hyperbaric Oxygen .......................................................................................... S ................. 1.5679 $99.86 .................... $19.97
0660 ........... Level II Otorhinolaryngologic Function Tests .................................................. X ................. 1.4408 $91.77 $28.00 $18.35
0661 ........... Level V Pathology ........................................................................................... X ................. 2.8336 $180.48 $62.00 $36.10
0662 ........... CT Angiography ............................................................................................... S ................. 5.2818 $336.41 $118.80 $67.28
0663 ........... Level I Electronic Analysis of Neurostimulator Pulse Generators .................. S ................. 1.6671 $106.18 .................... $21.24
0664 ........... Level I Proton Beam Radiation Therapy ......................................................... S ................. 13.2746 $845.50 .................... $169.10
0665 ........... Bone Density:AppendicularSkeleton ............................................................... S ................. 0.5225 $33.28 $13.31 $6.66
0667 ........... Level II Proton Beam Radiation Therapy ........................................................ S ................. 15.8841 $1,011.71 .................... $202.34
0668 ........... Level I Angiography and Venography ............................................................. S ................. 3.3354 $212.44 $48.81 $42.49
0672 ........... Level IV Posterior Segment Eye Procedures .................................................. T ................. 38.1121 $2,427.47 .................... $485.49
0673 ........... Level IV Anterior Segment Eye Procedures ................................................... T ................. 40.8481 $2,601.74 $649.50 $520.35

National Minimum
Relative Payment
0674 ........... Prostate Cryoablation ...................................................................................... T ................. 123.7218 $7,880.21 .................... $1,576.04
0676 ........... Thrombolysis and Thrombectomy ................................................................... T ................. 2.5179 $160.37 .................... $32.07
0678 ........... External Counterpulsation ............................................................................... T ................. 1.7081 $108.79 .................... $21.76
0679 ........... Level II Resuscitation and Cardioversion ........................................................ S ................. 5.5905 $356.08 $95.30 $71.22
0680 ........... Insertion of Patient Activated Event Recorders .............................................. S ................. 71.6463 $4,563.37 .................... $912.67
0681 ........... Knee Arthroplasty ............................................................................................ T ................. 191.2387 $12,180.57 .................... $2,436.11
0682 ........... Level V Debridement & Destruction ................................................................ T ................. 7.1126 $453.02 $158.60 $90.60
0683 ........... Level II Photochemotherapy ............................................................................ S ................. 2.9292 $186.57 .................... $37.31
0685 ........... Level III Needle Biopsy/Aspiration Except Bone Marrow ................................ T ................. 9.5741 $609.80 .................... $121.96
0687 ........... Revision/Removal of Neurostimulator Electrodes ........................................... T ................. 24.1752 $1,539.79 $438.40 $307.96
0688 ........... Revision/Removal of Neurostimulator Pulse Generator Receiver .................. T ................. 35.7248 $2,275.42 $874.50 $455.08
0689 ........... Electronic Analysis of Cardioverter-defibrillators ............................................. S ................. 0.5936 $37.81 .................... $7.56
0690 ........... Electronic Analysis of Pacemakers and other Cardiac Devices ..................... S ................. 0.3590 $22.87 $8.60 $4.57
0691 ........... Electronic Analysis of Programmable Shunts/Pumps ..................................... S ................. 2.5849 $164.64 $56.08 $32.93
0692 ........... Level II Electronic Analysis of Neurostimulator Pulse Generators ................. S ................. 1.9206 $122.33 $30.10 $24.47
0694 ........... Mohs Surgery .................................................................................................. T ................. 3.9713 $252.94 $91.60 $50.59
0697 ........... Level I Echocardiogram Except Transesophageal ......................................... S ................. 4.8072 $306.18 .................... $61.24
0698 ........... Level II Eye Tests & Treatments ..................................................................... S ................. 1.1576 $73.73 .................... $14.75
0699 ........... Level IV Eye Tests & Treatments ................................................................... T ................. 14.2784 $909.43 .................... $181.89
0701 ........... Sr89 strontium ................................................................................................. K ................. .................... $610.07 .................... $122.01
0702 ........... Sm 153 lexidronm ........................................................................................... K ................. .................... $1,446.05 .................... $289.21
0726 ........... Dexrazoxane HCl injection .............................................................................. K ................. .................... $172.43 .................... $34.49
0728 ........... Filgrastim 300 mcg injection ............................................................................ K ................. .................... $187.68 .................... $37.54
0730 ........... Pamidronate disodium/30 MG ......................................................................... K ................. .................... $30.49 .................... $6.10
0731 ........... Sargramostim injection .................................................................................... K ................. .................... $25.08 .................... $5.02
0732 ........... Mesna injection ................................................................................................ K ................. .................... $8.89 .................... $1.78
0735 ........... Ampho b cholesteryl sulfate ............................................................................ K ................. .................... $11.89 .................... $2.38
0736 ........... Amphotericin b liposome inj ............................................................................ K ................. .................... $17.07 .................... $3.41
0738 ........... Rasburicase ..................................................................................................... K ................. .................... $131.28 .................... $26.26
0747 ........... Chlorothiazide sodium inj ................................................................................ K ................. .................... $122.67 .................... $24.53
0748 ........... Bleomycin sulfate injection .............................................................................. K ................. .................... $35.52 .................... $7.10
0750 ........... Dolasetron mesylate ........................................................................................ K ................. .................... $6.05 .................... $1.21
0751 ........... Mechlorethamine hcl inj ................................................................................... K ................. .................... $140.27 .................... $28.05
0752 ........... Dactinomycin actinomycin d ............................................................................ K ................. .................... $488.78 .................... $97.76
0759 ........... Naltrexone, depot form .................................................................................... K ................. .................... $1.88 .................... $0.38
0760 ........... Anadulafungin injection ................................................................................... G ................ .................... $1.91 .................... $0.38
0763 ........... Dolasetron mesylate oral ................................................................................. K ................. .................... $47.07 .................... $9.41
0764 ........... Granisetron HCl injection ................................................................................ K ................. .................... $7.43 .................... $1.49
0765 ........... Granisetron HCl 1 mg oral .............................................................................. K ................. .................... $44.44 .................... $8.89
0767 ........... Enfuvirtide injection ......................................................................................... K ................. .................... $22.69 .................... $4.54
0768 ........... Ondansetron hcl injection ................................................................................ K ................. .................... $3.37 .................... $0.67
0769 ........... Ondansetron HCl 8mg oral ............................................................................. K ................. .................... $36.21 .................... $7.24
0800 ........... Leuprolide acetate/3.75 MG ............................................................................ K ................. .................... $429.83 .................... $85.97
0802 ........... Etoposide oral 50 MG ..................................................................................... K ................. .................... $29.32 .................... $5.86
0804 ........... Immune globulin subcutaneous ....................................................................... K ................. .................... $12.60 .................... $2.52
0805 ........... Mecasermin injection ....................................................................................... K ................. .................... $11.81 .................... $2.36
0806 ........... Hyaluronidase recombinant ............................................................................. G ................ .................... $0.40 .................... $0.08
0807 ........... Aldesleukin/single use vial .............................................................................. K ................. .................... $755.78 .................... $151.16
0808 ........... Nabilone oral ................................................................................................... K ................. .................... $16.80 .................... $3.36
0809 ........... Bcg live intravesical vac .................................................................................. K ................. .................... $109.63 .................... $21.93
0810 ........... Goserelin acetate implant ................................................................................ K ................. .................... $196.81 .................... $39.36
0811 ........... Carboplatin injection ........................................................................................ K ................. .................... $8.38 .................... $1.68
0812 ........... Carmus bischl nitro inj ..................................................................................... K ................. .................... $138.52 .................... $27.70
0814 ........... Asparaginase injection .................................................................................... K ................. .................... $54.20 .................... $10.84
0820 ........... Daunorubicin .................................................................................................... K ................. .................... $20.28 .................... $4.06
0821 ........... Daunorubicin citrate liposom ........................................................................... K ................. .................... $55.40 .................... $11.08
0823 ........... Docetaxel ......................................................................................................... K ................. .................... $303.92 .................... $60.78
0825 ........... Nelarabine injection ......................................................................................... K ................. .................... $82.54 .................... $16.51
0827 ........... Floxuridine injection ......................................................................................... K ................. .................... $50.82 .................... $10.16
0828 ........... Gemcitabine HCl ............................................................................................. K ................. .................... $123.98 .................... $24.80
0830 ........... Irinotecan injection ........................................................................................... K ................. .................... $124.81 .................... $24.96
0831 ........... Ifosfomide injection .......................................................................................... K ................. .................... $46.15 .................... $9.23
0832 ........... Idarubicin hcl injection ..................................................................................... K ................. .................... $301.74 .................... $60.35
0834 ........... Interferon alfa-2a inj ........................................................................................ K ................. .................... $37.53 .................... $7.51
0835 ........... Inj cosyntropin per 0.25 MG ............................................................................ K ................. .................... $63.25 .................... $12.65
0836 ........... Interferon alfa-2b inj ........................................................................................ K ................. .................... $13.75 .................... $2.75
0837 ........... Non-human, non-metab tissue ........................................................................ K ................. .................... $35.76 .................... $7.15
0838 ........... Interferon gamma 1-b inj ................................................................................. K ................. .................... $287.13 .................... $57.43
0840 ........... Inj melphalan hydrochl 50 MG ........................................................................ K ................. .................... $1,272.00 .................... $254.40
0842 ........... Fludarabine phosphate inj ............................................................................... K ................. .................... $234.21 .................... $46.84
0843 ........... Pegaspargase/singl dose vial .......................................................................... K ................. .................... $1,667.61 .................... $333.52
0844 ........... Pentostatin injection ........................................................................................ K ................. .................... $1,916.66 .................... $383.33
0849 ........... Rituximab cancer treatment ............................................................................ K ................. .................... $491.54 .................... $98.31
0850 ........... Streptozocin injection ...................................................................................... K ................. .................... $152.28 .................... $30.46
0851 ........... Thiotepa injection ............................................................................................ K ................. .................... $40.32 .................... $8.06
0852 ........... Topotecan ........................................................................................................ K ................. .................... $822.90 .................... $164.58
0855 ........... Vinorelbine tartrate/10 mg ............................................................................... K ................. .................... $19.88 .................... $3.98
0856 ........... Porfimer sodium .............................................................................................. K ................. .................... $2,539.13 .................... $507.83
0858 ........... Inj cladribine per 1 MG .................................................................................... K ................. .................... $35.78 .................... $7.16
0861 ........... Leuprolide acetate injeciton ............................................................................. K ................. .................... $8.79 .................... $1.76

National Minimum
Relative Payment
0862 ........... Mitomycin 5 MG inj .......................................................................................... K ................. .................... $15.98 .................... $3.20
0863 ........... Paclitaxel injection ........................................................................................... K ................. .................... $12.47 .................... $2.49
0864 ........... Mitoxantrone hydrochl/5 MG ........................................................................... K ................. .................... $166.64 .................... $33.33
0865 ........... Interferon alfa-n3 inj ........................................................................................ K ................. .................... $9.03 .................... $1.81
0868 ........... Oral aprepitant ................................................................................................. K ................. .................... $5.02 .................... $1.00
0873 ........... Hyalgan/supartz inj per dose ........................................................................... K ................. .................... $103.86 .................... $20.77
0874 ........... Synvisc inj per dose ........................................................................................ K ................. .................... $184.89 .................... $36.98
0875 ........... Euflexxa inj per dose ....................................................................................... K ................. .................... $115.19 .................... $23.04
0877 ........... Orthovisc inj per dose ..................................................................................... K ................. .................... $196.47 .................... $39.29
0878 ........... Gallium nitrate injection ................................................................................... K ................. .................... $1.47 .................... $0.29
0879 ........... Bethanechol chloride inject ............................................................................. K ................. 0.5128 $32.66 .................... $6.53
0880 ........... Pentastarch 10% solution ................................................................................ K ................. 0.3707 $23.61 .................... $4.72
0881 ........... Urokinase 5000 IU injection ............................................................................ K ................. .................... $9.07 .................... $1.81
0882 ........... Melphalan oral 2 MG ....................................................................................... K ................. 0.0681 $4.34 .................... $0.87
0883 ........... Fondaparinux sodium ...................................................................................... K ................. .................... $5.82 .................... $1.16
0884 ........... Rho d immune globulin inj ............................................................................... K ................. .................... $80.71 .................... $16.14
0887 ........... Azathioprine parenteral ................................................................................... K ................. .................... $47.99 .................... $9.60
0888 ........... Cyclosporine oral 100 mg ............................................................................... K ................. .................... $3.57 .................... $0.71
0890 ........... Lymphocyte immune globulin .......................................................................... K ................. .................... $314.19 .................... $62.84
0891 ........... Tacrolimus oral per 1 MG ............................................................................... K ................. .................... $3.63 .................... $0.73
0898 ........... Gamma globulin 2 CC inj ................................................................................ K ................. .................... $22.63 .................... $4.53
0900 ........... Alglucerase injection ........................................................................................ K ................. .................... $38.85 .................... $7.77
0901 ........... Alpha 1 proteinase inhibitor ............................................................................. K ................. .................... $3.24 .................... $0.65
0902 ........... Botulinum toxin a per unit ............................................................................... K ................. .................... $5.05 .................... $1.01
0903 ........... Cytomegalovirus imm IV/vial ........................................................................... K ................. .................... $859.86 .................... $171.97
0906 ........... RSV-ivig ........................................................................................................... K ................. .................... $16.02 .................... $3.20
0910 ........... Interferon beta-1b/.25 MG ............................................................................... K ................. .................... $84.12 .................... $16.82
0911 ........... Inj streptokinase/250000 IU ............................................................................. K ................. 1.1851 $75.48 .................... $15.10
0912 ........... Interferon alfacon-1 ......................................................................................... K ................. .................... $4.60 .................... $0.92
0913 ........... Ganciclovir long act implant ............................................................................ K ................. .................... $4,707.42 .................... $941.48
0916 ........... Injection imiglucerase/unit ............................................................................... K ................. .................... $3.89 .................... $0.78
0917 ........... Adenosine injection ......................................................................................... K ................. .................... $68.50 .................... $13.70
0924 ........... Gamma globulin 10 CC inj .............................................................................. K ................. .................... $113.13 .................... $22.63
0925 ........... Factor viii ......................................................................................................... K ................. .................... $0.70 .................... $0.14
0927 ........... Factor viii recombinant .................................................................................... K ................. .................... $1.07 .................... $0.21
0928 ........... Factor ix complex ............................................................................................ K ................. .................... $0.75 .................... $0.15
0929 ........... Anti-inhibitor ..................................................................................................... K ................. .................... $1.35 .................... $0.27
0930 ........... Antithrombin iii injection ................................................................................... K ................. .................... $1.62 .................... $0.32
0931 ........... Factor IX non-recombinant .............................................................................. K ................. .................... $0.89 .................... $0.18
0932 ........... Factor IX recombinant ..................................................................................... K ................. .................... $0.99 .................... $0.20
0933 ........... Gamma globulin ≤ 10 CC inj ........................................................................... K ................. .................... $113.13 .................... $22.63
0934 ........... Capecitabine, oral, 500 mg ............................................................................. K ................. .................... $13.12 .................... $2.62
0935 ........... Clonidine hydrochloride ................................................................................... K ................. .................... $62.86 .................... $12.57
0941 ........... Mitomycin 20 MG inj ........................................................................................ K ................. .................... $63.93 .................... $12.79
0942 ........... Mitomycin 40 MG inj ........................................................................................ K ................. .................... $127.85 .................... $25.57
0949 ........... Frozen plasma, pooled, sd .............................................................................. K ................. 1.1981 $76.31 .................... $15.26
0950 ........... Whole blood for transfusion ............................................................................ K ................. 4.4374 $282.63 .................... $56.53
0952 ........... Cryoprecipitate each unit ................................................................................. K ................. 0.6843 $43.59 .................... $8.72
0954 ........... RBC leukocytes reduced ................................................................................. K ................. 2.9590 $188.47 .................... $37.69
0955 ........... Plasma, frz between 8-24hour ........................................................................ K ................. 1.2456 $79.34 .................... $15.87
0956 ........... Plasma protein fract,5%,50ml ......................................................................... K ................. 1.4392 $91.67 .................... $18.33
0957 ........... Platelets, each unit .......................................................................................... K ................. 1.0834 $69.00 .................... $13.80
0958 ........... Plaelet rich plasma unit ................................................................................... K ................. 5.3744 $342.31 .................... $68.46
0959 ........... Red blood cells unit ......................................................................................... K ................. 2.0343 $129.57 .................... $25.91
0960 ........... Washed red blood cells unit ............................................................................ K ................. 4.2092 $268.10 .................... $53.62
0961 ........... Albumin (human),5%, 50ml ............................................................................. K ................. 0.3757 $23.93 .................... $4.79
0963 ........... Albumin (human), 5%, 250 ml ......................................................................... K ................. 1.1351 $72.30 .................... $14.46
0964 ........... Albumin (human), 25%, 20 ml ......................................................................... K ................. 0.4448 $28.33 .................... $5.67
0965 ........... Albumin (human), 25%, 50ml .......................................................................... K ................. 1.1679 $74.39 .................... $14.88
0966 ........... Plasmaprotein fract,5%,250ml ......................................................................... K ................. 3.9009 $248.46 .................... $49.69
0967 ........... Blood split unit ................................................................................................. K ................. 2.1237 $135.26 .................... $27.05
0968 ........... Platelets leukoreduced irrad ............................................................................ K ................. 2.0280 $129.17 .................... $25.83
0969 ........... RBC leukoreduced irradiated .......................................................................... K ................. 3.8191 $243.25 .................... $48.65
1009 ........... Cryoprecipitatereducedplasma ........................................................................ K ................. 1.3131 $83.64 .................... $16.73
1010 ........... Blood, l/r, cmv-neg .......................................................................................... K ................. 2.3865 $152.00 .................... $30.40
1011 ........... Platelets, hla-m, l/r, unit ................................................................................... K ................. 9.6766 $616.33 .................... $123.27
1013 ........... Platelets leukocytes reduced ........................................................................... K ................. 1.7207 $109.60 .................... $21.92
1016 ........... Blood, l/r, froz/degly/wash ............................................................................... K ................. 3.3520 $213.50 .................... $42.70
1017 ........... Plt, aph/pher, l/r, cmv-neg ............................................................................... K ................. 7.7915 $496.26 .................... $99.25
1018 ........... Blood, l/r, irradiated ......................................................................................... K ................. 2.4372 $155.23 .................... $31.05
1019 ........... Plate pheres leukoredu irrad ........................................................................... K ................. 10.0408 $639.53 .................... $127.91
1020 ........... Plt, pher, l/r cmv-neg, irr .................................................................................. K ................. 10.7802 $686.62 .................... $137.32
1021 ........... RBC, frz/deg/wsh, l/r, irrad .............................................................................. K ................. 6.4694 $412.06 .................... $82.41

National Minimum
Relative Payment
1022 ........... RBC, l/r, cmv-neg, irrad ................................................................................... K ................. 4.6286 $294.81 .................... $58.96
1032 ........... Aud osseo dev, int/ext comp ........................................................................... H ................. .................... .................... .................... .
1052 ........... Injection, voriconazole ..................................................................................... K ................. .................... $4.94 .................... $0.99
1064 ........... I131 iodide cap, rx ........................................................................................... K ................. .................... $16.22 .................... $3.24
1083 ........... Adalimumab injection ...................................................................................... K ................. .................... $316.02 .................... $63.20
1084 ........... Denileukin diftitox, 300 mcg ............................................................................ K ................. .................... $1,393.32 .................... $278.66
1086 ........... Temozolomide ................................................................................................. K ................. .................... $7.34 .................... $1.47
1150 ........... I131 iodide sol, rx ............................................................................................ K ................. .................... $11.74 .................... $2.35
1166 ........... Cytarabine liposome ........................................................................................ K ................. .................... $391.31 .................... $78.26
1167 ........... Inj, epirubicin hcl, 2 mg ................................................................................... K ................. .................... $21.01 .................... $4.20
1178 ........... Busulfan injection ............................................................................................ K ................. .................... $8.80 .................... $1.76
1203 ........... Verteporfin injection ......................................................................................... K ................. .................... $8.84 .................... $1.77
1207 ........... Octreotide injection, depot ............................................................................... K ................. .................... $95.86 .................... $19.17
1280 ........... Corticotropin injection ...................................................................................... K ................. .................... $126.52 .................... $25.30
1436 ........... Etidronate disodium inj .................................................................................... K ................. .................... $70.73 .................... $14.15
1491 ........... New Technology—Level IA ($0–$10) ............................................................. S ................. .................... $5.00 .................... $1.00
1492 ........... New Technology—Level IB ($10–$20) ........................................................... S ................. .................... $15.00 .................... $3.00
1493 ........... New Technology—Level IC ($20–$30) ........................................................... S ................. .................... $25.00 .................... $5.00
1494 ........... New Technology—Level ID ($30–$40) ........................................................... S ................. .................... $35.00 .................... $7.00
1495 ........... New Technology—Level IE ($40–$50) ........................................................... S ................. .................... $45.00 .................... $9.00
1496 ........... New Technology—Level IA ($0–$10) ............................................................. T ................. .................... $5.00 .................... $1.00
1497 ........... New Technology—Level IB ($10–$20) ........................................................... T ................. .................... $15.00 .................... $3.00
1498 ........... New Technology—Level IC ($20–$30) ........................................................... T ................. .................... $25.00 .................... $5.00
1499 ........... New Technology—Level ID ($30–$40) ........................................................... T ................. .................... $35.00 .................... $7.00
1500 ........... New Technology—Level IE ($40–$50) ........................................................... T ................. .................... $45.00 .................... $9.00
1502 ........... New Technology—Level II ($50–$100) ........................................................... S ................. .................... $75.00 .................... $15.00
1503 ........... New Technology—Level III ($100–$200) ........................................................ S ................. .................... $150.00 .................... $30.00
1504 ........... New Technology—Level IV ($200–$300) ....................................................... S ................. .................... $250.00 .................... $50.00
1505 ........... New Technology—Level V ($300–$400) ........................................................ S ................. .................... $350.00 .................... $70.00
1506 ........... New Technology—Level VI ($400–$500) ....................................................... S ................. .................... $450.00 .................... $90.00
1507 ........... New Technology—Level VII ($500–$600) ...................................................... S ................. .................... $550.00 .................... $110.00
1508 ........... New Technology—Level VIII ($600–$700) ..................................................... S ................. .................... $650.00 .................... $130.00
1509 ........... New Technology—Level IX ($700–$800) ....................................................... S ................. .................... $750.00 .................... $150.00
1510 ........... New Technology—Level X ($800–$900) ........................................................ S ................. .................... $850.00 .................... $170.00
1511 ........... New Technology—Level XI ($900–$1000) ..................................................... S ................. .................... $950.00 .................... $190.00
1512 ........... New Technology—Level XII ($1000–$1100) .................................................. S ................. .................... $1,050.00 .................... $210.00
1513 ........... New Technology—Level XIII ($1100–$1200) ................................................. S ................. .................... $1,150.00 .................... $230.00
1514 ........... New Technology—Level XIV ($1200- $1300) ................................................. S ................. .................... $1,250.00 .................... $250.00
1515 ........... New Technology—Level XV ($1300–$1400) .................................................. S ................. .................... $1,350.00 .................... $270.00
1516 ........... New Technology—Level XVI ($1400–$1500) ................................................. S ................. .................... $1,450.00 .................... $290.00
1517 ........... New Technology—Level XVII ($1500–$1600) ................................................ S ................. .................... $1,550.00 .................... $310.00
1518 ........... New Technology—Level XVIII ($1600–$1700) ............................................... S ................. .................... $1,650.00 .................... $330.00
1519 ........... New Technology—Level IXX ($1700–$1800) ................................................. S ................. .................... $1,750.00 .................... $350.00
1520 ........... New Technology—Level XX ($1800–$1900) .................................................. S ................. .................... $1,850.00 .................... $370.00
1521 ........... New Technology—Level XXI ($1900–$2000) ................................................. S ................. .................... $1,950.00 .................... $390.00
1522 ........... New Technology—Level XXII ($2000–$2500) ................................................ S ................. .................... $2,250.00 .................... $450.00
1523 ........... New Technology—Level XXIII ($2500–$3000) ............................................... S ................. .................... $2,750.00 .................... $550.00
1524 ........... New Technology—Level XXIV ($3000–$3500) ............................................... S ................. .................... $3,250.00 .................... $650.00
1525 ........... New Technology—Level XXV ($3500–$4000) ................................................ S ................. .................... $3,750.00 .................... $750.00
1526 ........... New Technology—Level XXVI ($4000–$4500) ............................................... S ................. .................... $4,250.00 .................... $850.00
1527 ........... New Technology—Level XXVII ($4500–$5000) .............................................. S ................. .................... $4,750.00 .................... $950.00
1528 ........... New Technology—Level XXVIII ($5000–$5500) ............................................. S ................. .................... $5,250.00 .................... $1,050.00
1529 ........... New Technology—Level XXIX ($5500–$6000) ............................................... S ................. .................... $5,750.00 .................... $1,150.00
1530 ........... New Technology—Level XXX ($6000–$6500) ................................................ S ................. .................... $6,250.00 .................... $1,250.00
1531 ........... New Technology—Level XXXI ($6500–$7000) ............................................... S ................. .................... $6,750.00 .................... $1,350.00
1532 ........... New Technology—Level XXXII ($7000–$7500) .............................................. S ................. .................... $7,250.00 .................... $1,450.00
1533 ........... New Technology—Level XXXIII ($7500–$8000) ............................................. S ................. .................... $7,750.00 .................... $1,550.00
1534 ........... New Technology—Level XXXIV ($8000–$8500) ............................................ S ................. .................... $8,250.00 .................... $1,650.00
1535 ........... New Technology—Level XXXV ($8500–$9000) ............................................. S ................. .................... $8,750.00 .................... $1,750.00
1536 ........... New Technology—Level XXXVI ($9000–$9500) ............................................ S ................. .................... $9,250.00 .................... $1,850.00
1537 ........... New Technology—Level XXXVII ($9500–$10000) ......................................... S ................. .................... $9,750.00 .................... $1,950.00
1539 ........... New Technology—Level II ($50–$100) ........................................................... T ................. .................... $75.00 .................... $15.00
1540 ........... New Technology—Level III ($100–$200) ........................................................ T ................. .................... $150.00 .................... $30.00
1541 ........... New Technology—Level IV ($200–$300) ....................................................... T ................. .................... $250.00 .................... $50.00
1542 ........... New Technology—Level V ($300–$400) ........................................................ T ................. .................... $350.00 .................... $70.00
1543 ........... New Technology—Level VI ($400–$500) ....................................................... T ................. .................... $450.00 .................... $90.00
1544 ........... New Technology—Level VII ($500–$600) ...................................................... T ................. .................... $550.00 .................... $110.00
1545 ........... New Technology—Level VIII ($600–$700) ..................................................... T ................. .................... $650.00 .................... $130.00
1546 ........... New Technology—Level IX ($700–$800) ....................................................... T ................. .................... $750.00 .................... $150.00
1547 ........... New Technology—Level X ($800–$900) ........................................................ T ................. .................... $850.00 .................... $170.00
1548 ........... New Technology—Level XI ($900–$1000) ..................................................... T ................. .................... $950.00 .................... $190.00
1549 ........... New Technology—Level XII ($1000–$1100) .................................................. T ................. .................... $1,050.00 .................... $210.00
1550 ........... New Technology—Level XIII ($1100–$1200) ................................................. T ................. .................... $1,150.00 .................... $230.00
1551 ........... New Technology—Level XIV ($1200–$1300) ................................................. T ................. .................... $1,250.00 .................... $250.00
1552 ........... New Technology—Level XV ($1300–$1400) .................................................. T ................. .................... $1,350.00 .................... $270.00
1553 ........... New Technology—Level XVI ($1400–$1500) ................................................. T ................. .................... $1,450.00 .................... $290.00
1554 ........... New Technology—Level XVII ($1500-$1600) ................................................. T ................. .................... $1,550.00 .................... $310.00
1555 ........... New Technology—Level XVIII ($1600–$1700) ............................................... T ................. .................... $1,650.00 .................... $330.00
1556 ........... New Technology—Level XIX ($1700–$1800) ................................................. T ................. .................... $1,750.00 .................... $350.00
1557 ........... New Technology—Level XX ($1800–$1900) .................................................. T ................. .................... $1,850.00 .................... $370.00

National Minimum
Relative Payment
1558 ........... New Technology—Level XXI ($1900–$2000) ................................................. T ................. .................... $1,950.00 .................... $390.00
1559 ........... New Technology—Level XXII ($2000–$2500) ................................................ T ................. .................... $2,250.00 .................... $450.00
1560 ........... New Technology—Level XXIII ($2500–$3000) ............................................... T ................. .................... $2,750.00 .................... $550.00
1561 ........... New Technology—Level XXIV ($3000–$3500) ............................................... T ................. .................... $3,250.00 .................... $650.00
1562 ........... New Technology—Level XXV ($3500–$4000) ................................................ T ................. .................... $3,750.00 .................... $750.00
1563 ........... New Technology—Level XXVI ($4000–$4500) ............................................... T ................. .................... $4,250.00 .................... $850.00
1564 ........... New Technology—Level XXVII ($4500–$5000) .............................................. T ................. .................... $4,750.00 .................... $950.00
1565 ........... New Technology—Level XXVIII ($5000–$5500) ............................................. T ................. .................... $5,250.00 .................... $1,050.00
1566 ........... New Technology—Level XXIX ($5500–$6000) ............................................... T ................. .................... $5,750.00 .................... $1,150.00
1567 ........... New Technology—Level XXX ($6000–$6500) ................................................ T ................. .................... $6,250.00 .................... $1,250.00
1568 ........... New Technology—Level XXXI ($6500–$7000) ............................................... T ................. .................... $6,750.00 .................... $1,350.00
1569 ........... New Technology—Level XXXII ($7000–$7500) .............................................. T ................. .................... $7,250.00 .................... $1,450.00
1570 ........... New Technology—Level XXXIII ($7500–$8000) ............................................. T ................. .................... $7,750.00 .................... $1,550.00
1571 ........... New Technology—Level XXXIV ($8000–$8500) ............................................ T ................. .................... $8,250.00 .................... $1,650.00
1572 ........... New Technology—Level XXXV ($8500–$9000) ............................................. T ................. .................... $8,750.00 .................... $1,750.00
1573 ........... New Technology—Level XXXVI ($9000–$9500) ............................................ T ................. .................... $9,250.00 .................... $1,850.00
1574 ........... New Technology—Level XXXVII ($9500–$10000) ......................................... T ................. .................... $9,750.00 .................... $1,950.00
1605 ........... Abciximab injection .......................................................................................... K ................. .................... $409.26 .................... $81.85
1606 ........... Injection anistreplase 30 u .............................................................................. K ................. 42.2935 $2,693.80 .................... $538.76
1607 ........... Eptifibatide injection ......................................................................................... K ................. .................... $15.90 .................... $3.18
1608 ........... Etanercept injection ......................................................................................... K ................. .................... $160.03 .................... $32.01
1609 ........... Rho(D) immune globulin h, sd ........................................................................ K ................. .................... $15.76 .................... $3.15
1612 ........... Daclizumab, parenteral .................................................................................... K ................. .................... $297.03 .................... $59.41
1613 ........... Trastuzumab .................................................................................................... K ................. .................... $57.33 .................... $11.47
1629 ........... Nonmetabolic act d/e tissue ............................................................................ K ................. .................... $18.13 .................... $3.63
1630 ........... Hep b ig, im ..................................................................................................... K ................. .................... $132.42 .................... $26.48
1631 ........... Baclofen intrathecal trial .................................................................................. K ................. .................... $70.92 .................... $14.18
1632 ........... Metabolic active D/E tissue ............................................................................. K ................. .................... $28.51 .................... $5.70
1633 ........... Alefacept .......................................................................................................... K ................. .................... $25.82 .................... $5.16
1643 ........... Y90 ibritumomab, rx ........................................................................................ K ................. .................... $12,030.02 .................... $2,406.00
1645 ........... I131 tositumomab, rx ....................................................................................... K ................. .................... $8,283.41 .................... $1,656.68
1670 ........... Tetanus immune globulin inj ........................................................................... K ................. .................... $96.35 .................... $19.27
1675 ........... P32 Na phosphate ........................................................................................... K ................. .................... $118.02 .................... $23.60
1676 ........... P32 chromic phosphate ................................................................................... K ................. .................... $122.17 .................... $24.43
1682 ........... Aprotonin, 10,000 kiu ...................................................................................... K ................. .................... $2.50 .................... $0.50
1683 ........... Basiliximab ....................................................................................................... K ................. .................... $1,347.14 .................... $269.43
1684 ........... Corticorelin ovine triflutal ................................................................................. K ................. .................... $4.26 .................... $0.85
1685 ........... Darbepoetin alfa, non-esrd .............................................................................. K ................. .................... $3.11 .................... $0.62
1686 ........... Epoetin alfa, non-esrd ..................................................................................... K ................. .................... $9.36 .................... $1.87
1687 ........... Digoxin immune fab (ovine) ............................................................................ K ................. .................... $511.48 .................... $102.30
1688 ........... Ethanolamine oleate 100 mg .......................................................................... K ................. .................... $78.26 .................... $15.65
1689 ........... Fomepizole, 15 mg .......................................................................................... K ................. .................... $12.28 .................... $2.46
1690 ........... Hemin, 1 mg .................................................................................................... K ................. .................... $6.74 .................... $1.35
1691 ........... Iron dextran 165 injection ................................................................................ K ................. .................... $11.61 .................... $2.32
1692 ........... Iron dextran 267 injection ................................................................................ K ................. .................... $10.32 .................... $2.06
1693 ........... Lepirudin .......................................................................................................... K ................. .................... $153.42 .................... $30.68
1694 ........... Ziconotide injection .......................................................................................... K ................. .................... $6.46 .................... $1.29
1695 ........... Nesiritide injection ........................................................................................... K ................. .................... $31.36 .................... $6.27
1696 ........... Palifermin injection .......................................................................................... K ................. .................... $11.32 .................... $2.26
1697 ........... Pegaptanib sodium injection ........................................................................... K ................. .................... $1,054.70 .................... $210.94
1700 ........... Inj secretin synthetic human ............................................................................ K ................. .................... $20.12 .................... $4.02
1701 ........... Treprostinil injection ......................................................................................... K ................. .................... $55.36 .................... $11.07
1703 ........... Ovine, 1000 USP units .................................................................................... K ................. .................... $133.77 .................... $26.75
1704 ........... Inj Vonwillebrand factor IU .............................................................................. K ................. .................... $0.88 .................... $0.18
1705 ........... Factor viia ........................................................................................................ K ................. .................... $1.11 .................... $0.22
1709 ........... Azacitidine injection ......................................................................................... K ................. .................... $4.26 .................... $0.85
1710 ........... Clofarabine injection ........................................................................................ K ................. .................... $115.64 .................... $23.13
1711 ........... Histrelin implant ............................................................................................... K ................. .................... $1,446.98 .................... $289.40
1712 ........... Paclitaxel protein bound .................................................................................. K ................. .................... $7.03 .................... $1.41
1716 ........... Brachytx source, Gold 198 .............................................................................. K ................. 0.5016 $31.95 .................... $6.39
1717 ........... Brachytx source, HDR Ir–192 ......................................................................... K ................. 2.7225 $173.40 .................... $34.68
1719 ........... Brachytx sour,Non-HDR Ir–192 ....................................................................... K ................. 0.9012 $57.40 .................... $11.48
1738 ........... Oxaliplatin ........................................................................................................ K ................. .................... $8.89 .................... $1.78
1739 ........... Pegademase bovine, 25 iu .............................................................................. K ................. .................... $176.16 .................... $35.23
1740 ........... Diazoxide injection ........................................................................................... K ................. .................... $113.24 .................... $22.65
1741 ........... Urofollitropin, 75 iu .......................................................................................... K ................. .................... $50.22 .................... $10.04
1821 ........... Interspinous implant ........................................................................................ H ................. .................... .................... .................... .
2210 ........... Methyldopate hcl injection ............................................................................... K ................. .................... $10.01 .................... $2.00
2616 ........... Brachytx source, Yttrium-90 ............................................................................ K ................. 187.5212 $11,943.79 .................... $2,388.76
2632 ........... Iodine I-125 sodium iodide .............................................................................. K ................. 0.4494 $28.62 .................... $5.72
2634 ........... Brachytx source, HA, I–125 ............................................................................ K ................. 0.4699 $29.93 .................... $5.99
2635 ........... Brachytx source, HA, P–103 ........................................................................... K ................. 0.7389 $47.06 .................... $9.41
2636 ........... Brachytx linear source, P–103 ........................................................................ K ................. 0.5824 $37.09 .................... $7.42
2731 ........... Immune globulin, powder ................................................................................ K ................. .................... $25.48 .................... $5.10
2732 ........... Immune globulin, liquid .................................................................................... K ................. .................... $30.28 .................... $6.06
2770 ........... Quinupristin/dalfopristin ................................................................................... K ................. .................... $116.70 .................... $23.34
2940 ........... Somatrem injection .......................................................................................... K ................. 1.0916 $69.53 .................... $13.91
3030 ........... Sumatriptan succinate/6 MG ........................................................................... K ................. .................... $58.82 .................... $11.76
3041 ........... Bivalirudin ........................................................................................................ K ................. .................... $1.72 .................... $0.34

National Minimum
Relative Payment
3050 ........... Sermorelin acetate injection ............................................................................ K ................. .................... $1.74 .................... $0.35
7000 ........... Amifostine ........................................................................................................ K ................. .................... $476.10 .................... $95.22
7005 ........... Gonadorelin hydroch/100 mcg ........................................................................ K ................. .................... $178.59 .................... $35.72
7011 ........... Oprelvekin injection ......................................................................................... K ................. .................... $244.98 .................... $49.00
7015 ........... Oral busulfan ................................................................................................... K ................. .................... $2.12 .................... $0.42
7028 ........... Fosphenytoin, 50 mg ....................................................................................... K ................. .................... $5.50 .................... $1.10
7034 ........... Somatropin injection ........................................................................................ K ................. .................... $46.75 .................... $9.35
7035 ........... Teniposide, 50 mg ........................................................................................... K ................. .................... $261.93 .................... $52.39
7036 ........... Urokinase 250,000 IU inj ................................................................................. K ................. .................... $453.41 .................... $90.68
7038 ........... Monoclonal antibodies ..................................................................................... K ................. .................... $886.70 .................... $177.34
7041 ........... Tirofiban HCl .................................................................................................... K ................. .................... $7.66 .................... $1.53
7042 ........... Capecitabine, oral, 150 mg ............................................................................. K ................. .................... $3.94 .................... $0.79
7043 ........... Infliximab injection ........................................................................................... K ................. .................... $53.25 .................... $10.65
7045 ........... Inj trimetrexate glucoronate ............................................................................. K ................. .................... $143.89 .................... $28.78
7046 ........... Doxorubicin hcl liposome inj ............................................................................ K ................. .................... $385.81 .................... $77.16
7048 ........... Alteplase recombinant ..................................................................................... K ................. .................... $32.48 .................... $6.50
7049 ........... Filgrastim 480 mcg injection ............................................................................ K ................. .................... $297.75 .................... $59.55
7051 ........... Leuprolide acetate implant .............................................................................. K ................. .................... $1,696.96 .................... $339.39
7308 ........... Aminolevulinic acid hcl top .............................................................................. K ................. .................... $104.43 .................... $20.89
8000 ........... Cardiac Electrophysiologic Evaluation and Ablation Composite ..................... T ................. 135.5822 $8,635.64 .................... $1,727.13
8001 ........... LDR Prostate Brachytherapy Composite ........................................................ T ................. 49.7153 $3,166.52 .................... $633.30
9001 ........... Linezolid injection ............................................................................................ K ................. .................... $24.93 .................... $4.99
9002 ........... Tenecteplase injection ..................................................................................... K ................. .................... $2,024.13 .................... $404.83
9003 ........... Palivizumab, per 50 mg ................................................................................... K ................. .................... $677.97 .................... $135.59
9004 ........... Gemtuzumab ozogamicin ................................................................................ K ................. .................... $2,334.75 .................... $466.95
9005 ........... Reteplase injection .......................................................................................... K ................. .................... $891.03 .................... $178.21
9006 ........... Tacrolimus injection ......................................................................................... K ................. .................... $139.11 .................... $27.82
9012 ........... Arsenic trioxide ................................................................................................ K ................. .................... $33.84 .................... $6.77
9015 ........... Mycophenolate mofetil oral ............................................................................. K ................. .................... $2.60 .................... $0.52
9018 ........... Botulinum toxin type B .................................................................................... K ................. .................... $8.30 .................... $1.66
9019 ........... Caspofungin acetate ........................................................................................ K ................. .................... $30.07 .................... $6.01
9020 ........... Sirolimus, oral .................................................................................................. K ................. .................... $7.15 .................... $1.43
9022 ........... IM inj interferon beta 1–a ................................................................................ K ................. .................... $113.49 .................... $22.70
9023 ........... Rho d immune globulin 50 mcg ...................................................................... K ................. .................... $26.41 .................... $5.28
9024 ........... Amphotericin b lipid complex .......................................................................... K ................. .................... $10.28 .................... $2.06
9032 ........... Baclofen 10 MG injection ................................................................................ K ................. .................... $195.18 .................... $39.04
9033 ........... Cidofovir injection ............................................................................................ K ................. .................... $754.62 .................... $150.92
9038 ........... Inj estrogen conjugate 25 MG ......................................................................... K ................. .................... $60.32 .................... $12.06
9042 ........... Glucagon hydrochloride/1 MG ......................................................................... K ................. .................... $65.64 .................... $13.13
9044 ........... Ibutilide fumarate injection ............................................................................... K ................. .................... $264.40 .................... $52.88
9046 ........... Iron sucrose injection ...................................................................................... K ................. .................... $0.37 .................... $0.08
9047 ........... Itraconazole injection ....................................................................................... K ................. .................... $38.05 .................... $7.61
9051 ........... Urea injection ................................................................................................... K ................. .................... $73.46 .................... $14.69
9054 ........... Metabolically active tissue ............................................................................... K ................. .................... $31.36 .................... $6.27
9104 ........... Antithymocyte globuln rabbit ........................................................................... K ................. .................... $324.66 .................... $64.93
9108 ........... Thyrotropin injection ........................................................................................ K ................. .................... $758.16 .................... $151.63
9110 ........... Alemtuzumab injection .................................................................................... K ................. .................... $536.10 .................... $107.22
9115 ........... Zoledronic acid ................................................................................................ K ................. .................... $204.09 .................... $40.82
9119 ........... Injection, pegfilgrastim 6mg ............................................................................. K ................. .................... $2,142.92 .................... $428.58
9120 ........... Injection, Fulvestrant ....................................................................................... K ................. .................... $79.80 .................... $15.96
9121 ........... Injection, argatroban ........................................................................................ K ................. .................... $17.87 .................... $3.57
9122 ........... Triptorelin pamoate .......................................................................................... K ................. .................... $153.97 .................... $30.79
9124 ........... Daptomycin injection ....................................................................................... K ................. .................... $0.33 .................... $0.07
9125 ........... Risperidone, long acting .................................................................................. K ................. .................... $4.80 .................... $0.96
9126 ........... Natalizumab injection ...................................................................................... K ................. .................... $7.45 .................... $1.49
9133 ........... Rabies ig, im/sc ............................................................................................... K ................. .................... $64.82 .................... $12.96
9134 ........... Rabies ig, heat treated .................................................................................... K ................. .................... $69.40 .................... $13.88
9135 ........... Varicella-zoster ig, im ...................................................................................... K ................. .................... $121.58 .................... $24.32
9137 ........... Bcg vaccine, percut ......................................................................................... K ................. .................... $112.56 .................... $22.51
9139 ........... Rabies vaccine, im .......................................................................................... K ................. .................... $145.53 .................... $29.11
9140 ........... Rabies vaccine, id ........................................................................................... K ................. 1.9483 $124.09 .................... $24.82
9141 ........... Measles-rubella vaccine, sc ............................................................................ K ................. 0.9593 $61.10 .................... $12.22
9143 ........... Meningococcal vaccine, sc .............................................................................. K ................. .................... $88.59 .................... $17.72
9144 ........... Encephalitis vaccine, sc .................................................................................. K ................. .................... $98.17 .................... $19.63
9145 ........... Meningococcal vaccine, im ............................................................................. K ................. 1.1309 $72.03 .................... $14.41
9156 ........... Nonmetabolic active tissue .............................................................................. K ................. .................... $88.37 .................... $17.67
9167 ........... Valrubicin, 200 mg ........................................................................................... K ................. 3.4445 $219.39 .................... $43.88
9207 ........... Bortezomib injection ........................................................................................ K ................. .................... $32.37 .................... $6.47
9208 ........... Agalsidase beta injection ................................................................................. K ................. .................... $126.00 .................... $25.20
9209 ........... Laronidase injection ......................................................................................... K ................. .................... $23.64 .................... $4.73
9210 ........... Palonosetron HCl ............................................................................................ K ................. .................... $15.85 .................... $3.17
9213 ........... Pemetrexed injection ....................................................................................... K ................. .................... $43.38 .................... $8.68
9214 ........... Bevacizumab injection ..................................................................................... K ................. .................... $56.98 .................... $11.40
9215 ........... Cetuximab injection ......................................................................................... K ................. .................... $49.34 .................... $9.87
9216 ........... Abarelix injection ............................................................................................. K ................. .................... $67.97 .................... $13.59
9217 ........... Leuprolide acetate suspnsion .......................................................................... K ................. .................... $227.34 .................... $45.47
9219 ........... Mycophenolic acid ........................................................................................... K ................. .................... $2.25 .................... $0.45
9222 ........... Injectable human tissue ................................................................................... K ................. .................... $728.44 .................... $145.69
9224 ........... Galsulfase injection ......................................................................................... K ................. .................... $297.09 .................... $59.42
9225 ........... Fluocinolone acetonide implt ........................................................................... K ................. .................... $19,162.50 .................... $3,832.50

National Minimum
Relative Payment
9227 ........... Micafungin sodium injection ............................................................................ G ................ .................... $1.71 .................... $0.34
9228 ........... Tigecycline injection ........................................................................................ G ................ .................... $0.91 .................... $0.18
9229 ........... Ibandronate sodium injection .......................................................................... G ................ .................... $138.71 .................... $27.74
9230 ........... Abatacept injection .......................................................................................... G ................ .................... $18.69 .................... $3.74
9231 ........... Decitabine injection ......................................................................................... G ................ 0.4157 $26.48 .................... $5.30
9232 ........... Injection, idursulfase ........................................................................................ G ................ .................... $455.03 .................... $91.01
9233 ........... Injection, ranibizumab ...................................................................................... G ................ .................... $2,030.92 .................... $406.18
9234 ........... Inj, alglucosidase alfa ...................................................................................... K ................. .................... $126.00 .................... $25.20
9235 ........... Injection, panitumumab ................................................................................... G ................ .................... $84.80 .................... $16.96
9300 ........... Omalizumab injection ...................................................................................... K ................. .................... $16.79 .................... $3.36
9350 ........... Porous collagen tube per cm .......................................................................... G ................ .................... $485.91 .................... $97.18
9351 ........... Acellular derm tissue percm2 .......................................................................... G ................ .................... $41.59 .................... $8.32
9500 ........... Platelets, irradiated .......................................................................................... K ................. 2.0742 $132.11 .................... $26.42
9501 ........... Platelet pheres leukoreduced .......................................................................... K ................. 7.9954 $509.25 .................... $101.85
9502 ........... Platelet pheresis irradiated .............................................................................. K ................. 7.0075 $446.33 .................... $89.27
9503 ........... Fr frz plasma donor retested ........................................................................... K ................. 1.1632 $74.09 .................... $14.82
9504 ........... RBC deglycerolized ......................................................................................... K ................. 5.7938 $369.02 .................... $73.80
9505 ........... RBC irradiated ................................................................................................. K ................. 3.3259 $211.84 .................... $42.37
9506 ........... Granulocytes, pheresis unit ............................................................................. K ................. 15.5519 $990.55 .................... $198.11
9507 ........... Platelets, pheresis ........................................................................................... K ................. 7.0406 $448.44 .................... $89.69
9508 ........... Plasma 1 donor frz w/in 8 hr ........................................................................... K ................. 1.0902 $69.44 .................... $13.89
ADDENDUM AA.—PROPOSED ASC COVERED SURGICAL PROCEDURES FOR CY 2008 (INCLUDING SURGICAL PROCEDURES
FOR WHICH PAYMENT IS PACKAGED)
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
HCPCS multiple pro- Comment in- Payment in- fully imple-
Short Descriptor ASC pay- fully imple- first transi-
Code cedure dis- dicator dicator mented pay-
ment rate mented pay- tion year
counting ment weight ment payment
0016T ......... Thermotx choroid vasc lesion ........................ Y ................. .................... R2 ............... .................... 4.0100 $166.01 $166.01
0017T ......... Photocoagulat macular drusen ...................... Y ................. .................... R2 ............... .................... 4.0100 $166.01 $166.01
0027T ......... Endoscopic epidural lysis ............................... Y ................. .................... G2 .............. .................... 18.5069 $766.19 $766.19
0031T ......... Speculoscopy ................................................. N ................. .................... N1 .............. .................... .................... .................... ....................
0032T ......... Speculoscopy w/direct sample ....................... N ................. .................... N1 ............... .................... .................... .................... ....................
0046T ......... Cath lavage, mammary duct(s) ...................... Y ................. .................... R2 ............... .................... 16.5832 $686.54 $686.54
0047T ......... Cath lavage, mammary duct(s) ...................... Y ................. .................... R2 ............... .................... 16.5832 $686.54 $686.54
0062T ......... Rep intradisc annulus; 1 lev ........................... Y ................. .................... G2 .............. .................... 29.3263 $1,214.11 $1,214.11
0063T ......... Rep intradisc annulus; >1 lev ........................ Y ................. .................... G2 .............. .................... 29.3263 $1,214.11 $1,214.11
0084T ......... Temp prostate urethral stent .......................... Y ................. .................... G2 .............. .................... 2.1659 $89.67 $89.67
0099T* ........ Implant corneal ring ........................................ Y ................. .................... R2 ............... .................... 16.5252 $684.14 $684.14
0100T ......... Prosth retina receive&gen .............................. Y ................. .................... G2 .............. .................... 38.1121 $1,577.84 $1,577.84
0101T ......... Extracorp shockwv tx,hi enrg ......................... Y ................. .................... G2 .............. .................... 29.3263 $1,214.11 $1,214.11
0102T ......... Extracorp shockwv tx,anesth ......................... Y ................. .................... G2 .............. .................... 29.3263 $1,214.11 $1,214.11
0123T ......... Scleral fistulization .......................................... Y ................. .................... G2 .............. .................... 24.0821 $997.00 $997.00
0124T* ........ Conjunctival drug placement .......................... Y ................. .................... R2 ............... .................... 5.1145 $211.74 $211.74
0133T ......... Esophageal implant injexn ............................. Y ................. .................... G2 .............. .................... 24.6480 $1,020.43 $1,020.43
0176T ......... Aqu canal dilat w/o retent .............................. Y ................. .................... A2 ............... $1,339.00 40.8481 $1,691.11 $1,427.03
0177T ......... Aqu canal dilat w retent ................................. Y ................. .................... A2 ............... $1,339.00 40.8481 $1,691.11 $1,427.03
10021 .......... Fna w/o image ................................................ Y ................. .................... P2 ............... .................... 1.1915 $49.33 $49.33
10022 .......... Fna w/image ................................................... Y ................. .................... G2 .............. .................... 4.5062 $186.56 $186.56
10040 .......... Acne surgery .................................................. Y ................. .................... P2 ............... .................... 0.8046 $33.31 $33.31
10060 .......... Drainage of skin abscess ............................... Y ................. .................... P3 ............... .................... 1.1130 $46.08 $46.08
10061 .......... Drainage of skin abscess ............................... Y ................. .................... P2 ............... .................... 1.4630 $60.57 $60.57
10080 .......... Drainage of pilonidal cyst ............................... Y ................. .................... P2 ............... .................... 1.4630 $60.57 $60.57
10081 .......... Drainage of pilonidal cyst ............................... Y ................. .................... P3 ............... .................... 3.1002 $128.35 $128.35
10120 .......... Remove foreign body ..................................... Y ................. .................... P2 ............... .................... 1.4630 $60.57 $60.57
10121 .......... Remove foreign body ..................................... Y ................. .................... A2 ............... $446.00 16.5832 $686.54 $506.14
10140 .......... Drainage of hematoma/fluid ........................... Y ................. .................... P3 ............... .................... 1.6490 $68.27 $68.27
10160 .......... Puncture drainage of lesion ........................... Y ................. CH .............. P3 ............... .................... 1.4099 $58.37 $58.37
10180 .......... Complex drainage, wound ............................. Y ................. .................... A2 ............... $446.00 19.0457 $788.49 $531.62
11000 .......... Debride infected skin ...................................... Y ................. .................... P3 ............... .................... 0.5360 $22.19 $22.19
11001 .......... Debride infected skin add-on ......................... Y ................. .................... P3 ............... .................... 0.1896 $7.85 $7.85
11010 .......... Debride skin, fx .............................................. Y ................. .................... A2 ............... $251.52 4.4463 $184.08 $234.66
11011 .......... Debride skin/muscle, fx .................................. Y ................. .................... A2 ............... $251.52 4.4463 $184.08 $234.66
11012 .......... Debride skin/muscle/bone, fx ......................... Y ................. .................... A2 ............... $251.52 4.4463 $184.08 $234.66
11040 .......... Debride skin, partial ....................................... Y ................. .................... P3 ............... .................... 0.4865 $20.14 $20.14
11041 .......... Debride skin, full ............................................. Y ................. .................... P3 ............... .................... 0.5688 $23.55 $23.55
11042 .......... Debride skin/tissue ......................................... Y ................. .................... A2 ............... $164.42 2.7493 $113.82 $151.77
11043 .......... Debride tissue/muscle .................................... Y ................. .................... A2 ............... $164.42 2.7493 $113.82 $151.77
11044 .......... Debride tissue/muscle/bone ........................... Y ................. .................... A2 ............... $423.10 7.1126 $294.46 $390.94
11055 .......... Trim skin lesion .............................................. Y ................. .................... P3 ............... .................... 0.5606 $23.21 $23.21
11056 .......... Trim skin lesions, 2 to 4 ................................. Y ................. .................... P3 ............... .................... 0.6184 $25.60 $25.60
11057 .......... Trim skin lesions, over 4 ................................ Y ................. .................... P3 ............... .................... 0.7092 $29.36 $29.36
11100 .......... Biopsy, skin lesion .......................................... Y ................. .................... P2 ............... .................... 0.8046 $33.31 $33.31
11101 .......... Biopsy, skin add-on ........................................ Y ................. .................... P3 ............... .................... 0.3051 $12.63 $12.63
11200 .......... Removal of skin tags ...................................... Y ................. CH .............. P2 ............... .................... 0.8046 $33.31 $33.31
11201 .......... Remove skin tags add-on .............................. Y ................. .................... P3 ............... .................... 0.1319 $5.46 $5.46
11300 .......... Shave skin lesion ........................................... Y ................. .................... P2 ............... .................... 0.8046 $33.31 $33.31
11306 .......... Shave skin lesion ........................................... Y ................. CH .............. P2 ............... .................... 0.8046 $33.31 $33.31
11400 .......... Exc tr-ext b9+marg 0.5 < cm ......................... Y ................. .................... P3 ............... .................... 1.5913 $65.88 $65.88
11401 .......... Exc tr-ext b9+marg 0.6–1 cm ........................ Y ................. .................... P3 ............... .................... 1.7396 $72.02 $72.02
11404 .......... Exc tr-ext b9+marg 3.1–4 cm ........................ Y ................. .................... A2 ............... $333.00 16.5832 $686.54 $421.39
11406 .......... Exc tr-ext b9+marg > 4.0 cm ......................... Y ................. .................... A2 ............... $446.00 16.5832 $686.54 $506.14
11420 .......... Exc h-f-nk-sp b9+marg 0.5 < ......................... Y ................. .................... P3 ............... .................... 1.4758 $61.10 $61.10
11421 .......... Exc h-f-nk-sp b9+marg 0.6–1 ........................ Y ................. .................... P3 ............... .................... 1.7563 $72.71 $72.71
11424 .......... Exc h-f-nk-sp b9+marg 3.1–4 ........................ Y ................. .................... A2 ............... $446.00 16.5832 $686.54 $506.14
11426 .......... Exc h-f-nk-sp b9+marg > 4 cm ...................... Y ................. .................... A2 ............... $446.00 21.4534 $888.17 $556.54
11440 .......... Exc face-mm b9+marg 0.5 < cm ................... Y ................. .................... P3 ............... .................... 1.7314 $71.68 $71.68
11441 .......... Exc face-mm b9+marg 0.6–1 cm ................... Y ................. .................... P3 ............... .................... 1.9459 $80.56 $80.56
FOR WHICH PAYMENT IS PACKAGED)—Continued
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
11444 .......... Exc face-mm b9+marg 3.1–4 cm ................... Y ................. .................... A2 ............... $333.00 8.7155 $360.82 $339.96
11446 .......... Exc face-mm b9+marg > 4 cm ...................... Y ................. .................... A2 ............... $446.00 21.4534 $888.17 $556.54
11450 .......... Removal, sweat gland lesion ......................... Y ................. .................... A2 ............... $446.00 21.4534 $888.17 $556.54
11600 .......... Exc tr-ext mlg+marg 0.5 < cm ....................... Y ................. .................... P3 ............... .................... 2.2097 $91.48 $91.48
11601 .......... Exc tr-ext mlg+marg 0.6–1 cm ....................... Y ................. .................... P3 ............... .................... 2.5312 $104.79 $104.79
11604 .......... Exc tr-ext mlg+marg 3.1–4 cm ....................... Y ................. .................... A2 ............... $418.49 8.7155 $360.82 $404.07
11606 .......... Exc tr-ext mlg+marg > 4 cm .......................... Y ................. .................... A2 ............... $446.00 16.5832 $686.54 $506.14
11620 .......... Exc h-f-nk-sp mlg+marg 0.5 < ....................... Y ................. .................... P3 ............... .................... 2.2428 $92.85 $92.85
11621 .......... Exc h-f-nk-sp mlg+marg 0.6–1 ....................... Y ................. .................... P3 ............... .................... 2.5560 $105.82 $105.82
11624 .......... Exc h-f-nk-sp mlg+marg 3.1–4 ....................... Y ................. .................... A2 ............... $446.00 16.5832 $686.54 $506.14
11626 .......... Exc h-f-nk-sp mlg+mar > 4 cm ...................... Y ................. .................... A2 ............... $446.00 21.4534 $888.17 $556.54
11640 .......... Exc face-mm malig+marg 0.5 < ..................... Y ................. .................... P3 ............... .................... 2.3498 $97.28 $97.28
11641 .......... Exc face-mm malig+marg 0.6–1 .................... Y ................. .................... P3 ............... .................... 2.7457 $113.67 $113.67
11644 .......... Exc face-mm malig+marg 3.1–4 .................... Y ................. .................... A2 ............... $446.00 16.5832 $686.54 $506.14
11646 .......... Exc face-mm mlg+marg > 4 cm ..................... Y ................. .................... A2 ............... $446.00 21.4534 $888.17 $556.54
11719 .......... Trim nail(s) ..................................................... Y ................. .................... P3 ............... .................... 0.2556 $10.58 $10.58
11720 .......... Debride nail, 1–5 ............................................ Y ................. .................... P3 ............... .................... 0.3297 $13.65 $13.65
11721 .......... Debride nail, 6 or more .................................. Y ................. .................... P3 ............... .................... 0.4041 $16.73 $16.73
11730 .......... Removal of nail plate ..................................... Y ................. CH .............. P2 ............... .................... 0.8046 $33.31 $33.31
11732 .......... Remove nail plate, add-on ............................. Y ................. .................... P3 ............... .................... 0.4041 $16.73 $16.73
11740 .......... Drain blood from under nail ........................... Y ................. CH .............. P2 ............... .................... 0.2682 $11.10 $11.10
11750 .......... Removal of nail bed ....................................... Y ................. .................... P3 ............... .................... 2.0942 $86.70 $86.70
11752 .......... Remove nail bed/finger tip ............................. Y ................. .................... P3 ............... .................... 2.8940 $119.81 $119.81
11755 .......... Biopsy, nail unit .............................................. Y ................. .................... P3 ............... .................... 1.4758 $61.10 $61.10
11760 .......... Repair of nail bed ........................................... Y ................. .................... G2 .............. .................... 2.1114 $87.41 $87.41
11762 .......... Reconstruction of nail bed ............................. Y ................. CH .............. P3 ............... .................... 2.6961 $111.62 $111.62
11765 .......... Excision of nail fold, toe ................................. Y ................. .................... P2 ............... .................... 1.5119 $62.59 $62.59
11770 .......... Removal of pilonidal lesion ............................ Y ................. .................... A2 ............... $510.00 21.4534 $888.17 $604.54
11900 .......... Injection into skin lesions ............................... Y ................. .................... P3 ............... .................... 0.6514 $26.97 $26.97
11901 .......... Added skin lesions injection ........................... Y ................. .................... P3 ............... .................... 0.6925 $28.67 $28.67
11920 .......... Correct skin color defects .............................. Y ................. .................... P2 ............... .................... 2.1114 $87.41 $87.41
11950 .......... Therapy for contour defects ........................... Y ................. .................... P3 ............... .................... 0.8329 $34.48 $34.48
11952 .......... Therapy for contour defects ........................... Y ................. CH .............. P2 ............... .................... 1.3340 $55.23 $55.23
11960 .......... Insert tissue expander(s) ................................ Y ................. .................... A2 ............... $446.00 20.9338 $866.66 $551.17
11970 .......... Replace tissue expander ................................ Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
11971 .......... Remove tissue expander(s) ........................... Y ................. .................... A2 ............... $333.00 21.4534 $888.17 $471.79
11976 .......... Removal of contraceptive cap ........................ Y ................. .................... P3 ............... .................... 1.4181 $58.71 $58.71
11980 .......... Implant hormone pellet(s) .............................. N ................. .................... P2 ............... .................... 0.6416 $26.56 $26.56
11981 .......... Insert drug implant device .............................. N ................. .................... P2 ............... .................... 0.6416 $26.56 $26.56
11982 .......... Remove drug implant device ......................... N ................. .................... P2 ............... .................... 0.6416 $26.56 $26.56
11983 .......... Remove/insert drug implant ........................... N ................. .................... P2 ............... .................... 0.6416 $26.56 $26.56
12001 .......... Repair superficial wound(s) ............................ Y ................. .................... P2 ............... .................... 1.3340 $55.23 $55.23
12005 .......... Repair superficial wound(s) ............................ Y ................. .................... A2 ............... $91.24 1.3340 $55.23 $82.24
12015 .......... Repair superficial wound(s) ............................ Y ................. .................... G2 .............. .................... 1.3340 $55.23 $55.23
12020 .......... Closure of split wound .................................... Y ................. .................... A2 ............... $91.24 4.6816 $193.82 $116.89
12021 .......... Closure of split wound .................................... Y ................. .................... A2 ............... $91.24 4.6816 $193.82 $116.89
12031 .......... Layer closure of wound(s) .............................. Y ................. .................... P2 ............... .................... 2.1114 $87.41 $87.41
12034 .......... Layer closure of wound(s) .............................. Y ................. .................... A2 ............... $91.24 2.1114 $87.41 $90.28
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
13100 .......... Repair of wound or lesion .............................. Y ................. .................... A2 ............... $323.28 4.6816 $193.82 $290.92
13102 .......... Repair wound/lesion add-on .......................... Y ................. .................... A2 ............... $91.24 4.6816 $193.82 $116.89
13160 .......... Late closure of wound .................................... Y ................. .................... A2 ............... $446.00 20.9338 $866.66 $551.17
14000 .......... Skin tissue rearrangement ............................. Y ................. .................... A2 ............... $446.00 15.4399 $639.21 $494.30
15002 .......... Wnd prep, ch/inf, trk/arm/lg ............................ Y ................. .................... A2 ............... $323.28 4.6816 $193.82 $290.92
15003 .......... Wnd prep, ch/inf addl 100 cm ........................ Y ................. .................... A2 ............... $323.28 4.6816 $193.82 $290.92
15004 .......... Wnd prep ch/inf, f/n/hf/g ................................. Y ................. .................... A2 ............... $323.28 4.6816 $193.82 $290.92
15005 .......... Wnd prep, f/n/hf/g, addl cm ............................ Y ................. .................... A2 ............... $323.28 4.6816 $193.82 $290.92
15040 .......... Harvest cultured skin graft ............................. Y ................. .................... A2 ............... $91.24 2.1114 $87.41 $90.28
15050 .......... Skin pinch graft .............................................. Y ................. .................... A2 ............... $323.28 4.6816 $193.82 $290.92
15100 .......... Skin splt grft, trnk/arm/leg .............................. Y ................. .................... A2 ............... $446.00 20.9338 $866.66 $551.17
15101 .......... Skin splt grft t/a/l, add-on ............................... Y ................. .................... A2 ............... $510.00 20.9338 $866.66 $599.17
15110 .......... Epidrm autogrft trnk/arm/leg ........................... Y ................. .................... A2 ............... $446.00 4.6816 $193.82 $382.96
15111 .......... Epidrm autogrft t/a/l add-on ........................... Y ................. .................... A2 ............... $333.00 4.6816 $193.82 $298.21
15115 .......... Epidrm a-grft face/nck/hf/g ............................. Y ................. .................... A2 ............... $446.00 4.6816 $193.82 $382.96
15116 .......... Epidrm a-grft f/n/hf/g addl .............................. Y ................. .................... A2 ............... $333.00 4.6816 $193.82 $298.21
15120 .......... Skn splt a-grft fac/nck/hf/g ............................. Y ................. .................... A2 ............... $446.00 20.9338 $866.66 $551.17
15121 .......... Skn splt a-grft f/n/hf/g add .............................. Y ................. .................... A2 ............... $510.00 20.9338 $866.66 $599.17
15130 .......... Derm autograft, trnk/arm/leg .......................... Y ................. .................... A2 ............... $446.00 15.4399 $639.21 $494.30
15131 .......... Derm autograft t/a/l add-on ............................ Y ................. .................... A2 ............... $333.00 15.4399 $639.21 $409.55
15135 .......... Derm autograft face/nck/hf/g .......................... Y ................. .................... A2 ............... $446.00 15.4399 $639.21 $494.30
15136 .......... Derm autograft, f/n/hf/g add ........................... Y ................. .................... A2 ............... $333.00 15.4399 $639.21 $409.55
15150 .......... Cult epiderm grft t/arm/leg ............................. Y ................. .................... A2 ............... $446.00 4.6816 $193.82 $382.96
15151 .......... Cult epiderm grft t/a/l addl .............................. Y ................. .................... A2 ............... $333.00 4.6816 $193.82 $298.21
15152 .......... Cult epiderm graft t/a/l +% ............................. Y ................. .................... A2 ............... $333.00 4.6816 $193.82 $298.21
15155 .......... Cult epiderm graft, f/n/hf/g ............................. Y ................. .................... A2 ............... $446.00 4.6816 $193.82 $382.96
15156 .......... Cult epidrm grft f/n/hfg add ............................ Y ................. .................... A2 ............... $333.00 4.6816 $193.82 $298.21
15157 .......... Cult epiderm grft f/n/hfg +% ........................... Y ................. .................... A2 ............... $333.00 4.6816 $193.82 $298.21
15200 .......... Skin full graft, trunk ........................................ Y ................. .................... A2 ............... $510.00 15.4399 $639.21 $542.30
15201 .......... Skin full graft trunk add-on ............................. Y ................. .................... A2 ............... $323.28 15.4399 $639.21 $402.26
15220 .......... Skin full graft sclp/arm/leg .............................. Y ................. .................... A2 ............... $446.00 15.4399 $639.21 $494.30
15221 .......... Skin full graft add-on ...................................... Y ................. .................... A2 ............... $323.28 4.6816 $193.82 $290.92
15240 .......... Skin full grft face/genit/hf ................................ Y ................. .................... A2 ............... $510.00 15.4399 $639.21 $542.30
15260 .......... Skin full graft een & lips ................................. Y ................. .................... A2 ............... $446.00 15.4399 $639.21 $494.30
15300 .......... Apply skinallogrft, t/arm/lg .............................. Y ................. .................... A2 ............... $323.28 4.6816 $193.82 $290.92
15301 .......... Apply sknallogrft t/a/l addl .............................. Y ................. .................... A2 ............... $323.28 4.6816 $193.82 $290.92
15320 .......... Apply skin allogrft f/n/hf/g ............................... Y ................. .................... A2 ............... $323.28 4.6816 $193.82 $290.92
15321 .......... Aply sknallogrft f/n/hfg add ............................. Y ................. .................... A2 ............... $323.28 4.6816 $193.82 $290.92
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
15330 .......... Aply acell alogrft t/arm/leg .............................. Y ................. .................... A2 ............... $323.28 4.6816 $193.82 $290.92
15331 .......... Aply acell grft t/a/l add-on .............................. Y ................. .................... A2 ............... $323.28 4.6816 $193.82 $290.92
15335 .......... Apply acell graft, f/n/hf/g ................................ Y ................. .................... A2 ............... $323.28 4.6816 $193.82 $290.92
15336 .......... Aply acell grft f/n/hf/g add .............................. Y ................. .................... A2 ............... $323.28 4.6816 $193.82 $290.92
15340 .......... Apply cult skin substitute ................................ Y ................. .................... G2 .............. .................... 2.1114 $87.41 $87.41
15341 .......... Apply cult skin sub add-on ............................. Y ................. .................... G2 .............. .................... 2.1114 $87.41 $87.41
15360 .......... Apply cult derm sub, t/a/l ............................... Y ................. .................... G2 .............. .................... 2.1114 $87.41 $87.41
15361 .......... Aply cult derm sub t/a/l add ........................... Y ................. .................... G2 .............. .................... 2.1114 $87.41 $87.41
15365 .......... Apply cult derm sub f/n/hf/g ........................... Y ................. .................... G2 .............. .................... 2.1114 $87.41 $87.41
15366 .......... Apply cult derm f/hf/g add .............................. Y ................. .................... G2 .............. .................... 2.1114 $87.41 $87.41
15400 .......... Apply skin xenograft, t/a/l ............................... Y ................. .................... A2 ............... $323.28 4.6816 $193.82 $290.92
15401 .......... Apply skn xenogrft t/a/l add ........................... Y ................. .................... A2 ............... $323.28 4.6816 $193.82 $290.92
15420 .......... Apply skin xgraft, f/n/hf/g ................................ Y ................. .................... A2 ............... $323.28 4.6816 $193.82 $290.92
15421 .......... Apply skn xgrft f/n/hf/g add ............................ Y ................. .................... A2 ............... $323.28 4.6816 $193.82 $290.92
15430 .......... Apply acellular xenograft ................................ Y ................. .................... A2 ............... $323.28 4.6816 $193.82 $290.92
15431 .......... Apply acellular xgraft add ............................... Y ................. .................... A2 ............... $323.28 4.6816 $193.82 $290.92
15570 .......... Form skin pedicle flap .................................... Y ................. .................... A2 ............... $510.00 20.9338 $866.66 $599.17
15600 .......... Skin graft ........................................................ Y ................. .................... A2 ............... $510.00 20.9338 $866.66 $599.17
15610 .......... Skin graft ........................................................ Y ................. .................... A2 ............... $510.00 20.9338 $866.66 $599.17
15620 .......... Skin graft ........................................................ Y ................. .................... A2 ............... $630.00 20.9338 $866.66 $689.17
15630 .......... Skin graft ........................................................ Y ................. .................... A2 ............... $510.00 20.9338 $866.66 $599.17
15650 .......... Transfer skin pedicle flap ............................... Y ................. .................... A2 ............... $717.00 20.9338 $866.66 $754.42
15731 .......... Forehead flap w/vasc pedicle ........................ Y ................. .................... A2 ............... $510.00 20.9338 $866.66 $599.17
15732 .......... Muscle-skin graft, head/neck ......................... Y ................. .................... A2 ............... $510.00 20.9338 $866.66 $599.17
15734 .......... Muscle-skin graft, trunk .................................. Y ................. .................... A2 ............... $510.00 20.9338 $866.66 $599.17
15736 .......... Muscle-skin graft, arm .................................... Y ................. .................... A2 ............... $510.00 20.9338 $866.66 $599.17
15738 .......... Muscle-skin graft, leg ..................................... Y ................. .................... A2 ............... $510.00 20.9338 $866.66 $599.17
15740 .......... Island pedicle flap graft .................................. Y ................. .................... A2 ............... $446.00 15.4399 $639.21 $494.30
15750 .......... Neurovascular pedicle graft ........................... Y ................. .................... A2 ............... $446.00 20.9338 $866.66 $551.17
15760 .......... Composite skin graft ...................................... Y ................. .................... A2 ............... $446.00 20.9338 $866.66 $551.17
15770 .......... Derma-fat-fascia graft ..................................... Y ................. .................... A2 ............... $510.00 20.9338 $866.66 $599.17
15775 .......... Hair transplant punch grafts ........................... Y ................. .................... A2 ............... $323.28 1.3340 $55.23 $256.27
15776 .......... Hair transplant punch grafts ........................... Y ................. .................... A2 ............... $323.28 1.3340 $55.23 $256.27
15780 .......... Abrasion treatment of skin ............................. Y ................. .................... P3 ............... .................... 9.5232 $394.26 $394.26
15786 .......... Abrasion, lesion, single .................................. Y ................. .................... P2 ............... .................... 0.8046 $33.31 $33.31
15787 .......... Abrasion, lesions, add-on ............................... Y ................. .................... P3 ............... .................... 0.7915 $32.77 $32.77
15788 .......... Chemical peel, face, epiderm ........................ Y ................. .................... P2 ............... .................... 0.8046 $33.31 $33.31
15789 .......... Chemical peel, face, dermal .......................... Y ................. .................... P2 ............... .................... 1.5119 $62.59 $62.59
15792 .......... Chemical peel, nonfacial ................................ Y ................. .................... P2 ............... .................... 1.5119 $62.59 $62.59
15793 .......... Chemical peel, nonfacial ................................ Y ................. .................... P2 ............... .................... 0.8046 $33.31 $33.31
15819 .......... Plastic surgery, neck ...................................... Y ................. .................... G2 .............. .................... 2.1114 $87.41 $87.41
15820 .......... Revision of lower eyelid ................................. Y ................. .................... A2 ............... $510.00 20.9338 $866.66 $599.17
15821 .......... Revision of lower eyelid ................................. Y ................. .................... A2 ............... $510.00 20.9338 $866.66 $599.17
15822 .......... Revision of upper eyelid ................................. Y ................. .................... A2 ............... $510.00 20.9338 $866.66 $599.17
15823 .......... Revision of upper eyelid ................................. Y ................. .................... A2 ............... $717.00 20.9338 $866.66 $754.42
15824 .......... Removal of forehead wrinkles ........................ Y ................. .................... A2 ............... $510.00 20.9338 $866.66 $599.17
15825 .......... Removal of neck wrinkles .............................. Y ................. .................... A2 ............... $510.00 20.9338 $866.66 $599.17
15826 .......... Removal of brow wrinkles .............................. Y ................. .................... A2 ............... $510.00 20.9338 $866.66 $599.17
15828 .......... Removal of face wrinkles ............................... Y ................. .................... A2 ............... $510.00 20.9338 $866.66 $599.17
15829 .......... Removal of skin wrinkles ............................... Y ................. .................... A2 ............... $717.00 20.9338 $866.66 $754.42
15830 .......... Exc skin abd ................................................... Y ................. .................... A2 ............... $510.00 21.4534 $888.17 $604.54
15832 .......... Excise excessive skin tissue .......................... Y ................. .................... A2 ............... $510.00 21.4534 $888.17 $604.54
15837 .......... Excise excessive skin tissue .......................... Y ................. .................... G2 .............. .................... 16.5832 $686.54 $686.54
15838 .......... Excise excessive skin tissue .......................... Y ................. .................... G2 .............. .................... 16.5832 $686.54 $686.54
15840 .......... Graft for face nerve palsy .............................. Y ................. .................... A2 ............... $630.00 20.9338 $866.66 $689.17
15841 .......... Graft for face nerve palsy .............................. Y ................. .................... A2 ............... $630.00 20.9338 $866.66 $689.17
15842 .......... Flap for face nerve palsy ............................... Y ................. .................... G2 .............. .................... 20.9338 $866.66 $866.66
15845 .......... Skin and muscle repair, face ......................... Y ................. .................... A2 ............... $630.00 20.9338 $866.66 $689.17
15847 .......... Exc skin abd add-on ...................................... Y ................. .................... A2 ............... $510.00 21.4534 $888.17 $604.54
15850 .......... Removal of sutures ........................................ Y ................. .................... G2 .............. .................... 2.7493 $113.82 $113.82
15851 .......... Removal of sutures ........................................ Y ................. .................... P3 ............... .................... 1.2367 $51.20 $51.20
15852 .......... Dressing change not for burn ........................ N ................. .................... G2 .............. .................... 0.6416 $26.56 $26.56
15860 .......... Test for blood flow in graft ............................. N ................. .................... G2 .............. .................... 0.6416 $26.56 $26.56
15876 .......... Suction assisted lipectomy ............................. Y ................. .................... A2 ............... $510.00 20.9338 $866.66 $599.17
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
15920 .......... Removal of tail bone ulcer ............................. Y ................. .................... A2 ............... $251.52 4.4463 $184.08 $234.66
15922 .......... Removal of tail bone ulcer ............................. Y ................. .................... A2 ............... $630.00 20.9338 $866.66 $689.17
15931 .......... Remove sacrum pressure sore ...................... Y ................. .................... A2 ............... $510.00 21.4534 $888.17 $604.54
15940 .......... Remove hip pressure sore ............................. Y ................. .................... A2 ............... $510.00 21.4534 $888.17 $604.54
15950 .......... Remove thigh pressure sore .......................... Y ................. .................... A2 ............... $510.00 21.4534 $888.17 $604.54
16000 .......... Initial treatment of burn(s) .............................. Y ................. .................... P3 ............... .................... 0.6514 $26.97 $26.97
16020 .......... Dress/debrid p-thick burn, s ........................... Y ................. .................... P3 ............... .................... 0.9894 $40.96 $40.96
16025 .......... Dress/debrid p-thick burn, m .......................... Y ................. .................... A2 ............... $67.11 2.7493 $113.82 $78.79
16030 .......... Dress/debrid p-thick burn, l ............................ Y ................. .................... A2 ............... $99.83 2.7493 $113.82 $103.33
16035 .......... Incision of burn scab, initi .............................. Y ................. .................... G2 .............. .................... 2.7493 $113.82 $113.82
17000 .......... Destruct premalg lesion ................................. Y ................. .................... P2 ............... .................... 0.8046 $33.31 $33.31
17003 .......... Destruct premalg les, 2–14 ............................ Y ................. .................... P3 ............... .................... 0.0906 $3.75 $3.75
17004 .......... Destroy premlg lesions 15+ ........................... Y ................. .................... P3 ............... .................... 1.9541 $80.90 $80.90
17106 .......... Destruction of skin lesions ............................. Y ................. .................... P2 ............... .................... 2.7493 $113.82 $113.82
17110 .......... Destruct b9 lesion, 1–14 ................................ Y ................. .................... P2 ............... .................... 0.8046 $33.31 $33.31
17111 .......... Destruct lesion, 15 or more ............................ Y ................. .................... P2 ............... .................... 1.5119 $62.59 $62.59
17250 .......... Chemical cautery, tissue ................................ Y ................. .................... P3 ............... .................... 1.0471 $43.35 $43.35
17273 .......... Destruction of skin lesions ............................. Y ................. CH .............. P3 ............... .................... 2.2345 $92.51 $92.51
17311 .......... Mohs, 1 stage, h/n/hf/g .................................. Y ................. .................... P2 ............... .................... 3.9713 $164.41 $164.41
17312 .......... Mohs addl stage ............................................. Y ................. .................... P2 ............... .................... 3.9713 $164.41 $164.41
17313 .......... Mohs, 1 stage, t/a/l ......................................... Y ................. .................... P2 ............... .................... 3.9713 $164.41 $164.41
17314 .......... Mohs, addl stage, t/a/l .................................... Y ................. .................... P2 ............... .................... 3.9713 $164.41 $164.41
17315 .......... Mohs surg, addl block .................................... Y ................. .................... P3 ............... .................... 0.9483 $39.26 $39.26
17340 .......... Cryotherapy of skin ........................................ Y ................. .................... P3 ............... .................... 0.2969 $12.29 $12.29
17360 .......... Skin peel therapy ........................................... Y ................. .................... P2 ............... .................... 0.8046 $33.31 $33.31
17380 .......... Hair removal by electrolysis ........................... Y ................. .................... R2 .............. .................... 0.8046 $33.31 $33.31
19000 .......... Drainage of breast lesion ............................... Y ................. .................... P3 ............... .................... 1.5831 $65.54 $65.54
19001 .......... Drain breast lesion add-on ............................. Y ................. .................... P3 ............... .................... 0.2060 $8.53 $8.53
19020 .......... Incision of breast lesion ................................. Y ................. .................... A2 ............... $446.00 19.0457 $788.49 $531.62
19030 .......... Injection for breast x-ray ................................ N ................. .................... N1 .............. .................... .................... .................... ....................
19100 .......... Bx breast percut w/o image ........................... Y ................. .................... A2 ............... $240.00 4.5062 $186.56 $226.64
19101 .......... Biopsy of breast, open ................................... Y ................. .................... A2 ............... $446.00 20.9980 $869.32 $551.83
19102 .......... Bx breast percut w/image .............................. Y ................. .................... A2 ............... $240.00 7.3012 $302.27 $255.57
19103 .......... Bx breast percut w/device .............................. Y ................. .................... A2 ............... $395.77 13.9599 $577.94 $441.31
19105 .......... Cryosurg ablate fa, each ................................ Y ................. .................... G2 .............. .................... 32.4940 $1,345.25 $1,345.25
19110 .......... Nipple exploration ........................................... Y ................. .................... A2 ............... $446.00 20.9980 $869.32 $551.83
19112 .......... Excise breast duct fistula ............................... Y ................. .................... A2 ............... $510.00 20.9980 $869.32 $599.83
19120 .......... Removal of breast lesion ............................... Y ................. .................... A2 ............... $510.00 20.9980 $869.32 $599.83
19125 .......... Excision, breast lesion ................................... Y ................. .................... A2 ............... $510.00 20.9980 $869.32 $599.83
19126 .......... Excision, addl breast lesion ........................... Y ................. .................... A2 ............... $510.00 20.9980 $869.32 $599.83
19290 .......... Place needle wire, breast ............................... N ................. .................... N1 ............... $333.00 .................... .................... ....................
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
19291 .......... Place needle wire, breast ............................... N ................. .................... N1 ............... $333.00 .................... .................... ....................
19295 .......... Place breast clip, percut ................................. N ................. CH .............. N1 .............. $106.76 .................... .................... ....................
19296 .......... Place po breast cath for rad .......................... Y ................. .................... A2 ............... $1,339.00 52.9438 $2,191.87 $1,552.22
19297 .......... Place breast cath for rad ................................ Y ................. .................... A2 ............... $1,339.00 52.9438 $2,191.87 $1,552.22
19298 .......... Place breast rad tube/caths ........................... Y ................. CH .............. A2 ............... $1,339.00 52.9438 $2,191.87 $1,552.22
19300 .......... Removal of breast tissue ............................... Y ................. .................... A2 ............... $630.00 20.9980 $869.32 $689.83
19301 .......... Partical mastectomy ....................................... Y ................. .................... A2 ............... $510.00 20.9980 $869.32 $599.83
19302 .......... P-mastectomy w/ln removal ........................... Y ................. .................... A2 ............... $995.00 40.4634 $1,675.18 $1,165.05
19303 .......... Mast, simple, complete .................................. Y ................. .................... A2 ............... $630.00 32.4940 $1,345.25 $808.81
19304 .......... Mast, subq ...................................................... Y ................. .................... A2 ............... $630.00 32.4940 $1,345.25 $808.81
19316 .......... Suspension of breast ..................................... Y ................. .................... A2 ............... $630.00 32.4940 $1,345.25 $808.81
19318 .......... Reduction of large breast ............................... Y ................. .................... A2 ............... $630.00 40.4634 $1,675.18 $891.30
19324 .......... Enlarge breast ................................................ Y ................. .................... A2 ............... $630.00 40.4634 $1,675.18 $891.30
19325 .......... Enlarge breast with implant ............................ Y ................. .................... A2 ............... $1,339.00 52.9438 $2,191.87 $1,552.22
19328 .......... Removal of breast implant ............................. Y ................. .................... A2 ............... $333.00 32.4940 $1,345.25 $586.06
19330 .......... Removal of implant material .......................... Y ................. .................... A2 ............... $333.00 32.4940 $1,345.25 $586.06
19340 .......... Immediate breast prosthesis .......................... Y ................. .................... A2 ............... $446.00 40.4634 $1,675.18 $753.30
19342 .......... Delayed breast prosthesis .............................. Y ................. .................... A2 ............... $510.00 52.9438 $2,191.87 $930.47
19350 .......... Breast reconstruction ..................................... Y ................. .................... A2 ............... $630.00 20.9980 $869.32 $689.83
19355 .......... Correct inverted nipple(s) ............................... Y ................. .................... A2 ............... $630.00 32.4940 $1,345.25 $808.81
19357 .......... Breast reconstruction ..................................... Y ................. .................... A2 ............... $717.00 52.9438 $2,191.87 $1,085.72
19366 .......... Breast reconstruction ..................................... Y ................. .................... A2 ............... $717.00 32.4940 $1,345.25 $874.06
19370 .......... Surgery of breast capsule .............................. Y ................. .................... A2 ............... $630.00 32.4940 $1,345.25 $808.81
19371 .......... Removal of breast capsule ............................ Y ................. .................... A2 ............... $630.00 32.4940 $1,345.25 $808.81
19380 .......... Revise breast reconstruction .......................... Y ................. .................... A2 ............... $717.00 40.4634 $1,675.18 $956.55
19396 .......... Design custom breast implant ........................ Y ................. .................... G2 .............. .................... 32.4940 $1,345.25 $1,345.25
20000 .......... Incision of abscess ......................................... Y ................. .................... P2 ............... .................... 1.4630 $60.57 $60.57
20005 .......... Incision of deep abscess ................................ Y ................. .................... A2 ............... $446.00 21.5761 $893.25 $557.81
20103 .......... Explore wound, extremity ............................... Y ................. .................... G2 .............. .................... 9.5721 $396.28 $396.28
20150 .......... Excise epiphyseal bar .................................... Y ................. .................... G2 .............. .................... 43.5953 $1,804.85 $1,804.85
20200 .......... Muscle biopsy ................................................. Y ................. .................... A2 ............... $446.00 16.5832 $686.54 $506.14
20205 .......... Deep muscle biopsy ....................................... Y ................. .................... A2 ............... $510.00 16.5832 $686.54 $554.14
20206 .......... Needle biopsy, muscle ................................... Y ................. .................... A2 ............... $240.00 7.3012 $302.27 $255.57
20220 .......... Bone biopsy, trocar/needle ............................ Y ................. .................... A2 ............... $251.52 8.7155 $360.82 $278.85
20225 .......... Bone biopsy, trocar/needle ............................ Y ................. .................... A2 ............... $418.49 8.7155 $360.82 $404.07
20240 .......... Bone biopsy, excisional .................................. Y ................. .................... A2 ............... $446.00 21.4534 $888.17 $556.54
20245 .......... Bone biopsy, excisional .................................. Y ................. .................... A2 ............... $510.00 21.4534 $888.17 $604.54
20250 .......... Open bone biopsy .......................................... Y ................. .................... A2 ............... $510.00 21.5761 $893.25 $605.81
20251 .......... Open bone biopsy .......................................... Y ................. .................... A2 ............... $510.00 21.5761 $893.25 $605.81
20500 .......... Injection of sinus tract .................................... Y ................. .................... P3 ............... .................... 1.4676 $60.76 $60.76
20501 .......... Inject sinus tract for x-ray ............................... N ................. .................... N1 ............... .................... .................... .................... ....................
20520 .......... Removal of foreign body ................................ Y ................. .................... P3 ............... .................... 2.2674 $93.87 $93.87
20525 .......... Removal of foreign body ................................ Y ................. .................... A2 ............... $510.00 21.4534 $888.17 $604.54
20526 .......... Ther injection, carp tunnel .............................. Y ................. .................... P3 ............... .................... 0.7338 $30.38 $30.38
20550 .......... Inj tendon sheath/ligament ............................. Y ................. .................... P3 ............... .................... 0.5524 $22.87 $22.87
20551 .......... Inj tendon origin/insertion ............................... Y ................. .................... P3 ............... .................... 0.5442 $22.53 $22.53
20552 .......... Inj trigger point, 1/2 muscl .............................. Y ................. .................... P3 ............... .................... 0.5360 $22.19 $22.19
20553 .......... Inject trigger points, =/> 3 .............................. Y ................. .................... P3 ............... .................... 0.6019 $24.92 $24.92
20600 .......... Drain/inject, joint/bursa ................................... Y ................. .................... P3 ............... .................... 0.5442 $22.53 $22.53
20612 .......... Aspirate/inj ganglion cyst ............................... Y ................. .................... P3 ............... .................... 0.5771 $23.89 $23.89
20615 .......... Treatment of bone cyst .................................. Y ................. CH .............. P3 ............... .................... 2.5560 $105.82 $105.82
20650 .......... Insert and remove bone pin ........................... Y ................. .................... A2 ............... $510.00 21.5761 $893.25 $605.81
20662 .......... Application of pelvis brace ............................. Y ................. .................... R2 ............... .................... 21.5761 $893.25 $893.25
20663 .......... Application of thigh brace ............................... Y ................. .................... R2 ............... .................... 21.5761 $893.25 $893.25
20665 .......... Removal of fixation device ............................. N ................. .................... G2 .............. .................... 0.6416 $26.56 $26.56
20670 .......... Removal of support implant ........................... Y ................. .................... A2 ............... $333.00 16.5832 $686.54 $421.39
20680 .......... Removal of support implant ........................... Y ................. .................... A2 ............... $510.00 21.4534 $888.17 $604.54
20690 .......... Apply bone fixation device ............................. Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
20692 .......... Apply bone fixation device ............................. Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
20693 .......... Adjust bone fixation device ............................ Y ................. .................... A2 ............... $510.00 21.5761 $893.25 $605.81
20694 .......... Remove bone fixation device ......................... Y ................. .................... A2 ............... $333.00 21.5761 $893.25 $473.06
20822 .......... Replantation digit, complete ........................... Y ................. .................... G2 .............. .................... 26.7322 $1,106.71 $1,106.71
20900 .......... Removal of bone for graft .............................. Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
20902 .......... Removal of bone for graft .............................. Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
20910 .......... Remove cartilage for graft .............................. Y ................. .................... A2 ............... $510.00 20.9338 $866.66 $599.17
20912 .......... Remove cartilage for graft .............................. Y ................. .................... A2 ............... $510.00 20.9338 $866.66 $599.17
20920 .......... Removal of fascia for graft ............................. Y ................. .................... A2 ............... $630.00 15.4399 $639.21 $632.30
20922 .......... Removal of fascia for graft ............................. Y ................. .................... A2 ............... $510.00 15.4399 $639.21 $542.30
20924 .......... Removal of tendon for graft ........................... Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
20926 .......... Removal of tissue for graft ............................. Y ................. .................... A2 ............... $630.00 4.6816 $193.82 $520.96
20950 .......... Fluid pressure, muscle ................................... Y ................. .................... G2 .............. .................... 1.4630 $60.57 $60.57
20972 .......... Bone/skin graft, metatarsal ............................ Y ................. .................... G2 .............. .................... 44.4710 $1,841.10 $1,841.10
20973 .......... Bone/skin graft, great toe ............................... Y ................. .................... R2 ............... .................... 44.4710 $1,841.10 $1,841.10
20975 .......... Electrical bone stimulation ............................. N ................. CH .............. N1 ............... $37.51 .................... .................... ....................
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
20979 .......... Us bone stimulation ........................................ N ................. .................... P3 ............... .................... 0.5771 $23.89 $23.89
20982 .......... Ablate, bone tumor(s) perq ............................ Y ................. .................... G2 .............. .................... 43.5953 $1,804.85 $1,804.85
21010 .......... Incision of jaw joint ......................................... Y ................. .................... A2 ............... $446.00 24.3535 $1,008.23 $586.56
21015 .......... Resection of facial tumor ............................... Y ................. .................... A2 ............... $510.00 16.6341 $688.65 $554.66
21025 .......... Excision of bone, lower jaw ........................... Y ................. .................... A2 ............... $446.00 40.5598 $1,679.18 $754.30
21026 .......... Excision of facial bone(s) ............................... Y ................. .................... A2 ............... $446.00 40.5598 $1,679.18 $754.30
21029 .......... Contour of face bone lesion ........................... Y ................. .................... A2 ............... $446.00 40.5598 $1,679.18 $754.30
21030 .......... Excise max/zygoma b9 tumor ........................ Y ................. .................... P3 ............... .................... 5.5737 $230.75 $230.75
21031 .......... Remove exostosis, mandible ......................... Y ................. .................... P3 ............... .................... 4.5761 $189.45 $189.45
21032 .......... Remove exostosis, maxilla ............................. Y ................. .................... P3 ............... .................... 4.6915 $194.23 $194.23
21034 .......... Excise max/zygoma mlg tumor ...................... Y ................. .................... A2 ............... $510.00 40.5598 $1,679.18 $802.30
21040 .......... Excise mandible lesion ................................... Y ................. .................... A2 ............... $446.00 24.3535 $1,008.23 $586.56
21044 .......... Removal of jaw bone lesion ........................... Y ................. .................... A2 ............... $446.00 40.5598 $1,679.18 $754.30
21046 .......... Remove mandible cyst complex .................... Y ................. .................... A2 ............... $446.00 40.5598 $1,679.18 $754.30
21047 .......... Excise lwr jaw cyst w/repair ........................... Y ................. .................... A2 ............... $446.00 40.5598 $1,679.18 $754.30
21048 .......... Remove maxilla cyst complex ........................ Y ................. .................... R2 ............... .................... 40.5598 $1,679.18 $1,679.18
21050 .......... Removal of jaw joint ....................................... Y ................. .................... A2 ............... $510.00 40.5598 $1,679.18 $802.30
21060 .......... Remove jaw joint cartilage ............................. Y ................. .................... A2 ............... $446.00 40.5598 $1,679.18 $754.30
21070 .......... Remove coronoid process ............................. Y ................. .................... A2 ............... $510.00 40.5598 $1,679.18 $802.30
21076 .......... Prepare face/oral prosthesis .......................... Y ................. .................... P3 ............... .................... 8.3442 $345.45 $345.45
21088 .......... Prepare face/oral prosthesis .......................... Y ................. .................... R2 ............... .................... 40.5598 $1,679.18 $1,679.18
21100 .......... Maxillofacial fixation ....................................... Y ................. .................... A2 ............... $446.00 40.5598 $1,679.18 $754.30
21110 .......... Interdental fixation .......................................... Y ................. .................... P2 ............... .................... 7.6539 $316.87 $316.87
21116 .......... Injection, jaw joint x-ray .................................. N ................. .................... N1 .............. .................... .................... .................... ....................
21120 .......... Reconstruction of chin .................................... Y ................. .................... A2 ............... $995.00 24.3535 $1,008.23 $998.31
21125 .......... Augmentation, lower jaw bone ....................... Y ................. .................... A2 ............... $995.00 24.3535 $1,008.23 $998.31
21127 .......... Augmentation, lower jaw bone ....................... Y ................. .................... A2 ............... $1,339.00 40.5598 $1,679.18 $1,424.05
21137 .......... Reduction of forehead .................................... Y ................. .................... G2 .............. .................... 24.3535 $1,008.23 $1,008.23
21150 .......... Reconstruct midface, lefort ............................ Y ................. .................... G2 .............. .................... 40.5598 $1,679.18 $1,679.18
21181 .......... Contour cranial bone lesion ........................... Y ................. .................... A2 ............... $995.00 24.3535 $1,008.23 $998.31
21198 .......... Reconstr lwr jaw segment .............................. Y ................. .................... G2 .............. .................... 40.5598 $1,679.18 $1,679.18
21199 .......... Reconstr lwr jaw w/advance .......................... Y ................. .................... G2 .............. .................... 40.5598 $1,679.18 $1,679.18
21206 .......... Reconstruct upper jaw bone .......................... Y ................. .................... A2 ............... $717.00 40.5598 $1,679.18 $957.55
21208 .......... Augmentation of facial bones ......................... Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
21209 .......... Reduction of facial bones ............................... Y ................. .................... A2 ............... $717.00 40.5598 $1,679.18 $957.55
21210 .......... Face bone graft .............................................. Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
21215 .......... Lower jaw bone graft ...................................... Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
21230 .......... Rib cartilage graft ........................................... Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
21235 .......... Ear cartilage graft ........................................... Y ................. .................... A2 ............... $995.00 24.3535 $1,008.23 $998.31
21240 .......... Reconstruction of jaw joint ............................. Y ................. .................... A2 ............... $630.00 40.5598 $1,679.18 $892.30
21244 .......... Reconstruction of lower jaw ........................... Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
21245 .......... Reconstruction of jaw ..................................... Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
21260 .......... Revise eye sockets ........................................ Y ................. .................... G2 .............. .................... 40.5598 $1,679.18 $1,679.18
21267 .......... Revise eye sockets ........................................ Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
21270 .......... Augmentation, cheek bone ............................ Y ................. .................... A2 ............... $717.00 40.5598 $1,679.18 $957.55
21275 .......... Revision, orbitofacial bones ........................... Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
21280 .......... Revision of eyelid ........................................... Y ................. .................... A2 ............... $717.00 40.5598 $1,679.18 $957.55
21282 .......... Revision of eyelid ........................................... Y ................. .................... A2 ............... $717.00 16.6341 $688.65 $709.91
21295 .......... Revision of jaw muscle/bone ......................... Y ................. .................... A2 ............... $333.00 7.6539 $316.87 $328.97
21296 .......... Revision of jaw muscle/bone ......................... Y ................. .................... A2 ............... $333.00 24.3535 $1,008.23 $501.81
21310 .......... Treatment of nose fracture ............................. Y ................. .................... A2 ............... $150.72 2.5765 $106.67 $139.71
21325 .......... Treatment of nose fracture ............................. Y ................. .................... A2 ............... $630.00 24.3535 $1,008.23 $724.56
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
21336 .......... Treat nasal septal fracture ............................. Y ................. .................... A2 ............... $630.00 40.3466 $1,670.35 $890.09
21337 .......... Treat nasal septal fracture ............................. Y ................. .................... A2 ............... $446.00 16.6341 $688.65 $506.66
21338 .......... Treat nasoethmoid fracture ............................ Y ................. .................... A2 ............... $630.00 24.3535 $1,008.23 $724.56
21339 .......... Treat nasoethmoid fracture ............................ Y ................. .................... A2 ............... $717.00 24.3535 $1,008.23 $789.81
21345 .......... Treat nose/jaw fracture .................................. Y ................. .................... A2 ............... $995.00 24.3535 $1,008.23 $998.31
21355 .......... Treat cheek bone fracture .............................. Y ................. .................... A2 ............... $510.00 40.5598 $1,679.18 $802.30
21356 .......... Treat cheek bone fracture .............................. Y ................. .................... A2 ............... $510.00 24.3535 $1,008.23 $634.56
21390 .......... Treat eye socket fracture ............................... Y ................. .................... G2 .............. .................... 40.5598 $1,679.18 $1,679.18
21400 .......... Treat eye socket fracture ............................... Y ................. .................... A2 ............... $446.00 7.6539 $316.87 $413.72
21401 .......... Treat eye socket fracture ............................... Y ................. .................... A2 ............... $510.00 16.6341 $688.65 $554.66
21421 .......... Treat mouth roof fracture ............................... Y ................. .................... A2 ............... $630.00 24.3535 $1,008.23 $724.56
21440 .......... Treat dental ridge fracture .............................. Y ................. .................... P3 ............... .................... 7.0990 $293.90 $293.90
21445 .......... Treat dental ridge fracture .............................. Y ................. .................... A2 ............... $630.00 24.3535 $1,008.23 $724.56
21450 .......... Treat lower jaw fracture ................................. Y ................. .................... A2 ............... $150.72 2.5765 $106.67 $139.71
21453 .......... Treat lower jaw fracture ................................. Y ................. .................... A2 ............... $510.00 40.5598 $1,679.18 $802.30
21480 .......... Reset dislocated jaw ...................................... Y ................. .................... A2 ............... $150.72 2.5765 $106.67 $139.71
21485 .......... Reset dislocated jaw ...................................... Y ................. .................... A2 ............... $446.00 16.6341 $688.65 $506.66
21490 .......... Repair dislocated jaw ..................................... Y ................. .................... A2 ............... $510.00 40.5598 $1,679.18 $802.30
21495 .......... Treat hyoid bone fracture ............................... Y ................. .................... G2 .............. .................... 16.6341 $688.65 $688.65
21497 .......... Interdental wiring ............................................ Y ................. .................... A2 ............... $446.00 16.6341 $688.65 $506.66
21501 .......... Drain neck/chest lesion .................................. Y ................. .................... A2 ............... $446.00 19.0457 $788.49 $531.62
21502 .......... Drain chest lesion ........................................... Y ................. .................... A2 ............... $446.00 21.5761 $893.25 $557.81
21550 .......... Biopsy of neck/chest ...................................... Y ................. .................... G2 .............. .................... 8.7155 $360.82 $360.82
21555 .......... Remove lesion, neck/chest ............................ Y ................. .................... A2 ............... $446.00 21.4534 $888.17 $556.54
21556 .......... Remove lesion, neck/chest ............................ Y ................. .................... A2 ............... $446.00 21.4534 $888.17 $556.54
21557 .......... Remove tumor, neck/chest ............................ Y ................. .................... G2 .............. .................... 21.4534 $888.17 $888.17
21600 .......... Partial removal of rib ...................................... Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
21610 .......... Partial removal of rib ...................................... Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
21685 .......... Hyoid myotomy & suspension ........................ Y ................. .................... G2 .............. .................... 7.6539 $316.87 $316.87
21700 .......... Revision of neck muscle ................................ Y ................. .................... A2 ............... $446.00 21.5761 $893.25 $557.81
21800 .......... Treatment of rib fracture ................................ Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
21805 .......... Treatment of rib fracture ................................ Y ................. .................... A2 ............... $446.00 26.3092 $1,089.20 $606.80
21820 .......... Treat sternum fracture .................................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
21920 .......... Biopsy soft tissue of back .............................. Y ................. .................... P3 ............... .................... 3.1744 $131.42 $131.42
21925 .......... Biopsy soft tissue of back .............................. Y ................. .................... A2 ............... $446.00 21.4534 $888.17 $556.54
21930 .......... Remove lesion, back or flank ......................... Y ................. .................... A2 ............... $446.00 21.4534 $888.17 $556.54
21935 .......... Remove tumor, back ...................................... Y ................. .................... A2 ............... $510.00 21.4534 $888.17 $604.54
22102 .......... Remove part, lumbar vertebra ....................... Y ................. .................... G2 .............. .................... 47.6714 $1,973.60 $1,973.60
22103 .......... Remove extra spine segment ........................ Y ................. .................... G2 .............. .................... 47.6714 $1,973.60 $1,973.60
22305 .......... Treat spine process fracture .......................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
22310 .......... Treat spine fracture ........................................ Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
22315 .......... Treat spine fracture ........................................ Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
22505 .......... Manipulation of spine ..................................... Y ................. .................... A2 ............... $446.00 15.0176 $621.73 $489.93
22520 .......... Percut vertebroplasty thor .............................. Y ................. .................... A2 ............... $1,339.00 29.3263 $1,214.11 $1,307.78
22521 .......... Percut vertebroplasty lumb ............................ Y ................. .................... A2 ............... $1,339.00 29.3263 $1,214.11 $1,307.78
22522 .......... Percut vertebroplasty add’l ............................. Y ................. .................... A2 ............... $1,339.00 29.3263 $1,214.11 $1,307.78
22523 .......... Percut kyphoplasty, thor ................................. Y ................. .................... G2 .............. .................... 78.6518 $3,256.18 $3,256.18
22524 .......... Percut kyphoplasty, lumbar ............................ Y ................. .................... G2 .............. .................... 78.6518 $3,256.18 $3,256.18
22525 .......... Percut kyphoplasty, add-on ............................ Y ................. .................... G2 .............. .................... 78.6518 $3,256.18 $3,256.18
22900 .......... Remove abdominal wall lesion ...................... Y ................. .................... A2 ............... $630.00 21.4534 $888.17 $694.54
23000 .......... Removal of calcium deposits ......................... Y ................. .................... A2 ............... $446.00 16.5832 $686.54 $506.14
23020 .......... Release shoulder joint .................................... Y ................. .................... A2 ............... $446.00 43.5953 $1,804.85 $785.71
23030 .......... Drain shoulder lesion ..................................... Y ................. .................... A2 ............... $333.00 19.0457 $788.49 $446.87
23031 .......... Drain shoulder bursa ...................................... Y ................. .................... A2 ............... $510.00 19.0457 $788.49 $579.62
23035 .......... Drain shoulder bone lesion ............................ Y ................. .................... A2 ............... $510.00 21.5761 $893.25 $605.81
23040 .......... Exploratory shoulder surgery ......................... Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
23044 .......... Exploratory shoulder surgery ......................... Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
23065 .......... Biopsy shoulder tissues ................................. Y ................. .................... P3 ............... .................... 2.2428 $92.85 $92.85
23066 .......... Biopsy shoulder tissues ................................. Y ................. .................... A2 ............... $446.00 21.4534 $888.17 $556.54
23075 .......... Removal of shoulder lesion ............................ Y ................. .................... A2 ............... $446.00 16.5832 $686.54 $506.14
23076 .......... Removal of shoulder lesion ............................ Y ................. .................... A2 ............... $446.00 21.4534 $888.17 $556.54
23077 .......... Remove tumor of shoulder ............................. Y ................. .................... A2 ............... $510.00 21.4534 $888.17 $604.54
23100 .......... Biopsy of shoulder joint .................................. Y ................. .................... A2 ............... $446.00 21.5761 $893.25 $557.81
23101 .......... Shoulder joint surgery .................................... Y ................. .................... A2 ............... $995.00 29.3263 $1,214.11 $1,049.78
23105 .......... Remove shoulder joint lining .......................... Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
23106 .......... Incision of collarbone joint .............................. Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
23107 .......... Explore treat shoulder joint ............................ Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
23120 .......... Partial removal, collar bone ........................... Y ................. .................... A2 ............... $717.00 29.3263 $1,214.11 $841.28
23125 .......... Removal of collar bone .................................. Y ................. .................... A2 ............... $717.00 29.3263 $1,214.11 $841.28
23130 .......... Remove shoulder bone, part .......................... Y ................. .................... A2 ............... $717.00 43.5953 $1,804.85 $988.96
23140 .......... Removal of bone lesion ................................. Y ................. .................... A2 ............... $630.00 21.5761 $893.25 $695.81
23145 .......... Removal of bone lesion ................................. Y ................. .................... A2 ............... $717.00 29.3263 $1,214.11 $841.28
23146 .......... Removal of bone lesion ................................. Y ................. .................... A2 ............... $717.00 29.3263 $1,214.11 $841.28
23150 .......... Removal of humerus lesion ........................... Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
23170 .......... Remove collar bone lesion ............................. Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
23172 .......... Remove shoulder blade lesion ....................... Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
23174 .......... Remove humerus lesion ................................ Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
23180 .......... Remove collar bone lesion ............................. Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
23182 .......... Remove shoulder blade lesion ....................... Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
23184 .......... Remove humerus lesion ................................ Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
23190 .......... Partial removal of scapula .............................. Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
23195 .......... Removal of head of humerus ......................... Y ................. .................... A2 ............... $717.00 29.3263 $1,214.11 $841.28
23330 .......... Remove shoulder foreign body ...................... Y ................. .................... A2 ............... $333.00 8.7155 $360.82 $339.96
23331 .......... Remove shoulder foreign body ...................... Y ................. .................... A2 ............... $333.00 21.4534 $888.17 $471.79
23350 .......... Injection for shoulder x-ray ............................. N ................. .................... N1 ............... .................... .................... .................... ....................
23395 .......... Muscle transfer,shoulder/arm ......................... Y ................. .................... A2 ............... $717.00 43.5953 $1,804.85 $988.96
23397 .......... Muscle transfers ............................................. Y ................. .................... A2 ............... $995.00 78.6518 $3,256.18 $1,560.30
23400 .......... Fixation of shoulder blade .............................. Y ................. .................... A2 ............... $995.00 29.3263 $1,214.11 $1,049.78
23405 .......... Incision of tendon & muscle ........................... Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
23406 .......... Incise tendon(s) & muscle(s) ......................... Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
23410 .......... Repair rotator cuff, acute ............................... Y ................. .................... A2 ............... $717.00 43.5953 $1,804.85 $988.96
23412 .......... Repair rotator cuff, chronic ............................. Y ................. .................... A2 ............... $995.00 43.5953 $1,804.85 $1,197.46
23415 .......... Release of shoulder ligament ........................ Y ................. .................... A2 ............... $717.00 43.5953 $1,804.85 $988.96
23420 .......... Repair of shoulder .......................................... Y ................. .................... A2 ............... $995.00 43.5953 $1,804.85 $1,197.46
23430 .......... Repair biceps tendon ..................................... Y ................. .................... A2 ............... $630.00 43.5953 $1,804.85 $923.71
23440 .......... Remove/transplant tendon ............................. Y ................. .................... A2 ............... $630.00 43.5953 $1,804.85 $923.71
23450 .......... Repair shoulder capsule ................................ Y ................. .................... A2 ............... $717.00 78.6518 $3,256.18 $1,351.80
23480 .......... Revision of collar bone ................................... Y ................. .................... A2 ............... $630.00 43.5953 $1,804.85 $923.71
23485 .......... Revision of collar bone ................................... Y ................. .................... A2 ............... $995.00 78.6518 $3,256.18 $1,560.30
23490 .......... Reinforce clavicle ........................................... Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
23491 .......... Reinforce shoulder bones .............................. Y ................. .................... A2 ............... $510.00 78.6518 $3,256.18 $1,196.55
23500 .......... Treat clavicle fracture ..................................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
23505 .......... Treat clavicle fracture ..................................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
23515 .......... Treat clavicle fracture ..................................... Y ................. .................... A2 ............... $510.00 60.0595 $2,486.46 $1,004.12
23520 .......... Treat clavicle dislocation ................................ Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
23530 .......... Treat clavicle dislocation ................................ Y ................. .................... A2 ............... $510.00 40.3466 $1,670.35 $800.09
23570 .......... Treat shoulder blade fx .................................. Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
23575 .......... Treat shoulder blade fx .................................. Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
23585 .......... Treat scapula fracture .................................... Y ................. .................... A2 ............... $510.00 60.0595 $2,486.46 $1,004.12
23600 .......... Treat humerus fracture ................................... Y ................. .................... P2 ............... .................... 1.8742 $77.59 $77.59
23605 .......... Treat humerus fracture ................................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
23615 .......... Treat humerus fracture ................................... Y ................. .................... A2 ............... $630.00 60.0595 $2,486.46 $1,094.12
23620 .......... Treat humerus fracture ................................... Y ................. .................... P2 ............... .................... 1.8742 $77.59 $77.59
23650 .......... Treat shoulder dislocation .............................. Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
23655 .......... Treat shoulder dislocation .............................. Y ................. .................... A2 ............... $333.00 15.0176 $621.73 $405.18
23660 .......... Treat shoulder dislocation .............................. Y ................. .................... A2 ............... $510.00 40.3466 $1,670.35 $800.09
23665 .......... Treat dislocation/fracture ................................ Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
23670 .......... Treat dislocation/fracture ................................ Y ................. .................... A2 ............... $510.00 60.0595 $2,486.46 $1,004.12
23675 .......... Treat dislocation/fracture ................................ Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
23680 .......... Treat dislocation/fracture ................................ Y ................. .................... A2 ............... $510.00 40.3466 $1,670.35 $800.09
23700 .......... Fixation of shoulder ........................................ Y ................. .................... A2 ............... $333.00 15.0176 $621.73 $405.18
23800 .......... Fusion of shoulder joint .................................. Y ................. .................... A2 ............... $630.00 78.6518 $3,256.18 $1,286.55
23802 .......... Fusion of shoulder joint .................................. Y ................. .................... A2 ............... $995.00 43.5953 $1,804.85 $1,197.46
23921 .......... Amputation follow-up surgery ......................... Y ................. .................... A2 ............... $323.28 15.4399 $639.21 $402.26
23930 .......... Drainage of arm lesion ................................... Y ................. .................... A2 ............... $333.00 19.0457 $788.49 $446.87
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
23931 .......... Drainage of arm bursa ................................... Y ................. .................... A2 ............... $446.00 19.0457 $788.49 $531.62
23935 .......... Drain arm/elbow bone lesion ......................... Y ................. .................... A2 ............... $446.00 21.5761 $893.25 $557.81
24000 .......... Exploratory elbow surgery .............................. Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
24006 .......... Release elbow joint ........................................ Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
24065 .......... Biopsy arm/elbow soft tissue ......................... Y ................. .................... P3 ............... .................... 3.0343 $125.62 $125.62
24066 .......... Biopsy arm/elbow soft tissue ......................... Y ................. .................... A2 ............... $446.00 16.5832 $686.54 $506.14
24075 .......... Remove arm/elbow lesion .............................. Y ................. .................... A2 ............... $446.00 16.5832 $686.54 $506.14
24076 .......... Remove arm/elbow lesion .............................. Y ................. .................... A2 ............... $446.00 21.4534 $888.17 $556.54
24077 .......... Remove tumor of arm/elbow .......................... Y ................. .................... A2 ............... $510.00 21.4534 $888.17 $604.54
24100 .......... Biopsy elbow joint lining ................................. Y ................. .................... A2 ............... $333.00 21.5761 $893.25 $473.06
24101 .......... Explore/treat elbow joint ................................. Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
24102 .......... Remove elbow joint lining .............................. Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
24105 .......... Removal of elbow bursa ................................ Y ................. .................... A2 ............... $510.00 21.5761 $893.25 $605.81
24110 .......... Remove humerus lesion ................................ Y ................. .................... A2 ............... $446.00 21.5761 $893.25 $557.81
24115 .......... Remove/graft bone lesion .............................. Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
24120 .......... Remove elbow lesion ..................................... Y ................. .................... A2 ............... $510.00 21.5761 $893.25 $605.81
24130 .......... Removal of head of radius ............................. Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
24134 .......... Removal of arm bone lesion .......................... Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
24136 .......... Remove radius bone lesion ........................... Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
24138 .......... Remove elbow bone lesion ............................ Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
24140 .......... Partial removal of arm bone ........................... Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
24145 .......... Partial removal of radius ................................ Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
24147 .......... Partial removal of elbow ................................. Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
24149 .......... Radical resection of elbow ............................. Y ................. .................... G2 .............. .................... 29.3263 $1,214.11 $1,214.11
24152 .......... Extensive radius surgery ................................ Y ................. .................... G2 .............. .................... 43.5953 $1,804.85 $1,804.85
24153 .......... Extensive radius surgery ................................ Y ................. .................... G2 .............. .................... 78.6518 $3,256.18 $3,256.18
24155 .......... Removal of elbow joint ................................... Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
24160 .......... Remove elbow joint implant ........................... Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
24164 .......... Remove radius head implant ......................... Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
24200 .......... Removal of arm foreign body ......................... Y ................. .................... P3 ............... .................... 2.5312 $104.79 $104.79
24201 .......... Removal of arm foreign body ......................... Y ................. .................... A2 ............... $446.00 16.5832 $686.54 $506.14
24220 .......... Injection for elbow x-ray ................................. N ................. .................... N1 ............... .................... .................... .................... ....................
24300 .......... Manipulate elbow w/anesth ............................ Y ................. .................... G2 .............. .................... 15.0176 $621.73 $621.73
24301 .......... Muscle/tendon transfer ................................... Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
24305 .......... Arm tendon lengthening ................................. Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
24310 .......... Revision of arm tendon .................................. Y ................. .................... A2 ............... $510.00 21.5761 $893.25 $605.81
24320 .......... Repair of arm tendon ..................................... Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
24330 .......... Revision of arm muscles ................................ Y ................. .................... A2 ............... $510.00 78.6518 $3,256.18 $1,196.55
24331 .......... Revision of arm muscles ................................ Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
24332 .......... Tenolysis, triceps ............................................ Y ................. .................... G2 .............. .................... 21.5761 $893.25 $893.25
24340 .......... Repair of biceps tendon ................................. Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
24341 .......... Repair arm tendon/muscle ............................. Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
24342 .......... Repair of ruptured tendon .............................. Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
24343 .......... Repr elbow lat ligmnt w/tiss ........................... Y ................. .................... G2 .............. .................... 29.3263 $1,214.11 $1,214.11
24344 .......... Reconstruct elbow lat ligmnt .......................... Y ................. .................... G2 .............. .................... 78.6518 $3,256.18 $3,256.18
24345 .......... Repr elbw med ligmnt w/tissu ........................ Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
24346 .......... Reconstruct elbow med ligmnt ....................... Y ................. .................... G2 .............. .................... 43.5953 $1,804.85 $1,804.85
24350 .......... Repair of tennis elbow ................................... Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
24356 .......... Revision of tennis elbow ................................ Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
24360 .......... Reconstruct elbow joint .................................. Y ................. .................... A2 ............... $717.00 35.9249 $1,487.29 $909.57
24361 .......... Reconstruct elbow joint .................................. Y ................. .................... A2 ............... $717.00 113.6713 $4,705.99 $1,714.25
24362 .......... Reconstruct elbow joint .................................. Y ................. .................... A2 ............... $717.00 51.0431 $2,113.18 $1,066.05
24363 .......... Replace elbow joint ........................................ Y ................. .................... A2 ............... $995.00 113.6713 $4,705.99 $1,922.75
24365 .......... Reconstruct head of radius ............................ Y ................. .................... A2 ............... $717.00 35.9249 $1,487.29 $909.57
24366 .......... Reconstruct head of radius ............................ Y ................. .................... A2 ............... $717.00 113.6713 $4,705.99 $1,714.25
24400 .......... Revision of humerus ...................................... Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
24430 .......... Repair of humerus .......................................... Y ................. .................... A2 ............... $510.00 78.6518 $3,256.18 $1,196.55
24435 .......... Repair humerus with graft .............................. Y ................. .................... A2 ............... $630.00 78.6518 $3,256.18 $1,286.55
24470 .......... Revision of elbow joint ................................... Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
24495 .......... Decompression of forearm ............................. Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
24498 .......... Reinforce humerus ......................................... Y ................. .................... A2 ............... $510.00 78.6518 $3,256.18 $1,196.55
24538 .......... Treat humerus fracture ................................... Y ................. .................... A2 ............... $446.00 26.3092 $1,089.20 $606.80
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
24586 .......... Treat elbow fracture ....................................... Y ................. .................... A2 ............... $630.00 60.0595 $2,486.46 $1,094.12
24600 .......... Treat elbow dislocation .................................. Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
24605 .......... Treat elbow dislocation .................................. Y ................. .................... A2 ............... $446.00 15.0176 $621.73 $489.93
24615 .......... Treat elbow dislocation .................................. Y ................. .................... A2 ............... $510.00 60.0595 $2,486.46 $1,004.12
24620 .......... Treat elbow fracture ....................................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
24640 .......... Treat elbow dislocation .................................. Y ................. CH .............. P3 ............... .................... 1.3771 $57.01 $57.01
24650 .......... Treat radius fracture ....................................... Y ................. .................... P2 ............... .................... 1.8742 $77.59 $77.59
24655 .......... Treat radius fracture ....................................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
24665 .......... Treat radius fracture ....................................... Y ................. .................... A2 ............... $630.00 40.3466 $1,670.35 $890.09
24666 .......... Treat radius fracture ....................................... Y ................. .................... A2 ............... $630.00 60.0595 $2,486.46 $1,094.12
24670 .......... Treat ulnar fracture ......................................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
24675 .......... Treat ulnar fracture ......................................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
24685 .......... Treat ulnar fracture ......................................... Y ................. .................... A2 ............... $510.00 40.3466 $1,670.35 $800.09
24800 .......... Fusion of elbow joint ...................................... Y ................. .................... A2 ............... $630.00 43.5953 $1,804.85 $923.71
24802 .......... Fusion/graft of elbow joint .............................. Y ................. .................... A2 ............... $717.00 43.5953 $1,804.85 $988.96
25000 .......... Incision of tendon sheath ............................... Y ................. .................... A2 ............... $510.00 21.5761 $893.25 $605.81
25001 .......... Incise flexor carpi radialis ............................... Y ................. .................... G2 .............. .................... 21.5761 $893.25 $893.25
25020 .......... Decompress forearm 1 space ........................ Y ................. .................... A2 ............... $510.00 21.5761 $893.25 $605.81
25023 .......... Decompress forearm 1 space ........................ Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
25024 .......... Decompress forearm 2 spaces ...................... Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
25025 .......... Decompress forearm 2 spaces ...................... Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
25028 .......... Drainage of forearm lesion ............................. Y ................. .................... A2 ............... $333.00 21.5761 $893.25 $473.06
25031 .......... Drainage of forearm bursa ............................. Y ................. .................... A2 ............... $446.00 21.5761 $893.25 $557.81
25035 .......... Treat forearm bone lesion .............................. Y ................. .................... A2 ............... $446.00 21.5761 $893.25 $557.81
25040 .......... Explore/treat wrist joint ................................... Y ................. .................... A2 ............... $717.00 29.3263 $1,214.11 $841.28
25065 .......... Biopsy forearm soft tissues ............................ Y ................. .................... P3 ............... .................... 3.1085 $128.69 $128.69
25066 .......... Biopsy forearm soft tissues ............................ Y ................. .................... A2 ............... $446.00 21.4534 $888.17 $556.54
25075 .......... Removal forearm lesion subcu ...................... Y ................. .................... A2 ............... $446.00 16.5832 $686.54 $506.14
25076 .......... Removal forearm lesion deep ........................ Y ................. .................... A2 ............... $510.00 21.4534 $888.17 $604.54
25077 .......... Remove tumor, forearm/wrist ......................... Y ................. .................... A2 ............... $510.00 21.4534 $888.17 $604.54
25085 .......... Incision of wrist capsule ................................. Y ................. .................... A2 ............... $510.00 21.5761 $893.25 $605.81
25100 .......... Biopsy of wrist joint ........................................ Y ................. .................... A2 ............... $446.00 21.5761 $893.25 $557.81
25101 .......... Explore/treat wrist joint ................................... Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
25105 .......... Remove wrist joint lining ................................ Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
25107 .......... Remove wrist joint cartilage ........................... Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
25109 .......... Excise tendon forearm/wrist ........................... Y ................. .................... G2 .............. .................... 21.5761 $893.25 $893.25
25110 .......... Remove wrist tendon lesion ........................... Y ................. .................... A2 ............... $510.00 21.5761 $893.25 $605.81
25111 .......... Remove wrist tendon lesion ........................... Y ................. .................... A2 ............... $510.00 16.8220 $696.43 $556.61
25112 .......... Reremove wrist tendon lesion ........................ Y ................. .................... A2 ............... $630.00 16.8220 $696.43 $646.61
25115 .......... Remove wrist/forearm lesion .......................... Y ................. .................... A2 ............... $630.00 21.5761 $893.25 $695.81
25116 .......... Remove wrist/forearm lesion .......................... Y ................. .................... A2 ............... $630.00 21.5761 $893.25 $695.81
25118 .......... Excise wrist tendon sheath ............................ Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
25119 .......... Partial removal of ulna ................................... Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
25120 .......... Removal of forearm lesion ............................. Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
25125 .......... Remove/graft forearm lesion .......................... Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
25126 .......... Remove/graft forearm lesion .......................... Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
25130 .......... Removal of wrist lesion .................................. Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
25135 .......... Remove & graft wrist lesion ........................... Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
25136 .......... Remove & graft wrist lesion ........................... Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
25145 .......... Remove forearm bone lesion ......................... Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
25210 .......... Removal of wrist bone ................................... Y ................. .................... A2 ............... $510.00 26.7322 $1,106.71 $659.18
25215 .......... Removal of wrist bones .................................. Y ................. .................... A2 ............... $630.00 26.7322 $1,106.71 $749.18
25246 .......... Injection for wrist x-ray ................................... N ................. .................... N1 ............... .................... .................... .................... ....................
25248 .......... Remove forearm foreign body ....................... Y ................. .................... A2 ............... $446.00 21.5761 $893.25 $557.81
25250 .......... Removal of wrist prosthesis ........................... Y ................. .................... A2 ............... $333.00 29.3263 $1,214.11 $553.28
25251 .......... Removal of wrist prosthesis ........................... Y ................. .................... A2 ............... $333.00 29.3263 $1,214.11 $553.28
25259 .......... Manipulate wrist w/anesthes .......................... Y ................. .................... G2 .............. .................... 1.8742 $77.59 $77.59
25260 .......... Repair forearm tendon/muscle ....................... Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
25275 .......... Repair forearm tendon sheath ....................... Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
25280 .......... Revise wrist/forearm tendon .......................... Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
25290 .......... Incise wrist/forearm tendon ............................ Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
25295 .......... Release wrist/forearm tendon ........................ Y ................. .................... A2 ............... $510.00 21.5761 $893.25 $605.81
25300 .......... Fusion of tendons at wrist .............................. Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
25301 .......... Fusion of tendons at wrist .............................. Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
25310 .......... Transplant forearm tendon ............................. Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
25312 .......... Transplant forearm tendon ............................. Y ................. .................... A2 ............... $630.00 43.5953 $1,804.85 $923.71
25315 .......... Revise palsy hand tendon(s) ......................... Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
25316 .......... Revise palsy hand tendon(s) ......................... Y ................. .................... A2 ............... $510.00 78.6518 $3,256.18 $1,196.55
25320 .......... Repair/revise wrist joint .................................. Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
25332 .......... Revise wrist joint ............................................ Y ................. .................... A2 ............... $717.00 35.9249 $1,487.29 $909.57
25335 .......... Realignment of hand ...................................... Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
25337 .......... Reconstruct ulna/radioulnar ........................... Y ................. .................... A2 ............... $717.00 43.5953 $1,804.85 $988.96
25350 .......... Revision of radius ........................................... Y ................. .................... A2 ............... $510.00 78.6518 $3,256.18 $1,196.55
25355 .......... Revision of radius ........................................... Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
25360 .......... Revision of ulna .............................................. Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
25365 .......... Revise radius & ulna ...................................... Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
25370 .......... Revise radius or ulna ..................................... Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
25375 .......... Revise radius & ulna ...................................... Y ................. .................... A2 ............... $630.00 43.5953 $1,804.85 $923.71
25390 .......... Shorten radius or ulna .................................... Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
25391 .......... Lengthen radius or ulna ................................. Y ................. .................... A2 ............... $630.00 43.5953 $1,804.85 $923.71
25392 .......... Shorten radius & ulna .................................... Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
25393 .......... Lengthen radius & ulna .................................. Y ................. .................... A2 ............... $630.00 43.5953 $1,804.85 $923.71
25394 .......... Repair carpal bone, shorten ........................... Y ................. .................... G2 .............. .................... 16.8220 $696.43 $696.43
25400 .......... Repair radius or ulna ...................................... Y ................. .................... A2 ............... $510.00 78.6518 $3,256.18 $1,196.55
25405 .......... Repair/graft radius or ulna ............................. Y ................. .................... A2 ............... $630.00 78.6518 $3,256.18 $1,286.55
25415 .......... Repair radius & ulna ...................................... Y ................. .................... A2 ............... $510.00 78.6518 $3,256.18 $1,196.55
25420 .......... Repair/graft radius & ulna .............................. Y ................. .................... A2 ............... $630.00 78.6518 $3,256.18 $1,286.55
25425 .......... Repair/graft radius or ulna ............................. Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
25426 .......... Repair/graft radius & ulna .............................. Y ................. .................... A2 ............... $630.00 43.5953 $1,804.85 $923.71
25430 .......... Vasc graft into carpal bone ............................ Y ................. .................... G2 .............. .................... 26.7322 $1,106.71 $1,106.71
25431 .......... Repair nonunion carpal bone ......................... Y ................. .................... G2 .............. .................... 26.7322 $1,106.71 $1,106.71
25440 .......... Repair/graft wrist bone ................................... Y ................. .................... A2 ............... $630.00 78.6518 $3,256.18 $1,286.55
25441 .......... Reconstruct wrist joint .................................... Y ................. .................... A2 ............... $717.00 113.6713 $4,705.99 $1,714.25
25446 .......... Wrist replacement .......................................... Y ................. .................... A2 ............... $995.00 113.6713 $4,705.99 $1,922.75
25447 .......... Repair wrist joint(s) ........................................ Y ................. .................... A2 ............... $717.00 35.9249 $1,487.29 $909.57
25449 .......... Remove wrist joint implant ............................. Y ................. .................... A2 ............... $717.00 35.9249 $1,487.29 $909.57
25450 .......... Revision of wrist joint ..................................... Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
25455 .......... Revision of wrist joint ..................................... Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
25490 .......... Reinforce radius ............................................. Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
25491 .......... Reinforce ulna ................................................ Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
25492 .......... Reinforce radius and ulna .............................. Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
25500 .......... Treat fracture of radius ................................... Y ................. .................... P2 ............... .................... 1.8742 $77.59 $77.59
25505 .......... Treat fracture of radius ................................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
25515 .......... Treat fracture of radius ................................... Y ................. .................... A2 ............... $510.00 40.3466 $1,670.35 $800.09
25520 .......... Treat fracture of radius ................................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
25530 .......... Treat fracture of ulna ...................................... Y ................. .................... P2 ............... .................... 1.8742 $77.59 $77.59
25535 .......... Treat fracture of ulna ...................................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
25545 .......... Treat fracture of ulna ...................................... Y ................. .................... A2 ............... $510.00 40.3466 $1,670.35 $800.09
25560 .......... Treat fracture radius & ulna ........................... Y ................. .................... P2 ............... .................... 1.8742 $77.59 $77.59
25565 .......... Treat fracture radius & ulna ........................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
25574 .......... Treat fracture radius & ulna ........................... Y ................. .................... A2 ............... $510.00 60.0595 $2,486.46 $1,004.12
25575 .......... Treat fracture radius/ulna ............................... Y ................. .................... A2 ............... $510.00 60.0595 $2,486.46 $1,004.12
25600 .......... Treat fracture radius/ulna ............................... Y ................. .................... P2 ............... .................... 1.8742 $77.59 $77.59
25605 .......... Treat fracture radius/ulna ............................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
25606 .......... Treat fx distal radial ........................................ Y ................. .................... A2 ............... $510.00 26.3092 $1,089.20 $654.80
25607 .......... Treat fx rad extra-articul ................................. Y ................. .................... A2 ............... $717.00 60.0595 $2,486.46 $1,159.37
25608 .......... Treat fx rad intra-articul .................................. Y ................. .................... A2 ............... $717.00 60.0595 $2,486.46 $1,159.37
25609 .......... Treat fx radial 3+ frag .................................... Y ................. .................... A2 ............... $717.00 60.0595 $2,486.46 $1,159.37
25622 .......... Treat wrist bone fracture ................................ Y ................. .................... P2 ............... .................... 1.8742 $77.59 $77.59
25624 .......... Treat wrist bone fracture ................................ Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
25628 .......... Treat wrist bone fracture ................................ Y ................. .................... A2 ............... $510.00 40.3466 $1,670.35 $800.09
25635 .......... Treat wrist bone fracture ................................ Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
25645 .......... Treat wrist bone fracture ................................ Y ................. .................... A2 ............... $510.00 40.3466 $1,670.35 $800.09
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
25651 .......... Pin ulnar styloid fracture ................................ Y ................. .................... G2 .............. .................... 26.3092 $1,089.20 $1,089.20
25652 .......... Treat fracture ulnar styloid ............................. Y ................. .................... G2 .............. .................... 40.3466 $1,670.35 $1,670.35
25660 .......... Treat wrist dislocation .................................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
25670 .......... Treat wrist dislocation .................................... Y ................. .................... A2 ............... $510.00 26.3092 $1,089.20 $654.80
25671 .......... Pin radioulnar dislocation ............................... Y ................. .................... A2 ............... $333.00 26.3092 $1,089.20 $522.05
25680 .......... Treat wrist fracture ......................................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
25685 .......... Treat wrist fracture ......................................... Y ................. .................... A2 ............... $510.00 26.3092 $1,089.20 $654.80
25800 .......... Fusion of wrist joint ........................................ Y ................. .................... A2 ............... $630.00 78.6518 $3,256.18 $1,286.55
25805 .......... Fusion/graft of wrist joint ................................ Y ................. .................... A2 ............... $717.00 43.5953 $1,804.85 $988.96
25810 .......... Fusion/graft of wrist joint ................................ Y ................. .................... A2 ............... $717.00 78.6518 $3,256.18 $1,351.80
25820 .......... Fusion of hand bones .................................... Y ................. .................... A2 ............... $630.00 16.8220 $696.43 $646.61
25825 .......... Fuse hand bones with graft ........................... Y ................. .................... A2 ............... $717.00 78.6518 $3,256.18 $1,351.80
25830 .......... Fusion, radioulnar jnt/ulna .............................. Y ................. .................... A2 ............... $717.00 78.6518 $3,256.18 $1,351.80
25922 .......... Amputate hand at wrist .................................. Y ................. .................... A2 ............... $510.00 21.5761 $893.25 $605.81
25931 .......... Amputation follow-up surgery ......................... Y ................. CH .............. G2 .............. .................... 21.5761 $893.25 $893.25
26010 .......... Drainage of finger abscess ............................ Y ................. .................... P2 ............... .................... 1.4630 $60.57 $60.57
26011 .......... Drainage of finger abscess ............................ Y ................. .................... A2 ............... $333.00 12.5792 $520.78 $379.95
26020 .......... Drain hand tendon sheath .............................. Y ................. .................... A2 ............... $446.00 16.8220 $696.43 $508.61
26025 .......... Drainage of palm bursa .................................. Y ................. .................... A2 ............... $333.00 16.8220 $696.43 $423.86
26030 .......... Drainage of palm bursa(s) ............................. Y ................. .................... A2 ............... $446.00 16.8220 $696.43 $508.61
26034 .......... Treat hand bone lesion .................................. Y ................. .................... A2 ............... $446.00 16.8220 $696.43 $508.61
26035 .......... Decompress fingers/hand .............................. Y ................. .................... G2 .............. .................... 16.8220 $696.43 $696.43
26040 .......... Release palm contracture .............................. Y ................. .................... A2 ............... $630.00 26.7322 $1,106.71 $749.18
26055 .......... Incise finger tendon sheath ............................ Y ................. .................... A2 ............... $446.00 16.8220 $696.43 $508.61
26060 .......... Incision of finger tendon ................................. Y ................. .................... A2 ............... $446.00 16.8220 $696.43 $508.61
26070 .......... Explore/treat hand joint .................................. Y ................. .................... A2 ............... $446.00 16.8220 $696.43 $508.61
26075 .......... Explore/treat finger joint ................................. Y ................. .................... A2 ............... $630.00 16.8220 $696.43 $646.61
26080 .......... Explore/treat finger joint ................................. Y ................. .................... A2 ............... $630.00 16.8220 $696.43 $646.61
26100 .......... Biopsy hand joint lining .................................. Y ................. .................... A2 ............... $446.00 16.8220 $696.43 $508.61
26105 .......... Biopsy finger joint lining ................................. Y ................. .................... A2 ............... $333.00 16.8220 $696.43 $423.86
26110 .......... Biopsy finger joint lining ................................. Y ................. .................... A2 ............... $333.00 16.8220 $696.43 $423.86
26115 .......... Removal hand lesion subcut .......................... Y ................. .................... A2 ............... $446.00 21.4534 $888.17 $556.54
26116 .......... Removal hand lesion, deep ........................... Y ................. .................... A2 ............... $446.00 21.4534 $888.17 $556.54
26117 .......... Remove tumor, hand/finger ............................ Y ................. .................... A2 ............... $510.00 21.4534 $888.17 $604.54
26125 .......... Release palm contracture .............................. Y ................. .................... A2 ............... $630.00 16.8220 $696.43 $646.61
26130 .......... Remove wrist joint lining ................................ Y ................. .................... A2 ............... $510.00 16.8220 $696.43 $556.61
26135 .......... Revise finger joint, each ................................. Y ................. .................... A2 ............... $630.00 26.7322 $1,106.71 $749.18
26140 .......... Revise finger joint, each ................................. Y ................. .................... A2 ............... $446.00 16.8220 $696.43 $508.61
26145 .......... Tendon excision, palm/finger ......................... Y ................. .................... A2 ............... $510.00 16.8220 $696.43 $556.61
26160 .......... Remove tendon sheath lesion ....................... Y ................. .................... A2 ............... $510.00 16.8220 $696.43 $556.61
26170 .......... Removal of palm tendon, each ...................... Y ................. .................... A2 ............... $510.00 16.8220 $696.43 $556.61
26180 .......... Removal of finger tendon ............................... Y ................. .................... A2 ............... $510.00 16.8220 $696.43 $556.61
26185 .......... Remove finger bone ....................................... Y ................. .................... A2 ............... $630.00 16.8220 $696.43 $646.61
26200 .......... Remove hand bone lesion ............................. Y ................. .................... A2 ............... $446.00 16.8220 $696.43 $508.61
26210 .......... Removal of finger lesion ................................ Y ................. .................... A2 ............... $446.00 16.8220 $696.43 $508.61
26215 .......... Remove/graft finger lesion ............................. Y ................. .................... A2 ............... $510.00 16.8220 $696.43 $556.61
26230 .......... Partial removal of hand bone ......................... Y ................. .................... A2 ............... $992.95 16.8220 $696.43 $918.82
26235 .......... Partial removal, finger bone ........................... Y ................. .................... A2 ............... $510.00 16.8220 $696.43 $556.61
26236 .......... Partial removal, finger bone ........................... Y ................. .................... A2 ............... $510.00 16.8220 $696.43 $556.61
26250 .......... Extensive hand surgery .................................. Y ................. .................... A2 ............... $510.00 16.8220 $696.43 $556.61
26255 .......... Extensive hand surgery .................................. Y ................. .................... A2 ............... $510.00 26.7322 $1,106.71 $659.18
26260 .......... Extensive finger surgery ................................. Y ................. .................... A2 ............... $510.00 16.8220 $696.43 $556.61
26261 .......... Extensive finger surgery ................................. Y ................. .................... A2 ............... $510.00 16.8220 $696.43 $556.61
26262 .......... Partial removal of finger ................................. Y ................. .................... A2 ............... $446.00 16.8220 $696.43 $508.61
26320 .......... Removal of implant from hand ....................... Y ................. .................... A2 ............... $446.00 16.5832 $686.54 $506.14
26340 .......... Manipulate finger w/anesth ............................ Y ................. .................... G2 .............. .................... 1.8742 $77.59 $77.59
26350 .......... Repair finger/hand tendon .............................. Y ................. .................... A2 ............... $333.00 26.7322 $1,106.71 $526.43
26352 .......... Repair/graft hand tendon ............................... Y ................. .................... A2 ............... $630.00 26.7322 $1,106.71 $749.18
26390 .......... Revise hand/finger tendon ............................. Y ................. .................... A2 ............... $630.00 26.7322 $1,106.71 $749.18
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
26410 .......... Repair hand tendon ........................................ Y ................. .................... A2 ............... $510.00 16.8220 $696.43 $556.61
26415 .......... Excision, hand/finger tendon .......................... Y ................. .................... A2 ............... $630.00 26.7322 $1,106.71 $749.18
26416 .......... Graft hand or finger tendon ............................ Y ................. .................... A2 ............... $510.00 26.7322 $1,106.71 $659.18
26418 .......... Repair finger tendon ....................................... Y ................. .................... A2 ............... $630.00 16.8220 $696.43 $646.61
26420 .......... Repair/graft finger tendon .............................. Y ................. .................... A2 ............... $630.00 26.7322 $1,106.71 $749.18
26437 .......... Realignment of tendons ................................. Y ................. .................... A2 ............... $510.00 16.8220 $696.43 $556.61
26440 .......... Release palm/finger tendon ........................... Y ................. .................... A2 ............... $510.00 16.8220 $696.43 $556.61
26442 .......... Release palm & finger tendon ....................... Y ................. .................... A2 ............... $510.00 26.7322 $1,106.71 $659.18
26445 .......... Release hand/finger tendon ........................... Y ................. .................... A2 ............... $510.00 16.8220 $696.43 $556.61
26449 .......... Release forearm/hand tendon ........................ Y ................. .................... A2 ............... $510.00 26.7322 $1,106.71 $659.18
26450 .......... Incision of palm tendon .................................. Y ................. .................... A2 ............... $510.00 16.8220 $696.43 $556.61
26455 .......... Incision of finger tendon ................................. Y ................. .................... A2 ............... $510.00 16.8220 $696.43 $556.61
26460 .......... Incise hand/finger tendon ............................... Y ................. .................... A2 ............... $510.00 16.8220 $696.43 $556.61
26471 .......... Fusion of finger tendons ................................ Y ................. .................... A2 ............... $446.00 16.8220 $696.43 $508.61
26474 .......... Fusion of finger tendons ................................ Y ................. .................... A2 ............... $446.00 16.8220 $696.43 $508.61
26476 .......... Tendon lengthening ........................................ Y ................. .................... A2 ............... $333.00 16.8220 $696.43 $423.86
26477 .......... Tendon shortening ......................................... Y ................. .................... A2 ............... $333.00 16.8220 $696.43 $423.86
26478 .......... Lengthening of hand tendon .......................... Y ................. .................... A2 ............... $333.00 16.8220 $696.43 $423.86
26479 .......... Shortening of hand tendon ............................. Y ................. .................... A2 ............... $333.00 16.8220 $696.43 $423.86
26480 .......... Transplant hand tendon ................................. Y ................. .................... A2 ............... $510.00 26.7322 $1,106.71 $659.18
26483 .......... Transplant/graft hand tendon ......................... Y ................. .................... A2 ............... $510.00 26.7322 $1,106.71 $659.18
26485 .......... Transplant palm tendon ................................. Y ................. .................... A2 ............... $446.00 26.7322 $1,106.71 $611.18
26489 .......... Transplant/graft palm tendon ......................... Y ................. .................... A2 ............... $510.00 26.7322 $1,106.71 $659.18
26490 .......... Revise thumb tendon ..................................... Y ................. .................... A2 ............... $510.00 26.7322 $1,106.71 $659.18
26492 .......... Tendon transfer with graft .............................. Y ................. .................... A2 ............... $510.00 26.7322 $1,106.71 $659.18
26494 .......... Hand tendon/muscle transfer ......................... Y ................. .................... A2 ............... $510.00 26.7322 $1,106.71 $659.18
26496 .......... Revise thumb tendon ..................................... Y ................. .................... A2 ............... $510.00 26.7322 $1,106.71 $659.18
26497 .......... Finger tendon transfer .................................... Y ................. .................... A2 ............... $510.00 26.7322 $1,106.71 $659.18
26498 .......... Finger tendon transfer .................................... Y ................. .................... A2 ............... $630.00 26.7322 $1,106.71 $749.18
26499 .......... Revision of finger ........................................... Y ................. .................... A2 ............... $510.00 26.7322 $1,106.71 $659.18
26500 .......... Hand tendon reconstruction ........................... Y ................. .................... A2 ............... $630.00 16.8220 $696.43 $646.61
26502 .......... Hand tendon reconstruction ........................... Y ................. .................... A2 ............... $630.00 26.7322 $1,106.71 $749.18
26508 .......... Release thumb contracture ............................ Y ................. .................... A2 ............... $510.00 16.8220 $696.43 $556.61
26510 .......... Thumb tendon transfer ................................... Y ................. .................... A2 ............... $510.00 26.7322 $1,106.71 $659.18
26516 .......... Fusion of knuckle joint ................................... Y ................. .................... A2 ............... $333.00 26.7322 $1,106.71 $526.43
26517 .......... Fusion of knuckle joints .................................. Y ................. .................... A2 ............... $510.00 26.7322 $1,106.71 $659.18
26518 .......... Fusion of knuckle joints .................................. Y ................. .................... A2 ............... $510.00 26.7322 $1,106.71 $659.18
26520 .......... Release knuckle contracture .......................... Y ................. .................... A2 ............... $510.00 16.8220 $696.43 $556.61
26525 .......... Release finger contracture ............................. Y ................. .................... A2 ............... $510.00 16.8220 $696.43 $556.61
26530 .......... Revise knuckle joint ....................................... Y ................. .................... A2 ............... $510.00 35.9249 $1,487.29 $754.32
26531 .......... Revise knuckle with implant ........................... Y ................. .................... A2 ............... $995.00 51.0431 $2,113.18 $1,274.55
26535 .......... Revise finger joint ........................................... Y ................. .................... A2 ............... $717.00 35.9249 $1,487.29 $909.57
26536 .......... Revise/implant finger joint .............................. Y ................. .................... A2 ............... $717.00 51.0431 $2,113.18 $1,066.05
26540 .......... Repair hand joint ............................................ Y ................. .................... A2 ............... $630.00 16.8220 $696.43 $646.61
26541 .......... Repair hand joint with graft ............................ Y ................. .................... A2 ............... $995.00 26.7322 $1,106.71 $1,022.93
26542 .......... Repair hand joint with graft ............................ Y ................. .................... A2 ............... $630.00 16.8220 $696.43 $646.61
26545 .......... Reconstruct finger joint .................................. Y ................. .................... A2 ............... $630.00 26.7322 $1,106.71 $749.18
26546 .......... Repair nonunion hand .................................... Y ................. .................... A2 ............... $630.00 26.7322 $1,106.71 $749.18
26548 .......... Reconstruct finger joint .................................. Y ................. .................... A2 ............... $630.00 26.7322 $1,106.71 $749.18
26550 .......... Construct thumb replacement ........................ Y ................. .................... A2 ............... $446.00 26.7322 $1,106.71 $611.18
26555 .......... Positional change of finger ............................. Y ................. .................... A2 ............... $510.00 26.7322 $1,106.71 $659.18
26560 .......... Repair of web finger ....................................... Y ................. .................... A2 ............... $446.00 16.8220 $696.43 $508.61
26561 .......... Repair of web finger ....................................... Y ................. .................... A2 ............... $510.00 26.7322 $1,106.71 $659.18
26562 .......... Repair of web finger ....................................... Y ................. .................... A2 ............... $630.00 26.7322 $1,106.71 $749.18
26565 .......... Correct metacarpal flaw ................................. Y ................. .................... A2 ............... $717.00 26.7322 $1,106.71 $814.43
26567 .......... Correct finger deformity .................................. Y ................. .................... A2 ............... $717.00 26.7322 $1,106.71 $814.43
26568 .......... Lengthen metacarpal/finger ............................ Y ................. .................... A2 ............... $510.00 26.7322 $1,106.71 $659.18
26580 .......... Repair hand deformity .................................... Y ................. .................... A2 ............... $717.00 16.8220 $696.43 $711.86
26587 .......... Reconstruct extra finger ................................. Y ................. .................... A2 ............... $717.00 16.8220 $696.43 $711.86
26590 .......... Repair finger deformity ................................... Y ................. .................... A2 ............... $717.00 16.8220 $696.43 $711.86
26591 .......... Repair muscles of hand ................................. Y ................. .................... A2 ............... $510.00 26.7322 $1,106.71 $659.18
26593 .......... Release muscles of hand ............................... Y ................. .................... A2 ............... $510.00 16.8220 $696.43 $556.61
26596 .......... Excision constricting tissue ............................ Y ................. .................... A2 ............... $446.00 16.8220 $696.43 $508.61
26600 .......... Treat metacarpal fracture ............................... Y ................. .................... P2 ............... .................... 1.8742 $77.59 $77.59
26605 .......... Treat metacarpal fracture ............................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
26607 .......... Treat metacarpal fracture ............................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
26608 .......... Treat metacarpal fracture ............................... Y ................. .................... A2 ............... $630.00 26.3092 $1,089.20 $744.80
26615 .......... Treat metacarpal fracture ............................... Y ................. .................... A2 ............... $630.00 40.3466 $1,670.35 $890.09
26641 .......... Treat thumb dislocation .................................. Y ................. CH .............. P2 ............... .................... 1.8742 $77.59 $77.59
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
26645 .......... Treat thumb fracture ....................................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
26650 .......... Treat thumb fracture ....................................... Y ................. .................... A2 ............... $446.00 26.3092 $1,089.20 $606.80
26665 .......... Treat thumb fracture ....................................... Y ................. .................... A2 ............... $630.00 40.3466 $1,670.35 $890.09
26670 .......... Treat hand dislocation .................................... Y ................. CH .............. P2 ............... .................... 1.8742 $77.59 $77.59
26675 .......... Treat hand dislocation .................................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
26676 .......... Pin hand dislocation ....................................... Y ................. .................... A2 ............... $446.00 26.3092 $1,089.20 $606.80
26685 .......... Treat hand dislocation .................................... Y ................. .................... A2 ............... $510.00 40.3466 $1,670.35 $800.09
26686 .......... Treat hand dislocation .................................... Y ................. .................... A2 ............... $510.00 60.0595 $2,486.46 $1,004.12
26700 .......... Treat knuckle dislocation ................................ Y ................. CH .............. P2 ............... .................... 1.8742 $77.59 $77.59
26705 .......... Treat knuckle dislocation ................................ Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
26706 .......... Pin knuckle dislocation ................................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
26715 .......... Treat knuckle dislocation ................................ Y ................. .................... A2 ............... $630.00 40.3466 $1,670.35 $890.09
26720 .......... Treat finger fracture, each .............................. Y ................. .................... P2 ............... .................... 1.8742 $77.59 $77.59
26727 .......... Treat finger fracture, each .............................. Y ................. .................... A2 ............... $995.00 26.3092 $1,089.20 $1,018.55
26735 .......... Treat finger fracture, each .............................. Y ................. .................... A2 ............... $630.00 40.3466 $1,670.35 $890.09
26742 .......... Treat finger fracture, each .............................. Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
26755 .......... Treat finger fracture, each .............................. Y ................. .................... G2 .............. .................... 1.8742 $77.59 $77.59
26756 .......... Pin finger fracture, each ................................. Y ................. .................... A2 ............... $446.00 26.3092 $1,089.20 $606.80
26770 .......... Treat finger dislocation ................................... Y ................. .................... G2 .............. .................... 1.8742 $77.59 $77.59
26775 .......... Treat finger dislocation ................................... Y ................. CH .............. P3 ............... .................... 4.0319 $166.92 $166.92
26776 .......... Pin finger dislocation ...................................... Y ................. .................... A2 ............... $446.00 26.3092 $1,089.20 $606.80
26785 .......... Treat finger dislocation ................................... Y ................. .................... A2 ............... $446.00 26.3092 $1,089.20 $606.80
26820 .......... Thumb fusion with graft .................................. Y ................. .................... A2 ............... $717.00 26.7322 $1,106.71 $814.43
26841 .......... Fusion of thumb ............................................. Y ................. .................... A2 ............... $630.00 26.7322 $1,106.71 $749.18
26842 .......... Thumb fusion with graft .................................. Y ................. .................... A2 ............... $630.00 26.7322 $1,106.71 $749.18
26843 .......... Fusion of hand joint ........................................ Y ................. .................... A2 ............... $510.00 26.7322 $1,106.71 $659.18
26844 .......... Fusion/graft of hand joint ............................... Y ................. .................... A2 ............... $510.00 26.7322 $1,106.71 $659.18
26850 .......... Fusion of knuckle ........................................... Y ................. .................... A2 ............... $630.00 26.7322 $1,106.71 $749.18
26852 .......... Fusion of knuckle with graft ........................... Y ................. .................... A2 ............... $630.00 26.7322 $1,106.71 $749.18
26860 .......... Fusion of finger joint ....................................... Y ................. .................... A2 ............... $510.00 26.7322 $1,106.71 $659.18
26861 .......... Fusion of finger jnt, add-on ............................ Y ................. .................... A2 ............... $446.00 26.7322 $1,106.71 $611.18
26862 .......... Fusion/graft of finger joint .............................. Y ................. .................... A2 ............... $630.00 26.7322 $1,106.71 $749.18
26863 .......... Fuse/graft added joint .................................... Y ................. .................... A2 ............... $510.00 26.7322 $1,106.71 $659.18
26910 .......... Amputate metacarpal bone ............................ Y ................. .................... A2 ............... $510.00 26.7322 $1,106.71 $659.18
26951 .......... Amputation of finger/thumb ............................ Y ................. .................... A2 ............... $446.00 16.8220 $696.43 $508.61
26952 .......... Amputation of finger/thumb ............................ Y ................. .................... A2 ............... $630.00 16.8220 $696.43 $646.61
26990 .......... Drainage of pelvis lesion ................................ Y ................. .................... A2 ............... $333.00 21.5761 $893.25 $473.06
26991 .......... Drainage of pelvis bursa ................................ Y ................. .................... A2 ............... $333.00 21.5761 $893.25 $473.06
27000 .......... Incision of hip tendon ..................................... Y ................. .................... A2 ............... $446.00 21.5761 $893.25 $557.81
27001 .......... Incision of hip tendon ..................................... Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
27003 .......... Incision of hip tendon ..................................... Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
27033 .......... Exploration of hip joint .................................... Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
27035 .......... Denervation of hip joint .................................. Y ................. .................... A2 ............... $630.00 43.5953 $1,804.85 $923.71
27040 .......... Biopsy of soft tissues ..................................... Y ................. .................... A2 ............... $333.00 8.7155 $360.82 $339.96
27041 .......... Biopsy of soft tissues ..................................... Y ................. .................... A2 ............... $418.49 8.7155 $360.82 $404.07
27047 .......... Remove hip/pelvis lesion ............................... Y ................. .................... A2 ............... $446.00 21.4534 $888.17 $556.54
27048 .......... Remove hip/pelvis lesion ............................... Y ................. .................... A2 ............... $510.00 21.4534 $888.17 $604.54
27049 .......... Remove tumor, hip/pelvis ............................... Y ................. .................... A2 ............... $510.00 21.4534 $888.17 $604.54
27050 .......... Biopsy of sacroiliac joint ................................. Y ................. .................... A2 ............... $510.00 21.5761 $893.25 $605.81
27052 .......... Biopsy of hip joint ........................................... Y ................. .................... A2 ............... $510.00 21.5761 $893.25 $605.81
27060 .......... Removal of ischial bursa ................................ Y ................. .................... A2 ............... $717.00 21.5761 $893.25 $761.06
27062 .......... Remove femur lesion/bursa ........................... Y ................. .................... A2 ............... $717.00 21.5761 $893.25 $761.06
27065 .......... Removal of hip bone lesion ........................... Y ................. .................... A2 ............... $717.00 21.5761 $893.25 $761.06
27066 .......... Removal of hip bone lesion ........................... Y ................. .................... A2 ............... $717.00 29.3263 $1,214.11 $841.28
27067 .......... Remove/graft hip bone lesion ........................ Y ................. .................... A2 ............... $717.00 29.3263 $1,214.11 $841.28
27080 .......... Removal of tail bone ...................................... Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
27086 .......... Remove hip foreign body ............................... Y ................. .................... A2 ............... $333.00 8.7155 $360.82 $339.96
27087 .......... Remove hip foreign body ............................... Y ................. .................... A2 ............... $510.00 21.5761 $893.25 $605.81
27093 .......... Injection for hip x-ray ...................................... N ................. .................... N1 ............... .................... .................... .................... ....................
27095 .......... Injection for hip x-ray ...................................... N ................. .................... N1 ............... .................... .................... .................... ....................
27097 .......... Revision of hip tendon ................................... Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
27098 .......... Transfer tendon to pelvis ............................... Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
27100 .......... Transfer of abdominal muscle ........................ Y ................. .................... A2 ............... $630.00 43.5953 $1,804.85 $923.71
27105 .......... Transfer of spinal muscle ............................... Y ................. .................... A2 ............... $630.00 43.5953 $1,804.85 $923.71
27110 .......... Transfer of iliopsoas muscle .......................... Y ................. .................... A2 ............... $630.00 43.5953 $1,804.85 $923.71
27111 .......... Transfer of iliopsoas muscle .......................... Y ................. .................... A2 ............... $630.00 43.5953 $1,804.85 $923.71
27193 .......... Treat pelvic ring fracture ................................ Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
27194 .......... Treat pelvic ring fracture ................................ Y ................. .................... A2 ............... $446.00 15.0176 $621.73 $489.93
27200 .......... Treat tail bone fracture ................................... Y ................. .................... P3 ............... .................... 1.7727 $73.39 $73.39
27202 .......... Treat tail bone fracture ................................... Y ................. .................... A2 ............... $446.00 40.3466 $1,670.35 $752.09
27220 .......... Treat hip socket fracture ................................ Y ................. .................... G2 .............. .................... 1.8742 $77.59 $77.59
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
27230 .......... Treat thigh fracture ......................................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
27250 .......... Treat hip dislocation ....................................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
27256 .......... Treat hip dislocation ....................................... Y ................. .................... G2 .............. .................... 1.8742 $77.59 $77.59
27275 .......... Manipulation of hip joint ................................. Y ................. .................... A2 ............... $446.00 15.0176 $621.73 $489.93
27301 .......... Drain thigh/knee lesion ................................... Y ................. .................... A2 ............... $510.00 19.0457 $788.49 $579.62
27305 .......... Incise thigh tendon & fascia ........................... Y ................. .................... A2 ............... $446.00 21.5761 $893.25 $557.81
27306 .......... Incision of thigh tendon .................................. Y ................. .................... A2 ............... $510.00 21.5761 $893.25 $605.81
27307 .......... Incision of thigh tendons ................................ Y ................. .................... A2 ............... $510.00 21.5761 $893.25 $605.81
27310 .......... Exploration of knee joint ................................. Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
27323 .......... Biopsy, thigh soft tissues ............................... Y ................. .................... A2 ............... $333.00 8.7155 $360.82 $339.96
27324 .......... Biopsy, thigh soft tissues ............................... Y ................. .................... A2 ............... $333.00 21.4534 $888.17 $471.79
27325 .......... Neurectomy, hamstring .................................. Y ................. .................... A2 ............... $446.00 18.5069 $766.19 $526.05
27326 .......... Neurectomy, popliteal ..................................... Y ................. .................... A2 ............... $446.00 18.5069 $766.19 $526.05
27327 .......... Removal of thigh lesion .................................. Y ................. .................... A2 ............... $446.00 21.4534 $888.17 $556.54
27328 .......... Removal of thigh lesion .................................. Y ................. .................... A2 ............... $510.00 21.4534 $888.17 $604.54
27329 .......... Remove tumor, thigh/knee ............................. Y ................. .................... A2 ............... $630.00 21.4534 $888.17 $694.54
27330 .......... Biopsy, knee joint lining ................................. Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
27331 .......... Explore/treat knee joint .................................. Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
27332 .......... Removal of knee cartilage ............................. Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
27333 .......... Removal of knee cartilage ............................. Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
27334 .......... Remove knee joint lining ................................ Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
27335 .......... Remove knee joint lining ................................ Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
27340 .......... Removal of kneecap bursa ............................ Y ................. .................... A2 ............... $510.00 21.5761 $893.25 $605.81
27345 .......... Removal of knee cyst ..................................... Y ................. .................... A2 ............... $630.00 21.5761 $893.25 $695.81
27347 .......... Remove knee cyst .......................................... Y ................. .................... A2 ............... $630.00 21.5761 $893.25 $695.81
27350 .......... Removal of kneecap ...................................... Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
27355 .......... Remove femur lesion ..................................... Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
27356 .......... Remove femur lesion/graft ............................. Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
27357 .......... Remove femur lesion/graft ............................. Y ................. .................... A2 ............... $717.00 29.3263 $1,214.11 $841.28
27358 .......... Remove femur lesion/fixation ......................... Y ................. .................... A2 ............... $717.00 29.3263 $1,214.11 $841.28
27360 .......... Partial removal, leg bone(s) ........................... Y ................. .................... A2 ............... $717.00 29.3263 $1,214.11 $841.28
27370 .......... Injection for knee x-ray ................................... N ................. .................... N1 .............. .................... .................... .................... ....................
27372 .......... Removal of foreign body ................................ Y ................. .................... A2 ............... $995.00 21.4534 $888.17 $968.29
27380 .......... Repair of kneecap tendon .............................. Y ................. .................... A2 ............... $333.00 21.5761 $893.25 $473.06
27381 .......... Repair/graft kneecap tendon .......................... Y ................. .................... A2 ............... $510.00 21.5761 $893.25 $605.81
27385 .......... Repair of thigh muscle ................................... Y ................. .................... A2 ............... $510.00 21.5761 $893.25 $605.81
27386 .......... Repair/graft of thigh muscle ........................... Y ................. .................... A2 ............... $510.00 21.5761 $893.25 $605.81
27390 .......... Incision of thigh tendon .................................. Y ................. .................... A2 ............... $333.00 21.5761 $893.25 $473.06
27393 .......... Lengthening of thigh tendon .......................... Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
27394 .......... Lengthening of thigh tendons ......................... Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
27395 .......... Lengthening of thigh tendons ......................... Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
27396 .......... Transplant of thigh tendon ............................. Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
27397 .......... Transplants of thigh tendons .......................... Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
27400 .......... Revise thigh muscles/tendons ....................... Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
27403 .......... Repair of knee cartilage ................................. Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
27405 .......... Repair of knee ligament ................................. Y ................. .................... A2 ............... $630.00 43.5953 $1,804.85 $923.71
27407 .......... Repair of knee ligament ................................. Y ................. .................... A2 ............... $630.00 78.6518 $3,256.18 $1,286.55
27409 .......... Repair of knee ligaments ............................... Y ................. .................... A2 ............... $630.00 43.5953 $1,804.85 $923.71
27418 .......... Repair degenerated kneecap ......................... Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
27420 .......... Revision of unstable kneecap ........................ Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
27422 .......... Revision of unstable kneecap ........................ Y ................. .................... A2 ............... $995.00 43.5953 $1,804.85 $1,197.46
27424 .......... Revision/removal of kneecap ......................... Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
27425 .......... Lat retinacular release open .......................... Y ................. .................... A2 ............... $995.00 29.3263 $1,214.11 $1,049.78
27427 .......... Reconstruction, knee ...................................... Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
27428 .......... Reconstruction, knee ...................................... Y ................. .................... A2 ............... $630.00 78.6518 $3,256.18 $1,286.55
27429 .......... Reconstruction, knee ...................................... Y ................. .................... A2 ............... $630.00 78.6518 $3,256.18 $1,286.55
27430 .......... Revision of thigh muscles .............................. Y ................. .................... A2 ............... $630.00 43.5953 $1,804.85 $923.71
27435 .......... Incision of knee joint ...................................... Y ................. .................... A2 ............... $630.00 43.5953 $1,804.85 $923.71
27437 .......... Revise kneecap .............................................. Y ................. .................... A2 ............... $630.00 35.9249 $1,487.29 $844.32
27438 .......... Revise kneecap with implant ......................... Y ................. .................... A2 ............... $717.00 51.0431 $2,113.18 $1,066.05
27440 .......... Revision of knee joint ..................................... Y ................. .................... G2 .............. .................... 35.9249 $1,487.29 $1,487.29
27441 .......... Revision of knee joint ..................................... Y ................. .................... A2 ............... $717.00 35.9249 $1,487.29 $909.57
27446 .......... Revision of knee joint ..................................... Y ................. .................... G2 .............. .................... 191.2387 $7,917.28 $7,917.28
27496 .......... Decompression of thigh/knee ......................... Y ................. .................... A2 ............... $717.00 21.5761 $893.25 $761.06
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
27500 .......... Treatment of thigh fracture ............................. Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
27509 .......... Treatment of thigh fracture ............................. Y ................. .................... A2 ............... $510.00 26.3092 $1,089.20 $654.80
27516 .......... Treat thigh fx growth plate ............................. Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
27517 .......... Treat thigh fx growth plate ............................. Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
27520 .......... Treat kneecap fracture ................................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
27530 .......... Treat knee fracture ......................................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
27532 .......... Treat knee fracture ......................................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
27538 .......... Treat knee fracture(s) ..................................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
27550 .......... Treat knee dislocation .................................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
27552 .......... Treat knee dislocation .................................... Y ................. .................... A2 ............... $333.00 15.0176 $621.73 $405.18
27560 .......... Treat kneecap dislocation .............................. Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
27562 .......... Treat kneecap dislocation .............................. Y ................. .................... A2 ............... $333.00 15.0176 $621.73 $405.18
27566 .......... Treat kneecap dislocation .............................. Y ................. .................... A2 ............... $446.00 40.3466 $1,670.35 $752.09
27570 .......... Fixation of knee joint ...................................... Y ................. .................... A2 ............... $333.00 15.0176 $621.73 $405.18
27600 .......... Decompression of lower leg ........................... Y ................. .................... A2 ............... $510.00 21.5761 $893.25 $605.81
27603 .......... Drain lower leg lesion ..................................... Y ................. .................... A2 ............... $446.00 19.0457 $788.49 $531.62
27604 .......... Drain lower leg bursa ..................................... Y ................. .................... A2 ............... $446.00 21.5761 $893.25 $557.81
27605 .......... Incision of achilles tendon .............................. Y ................. .................... A2 ............... $333.00 21.1762 $876.69 $468.92
27606 .......... Incision of achilles tendon .............................. Y ................. .................... A2 ............... $333.00 21.5761 $893.25 $473.06
27607 .......... Treat lower leg bone lesion ............................ Y ................. .................... A2 ............... $446.00 21.5761 $893.25 $557.81
27610 .......... Explore/treat ankle joint .................................. Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
27612 .......... Exploration of ankle joint ................................ Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
27613 .......... Biopsy lower leg soft tissue ........................... Y ................. .................... P3 ............... .................... 2.9271 $121.18 $121.18
27614 .......... Biopsy lower leg soft tissue ........................... Y ................. .................... A2 ............... $446.00 21.4534 $888.17 $556.54
27615 .......... Remove tumor, lower leg ............................... Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
27618 .......... Remove lower leg lesion ................................ Y ................. .................... A2 ............... $446.00 16.5832 $686.54 $506.14
27619 .......... Remove lower leg lesion ................................ Y ................. .................... A2 ............... $510.00 21.4534 $888.17 $604.54
27620 .......... Explore/treat ankle joint .................................. Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
27625 .......... Remove ankle joint lining ............................... Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
27626 .......... Remove ankle joint lining ............................... Y ................. .................... A2 ............... $630.00 29.3263 $1,214.11 $776.03
27630 .......... Removal of tendon lesion .............................. Y ................. .................... A2 ............... $510.00 21.5761 $893.25 $605.81
27635 .......... Remove lower leg bone lesion ....................... Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
27637 .......... Remove/graft leg bone lesion ........................ Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
27638 .......... Remove/graft leg bone lesion ........................ Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
27640 .......... Partial removal of tibia ................................... Y ................. .................... A2 ............... $446.00 43.5953 $1,804.85 $785.71
27641 .......... Partial removal of fibula ................................. Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
27647 .......... Extensive ankle/heel surgery ......................... Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
27648 .......... Injection for ankle x-ray .................................. N ................. .................... N1 ............... .................... .................... .................... ....................
27650 .......... Repair achilles tendon .................................... Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
27652 .......... Repair/graft achilles tendon ........................... Y ................. .................... A2 ............... $510.00 78.6518 $3,256.18 $1,196.55
27654 .......... Repair of achilles tendon ............................... Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
27656 .......... Repair leg fascia defect ................................. Y ................. .................... A2 ............... $446.00 21.5761 $893.25 $557.81
27658 .......... Repair of leg tendon, each ............................. Y ................. .................... A2 ............... $333.00 21.5761 $893.25 $473.06
27665 .......... Repair of leg tendon, each ............................. Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
27675 .......... Repair lower leg tendons ............................... Y ................. .................... A2 ............... $446.00 21.5761 $893.25 $557.81
27676 .......... Repair lower leg tendons ............................... Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
27680 .......... Release of lower leg tendon .......................... Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
27681 .......... Release of lower leg tendons ........................ Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
27685 .......... Revision of lower leg tendon .......................... Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
27686 .......... Revise lower leg tendons ............................... Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
27687 .......... Revision of calf tendon ................................... Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
27690 .......... Revise lower leg tendon ................................. Y ................. .................... A2 ............... $630.00 43.5953 $1,804.85 $923.71
27691 .......... Revise lower leg tendon ................................. Y ................. .................... A2 ............... $630.00 43.5953 $1,804.85 $923.71
27692 .......... Revise additional leg tendon .......................... Y ................. .................... A2 ............... $510.00 43.5953 $1,804.85 $833.71
27695 .......... Repair of ankle ligament ................................ Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
27696 .......... Repair of ankle ligaments .............................. Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
27698 .......... Repair of ankle ligament ................................ Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
27700 .......... Revision of ankle joint .................................... Y ................. .................... A2 ............... $717.00 35.9249 $1,487.29 $909.57
27704 .......... Removal of ankle implant ............................... Y ................. .................... A2 ............... $446.00 21.5761 $893.25 $557.81
27705 .......... Incision of tibia ............................................... Y ................. .................... A2 ............... $446.00 43.5953 $1,804.85 $785.71
27707 .......... Incision of fibula ............................................. Y ................. .................... A2 ............... $446.00 21.5761 $893.25 $557.81
27709 .......... Incision of tibia & fibula .................................. Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
27730 .......... Repair of tibia epiphysis ................................. Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
27732 .......... Repair of fibula epiphysis ............................... Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
27734 .......... Repair lower leg epiphyses ............................ Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
27740 .......... Repair of leg epiphyses ................................. Y ................. .................... A2 ............... $446.00 29.3263 $1,214.11 $638.03
27742 .......... Repair of leg epiphyses ................................. Y ................. .................... A2 ............... $446.00 43.5953 $1,804.85 $785.71
27745 .......... Reinforce tibia ................................................ Y ................. .................... A2 ............... $510.00 78.6518 $3,256.18 $1,196.55
27750 .......... Treatment of tibia fracture .............................. Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
27752 .......... Treatment of tibia fracture .............................. Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
27756 .......... Treatment of tibia fracture .............................. Y ................. .................... A2 ............... $510.00 26.3092 $1,089.20 $654.80
27758 .......... Treatment of tibia fracture .............................. Y ................. .................... A2 ............... $630.00 40.3466 $1,670.35 $890.09
27759 .......... Treatment of tibia fracture .............................. Y ................. .................... A2 ............... $630.00 60.0595 $2,486.46 $1,094.12
27760 .......... Treatment of ankle fracture ............................ Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
27766 .......... Treatment of ankle fracture ............................ Y ................. .................... A2 ............... $510.00 40.3466 $1,670.35 $800.09
27780 .......... Treatment of fibula fracture ............................ Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
27781 .......... Treatment of fibula fracture ............................ Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
27784 .......... Treatment of fibula fracture ............................ Y ................. .................... A2 ............... $510.00 40.3466 $1,670.35 $800.09
27823 .......... Treatment of ankle fracture ............................ Y ................. .................... A2 ............... $510.00 60.0595 $2,486.46 $1,004.12
27824 .......... Treat lower leg fracture .................................. Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
27825 .......... Treat lower leg fracture .................................. Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
27826 .......... Treat lower leg fracture .................................. Y ................. .................... A2 ............... $510.00 40.3466 $1,670.35 $800.09
27827 .......... Treat lower leg fracture .................................. Y ................. .................... A2 ............... $510.00 60.0595 $2,486.46 $1,004.12
27828 .......... Treat lower leg fracture .................................. Y ................. .................... A2 ............... $630.00 60.0595 $2,486.46 $1,094.12
27829 .......... Treat lower leg joint ........................................ Y ................. .................... A2 ............... $446.00 40.3466 $1,670.35 $752.09
27830 .......... Treat lower leg dislocation ............................. Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
27831 .......... Treat lower leg dislocation ............................. Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
27832 .......... Treat lower leg dislocation ............................. Y ................. .................... A2 ............... $446.00 40.3466 $1,670.35 $752.09
27840 .......... Treat ankle dislocation ................................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
27842 .......... Treat ankle dislocation ................................... Y ................. .................... A2 ............... $333.00 15.0176 $621.73 $405.18
27846 .......... Treat ankle dislocation ................................... Y ................. .................... A2 ............... $510.00 40.3466 $1,670.35 $800.09
27848 .......... Treat ankle dislocation ................................... Y ................. .................... A2 ............... $510.00 40.3466 $1,670.35 $800.09
27860 .......... Fixation of ankle joint ..................................... Y ................. .................... A2 ............... $333.00 15.0176 $621.73 $405.18
27870 .......... Fusion of ankle joint, open ............................. Y ................. .................... A2 ............... $630.00 78.6518 $3,256.18 $1,286.55
27871 .......... Fusion of tibiofibular joint ............................... Y ................. .................... A2 ............... $630.00 78.6518 $3,256.18 $1,286.55
27889 .......... Amputation of foot at ankle ............................ Y ................. .................... A2 ............... $510.00 29.3263 $1,214.11 $686.03
27892 .......... Decompression of leg .................................... Y ................. .................... A2 ............... $510.00 21.5761 $893.25 $605.81
28001 .......... Drainage of bursa of foot ............................... Y ................. .................... P3 ............... .................... 2.8529 $118.11 $118.11
28002 .......... Treatment of foot infection ............................. Y ................. .................... A2 ............... $510.00 21.5761 $893.25 $605.81
28003 .......... Treatment of foot infection ............................. Y ................. .................... A2 ............... $510.00 21.5761 $893.25 $605.81
28005 .......... Treat foot bone lesion .................................... Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28008 .......... Incision of foot fascia ..................................... Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28010 .......... Incision of toe tendon ..................................... Y ................. .................... P3 ............... .................... 2.1437 $88.75 $88.75
28011 .......... Incision of toe tendons ................................... Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28020 .......... Exploration of foot joint .................................. Y ................. .................... A2 ............... $446.00 21.1762 $876.69 $553.67
28022 .......... Exploration of foot joint .................................. Y ................. .................... A2 ............... $446.00 21.1762 $876.69 $553.67
28024 .......... Exploration of toe joint ................................... Y ................. .................... A2 ............... $446.00 21.1762 $876.69 $553.67
28035 .......... Decompression of tibia nerve ........................ Y ................. .................... A2 ............... $630.00 18.5069 $766.19 $664.05
28043 .......... Excision of foot lesion .................................... Y ................. .................... A2 ............... $446.00 21.4534 $888.17 $556.54
28045 .......... Excision of foot lesion .................................... Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28046 .......... Resection of tumor, foot ................................. Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28050 .......... Biopsy of foot joint lining ................................ Y ................. .................... A2 ............... $446.00 21.1762 $876.69 $553.67
28052 .......... Biopsy of foot joint lining ................................ Y ................. .................... A2 ............... $446.00 21.1762 $876.69 $553.67
28054 .......... Biopsy of toe joint lining ................................. Y ................. .................... A2 ............... $446.00 21.1762 $876.69 $553.67
28055 .......... Neurectomy, foot ............................................ Y ................. .................... A2 ............... $630.00 18.5069 $766.19 $664.05
28060 .......... Partial removal, foot fascia ............................. Y ................. .................... A2 ............... $446.00 21.1762 $876.69 $553.67
28062 .......... Removal of foot fascia ................................... Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28070 .......... Removal of foot joint lining ............................. Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28072 .......... Removal of foot joint lining ............................. Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28080 .......... Removal of foot lesion ................................... Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28086 .......... Excise foot tendon sheath .............................. Y ................. .................... A2 ............... $446.00 21.1762 $876.69 $553.67
28088 .......... Excise foot tendon sheath .............................. Y ................. .................... A2 ............... $446.00 21.1762 $876.69 $553.67
28092 .......... Removal of toe lesions ................................... Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28100 .......... Removal of ankle/heel lesion ......................... Y ................. .................... A2 ............... $446.00 21.1762 $876.69 $553.67
28102 .......... Remove/graft foot lesion ................................ Y ................. .................... A2 ............... $510.00 44.4710 $1,841.10 $842.78
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
28108 .......... Removal of toe lesions ................................... Y ................. .................... A2 ............... $446.00 21.1762 $876.69 $553.67
28110 .......... Part removal of metatarsal ............................. Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28114 .......... Removal of metatarsal heads ........................ Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28116 .......... Revision of foot .............................................. Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28118 .......... Removal of heel bone .................................... Y ................. .................... A2 ............... $630.00 21.1762 $876.69 $691.67
28119 .......... Removal of heel spur ..................................... Y ................. .................... A2 ............... $630.00 21.1762 $876.69 $691.67
28120 .......... Part removal of ankle/heel ............................. Y ................. .................... A2 ............... $995.00 21.1762 $876.69 $965.42
28122 .......... Partial removal of foot bone ........................... Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28124 .......... Partial removal of toe ..................................... Y ................. .................... P3 ............... .................... 4.8152 $199.35 $199.35
28126 .......... Partial removal of toe ..................................... Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28130 .......... Removal of ankle bone .................................. Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28140 .......... Removal of metatarsal ................................... Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28150 .......... Removal of toe ............................................... Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28171 .......... Extensive foot surgery .................................... Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28190 .......... Removal of foot foreign body ......................... Y ................. .................... P3 ............... .................... 3.0261 $125.28 $125.28
28192 .......... Removal of foot foreign body ......................... Y ................. .................... A2 ............... $446.00 16.5832 $686.54 $506.14
28193 .......... Removal of foot foreign body ......................... Y ................. .................... A2 ............... $418.49 8.7155 $360.82 $404.07
28200 .......... Repair of foot tendon ..................................... Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28202 .......... Repair/graft of foot tendon ............................. Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28208 .......... Repair of foot tendon ..................................... Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28210 .......... Repair/graft of foot tendon ............................. Y ................. .................... A2 ............... $510.00 44.4710 $1,841.10 $842.78
28220 .......... Release of foot tendon ................................... Y ................. .................... P3 ............... .................... 4.5266 $187.40 $187.40
28222 .......... Release of foot tendons ................................. Y ................. .................... A2 ............... $333.00 21.1762 $876.69 $468.92
28225 .......... Release of foot tendon ................................... Y ................. .................... A2 ............... $333.00 21.1762 $876.69 $468.92
28226 .......... Release of foot tendons ................................. Y ................. .................... A2 ............... $333.00 21.1762 $876.69 $468.92
28230 .......... Incision of foot tendon(s) ................................ Y ................. .................... P3 ............... .................... 4.4771 $185.35 $185.35
28232 .......... Incision of toe tendon ..................................... Y ................. .................... P3 ............... .................... 4.2710 $176.82 $176.82
28234 .......... Incision of foot tendon .................................... Y ................. .................... A2 ............... $446.00 21.1762 $876.69 $553.67
28238 .......... Revision of foot tendon .................................. Y ................. .................... A2 ............... $510.00 44.4710 $1,841.10 $842.78
28240 .......... Release of big toe .......................................... Y ................. .................... A2 ............... $446.00 21.1762 $876.69 $553.67
28250 .......... Revision of foot fascia .................................... Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28260 .......... Release of midfoot joint ................................. Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28261 .......... Revision of foot tendon .................................. Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28262 .......... Revision of foot and ankle ............................. Y ................. .................... A2 ............... $630.00 21.1762 $876.69 $691.67
28264 .......... Release of midfoot joint ................................. Y ................. .................... A2 ............... $333.00 44.4710 $1,841.10 $710.03
28270 .......... Release of foot contracture ............................ Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28272 .......... Release of toe joint, each .............................. Y ................. .................... P3 ............... .................... 4.0896 $169.31 $169.31
28280 .......... Fusion of toes ................................................. Y ................. .................... A2 ............... $446.00 21.1762 $876.69 $553.67
28285 .......... Repair of hammertoe ..................................... Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28286 .......... Repair of hammertoe ..................................... Y ................. .................... A2 ............... $630.00 21.1762 $876.69 $691.67
28288 .......... Partial removal of foot bone ........................... Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28289 .......... Repair hallux rigidus ....................................... Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28290 .......... Correction of bunion ....................................... Y ................. .................... A2 ............... $446.00 29.8356 $1,235.19 $643.30
28300 .......... Incision of heel bone ...................................... Y ................. .................... A2 ............... $446.00 44.4710 $1,841.10 $794.78
28302 .......... Incision of ankle bone .................................... Y ................. .................... A2 ............... $446.00 21.1762 $876.69 $553.67
28304 .......... Incision of midfoot bones ............................... Y ................. .................... A2 ............... $446.00 44.4710 $1,841.10 $794.78
28305 .......... Incise/graft midfoot bones .............................. Y ................. .................... A2 ............... $510.00 44.4710 $1,841.10 $842.78
28306 .......... Incision of metatarsal ..................................... Y ................. .................... A2 ............... $630.00 21.1762 $876.69 $691.67
28309 .......... Incision of metatarsals ................................... Y ................. .................... A2 ............... $630.00 44.4710 $1,841.10 $932.78
28310 .......... Revision of big toe ......................................... Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28312 .......... Revision of toe ............................................... Y ................. .................... A2 ............... $510.00 21.1762 $876.69 $601.67
28313 .......... Repair deformity of toe ................................... Y ................. .................... A2 ............... $446.00 21.1762 $876.69 $553.67
28315 .......... Removal of sesamoid bone ........................... Y ................. .................... A2 ............... $630.00 21.1762 $876.69 $691.67
28320 .......... Repair of foot bones ....................................... Y ................. .................... A2 ............... $630.00 44.4710 $1,841.10 $932.78
28322 .......... Repair of metatarsals ..................................... Y ................. .................... A2 ............... $630.00 44.4710 $1,841.10 $932.78
28340 .......... Resect enlarged toe tissue ............................ Y ................. .................... A2 ............... $630.00 21.1762 $876.69 $691.67
28341 .......... Resect enlarged toe ....................................... Y ................. .................... A2 ............... $630.00 21.1762 $876.69 $691.67
28344 .......... Repair extra toe(s) ......................................... Y ................. .................... A2 ............... $630.00 21.1762 $876.69 $691.67
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
28345 .......... Repair webbed toe(s) ..................................... Y ................. .................... A2 ............... $630.00 21.1762 $876.69 $691.67
28400 .......... Treatment of heel fracture .............................. Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
28405 .......... Treatment of heel fracture .............................. Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
28406 .......... Treatment of heel fracture .............................. Y ................. .................... A2 ............... $446.00 26.3092 $1,089.20 $606.80
28415 .......... Treat heel fracture .......................................... Y ................. .................... A2 ............... $510.00 40.3466 $1,670.35 $800.09
28420 .......... Treat/graft heel fracture .................................. Y ................. .................... A2 ............... $630.00 40.3466 $1,670.35 $890.09
28430 .......... Treatment of ankle fracture ............................ Y ................. .................... P2 ............... .................... 1.8742 $77.59 $77.59
28445 .......... Treat ankle fracture ........................................ Y ................. .................... A2 ............... $510.00 40.3466 $1,670.35 $800.09
28450 .......... Treat midfoot fracture, each ........................... Y ................. .................... P2 ............... .................... 1.8742 $77.59 $77.59
28455 .......... Treat midfoot fracture, each ........................... Y ................. .................... P2 ............... .................... 1.8742 $77.59 $77.59
28456 .......... Treat midfoot fracture ..................................... Y ................. .................... A2 ............... $446.00 26.3092 $1,089.20 $606.80
28465 .......... Treat midfoot fracture, each ........................... Y ................. .................... A2 ............... $510.00 40.3466 $1,670.35 $800.09
28470 .......... Treat metatarsal fracture ................................ Y ................. .................... P2 ............... .................... 1.8742 $77.59 $77.59
28475 .......... Treat metatarsal fracture ................................ Y ................. .................... P2 ............... .................... 1.8742 $77.59 $77.59
28476 .......... Treat metatarsal fracture ................................ Y ................. .................... A2 ............... $446.00 26.3092 $1,089.20 $606.80
28485 .......... Treat metatarsal fracture ................................ Y ................. .................... A2 ............... $630.00 40.3466 $1,670.35 $890.09
28490 .......... Treat big toe fracture ...................................... Y ................. .................... P3 ............... .................... 1.6821 $69.64 $69.64
28495 .......... Treat big toe fracture ...................................... Y ................. .................... P2 ............... .................... 1.8742 $77.59 $77.59
28496 .......... Treat big toe fracture ...................................... Y ................. .................... A2 ............... $446.00 26.3092 $1,089.20 $606.80
28505 .......... Treat big toe fracture ...................................... Y ................. .................... A2 ............... $510.00 40.3466 $1,670.35 $800.09
28510 .......... Treatment of toe fracture ............................... Y ................. .................... P3 ............... .................... 1.3193 $54.62 $54.62
28515 .......... Treatment of toe fracture ............................... Y ................. .................... P3 ............... .................... 1.6821 $69.64 $69.64
28525 .......... Treat toe fracture ............................................ Y ................. .................... A2 ............... $510.00 40.3466 $1,670.35 $800.09
28530 .......... Treat sesamoid bone fracture ........................ Y ................. .................... P3 ............... .................... 1.2534 $51.89 $51.89
28531 .......... Treat sesamoid bone fracture ........................ Y ................. .................... A2 ............... $510.00 40.3466 $1,670.35 $800.09
28540 .......... Treat foot dislocation ...................................... Y ................. .................... P2 ............... .................... 1.8742 $77.59 $77.59
28545 .......... Treat foot dislocation ...................................... Y ................. .................... A2 ............... $333.00 26.3092 $1,089.20 $522.05
28555 .......... Repair foot dislocation .................................... Y ................. .................... A2 ............... $446.00 40.3466 $1,670.35 $752.09
28575 .......... Treat foot dislocation ...................................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
28605 .......... Treat foot dislocation ...................................... Y ................. .................... A2 ............... $103.62 1.8742 $77.59 $97.11
28630 .......... Treat toe dislocation ....................................... Y ................. CH .............. P3 ............... .................... 1.4181 $58.71 $58.71
28635 .......... Treat toe dislocation ....................................... Y ................. .................... A2 ............... $333.00 15.0176 $621.73 $405.18
28636 .......... Treat toe dislocation ....................................... Y ................. .................... A2 ............... $510.00 26.3092 $1,089.20 $654.80
28645 .......... Repair toe dislocation ..................................... Y ................. .................... A2 ............... $510.00 40.3466 $1,670.35 $800.09
28660 .......... Treat toe dislocation ....................................... Y ................. CH .............. P3 ............... .................... 1.0471 $43.35 $43.35
28665 .......... Treat toe dislocation ....................................... Y ................. .................... A2 ............... $333.00 15.0176 $621.73 $405.18
28666 .......... Treat toe dislocation ....................................... Y ................. .................... A2 ............... $510.00 26.3092 $1,089.20 $654.80
28675 .......... Repair of toe dislocation ................................ Y ................. .................... A2 ............... $510.00 40.3466 $1,670.35 $800.09
28705 .......... Fusion of foot bones ...................................... Y ................. .................... A2 ............... $630.00 44.4710 $1,841.10 $932.78
28715 .......... Fusion of foot bones ...................................... Y ................. .................... A2 ............... $630.00 78.6518 $3,256.18 $1,286.55
28737 .......... Revision of foot bones ................................... Y ................. .................... A2 ............... $717.00 44.4710 $1,841.10 $998.03
28750 .......... Fusion of big toe joint ..................................... Y ................. .................... A2 ............... $630.00 44.4710 $1,841.10 $932.78
28755 .......... Fusion of big toe joint ..................................... Y ................. .................... A2 ............... $630.00 21.1762 $876.69 $691.67
28760 .......... Fusion of big toe joint ..................................... Y ................. .................... A2 ............... $630.00 44.4710 $1,841.10 $932.78
28810 .......... Amputation toe & metatarsal .......................... Y ................. .................... A2 ............... $446.00 21.1762 $876.69 $553.67
28820 .......... Amputation of toe ........................................... Y ................. .................... A2 ............... $446.00 21.1762 $876.69 $553.67
28825 .......... Partial amputation of toe ................................ Y ................. .................... A2 ............... $446.00 21.1762 $876.69 $553.67
28890 .......... High energy eswt, plantar f ............................ Y ................. CH .............. P3 ............... .................... 4.2297 $175.11 $175.11
29000 .......... Application of body cast ................................. N ................. .................... G2 .............. .................... 1.1272 $46.67 $46.67
29010 .......... Application of body cast ................................. N ................. .................... P2 ............... .................... 2.2383 $92.67 $92.67
29035 .......... Application of body cast ................................. N ................. CH .............. P2 ............... .................... 2.2383 $92.67 $92.67
29049 .......... Application of figure eight ............................... N ................. .................... P3 ............... .................... 0.9976 $41.30 $41.30
29055 .......... Application of shoulder cast ........................... N ................. .................... P2 ............... .................... 2.2383 $92.67 $92.67
29058 .......... Application of shoulder cast ........................... N ................. .................... P2 ............... .................... 1.1272 $46.67 $46.67
29065 .......... Application of long arm cast ........................... N ................. .................... P3 ............... .................... 1.0720 $44.38 $44.38
29075 .......... Application of forearm cast ............................ N ................. .................... P3 ............... .................... 1.0225 $42.33 $42.33
29085 .......... Apply hand/wrist cast ..................................... N ................. .................... P3 ............... .................... 1.0471 $43.35 $43.35
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
29086 .......... Apply finger cast ............................................. N ................. .................... P3 ............... .................... 0.8329 $34.48 $34.48
29105 .......... Apply long arm splint ...................................... N ................. .................... P3 ............... .................... 0.9565 $39.60 $39.60
29125 .......... Apply forearm splint ....................................... N ................. .................... P3 ............... .................... 0.8162 $33.79 $33.79
29126 .......... Apply forearm splint ....................................... N ................. .................... P3 ............... .................... 0.9152 $37.89 $37.89
29130 .......... Application of finger splint .............................. N ................. .................... P3 ............... .................... 0.3710 $15.36 $15.36
29131 .......... Application of finger splint .............................. N ................. .................... P3 ............... .................... 0.5524 $22.87 $22.87
29200 .......... Strapping of chest .......................................... N ................. .................... P3 ............... .................... 0.5442 $22.53 $22.53
29220 .......... Strapping of low back ..................................... N ................. .................... P3 ............... .................... 0.5524 $22.87 $22.87
29240 .......... Strapping of shoulder ..................................... N ................. .................... P3 ............... .................... 0.6348 $26.28 $26.28
29260 .......... Strapping of elbow or wrist ............................ N ................. .................... P3 ............... .................... 0.5771 $23.89 $23.89
29280 .......... Strapping of hand or finger ............................ N ................. .................... P3 ............... .................... 0.6019 $24.92 $24.92
29305 .......... Application of hip cast .................................... N ................. CH .............. P2 ............... .................... 2.2383 $92.67 $92.67
29325 .......... Application of hip casts .................................. N ................. CH .............. P2 ............... .................... 2.2383 $92.67 $92.67
29345 .......... Application of long leg cast ............................ N ................. .................... P3 ............... .................... 1.4099 $58.37 $58.37
29358 .......... Apply long leg cast brace ............................... N ................. .................... P3 ............... .................... 1.6821 $69.64 $69.64
29405 .......... Apply short leg cast ........................................ N ................. .................... P3 ............... .................... 0.9976 $41.30 $41.30
29440 .......... Addition of walker to cast ............................... N ................. .................... P3 ............... .................... 0.5442 $22.53 $22.53
29445 .......... Apply rigid leg cast ......................................... N ................. .................... P3 ............... .................... 1.3935 $57.69 $57.69
29450 .......... Application of leg cast .................................... N ................. .................... P2 ............... .................... 1.1272 $46.67 $46.67
29505 .......... Application, long leg splint ............................. N ................. CH .............. P3 ............... .................... 0.9234 $38.23 $38.23
29515 .......... Application lower leg splint ............................. N ................. CH .............. P3 ............... .................... 0.7502 $31.06 $31.06
29520 .......... Strapping of hip .............................................. N ................. .................... P3 ............... .................... 0.6266 $25.94 $25.94
29530 .......... Strapping of knee ........................................... N ................. .................... P3 ............... .................... 0.5937 $24.58 $24.58
29540 .......... Strapping of ankle and/or ft ............................ N ................. .................... P3 ............... .................... 0.3957 $16.38 $16.38
29550 .......... Strapping of toes ............................................ N ................. .................... P3 ............... .................... 0.4041 $16.73 $16.73
29580 .......... Application of paste boot ................................ N ................. .................... P3 ............... .................... 0.5606 $23.21 $23.21
29590 .......... Application of foot splint ................................. N ................. .................... P3 ............... .................... 0.4534 $18.77 $18.77
29700 .......... Removal/revision of cast ................................ N ................. .................... P3 ............... .................... 0.7585 $31.40 $31.40
29720 .......... Repair of body cast ........................................ N ................. .................... P3 ............... .................... 0.9565 $39.60 $39.60
29730 .......... Windowing of cast .......................................... N ................. .................... P3 ............... .................... 0.6432 $26.63 $26.63
29740 .......... Wedging of cast ............................................. N ................. .................... P3 ............... .................... 0.9070 $37.55 $37.55
29750 .......... Wedging of clubfoot cast ................................ N ................. .................... P3 ............... .................... 0.8575 $35.50 $35.50
29800 .......... Jaw arthroscopy/surgery ................................ Y ................. .................... A2 ............... $510.00 29.4467 $1,219.09 $687.27
29804 .......... Jaw arthroscopy/surgery ................................ Y ................. .................... A2 ............... $510.00 29.4467 $1,219.09 $687.27
29805 .......... Shoulder arthroscopy, dx ............................... Y ................. .................... A2 ............... $510.00 29.4467 $1,219.09 $687.27
29806 .......... Shoulder arthroscopy/surgery ........................ Y ................. .................... A2 ............... $510.00 47.7765 $1,977.95 $876.99
29827 .......... Arthroscop rotator cuff repr ............................ Y ................. .................... A2 ............... $717.00 47.7765 $1,977.95 $1,032.24
29830 .......... Elbow arthroscopy .......................................... Y ................. .................... A2 ............... $510.00 29.4467 $1,219.09 $687.27
29834 .......... Elbow arthroscopy/surgery ............................. Y ................. .................... A2 ............... $510.00 29.4467 $1,219.09 $687.27
29840 .......... Wrist arthroscopy ........................................... Y ................. .................... A2 ............... $510.00 29.4467 $1,219.09 $687.27
29843 .......... Wrist arthroscopy/surgery .............................. Y ................. .................... A2 ............... $510.00 29.4467 $1,219.09 $687.27
29848 .......... Wrist endoscopy/surgery ................................ Y ................. .................... A2 ............... $1,339.00 29.4467 $1,219.09 $1,309.02
29850 .......... Knee arthroscopy/surgery .............................. Y ................. .................... A2 ............... $630.00 29.4467 $1,219.09 $777.27
29855 .......... Tibial arthroscopy/surgery .............................. Y ................. .................... A2 ............... $630.00 47.7765 $1,977.95 $966.99
29856 .......... Tibial arthroscopy/surgery .............................. Y ................. .................... A2 ............... $630.00 29.4467 $1,219.09 $777.27
29860 .......... Hip arthroscopy, dx ........................................ Y ................. .................... A2 ............... $630.00 29.4467 $1,219.09 $777.27
29861 .......... Hip arthroscopy/surgery ................................. Y ................. .................... A2 ............... $630.00 29.4467 $1,219.09 $777.27
29862 .......... Hip arthroscopy/surgery ................................. Y ................. .................... A2 ............... $1,339.00 47.7765 $1,977.95 $1,498.74
29863 .......... Hip arthroscopy/surgery ................................. Y ................. .................... A2 ............... $630.00 47.7765 $1,977.95 $966.99
29870 .......... Knee arthroscopy, dx ..................................... Y ................. .................... A2 ............... $510.00 29.4467 $1,219.09 $687.27
29871 .......... Knee arthroscopy/drainage ............................ Y ................. .................... A2 ............... $510.00 29.4467 $1,219.09 $687.27
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
29891 .......... Ankle arthroscopy/surgery .............................. Y ................. .................... A2 ............... $510.00 29.4467 $1,219.09 $687.27
29893 .......... Scope, plantar fasciotomy .............................. Y ................. .................... A2 ............... $1,255.56 21.1762 $876.69 $1,160.84
29900 .......... Mcp joint arthroscopy, dx ............................... Y ................. .................... A2 ............... $510.00 16.8220 $696.43 $556.61
29901 .......... Mcp joint arthroscopy, surg ............................ Y ................. .................... A2 ............... $510.00 16.8220 $696.43 $556.61
29902 .......... Mcp joint arthroscopy, surg ............................ Y ................. .................... A2 ............... $510.00 16.8220 $696.43 $556.61
30000 .......... Drainage of nose lesion ................................. Y ................. .................... P2 ............... .................... 2.5765 $106.67 $106.67
30020 .......... Drainage of nose lesion ................................. Y ................. .................... P2 ............... .................... 2.5765 $106.67 $106.67
30100 .......... Intranasal biopsy ............................................ Y ................. .................... P3 ............... .................... 1.8469 $76.46 $76.46
30110 .......... Removal of nose polyp(s) .............................. Y ................. .................... P3 ............... .................... 2.9024 $120.16 $120.16
30115 .......... Removal of nose polyp(s) .............................. Y ................. .................... A2 ............... $446.00 16.6341 $688.65 $506.66
30117 .......... Removal of intranasal lesion .......................... Y ................. .................... A2 ............... $510.00 16.6341 $688.65 $554.66
30118 .......... Removal of intranasal lesion .......................... Y ................. .................... A2 ............... $510.00 24.3535 $1,008.23 $634.56
30120 .......... Revision of nose ............................................. Y ................. .................... A2 ............... $333.00 16.6341 $688.65 $421.91
30124 .......... Removal of nose lesion .................................. Y ................. .................... R2 ............... .................... 7.6539 $316.87 $316.87
30125 .......... Removal of nose lesion .................................. Y ................. .................... A2 ............... $446.00 40.5598 $1,679.18 $754.30
30130 .......... Excise inferior turbinate .................................. Y ................. .................... A2 ............... $510.00 16.6341 $688.65 $554.66
30140 .......... Resect inferior turbinate ................................. Y ................. .................... A2 ............... $446.00 24.3535 $1,008.23 $586.56
30150 .......... Partial removal of nose .................................. Y ................. .................... A2 ............... $510.00 40.5598 $1,679.18 $802.30
30160 .......... Removal of nose ............................................ Y ................. .................... A2 ............... $630.00 40.5598 $1,679.18 $892.30
30200 .......... Injection treatment of nose ............................. Y ................. .................... P3 ............... .................... 1.4841 $61.44 $61.44
30210 .......... Nasal sinus therapy ........................................ Y ................. .................... P3 ............... .................... 1.8717 $77.49 $77.49
30220 .......... Insert nasal septal button ............................... Y ................. .................... A2 ............... $464.15 7.6539 $316.87 $427.33
30300 .......... Remove nasal foreign body ........................... N ................. .................... P2 ............... .................... 0.6416 $26.56 $26.56
30310 .......... Remove nasal foreign body ........................... Y ................. .................... A2 ............... $333.00 16.6341 $688.65 $421.91
30320 .......... Remove nasal foreign body ........................... Y ................. .................... A2 ............... $446.00 16.6341 $688.65 $506.66
30400 .......... Reconstruction of nose .................................. Y ................. .................... A2 ............... $630.00 40.5598 $1,679.18 $892.30
30430 .......... Revision of nose ............................................. Y ................. .................... A2 ............... $510.00 24.3535 $1,008.23 $634.56
30435 .......... Revision of nose ............................................. Y ................. .................... A2 ............... $717.00 40.5598 $1,679.18 $957.55
30450 .......... Revision of nose ............................................. Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
30460 .......... Revision of nose ............................................. Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
30462 .......... Revision of nose ............................................. Y ................. .................... A2 ............... $1,339.00 40.5598 $1,679.18 $1,424.05
30465 .......... Repair nasal stenosis ..................................... Y ................. .................... A2 ............... $1,339.00 40.5598 $1,679.18 $1,424.05
30520 .......... Repair of nasal septum .................................. Y ................. .................... A2 ............... $630.00 24.3535 $1,008.23 $724.56
30540 .......... Repair nasal defect ........................................ Y ................. .................... A2 ............... $717.00 40.5598 $1,679.18 $957.55
30545 .......... Repair nasal defect ........................................ Y ................. .................... A2 ............... $717.00 40.5598 $1,679.18 $957.55
30560 .......... Release of nasal adhesions ........................... Y ................. .................... A2 ............... $150.72 2.5765 $106.67 $139.71
30580 .......... Repair upper jaw fistula ................................. Y ................. .................... A2 ............... $630.00 40.5598 $1,679.18 $892.30
30600 .......... Repair mouth/nose fistula .............................. Y ................. .................... A2 ............... $630.00 40.5598 $1,679.18 $892.30
30620 .......... Intranasal reconstruction ................................ Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
30630 .......... Repair nasal septum defect ........................... Y ................. .................... A2 ............... $995.00 24.3535 $1,008.23 $998.31
30801 .......... Ablate inf turbinate, superf ............................. Y ................. .................... A2 ............... $333.00 7.6539 $316.87 $328.97
30802 .......... Cauterization, inner nose ............................... Y ................. .................... A2 ............... $333.00 7.6539 $316.87 $328.97
30901 .......... Control of nosebleed ...................................... Y ................. .................... P3 ............... .................... 1.0720 $44.38 $44.38
30903 .......... Control of nosebleed ...................................... Y ................. .................... A2 ............... $72.48 1.1708 $48.47 $66.48
30905 .......... Control of nosebleed ...................................... Y ................. .................... A2 ............... $72.48 1.1708 $48.47 $66.48
30906 .......... Repeat control of nosebleed .......................... Y ................. .................... A2 ............... $72.48 1.1708 $48.47 $66.48
30915 .......... Ligation, nasal sinus artery ............................ Y ................. .................... A2 ............... $446.00 26.4396 $1,094.60 $608.15
30920 .......... Ligation, upper jaw artery ............................... Y ................. .................... A2 ............... $510.00 26.4396 $1,094.60 $656.15
30930 .......... Ther fx, nasal inf turbinate ............................. Y ................. .................... A2 ............... $630.00 16.6341 $688.65 $644.66
31000 .......... Irrigation, maxillary sinus ................................ Y ................. .................... P3 ............... .................... 2.4570 $101.72 $101.72
31002 .......... Irrigation, sphenoid sinus ............................... Y ................. .................... R2 ............... .................... 7.6539 $316.87 $316.87
31020 .......... Exploration, maxillary sinus ............................ Y ................. .................... A2 ............... $446.00 24.3535 $1,008.23 $586.56
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
31030 .......... Exploration, maxillary sinus ............................ Y ................. .................... A2 ............... $510.00 40.5598 $1,679.18 $802.30
31032 .......... Explore sinus, remove polyps ........................ Y ................. .................... A2 ............... $630.00 40.5598 $1,679.18 $892.30
31040 .......... Exploration behind upper jaw ......................... Y ................. .................... R2 .............. .................... 24.3535 $1,008.23 $1,008.23
31050 .......... Exploration, sphenoid sinus ........................... Y ................. .................... A2 ............... $446.00 40.5598 $1,679.18 $754.30
31051 .......... Sphenoid sinus surgery .................................. Y ................. .................... A2 ............... $630.00 40.5598 $1,679.18 $892.30
31070 .......... Exploration of frontal sinus ............................. Y ................. .................... A2 ............... $446.00 24.3535 $1,008.23 $586.56
31075 .......... Exploration of frontal sinus ............................. Y ................. .................... A2 ............... $630.00 40.5598 $1,679.18 $892.30
31080 .......... Removal of frontal sinus ................................ Y ................. .................... A2 ............... $630.00 40.5598 $1,679.18 $892.30
31090 .......... Exploration of sinuses .................................... Y ................. .................... A2 ............... $717.00 40.5598 $1,679.18 $957.55
31200 .......... Removal of ethmoid sinus .............................. Y ................. .................... A2 ............... $446.00 40.5598 $1,679.18 $754.30
31231 .......... Nasal endoscopy, dx ...................................... Y ................. .................... P2 ............... .................... 1.5730 $65.12 $65.12
31233 .......... Nasal/sinus endoscopy, dx ............................ Y ................. .................... A2 ............... $86.39 1.5730 $65.12 $81.07
31235 .......... Nasal/sinus endoscopy, dx ............................ Y ................. .................... A2 ............... $333.00 17.4546 $722.62 $430.41
31237 .......... Nasal/sinus endoscopy, surg ......................... Y ................. .................... A2 ............... $446.00 17.4546 $722.62 $515.16
31254 .......... Revision of ethmoid sinus .............................. Y ................. .................... A2 ............... $510.00 23.2819 $963.87 $623.47
31255 .......... Removal of ethmoid sinus .............................. Y ................. .................... A2 ............... $717.00 23.2819 $963.87 $778.72
31256 .......... Exploration maxillary sinus ............................. Y ................. .................... A2 ............... $510.00 23.2819 $963.87 $623.47
31267 .......... Endoscopy, maxillary sinus ............................ Y ................. .................... A2 ............... $510.00 23.2819 $963.87 $623.47
31276 .......... Sinus endoscopy, surgical ............................. Y ................. .................... A2 ............... $510.00 23.2819 $963.87 $623.47
31300 .......... Removal of larynx lesion ................................ Y ................. .................... A2 ............... $717.00 24.3535 $1,008.23 $789.81
31320 .......... Diagnostic incision, larynx .............................. Y ................. .................... A2 ............... $446.00 40.5598 $1,679.18 $754.30
31400 .......... Revision of larynx ........................................... Y ................. .................... A2 ............... $446.00 40.5598 $1,679.18 $754.30
31420 .......... Removal of epiglottis ...................................... Y ................. .................... A2 ............... $446.00 40.5598 $1,679.18 $754.30
31500 .......... Insert emergency airway ................................ N ................. .................... G2 .............. .................... 2.5547 $105.76 $105.76
31502 .......... Change of windpipe airway ............................ N ................. CH .............. G2 .............. .................... 1.3636 $56.45 $56.45
31505 .......... Diagnostic laryngoscopy ................................ Y ................. .................... P2 ............... .................... 0.8256 $34.18 $34.18
31510 .......... Laryngoscopy with biopsy .............................. Y ................. .................... A2 ............... $446.00 17.4546 $722.62 $515.16
31511 .......... Remove foreign body, larynx ......................... Y ................. .................... A2 ............... $86.39 1.5730 $65.12 $81.07
31512 .......... Removal of larynx lesion ................................ Y ................. .................... A2 ............... $446.00 17.4546 $722.62 $515.16
31513 .......... Injection into vocal cord ................................. Y ................. .................... A2 ............... $86.39 1.5730 $65.12 $81.07
31515 .......... Laryngoscopy for aspiration ........................... Y ................. .................... A2 ............... $333.00 17.4546 $722.62 $430.41
31520 .......... Dx laryngoscopy, newborn ............................. Y ................. .................... G2 .............. .................... 1.5730 $65.12 $65.12
31525 .......... Dx laryngoscopy excl nb ................................ Y ................. .................... A2 ............... $333.00 17.4546 $722.62 $430.41
31526 .......... Dx laryngoscopy w/oper scope ...................... Y ................. .................... A2 ............... $446.00 23.2819 $963.87 $575.47
31527 .......... Laryngoscopy for treatment ........................... Y ................. .................... A2 ............... $333.00 23.2819 $963.87 $490.72
31528 .......... Laryngoscopy and dilation ............................. Y ................. .................... A2 ............... $446.00 17.4546 $722.62 $515.16
31529 .......... Laryngoscopy and dilation ............................. Y ................. .................... A2 ............... $446.00 17.4546 $722.62 $515.16
31530 .......... Laryngoscopy w/fb removal ........................... Y ................. .................... A2 ............... $446.00 23.2819 $963.87 $575.47
31531 .......... Laryngoscopy w/fb & op scope ...................... Y ................. .................... A2 ............... $510.00 23.2819 $963.87 $623.47
31535 .......... Laryngoscopy w/biopsy .................................. Y ................. .................... A2 ............... $446.00 23.2819 $963.87 $575.47
31536 .......... Laryngoscopy w/bx & op scope ..................... Y ................. .................... A2 ............... $510.00 23.2819 $963.87 $623.47
31540 .......... Laryngoscopy w/exc of tumor ........................ Y ................. .................... A2 ............... $510.00 23.2819 $963.87 $623.47
31541 .......... Larynscop w/tumr exc + scope ...................... Y ................. .................... A2 ............... $630.00 23.2819 $963.87 $713.47
31545 .......... Remove vc lesion w/scope ............................ Y ................. .................... A2 ............... $630.00 23.2819 $963.87 $713.47
31546 .......... Remove vc lesion scope/graft ........................ Y ................. .................... A2 ............... $630.00 23.2819 $963.87 $713.47
31560 .......... Laryngoscop w/arytenoidectom ...................... Y ................. .................... A2 ............... $717.00 23.2819 $963.87 $778.72
31561 .......... Larynscop, remve cart + scop ....................... Y ................. .................... A2 ............... $717.00 23.2819 $963.87 $778.72
31570 .......... Laryngoscope w/vc inj .................................... Y ................. .................... A2 ............... $446.00 17.4546 $722.62 $515.16
31571 .......... Laryngoscop w/vc inj + scope ........................ Y ................. .................... A2 ............... $446.00 23.2819 $963.87 $575.47
31576 .......... Laryngoscopy with biopsy .............................. Y ................. .................... A2 ............... $446.00 23.2819 $963.87 $575.47
31577 .......... Remove foreign body, larynx ......................... Y ................. .................... A2 ............... $236.42 4.2060 $174.13 $220.85
31578 .......... Removal of larynx lesion ................................ Y ................. .................... A2 ............... $446.00 23.2819 $963.87 $575.47
31590 .......... Reinnervate larynx ......................................... Y ................. .................... A2 ............... $717.00 40.5598 $1,679.18 $957.55
31595 .......... Larynx nerve surgery ..................................... Y ................. .................... A2 ............... $446.00 40.5598 $1,679.18 $754.30
31603 .......... Incision of windpipe ........................................ Y ................. .................... A2 ............... $333.00 7.6539 $316.87 $328.97
31605 .......... Incision of windpipe ........................................ Y ................. .................... G2 .............. .................... 7.6539 $316.87 $316.87
31611 .......... Surgery/speech prosthesis ............................. Y ................. .................... A2 ............... $510.00 24.3535 $1,008.23 $634.56
31612 .......... Puncture/clear windpipe ................................. Y ................. .................... A2 ............... $333.00 24.3535 $1,008.23 $501.81
31613 .......... Repair windpipe opening ................................ Y ................. .................... A2 ............... $446.00 24.3535 $1,008.23 $586.56
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
31614 .......... Repair windpipe opening ................................ Y ................. .................... A2 ............... $446.00 40.5598 $1,679.18 $754.30
31615 .......... Visualization of windpipe ................................ Y ................. .................... A2 ............... $333.00 10.1732 $421.17 $355.04
31620 .......... Endobronchial us add-on ............................... N ................. CH .............. N1 ............... $333.00 .................... .................... ....................
31622 .......... Dx bronchoscope/wash .................................. Y ................. .................... A2 ............... $333.00 10.1732 $421.17 $355.04
31623 .......... Dx bronchoscope/brush ................................. Y ................. .................... A2 ............... $446.00 10.1732 $421.17 $439.79
31624 .......... Dx bronchoscope/lavage ................................ Y ................. .................... A2 ............... $446.00 10.1732 $421.17 $439.79
31625 .......... Bronchoscopy w/biopsy(s) ............................. Y ................. .................... A2 ............... $446.00 10.1732 $421.17 $439.79
31628 .......... Bronchoscopy/lung bx, each .......................... Y ................. .................... A2 ............... $446.00 10.1732 $421.17 $439.79
31629 .......... Bronchoscopy/needle bx, each ...................... Y ................. .................... A2 ............... $446.00 10.1732 $421.17 $439.79
31630 .......... Bronchoscopy dilate/fx repr ............................ Y ................. .................... A2 ............... $446.00 24.2882 $1,005.53 $585.88
31631 .......... Bronchoscopy, dilate w/stent ......................... Y ................. .................... A2 ............... $446.00 24.2882 $1,005.53 $585.88
31632 .......... Bronchoscopy/lung bx, add’l .......................... Y ................. .................... G2 .............. .................... 10.1732 $421.17 $421.17
31633 .......... Bronchoscopy/needle bx add’l ....................... Y ................. .................... G2 .............. .................... 10.1732 $421.17 $421.17
31635 .......... Bronchoscopy w/fb removal ........................... Y ................. .................... A2 ............... $446.00 10.1732 $421.17 $439.79
31636 .......... Bronchoscopy, bronch stents ......................... Y ................. .................... A2 ............... $446.00 24.2882 $1,005.53 $585.88
31637 .......... Bronchoscopy, stent add-on .......................... Y ................. .................... A2 ............... $333.00 10.1732 $421.17 $355.04
31638 .......... Bronchoscopy, revise stent ............................ Y ................. .................... A2 ............... $446.00 24.2882 $1,005.53 $585.88
31640 .......... Bronchoscopy w/tumor excise ....................... Y ................. .................... A2 ............... $446.00 24.2882 $1,005.53 $585.88
31641 .......... Bronchoscopy, treat blockage ........................ Y ................. .................... A2 ............... $446.00 24.2882 $1,005.53 $585.88
31643 .......... Diag bronchoscope/catheter .......................... Y ................. .................... A2 ............... $446.00 10.1732 $421.17 $439.79
31645 .......... Bronchoscopy, clear airways ......................... Y ................. .................... A2 ............... $333.00 10.1732 $421.17 $355.04
31646 .......... Bronchoscopy, reclear airway ........................ Y ................. .................... A2 ............... $333.00 10.1732 $421.17 $355.04
31656 .......... Bronchoscopy, inj for x-ray ............................ Y ................. .................... A2 ............... $333.00 10.1732 $421.17 $355.04
31715 .......... Injection for bronchus x-ray ............................ N ................. .................... N1 .............. .................... .................... .................... ....................
31717 .......... Bronchial brush biopsy ................................... Y ................. .................... A2 ............... $236.42 4.2060 $174.13 $220.85
31720 .......... Clearance of airways ...................................... N ................. CH .............. A2 ............... $47.32 0.3904 $16.16 $39.53
31730 .......... Intro, windpipe wire/tube ................................ Y ................. .................... A2 ............... $236.42 4.2060 $174.13 $220.85
31750 .......... Repair of windpipe ......................................... Y ................. .................... A2 ............... $717.00 40.5598 $1,679.18 $957.55
31755 .......... Repair of windpipe ......................................... Y ................. .................... A2 ............... $446.00 40.5598 $1,679.18 $754.30
31820 .......... Closure of windpipe lesion ............................. Y ................. .................... A2 ............... $333.00 16.6341 $688.65 $421.91
31825 .......... Repair of windpipe defect .............................. Y ................. .................... A2 ............... $446.00 24.3535 $1,008.23 $586.56
31830 .......... Revise windpipe scar ..................................... Y ................. .................... A2 ............... $446.00 24.3535 $1,008.23 $586.56
32000 .......... Drainage of chest ........................................... Y ................. .................... A2 ............... $222.78 5.3095 $219.81 $222.04
32002 .......... Treatment of collapsed lung ........................... Y ................. .................... G2 .............. .................... 5.3095 $219.81 $219.81
32019 .......... Insert pleural catheter .................................... Y ................. .................... G2 .............. .................... 31.7598 $1,314.86 $1,314.86
32400 .......... Needle biopsy chest lining ............................. Y ................. .................... A2 ............... $333.00 9.5741 $396.37 $348.84
32405 .......... Biopsy, lung or mediastinum .......................... Y ................. .................... A2 ............... $333.00 9.5741 $396.37 $348.84
32420 .......... Puncture/clear lung ........................................ Y ................. .................... A2 ............... $222.78 5.3095 $219.81 $222.04
32960 .......... Therapeutic pneumothorax ............................ Y ................. .................... G2 .............. .................... 5.3095 $219.81 $219.81
33010 .......... Drainage of heart sac ..................................... Y ................. .................... A2 ............... $222.78 5.3095 $219.81 $222.04
33011 .......... Repeat drainage of heart sac ........................ Y ................. .................... A2 ............... $222.78 5.3095 $219.81 $222.04
33206 .......... Insertion of heart pacemaker ......................... Y ................. .................... J8 ............... .................... 171.4188 $7,096.74 $7,096.74
33210 .......... Insertion of heart electrode ............................ Y ................. CH .............. J8 ............... .................... 98.1097 $4,061.74 $4,061.74
33211 .......... Insertion of heart electrode ............................ Y ................. CH .............. J8 ............... .................... 98.1097 $4,061.74 $4,061.74
33212 .......... Insertion of pulse generator ........................... Y ................. .................... H8 ............... $510.00 140.4331 $5,813.93 $5,438.26
33213 .......... Insertion of pulse generator ........................... Y ................. .................... H8 ............... $510.00 150.5751 $6,233.81 $5,815.00
33214 .......... Upgrade of pacemaker system ...................... Y ................. .................... J8 ............... .................... 202.2251 $8,372.12 $8,372.12
33215 .......... Reposition pacing-defib lead .......................... Y ................. .................... G2 .............. .................... 24.7274 $1,023.71 $1,023.71
33216 .......... Insert lead pace-defib, one ............................ Y ................. CH .............. J8 ............... .................... 98.1097 $4,061.74 $4,061.74
33217 .......... Insert lead pace-defib, dual ............................ Y ................. CH .............. J8 ............... .................... 98.1097 $4,061.74 $4,061.74
33218 .......... Repair lead pace-defib, one ........................... Y ................. .................... G2 .............. .................... 24.7274 $1,023.71 $1,023.71
33220 .......... Repair lead pace-defib, dual .......................... Y ................. .................... G2 .............. .................... 24.7274 $1,023.71 $1,023.71
33222 .......... Revise pocket, pacemaker ............................. Y ................. .................... A2 ............... $446.00 15.4399 $639.21 $494.30
33223 .......... Revise pocket, pacing-defib ........................... Y ................. .................... A2 ............... $446.00 15.4399 $639.21 $494.30
33224 .......... Insert pacing lead & connect ......................... Y ................. .................... J8 ............... .................... 360.3278 $14,917.57 $14,917.57
33225 .......... Lventric pacing lead add-on ........................... Y ................. .................... J8 ............... .................... 360.3278 $14,917.57 $14,917.57
33226 .......... Reposition l ventric lead ................................. Y ................. .................... G2 .............. .................... 24.7274 $1,023.71 $1,023.71
33233 .......... Removal of pacemaker system ...................... Y ................. .................... A2 ............... $446.00 24.7274 $1,023.71 $590.43
33234 .......... Removal of pacemaker system ...................... Y ................. .................... G2 .............. .................... 24.7274 $1,023.71 $1,023.71
33235 .......... Removal pacemaker electrode ...................... Y ................. .................... G2 .............. .................... 24.7274 $1,023.71 $1,023.71
33240 .......... Insert pulse generator .................................... Y ................. CH .............. J8 ............... .................... 523.1751 $21,659.45 $21,659.45
33241 .......... Remove pulse generator ................................ Y ................. .................... G2 .............. .................... 24.7274 $1,023.71 $1,023.71
33249 .......... Eltrd/insert pace-defib .................................... Y ................. CH .............. J8 ............... .................... 596.7345 $24,704.81 $24,704.81
33282 .......... Implant pat-active ht record ........................... N ................. .................... J8 ............... .................... 99.4780 $4,118.39 $4,118.39
33284 .......... Remove pat-active ht record .......................... Y ................. .................... G2 .............. .................... 6.1077 $252.86 $252.86
33508 .......... Endoscopic vein harvest ................................ N ................. .................... N1 ............... .................... .................... .................... ....................
35188 .......... Repair blood vessel lesion ............................. Y ................. .................... A2 ............... $630.00 39.8001 $1,647.72 $884.43
35207 .......... Repair blood vessel lesion ............................. Y ................. .................... A2 ............... $630.00 39.8001 $1,647.72 $884.43
35473 .......... Repair arterial blockage ................................. Y ................. .................... G2 .............. .................... 46.0685 $1,907.24 $1,907.24
35474 .......... Repair arterial blockage ................................. Y ................. .................... G2 .............. .................... 46.0685 $1,907.24 $1,907.24
35476 .......... Repair venous blockage ................................. Y ................. .................... G2 .............. .................... 46.0685 $1,907.24 $1,907.24
35492 .......... Atherectomy, percutaneous ........................... Y ................. .................... G2 .............. .................... 88.7717 $3,675.15 $3,675.15
35572 .......... Harvest femoropopliteal vein .......................... N ................. .................... N1 ............... .................... .................... .................... ....................
35761 .......... Exploration of artery/vein ............................... Y ................. .................... G2 .............. .................... 30.5379 $1,264.27 $1,264.27
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
35875 .......... Removal of clot in graft .................................. Y ................. .................... A2 ............... $1,339.00 39.8001 $1,647.72 $1,416.18
35876 .......... Removal of clot in graft .................................. Y ................. .................... A2 ............... $1,339.00 39.8001 $1,647.72 $1,416.18
36000 .......... Place needle in vein ....................................... N ................. .................... N1 .............. .................... .................... .................... ....................
36002 .......... Pseudoaneurysm injection trt ......................... N ................. .................... G2 .............. .................... 2.4859 $102.92 $102.92
36005 .......... Injection ext venography ................................ N ................. .................... N1 ............... .................... .................... .................... ....................
36010 .......... Place catheter in vein ..................................... N ................. .................... N1 .............. .................... .................... .................... ....................
36013 .......... Place catheter in artery .................................. N ................. .................... N1 ............... .................... .................... .................... ....................
36100 .......... Establish access to artery .............................. N ................. .................... N1 ............... .................... .................... .................... ....................
36145 .......... Artery to vein shunt ........................................ N ................. .................... N1 .............. .................... .................... .................... ....................
36160 .......... Establish access to aorta ............................... N ................. .................... N1 ............... .................... .................... .................... ....................
36200 .......... Place catheter in aorta ................................... N ................. .................... N1 ............... .................... .................... .................... ....................
36260 .......... Insertion of infusion pump .............................. Y ................. .................... A2 ............... $510.00 29.3210 $1,213.89 $685.97
36261 .......... Revision of infusion pump .............................. Y ................. .................... A2 ............... $446.00 29.3210 $1,213.89 $637.97
36262 .......... Removal of infusion pump ............................. Y ................. .................... A2 ............... $333.00 24.5273 $1,015.43 $503.61
36400 .......... Bl draw < 3 yrs fem/jugular ............................ N ................. .................... N1 ............... .................... .................... .................... ....................
36405 .......... Bl draw < 3 yrs scalp vein ............................. N ................. .................... N1 ............... .................... .................... .................... ....................
36406 .......... Bl draw < 3 yrs other vein .............................. N ................. .................... N1 ............... .................... .................... .................... ....................
36410 .......... Non-routine bl draw > 3 yrs ........................... N ................. .................... N1 .............. .................... .................... .................... ....................
36416 .......... Capillary blood draw ....................................... N ................. .................... N1 ............... .................... .................... .................... ....................
36420 .......... Vein access cutdown < 1 yr ........................... Y ................. .................... G2 .............. .................... 0.2091 $8.66 $8.66
36425 .......... Vein access cutdown > 1 yr ........................... Y ................. .................... R2 ............... .................... 0.2091 $8.66 $8.66
36430 .......... Blood transfusion service ............................... N ................. .................... P3 ............... .................... 0.7998 $33.11 $33.11
36440 .......... Bl push transfuse, 2 yr or < ........................... N ................. .................... R2 ............... .................... 3.4924 $144.59 $144.59
36450 .......... Bl exchange/transfuse, nb .............................. N ................. .................... R2 ............... .................... 3.4924 $144.59 $144.59
36468 .......... Injection(s), spider veins ................................ Y ................. .................... R2 .............. .................... 0.8046 $33.31 $33.31
36469 .......... Injection(s), spider veins ................................ Y ................. CH .............. R2 ............... .................... 0.8046 $33.31 $33.31
36470 .......... Injection therapy of vein ................................. Y ................. .................... P2 ............... .................... 0.8046 $33.31 $33.31
36471 .......... Injection therapy of veins ............................... Y ................. .................... P2 ............... .................... 0.8046 $33.31 $33.31
36475 .......... Endovenous rf, 1st vein ................................. Y ................. .................... A2 ............... $1,339.00 43.6609 $1,807.56 $1,456.14
36476 .......... Endovenous rf, vein add-on ........................... Y ................. .................... A2 ............... $1,339.00 26.4396 $1,094.60 $1,277.90
36478 .......... Endovenous laser, 1st vein ............................ Y ................. .................... A2 ............... $1,339.00 26.4396 $1,094.60 $1,277.90
36479 .......... Endovenous laser vein addon ........................ Y ................. .................... A2 ............... $1,339.00 26.4396 $1,094.60 $1,277.90
36481 .......... Insertion of catheter, vein ............................... N ................. .................... N1 ............... .................... .................... .................... ....................
36511 .......... Apheresis wbc ................................................ N ................. .................... G2 .............. .................... 12.1982 $505.01 $505.01
36512 .......... Apheresis rbc ................................................. N ................. .................... G2 .............. .................... 12.1982 $505.01 $505.01
36513 .......... Apheresis platelets ......................................... N ................. .................... G2 .............. .................... 12.1982 $505.01 $505.01
36514 .......... Apheresis plasma ........................................... N ................. .................... G2 .............. .................... 12.1982 $505.01 $505.01
36515 .......... Apheresis, adsorp/reinfuse ............................. N ................. .................... G2 .............. .................... 31.9648 $1,323.34 $1,323.34
36516 .......... Apheresis, selective ....................................... N ................. .................... G2 .............. .................... 31.9648 $1,323.34 $1,323.34
36522 .......... Photopheresis ................................................. N ................. .................... G2 .............. .................... 31.9648 $1,323.34 $1,323.34
36540 .......... Collect blood venous device .......................... N ................. .................... N1 ............... .................... .................... .................... ....................
36550 .......... Declot vascular device ................................... Y ................. .................... P3 ............... .................... 0.2886 $11.95 $11.95
36555 .......... Insert non-tunnel cv cath ................................ Y ................. .................... A2 ............... $333.00 11.0043 $455.58 $363.65
36556 .......... Insert non-tunnel cv cath ................................ Y ................. .................... A2 ............... $333.00 11.0043 $455.58 $363.65
36557 .......... Insert tunneled cv cath ................................... Y ................. .................... A2 ............... $446.00 24.5273 $1,015.43 $588.36
36566 .......... Insert tunneled cv cath ................................... Y ................. .................... H8 .............. $510.00 116.7686 $4,834.22 $4,203.51
36568 .......... Insert picc cath ............................................... Y ................. .................... A2 ............... $333.00 11.0043 $455.58 $363.65
36569 .......... Insert picc cath ............................................... Y ................. .................... A2 ............... $333.00 11.0043 $455.58 $363.65
36570 .......... Insert picvad cath ........................................... Y ................. .................... A2 ............... $510.00 24.5273 $1,015.43 $636.36
36571 .......... Insert picvad cath ........................................... Y ................. .................... A2 ............... $510.00 24.5273 $1,015.43 $636.36
36575 .......... Repair tunneled cv cath ................................. Y ................. .................... A2 ............... $446.00 6.1077 $252.86 $397.72
36576 .......... Repair tunneled cv cath ................................. Y ................. .................... A2 ............... $446.00 11.0043 $455.58 $448.40
36578 .......... Replace tunneled cv cath ............................... Y ................. .................... A2 ............... $446.00 24.5273 $1,015.43 $588.36
36580 .......... Replace cvad cath .......................................... Y ................. .................... A2 ............... $333.00 11.0043 $455.58 $363.65
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
36584 .......... Replace picc cath ........................................... Y ................. .................... A2 ............... $333.00 11.0043 $455.58 $363.65
36585 .......... Replace picvad cath ....................................... Y ................. .................... A2 ............... $510.00 24.5273 $1,015.43 $636.36
36589 .......... Removal tunneled cv cath .............................. Y ................. .................... A2 ............... $333.00 6.1077 $252.86 $312.97
36590 .......... Removal tunneled cv cath .............................. Y ................. .................... A2 ............... $333.00 11.0043 $455.58 $363.65
36595 .......... Mech remov tunneled cv cath ........................ Y ................. .................... G2 .............. .................... 24.5273 $1,015.43 $1,015.43
36596 .......... Mech remov tunneled cv cath ........................ Y ................. .................... G2 .............. .................... 11.0043 $455.58 $455.58
36597 .......... Reposition venous catheter ............................ Y ................. .................... G2 .............. .................... 11.0043 $455.58 $455.58
36598 .......... Inj w/fluor, eval cv device ............................... Y ................. CH .............. P3 ............... .................... 1.9872 $82.27 $82.27
36600 .......... Withdrawal of arterial blood ........................... N ................. .................... N1 .............. .................... .................... .................... ....................
36620 .......... Insertion catheter, artery ................................ N ................. .................... N1 ............... .................... .................... .................... ....................
36625 .......... Insertion catheter, artery ................................ N ................. .................... N1 ............... .................... .................... .................... ....................
36640 .......... Insertion catheter, artery ................................ Y ................. .................... A2 ............... $333.00 29.3210 $1,213.89 $553.22
36680 .......... Insert needle, bone cavity .............................. Y ................. .................... G2 .............. .................... 1.1915 $49.33 $49.33
36800 .......... Insertion of cannula ........................................ Y ................. .................... A2 ............... $510.00 30.5379 $1,264.27 $698.57
36818 .......... Av fuse, uppr arm, cephalic ........................... Y ................. .................... A2 ............... $510.00 39.8001 $1,647.72 $794.43
36819 .......... Av fuse, uppr arm, basilic .............................. Y ................. .................... A2 ............... $510.00 39.8001 $1,647.72 $794.43
36820 .......... Av fusion/forearm vein ................................... Y ................. .................... A2 ............... $510.00 39.8001 $1,647.72 $794.43
36821 .......... Av fusion direct any site ................................. Y ................. .................... A2 ............... $510.00 39.8001 $1,647.72 $794.43
36825 .......... Artery-vein autograft ....................................... Y ................. .................... A2 ............... $630.00 39.8001 $1,647.72 $884.43
36830 .......... Artery-vein nonautograft ................................. Y ................. .................... A2 ............... $630.00 39.8001 $1,647.72 $884.43
36831 .......... Open thrombect av fistula .............................. Y ................. .................... A2 ............... $1,339.00 39.8001 $1,647.72 $1,416.18
36832 .......... Av fistula revision, open ................................. Y ................. .................... A2 ............... $630.00 39.8001 $1,647.72 $884.43
36833 .......... Av fistula revision ........................................... Y ................. .................... A2 ............... $630.00 39.8001 $1,647.72 $884.43
36834 .......... Repair A-V aneurysm ..................................... Y ................. .................... A2 ............... $510.00 39.8001 $1,647.72 $794.43
36835 .......... Artery to vein shunt ........................................ Y ................. .................... A2 ............... $630.00 30.5379 $1,264.27 $788.57
36860 .......... External cannula declotting ............................ Y ................. .................... A2 ............... $127.40 2.5179 $104.24 $121.61
36861 .......... Cannula declotting .......................................... Y ................. .................... A2 ............... $510.00 30.5379 $1,264.27 $698.57
36870 .......... Percut thrombect av fistula ............................ Y ................. .................... A2 ............... $1,339.00 41.0875 $1,701.02 $1,429.51
37184 .......... Prim art mech thrombectomy ......................... Y ................. .................... G2 .............. .................... 39.8001 $1,647.72 $1,647.72
37185 .......... Prim art m-thrombect add-on ......................... Y ................. .................... G2 .............. .................... 39.8001 $1,647.72 $1,647.72
37186 .......... Sec art m-thrombect add-on .......................... Y ................. .................... G2 .............. .................... 39.8001 $1,647.72 $1,647.72
37187 .......... Venous mech thrombectomy ......................... Y ................. .................... G2 .............. .................... 39.8001 $1,647.72 $1,647.72
37188 .......... Venous m-thrombectomy add-on ................... Y ................. .................... G2 .............. .................... 39.8001 $1,647.72 $1,647.72
37200 .......... Transcatheter biopsy ...................................... Y ................. .................... G2 .............. .................... 29.3210 $1,213.89 $1,213.89
37203 .......... Transcatheter retrieval ................................... Y ................. .................... G2 .............. .................... 29.3210 $1,213.89 $1,213.89
37250 .......... Iv us first vessel add-on ................................. N ................. CH .............. N1 ............... .................... .................... .................... ....................
37251 .......... Iv us each add vessel add-on ........................ N ................. CH .............. N1 ............... .................... .................... .................... ....................
37500 .......... Endoscopy ligate perf veins ........................... Y ................. .................... A2 ............... $510.00 43.6609 $1,807.56 $834.39
37607 .......... Ligation of a-v fistula ...................................... Y ................. .................... A2 ............... $510.00 26.4396 $1,094.60 $656.15
37609 .......... Temporal artery procedure ............................. Y ................. .................... A2 ............... $446.00 16.5832 $686.54 $506.14
37650 .......... Revision of major vein .................................... Y ................. .................... A2 ............... $446.00 26.4396 $1,094.60 $608.15
37700 .......... Revise leg vein ............................................... Y ................. .................... A2 ............... $446.00 26.4396 $1,094.60 $608.15
37718 .......... Ligate/strip short leg vein ............................... Y ................. .................... A2 ............... $510.00 26.4396 $1,094.60 $656.15
37722 .......... Ligate/strip long leg vein ................................ Y ................. .................... A2 ............... $510.00 43.6609 $1,807.56 $834.39
37735 .......... Removal of leg veins/lesion ........................... Y ................. .................... A2 ............... $510.00 43.6609 $1,807.56 $834.39
37760 .......... Ligation, leg veins, open ................................ Y ................. .................... A2 ............... $510.00 26.4396 $1,094.60 $656.15
37765 .......... Phleb veins—extrem—to 20 .......................... Y ................. .................... R2 ............... .................... 26.4396 $1,094.60 $1,094.60
37766 .......... Phleb veins—extrem 20+ ............................... Y ................. .................... R2 ............... .................... 26.4396 $1,094.60 $1,094.60
37780 .......... Revision of leg vein ........................................ Y ................. .................... A2 ............... $510.00 26.4396 $1,094.60 $656.15
37785 .......... Ligate/divide/excise vein ................................ Y ................. .................... A2 ............... $510.00 26.4396 $1,094.60 $656.15
37790 .......... Penile venous occlusion ................................. Y ................. .................... A2 ............... $510.00 35.1574 $1,455.52 $746.38
38200 .......... Injection for spleen x-ray ................................ N ................. .................... N1 ............... .................... .................... .................... ....................
38204 .......... Bl donor search management ........................ N ................. .................... N1 ............... .................... .................... .................... ....................
38205 .......... Harvest allogenic stem cells .......................... N ................. .................... G2 .............. .................... 12.1982 $505.01 $505.01
38206 .......... Harvest auto stem cells .................................. N ................. .................... G2 .............. .................... 12.1982 $505.01 $505.01
38220 .......... Bone marrow aspiration ................................. Y ................. CH .............. P3 ............... .................... 2.6302 $108.89 $108.89
38221 .......... Bone marrow biopsy ...................................... Y ................. CH .............. P3 ............... .................... 2.7621 $114.35 $114.35
38230 .......... Bone marrow collection .................................. N ................. .................... G2 .............. .................... 31.9648 $1,323.34 $1,323.34
38241 .......... Bone marrow/stem transplant ........................ N ................. .................... G2 .............. .................... 31.9648 $1,323.34 $1,323.34
38242 .......... Lymphocyte infuse transplant ........................ N ................. .................... R2 .............. .................... 12.1982 $505.01 $505.01
38300 .......... Drainage, lymph node lesion ......................... Y ................. .................... A2 ............... $333.00 12.5792 $520.78 $379.95
38305 .......... Drainage, lymph node lesion ......................... Y ................. .................... A2 ............... $446.00 19.0457 $788.49 $531.62
38308 .......... Incision of lymph channels ............................. Y ................. .................... A2 ............... $446.00 23.5105 $973.33 $577.83
38500 .......... Biopsy/removal, lymph nodes ........................ Y ................. .................... A2 ............... $446.00 23.5105 $973.33 $577.83
38505 .......... Needle biopsy, lymph nodes .......................... Y ................. .................... A2 ............... $240.00 7.3012 $302.27 $255.57
38542 .......... Explore deep node(s), neck ........................... Y ................. .................... A2 ............... $446.00 45.1729 $1,870.16 $802.04
38550 .......... Removal, neck/armpit lesion .......................... Y ................. .................... A2 ............... $510.00 23.5105 $973.33 $625.83
38555 .......... Removal, neck/armpit lesion .......................... Y ................. .................... A2 ............... $630.00 23.5105 $973.33 $715.83
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
38570 .......... Laparoscopy, lymph node biop ...................... Y ................. .................... A2 ............... $1,339.00 46.1201 $1,909.37 $1,481.59
38571 .......... Laparoscopy, lymphadenectomy .................... Y ................. .................... A2 ............... $1,339.00 71.0022 $2,939.49 $1,739.12
38572 .......... Laparoscopy, lymphadenectomy .................... Y ................. .................... A2 ............... $1,339.00 46.1201 $1,909.37 $1,481.59
38700 .......... Removal of lymph nodes, neck ...................... Y ................. .................... G2 .............. .................... 23.5105 $973.33 $973.33
38740 .......... Remove armpit lymph nodes ......................... Y ................. .................... A2 ............... $446.00 45.1729 $1,870.16 $802.04
38745 .......... Remove armpit lymph nodes ......................... Y ................. .................... A2 ............... $630.00 45.1729 $1,870.16 $940.04
38760 .......... Remove groin lymph nodes ........................... Y ................. .................... A2 ............... $446.00 23.5105 $973.33 $577.83
38790 .......... Inject for lymphatic x-ray ................................ N ................. .................... N1 ............... .................... .................... .................... ....................
38792 .......... Identify sentinel node ..................................... N ................. .................... N1 ............... .................... .................... .................... ....................
38794 .......... Access thoracic lymph duct ........................... N ................. .................... N1 .............. .................... .................... .................... ....................
40490 .......... Biopsy of lip .................................................... Y ................. .................... P3 ............... .................... 1.5336 $63.49 $63.49
40500 .......... Partial excision of lip ...................................... Y ................. .................... A2 ............... $446.00 16.6341 $688.65 $506.66
40510 .......... Partial excision of lip ...................................... Y ................. .................... A2 ............... $446.00 24.3535 $1,008.23 $586.56
40520 .......... Partial excision of lip ...................................... Y ................. .................... A2 ............... $446.00 16.6341 $688.65 $506.66
40525 .......... Reconstruct lip with flap ................................. Y ................. .................... A2 ............... $446.00 24.3535 $1,008.23 $586.56
40527 .......... Reconstruct lip with flap ................................. Y ................. .................... A2 ............... $446.00 24.3535 $1,008.23 $586.56
40530 .......... Partial removal of lip ...................................... Y ................. .................... A2 ............... $446.00 24.3535 $1,008.23 $586.56
40650 .......... Repair lip ........................................................ Y ................. .................... A2 ............... $464.15 7.6539 $316.87 $427.33
40652 .......... Repair lip ........................................................ Y ................. .................... A2 ............... $464.15 7.6539 $316.87 $427.33
40654 .......... Repair lip ........................................................ Y ................. .................... A2 ............... $464.15 7.6539 $316.87 $427.33
40700 .......... Repair cleft lip/nasal ....................................... Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
40702 .......... Repair cleft lip/nasal ....................................... Y ................. .................... R2 ............... .................... 40.5598 $1,679.18 $1,679.18
40761 .......... Repair cleft lip/nasal ....................................... Y ................. .................... A2 ............... $510.00 40.5598 $1,679.18 $802.30
40800 .......... Drainage of mouth lesion ............................... Y ................. .................... P2 ............... .................... 1.4630 $60.57 $60.57
40801 .......... Drainage of mouth lesion ............................... Y ................. .................... A2 ............... $446.00 7.6539 $316.87 $413.72
40804 .......... Removal, foreign body, mouth ....................... N ................. .................... P2 ............... .................... 0.6416 $26.56 $26.56
40805 .......... Removal, foreign body, mouth ....................... Y ................. .................... P3 ............... .................... 3.9495 $163.51 $163.51
40806 .......... Incision of lip fold ........................................... Y ................. .................... P3 ............... .................... 1.7481 $72.37 $72.37
40808 .......... Biopsy of mouth lesion ................................... Y ................. .................... P3 ............... .................... 2.5643 $106.16 $106.16
40810 .......... Excision of mouth lesion ................................ Y ................. .................... P3 ............... .................... 2.6879 $111.28 $111.28
40812 .......... Excise/repair mouth lesion ............................. Y ................. .................... P3 ............... .................... 3.4053 $140.98 $140.98
40814 .......... Excise/repair mouth lesion ............................. Y ................. .................... A2 ............... $446.00 16.6341 $688.65 $506.66
40816 .......... Excision of mouth lesion ................................ Y ................. .................... A2 ............... $446.00 24.3535 $1,008.23 $586.56
40818 .......... Excise oral mucosa for graft .......................... Y ................. .................... A2 ............... $150.72 2.5765 $106.67 $139.71
40819 .......... Excise lip or cheek fold .................................. Y ................. .................... A2 ............... $333.00 7.6539 $316.87 $328.97
40820 .......... Treatment of mouth lesion ............................. Y ................. .................... P3 ............... .................... 3.7763 $156.34 $156.34
40830 .......... Repair mouth laceration ................................. Y ................. .................... G2 .............. .................... 2.5765 $106.67 $106.67
40831 .......... Repair mouth laceration ................................. Y ................. .................... A2 ............... $333.00 7.6539 $316.87 $328.97
40840 .......... Reconstruction of mouth ................................ Y ................. .................... A2 ............... $446.00 24.3535 $1,008.23 $586.56
41000 .......... Drainage of mouth lesion ............................... Y ................. .................... P3 ............... .................... 1.9954 $82.61 $82.61
41006 .......... Drainage of mouth lesion ............................... Y ................. .................... A2 ............... $333.00 24.3535 $1,008.23 $501.81
41010 .......... Incision of tongue fold .................................... Y ................. .................... A2 ............... $333.00 7.6539 $316.87 $328.97
41100 .......... Biopsy of tongue ............................................ Y ................. .................... P3 ............... .................... 2.0860 $86.36 $86.36
41105 .......... Biopsy of tongue ............................................ Y ................. .................... P3 ............... .................... 2.0365 $84.31 $84.31
41108 .......... Biopsy of floor of mouth ................................. Y ................. .................... P3 ............... .................... 1.8717 $77.49 $77.49
41110 .......... Excision of tongue lesion ............................... Y ................. .................... P3 ............... .................... 2.7043 $111.96 $111.96
41112 .......... Excision of tongue lesion ............................... Y ................. .................... A2 ............... $446.00 16.6341 $688.65 $506.66
41113 .......... Excision of tongue lesion ............................... Y ................. .................... A2 ............... $446.00 16.6341 $688.65 $506.66
41114 .......... Excision of tongue lesion ............................... Y ................. .................... A2 ............... $446.00 24.3535 $1,008.23 $586.56
41115 .......... Excision of tongue fold ................................... Y ................. .................... P3 ............... .................... 3.0920 $128.01 $128.01
41116 .......... Excision of mouth lesion ................................ Y ................. .................... A2 ............... $333.00 16.6341 $688.65 $421.91
41120 .......... Partial removal of tongue ............................... Y ................. .................... A2 ............... $717.00 24.3535 $1,008.23 $789.81
41250 .......... Repair tongue laceration ................................ Y ................. .................... A2 ............... $150.72 2.5765 $106.67 $139.71
41500 .......... Fixation of tongue ........................................... Y ................. .................... A2 ............... $333.00 24.3535 $1,008.23 $501.81
41510 .......... Tongue to lip surgery ..................................... Y ................. .................... A2 ............... $333.00 16.6341 $688.65 $421.91
41520 .......... Reconstruction, tongue fold ........................... Y ................. .................... A2 ............... $446.00 7.6539 $316.87 $413.72
41800 .......... Drainage of gum lesion .................................. Y ................. .................... A2 ............... $88.46 1.4630 $60.57 $81.49
41805 .......... Removal foreign body, gum ........................... Y ................. .................... P3 ............... .................... 3.0176 $124.93 $124.93
41806 .......... Removal foreign body, jawbone ..................... Y ................. .................... P3 ............... .................... 3.8836 $160.78 $160.78
41820 .......... Excision, gum, each quadrant ........................ Y ................. .................... R2 ............... .................... 7.6539 $316.87 $316.87
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
41821 .......... Excision of gum flap ....................................... Y ................. .................... G2 .............. .................... 7.6539 $316.87 $316.87
41822 .......... Excision of gum lesion ................................... Y ................. .................... P3 ............... .................... 3.5618 $147.46 $147.46
41827 .......... Excision of gum lesion ................................... Y ................. .................... A2 ............... $446.00 24.3535 $1,008.23 $586.56
41830 .......... Removal of gum tissue .................................. Y ................. .................... P3 ............... .................... 4.5184 $187.06 $187.06
41850 .......... Treatment of gum lesion ................................ Y ................. .................... R2 ............... .................... 16.6341 $688.65 $688.65
41870 .......... Gum graft ....................................................... Y ................. .................... G2 .............. .................... 24.3535 $1,008.23 $1,008.23
41872 .......... Repair gum ..................................................... Y ................. .................... P3 ............... .................... 4.5348 $187.74 $187.74
41874 .......... Repair tooth socket ........................................ Y ................. .................... P3 ............... .................... 4.3452 $179.89 $179.89
42000 .......... Drainage mouth roof lesion ............................ Y ................. .................... A2 ............... $150.72 2.5765 $106.67 $139.71
42100 .......... Biopsy roof of mouth ...................................... Y ................. .................... P3 ............... .................... 1.7809 $73.73 $73.73
42104 .......... Excision lesion, mouth roof ............................ Y ................. .................... P3 ............... .................... 2.4983 $103.43 $103.43
42106 .......... Excision lesion, mouth roof ............................ Y ................. .................... P3 ............... .................... 3.1580 $130.74 $130.74
42107 .......... Excision lesion, mouth roof ............................ Y ................. .................... A2 ............... $446.00 24.3535 $1,008.23 $586.56
42120 .......... Remove palate/lesion ..................................... Y ................. .................... A2 ............... $630.00 40.5598 $1,679.18 $892.30
42140 .......... Excision of uvula ............................................ Y ................. .................... A2 ............... $446.00 7.6539 $316.87 $413.72
42145 .......... Repair palate, pharynx/uvula ......................... Y ................. .................... A2 ............... $717.00 24.3535 $1,008.23 $789.81
42160 .......... Treatment mouth roof lesion .......................... Y ................. .................... P3 ............... .................... 3.2899 $136.20 $136.20
42180 .......... Repair palate .................................................. Y ................. .................... A2 ............... $150.72 2.5765 $106.67 $139.71
42182 .......... Repair palate .................................................. Y ................. .................... A2 ............... $446.00 40.5598 $1,679.18 $754.30
42200 .......... Reconstruct cleft palate .................................. Y ................. .................... A2 ............... $717.00 40.5598 $1,679.18 $957.55
42215 .......... Reconstruct cleft palate .................................. Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
42226 .......... Lengthening of palate ..................................... Y ................. .................... A2 ............... $717.00 40.5598 $1,679.18 $957.55
42235 .......... Repair palate .................................................. Y ................. .................... A2 ............... $717.00 16.6341 $688.65 $709.91
42260 .......... Repair nose to lip fistula ................................ Y ................. .................... A2 ............... $630.00 24.3535 $1,008.23 $724.56
42280 .......... Preparation, palate mold ................................ Y ................. .................... P3 ............... .................... 1.7314 $71.68 $71.68
42281 .......... Insertion, palate prosthesis ............................ Y ................. .................... G2 .............. .................... 16.6341 $688.65 $688.65
42300 .......... Drainage of salivary gland ............................. Y ................. .................... A2 ............... $333.00 16.6341 $688.65 $421.91
42330 .......... Removal of salivary stone .............................. Y ................. .................... P3 ............... .................... 2.6715 $110.60 $110.60
42335 .......... Removal of salivary stone .............................. Y ................. .................... P3 ............... .................... 4.3534 $180.23 $180.23
42340 .......... Removal of salivary stone .............................. Y ................. .................... A2 ............... $446.00 16.6341 $688.65 $506.66
42400 .......... Biopsy of salivary gland ................................. Y ................. .................... P3 ............... .................... 1.4841 $61.44 $61.44
42405 .......... Biopsy of salivary gland ................................. Y ................. .................... A2 ............... $446.00 16.6341 $688.65 $506.66
42408 .......... Excision of salivary cyst ................................. Y ................. .................... A2 ............... $510.00 16.6341 $688.65 $554.66
42409 .......... Drainage of salivary cyst ................................ Y ................. .................... A2 ............... $510.00 16.6341 $688.65 $554.66
42410 .......... Excise parotid gland/lesion ............................ Y ................. .................... A2 ............... $510.00 40.5598 $1,679.18 $802.30
42415 .......... Excise parotid gland/lesion ............................ Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
42440 .......... Excise submaxillary gland .............................. Y ................. .................... A2 ............... $510.00 40.5598 $1,679.18 $802.30
42450 .......... Excise sublingual gland .................................. Y ................. .................... A2 ............... $446.00 24.3535 $1,008.23 $586.56
42500 .......... Repair salivary duct ........................................ Y ................. .................... A2 ............... $510.00 24.3535 $1,008.23 $634.56
42505 .......... Repair salivary duct ........................................ Y ................. .................... A2 ............... $630.00 40.5598 $1,679.18 $892.30
42507 .......... Parotid duct diversion ..................................... Y ................. .................... A2 ............... $510.00 40.5598 $1,679.18 $802.30
42550 .......... Injection for salivary x-ray .............................. N ................. .................... N1 ............... .................... .................... .................... ....................
42600 .......... Closure of salivary fistula ............................... Y ................. .................... A2 ............... $333.00 16.6341 $688.65 $421.91
42650 .......... Dilation of salivary duct .................................. Y ................. .................... P3 ............... .................... 0.9729 $40.28 $40.28
42660 .......... Dilation of salivary duct .................................. Y ................. .................... P3 ............... .................... 1.1543 $47.79 $47.79
42665 .......... Ligation of salivary duct ................................. Y ................. .................... A2 ............... $995.00 24.3535 $1,008.23 $998.31
42700 .......... Drainage of tonsil abscess ............................. Y ................. .................... A2 ............... $150.72 2.5765 $106.67 $139.71
42720 .......... Drainage of throat abscess ............................ Y ................. .................... A2 ............... $333.00 16.6341 $688.65 $421.91
42725 .......... Drainage of throat abscess ............................ Y ................. .................... A2 ............... $446.00 40.5598 $1,679.18 $754.30
42800 .......... Biopsy of throat .............................................. Y ................. .................... P3 ............... .................... 1.8882 $78.17 $78.17
42802 .......... Biopsy of throat .............................................. Y ................. .................... A2 ............... $333.00 16.6341 $688.65 $421.91
42804 .......... Biopsy of upper nose/throat ........................... Y ................. .................... A2 ............... $333.00 16.6341 $688.65 $421.91
42806 .......... Biopsy of upper nose/throat ........................... Y ................. .................... A2 ............... $446.00 24.3535 $1,008.23 $586.56
42808 .......... Excise pharynx lesion .................................... Y ................. .................... A2 ............... $446.00 16.6341 $688.65 $506.66
42809 .......... Remove pharynx foreign body ....................... N ................. .................... G2 .............. .................... 0.6416 $26.56 $26.56
42810 .......... Excision of neck cyst ...................................... Y ................. .................... A2 ............... $510.00 24.3535 $1,008.23 $634.56
42815 .......... Excision of neck cyst ...................................... Y ................. .................... A2 ............... $717.00 40.5598 $1,679.18 $957.55
42820 .......... Remove tonsils and adenoids ........................ Y ................. .................... A2 ............... $510.00 22.9075 $948.37 $619.59
42821 .......... Remove tonsils and adenoids ........................ Y ................. .................... A2 ............... $717.00 22.9075 $948.37 $774.84
42825 .......... Removal of tonsils .......................................... Y ................. .................... A2 ............... $630.00 22.9075 $948.37 $709.59
42826 .......... Removal of tonsils .......................................... Y ................. .................... A2 ............... $630.00 22.9075 $948.37 $709.59
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
42830 .......... Removal of adenoids ..................................... Y ................. .................... A2 ............... $630.00 22.9075 $948.37 $709.59
42860 .......... Excision of tonsil tags .................................... Y ................. .................... A2 ............... $510.00 22.9075 $948.37 $619.59
42870 .......... Excision of lingual tonsil ................................. Y ................. .................... A2 ............... $510.00 22.9075 $948.37 $619.59
42890 .......... Partial removal of pharynx ............................. Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
42892 .......... Revision of pharyngeal walls ......................... Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
42900 .......... Repair throat wound ....................................... Y ................. .................... A2 ............... $333.00 7.6539 $316.87 $328.97
42950 .......... Reconstruction of throat ................................. Y ................. .................... A2 ............... $446.00 24.3535 $1,008.23 $586.56
42955 .......... Surgical opening of throat .............................. Y ................. .................... A2 ............... $446.00 24.3535 $1,008.23 $586.56
42960 .......... Control throat bleeding ................................... Y ................. .................... A2 ............... $72.48 1.1708 $48.47 $66.48
42962 .......... Control throat bleeding ................................... Y ................. .................... A2 ............... $446.00 40.5598 $1,679.18 $754.30
42970 .......... Control nose/throat bleeding .......................... Y ................. .................... R2 ............... .................... 1.1708 $48.47 $48.47
42972 .......... Control nose/throat bleeding .......................... Y ................. .................... A2 ............... $510.00 16.6341 $688.65 $554.66
43030 .......... Throat muscle surgery ................................... Y ................. .................... G2 .............. .................... 16.6341 $688.65 $688.65
43200 .......... Esophagus endoscopy ................................... Y ................. .................... A2 ............... $333.00 8.6730 $359.06 $339.52
43201 .......... Esoph scope w/submucous inj ....................... Y ................. .................... A2 ............... $333.00 8.6730 $359.06 $339.52
43202 .......... Esophagus endoscopy, biopsy ...................... Y ................. .................... A2 ............... $333.00 8.6730 $359.06 $339.52
43204 .......... Esoph scope w/sclerosis inj ........................... Y ................. .................... A2 ............... $333.00 8.6730 $359.06 $339.52
43205 .......... Esophagus endoscopy/ligation ....................... Y ................. .................... A2 ............... $333.00 8.6730 $359.06 $339.52
43216 .......... Esophagus endoscopy/lesion ......................... Y ................. .................... A2 ............... $333.00 8.6730 $359.06 $339.52
43219 .......... Esophagus endoscopy ................................... Y ................. .................... A2 ............... $333.00 25.2289 $1,044.48 $510.87
43220 .......... Esoph endoscopy, dilation ............................. Y ................. .................... A2 ............... $333.00 8.6730 $359.06 $339.52
43227 .......... Esoph endoscopy, repair ............................... Y ................. .................... A2 ............... $446.00 8.6730 $359.06 $424.27
43228 .......... Esoph endoscopy, ablation ............................ Y ................. .................... A2 ............... $446.00 24.6480 $1,020.43 $589.61
43231 .......... Esoph endoscopy w/us exam ........................ Y ................. .................... A2 ............... $446.00 8.6730 $359.06 $424.27
43232 .......... Esoph endoscopy w/us fn bx ......................... Y ................. .................... A2 ............... $446.00 8.6730 $359.06 $424.27
43234 .......... Upper GI endoscopy, exam ........................... Y ................. .................... A2 ............... $333.00 8.6730 $359.06 $339.52
43235 .......... Uppr gi endoscopy, diagnosis ........................ Y ................. .................... A2 ............... $333.00 8.6730 $359.06 $339.52
43236 .......... Uppr gi scope w/submuc inj ........................... Y ................. .................... A2 ............... $446.00 8.6730 $359.06 $424.27
43237 .......... Endoscopic us exam, esoph .......................... Y ................. .................... A2 ............... $446.00 8.6730 $359.06 $424.27
43238 .......... Uppr gi endoscopy w/us fn bx ....................... Y ................. .................... A2 ............... $446.00 8.6730 $359.06 $424.27
43239 .......... Upper GI endoscopy, biopsy .......................... Y ................. .................... A2 ............... $446.00 8.6730 $359.06 $424.27
43240 .......... Esoph endoscope w/drain cyst ...................... Y ................. .................... A2 ............... $446.00 8.6730 $359.06 $424.27
43241 .......... Upper GI endoscopy with tube ...................... Y ................. .................... A2 ............... $446.00 8.6730 $359.06 $424.27
43242 .......... Uppr gi endoscopy w/us fn bx ....................... Y ................. .................... A2 ............... $446.00 8.6730 $359.06 $424.27
43243 .......... Upper gi endoscopy & inject .......................... Y ................. .................... A2 ............... $446.00 8.6730 $359.06 $424.27
43244 .......... Upper GI endoscopy/ligation .......................... Y ................. .................... A2 ............... $446.00 8.6730 $359.06 $424.27
43245 .......... Uppr gi scope dilate strictr ............................. Y ................. .................... A2 ............... $446.00 8.6730 $359.06 $424.27
43246 .......... Place gastrostomy tube .................................. Y ................. .................... A2 ............... $446.00 8.6730 $359.06 $424.27
43247 .......... Operative upper GI endoscopy ...................... Y ................. .................... A2 ............... $446.00 8.6730 $359.06 $424.27
43248 .......... Uppr gi endoscopy/guide wire ........................ Y ................. .................... A2 ............... $446.00 8.6730 $359.06 $424.27
43250 .......... Upper GI endoscopy/tumor ............................ Y ................. .................... A2 ............... $446.00 8.6730 $359.06 $424.27
43256 .......... Uppr gi endoscopy w/stent ............................. Y ................. .................... A2 ............... $510.00 25.2289 $1,044.48 $643.62
43257 .......... Uppr gi scope w/thrml txmnt .......................... Y ................. .................... A2 ............... $510.00 24.6480 $1,020.43 $637.61
43259 .......... Endoscopic ultrasound exam ......................... Y ................. .................... A2 ............... $510.00 8.6730 $359.06 $472.27
43260 .......... Endo cholangiopancreatograph ..................... Y ................. .................... A2 ............... $446.00 21.2820 $881.07 $554.77
43268 .......... Endo cholangiopancreatograph ..................... Y ................. .................... A2 ............... $446.00 25.2289 $1,044.48 $595.62
43269 .......... Endo cholangiopancreatograph ..................... Y ................. .................... A2 ............... $446.00 25.2289 $1,044.48 $595.62
43450 .......... Dilate esophagus ............................................ Y ................. .................... A2 ............... $333.00 6.0867 $251.99 $312.75
43600 .......... Biopsy of stomach .......................................... Y ................. .................... A2 ............... $333.00 8.6730 $359.06 $339.52
43653 .......... Laparoscopy, gastrostomy ............................. Y ................. .................... A2 ............... $1,339.00 46.1201 $1,909.37 $1,481.59
43750 .......... Place gastrostomy tube .................................. Y ................. .................... A2 ............... $446.00 8.6730 $359.06 $424.27
43760 .......... Change gastrostomy tube .............................. Y ................. .................... A2 ............... $144.98 3.2914 $136.26 $142.80
43761 .......... Reposition gastrostomy tube .......................... Y ................. .................... A2 ............... $333.00 8.6730 $359.06 $339.52
43870 .......... Repair stomach opening ................................ Y ................. .................... A2 ............... $333.00 8.6730 $359.06 $339.52
43886 .......... Revise gastric port, open ............................... Y ................. .................... G2 .............. .................... 20.9338 $866.66 $866.66
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
43887 .......... Remove gastric port, open ............................. Y ................. .................... G2 .............. .................... 4.6816 $193.82 $193.82
43888 .......... Change gastric port, open .............................. Y ................. .................... G2 .............. .................... 20.9338 $866.66 $866.66
44100 .......... Biopsy of bowel .............................................. Y ................. .................... A2 ............... $333.00 8.6730 $359.06 $339.52
44312 .......... Revision of ileostomy ..................................... Y ................. .................... A2 ............... $333.00 20.9338 $866.66 $466.42
44340 .......... Revision of colostomy .................................... Y ................. .................... A2 ............... $510.00 20.9338 $866.66 $599.17
44360 .......... Small bowel endoscopy ................................. Y ................. .................... A2 ............... $446.00 9.6264 $398.53 $434.13
44361 .......... Small bowel endoscopy/biopsy ...................... Y ................. .................... A2 ............... $446.00 9.6264 $398.53 $434.13
44370 .......... Small bowel endoscopy/stent ......................... Y ................. .................... A2 ............... $1,339.00 25.2289 $1,044.48 $1,265.37
44377 .......... Small bowel endoscopy/biopsy ...................... Y ................. .................... A2 ............... $446.00 9.6264 $398.53 $434.13
44379 .......... Sbowel endoscope w/stent ............................ Y ................. .................... A2 ............... $1,339.00 25.2289 $1,044.48 $1,265.37
44383 .......... Ileoscopy w/stent ............................................ Y ................. .................... A2 ............... $1,339.00 25.2289 $1,044.48 $1,265.37
44385 .......... Endoscopy of bowel pouch ............................ Y ................. .................... A2 ............... $333.00 9.0360 $374.09 $343.27
44386 .......... Endoscopy, bowel pouch/biop ....................... Y ................. .................... A2 ............... $333.00 9.0360 $374.09 $343.27
44388 .......... Colonoscopy ................................................... Y ................. .................... A2 ............... $333.00 9.0360 $374.09 $343.27
44389 .......... Colonoscopy with biopsy ................................ Y ................. .................... A2 ............... $333.00 9.0360 $374.09 $343.27
44390 .......... Colonoscopy for foreign body ........................ Y ................. .................... A2 ............... $333.00 9.0360 $374.09 $343.27
44391 .......... Colonoscopy for bleeding ............................... Y ................. .................... A2 ............... $333.00 9.0360 $374.09 $343.27
44392 .......... Colonoscopy & polypectomy .......................... Y ................. .................... A2 ............... $333.00 9.0360 $374.09 $343.27
44393 .......... Colonoscopy, lesion removal ......................... Y ................. .................... A2 ............... $333.00 9.0360 $374.09 $343.27
44394 .......... Colonoscopy w/snare ..................................... Y ................. .................... A2 ............... $333.00 9.0360 $374.09 $343.27
44397 .......... Colonoscopy w/stent ...................................... Y ................. .................... A2 ............... $333.00 25.2289 $1,044.48 $510.87
44701 .......... Intraop colon lavage add-on .......................... N ................. .................... N1 ............... .................... .................... .................... ....................
45000 .......... Drainage of pelvic abscess ............................ Y ................. .................... A2 ............... $312.07 11.6524 $482.41 $354.66
45005 .......... Drainage of rectal abscess ............................ Y ................. .................... A2 ............... $446.00 11.6524 $482.41 $455.10
45020 .......... Drainage of rectal abscess ............................ Y ................. .................... A2 ............... $446.00 11.6524 $482.41 $455.10
45100 .......... Biopsy of rectum ............................................ Y ................. .................... A2 ............... $333.00 23.2282 $961.65 $490.16
45108 .......... Removal of anorectal lesion ........................... Y ................. .................... A2 ............... $446.00 23.2282 $961.65 $574.91
45150 .......... Excision of rectal stricture .............................. Y ................. .................... A2 ............... $446.00 23.2282 $961.65 $574.91
45160 .......... Excision of rectal lesion ................................. Y ................. .................... A2 ............... $446.00 23.2282 $961.65 $574.91
45170 .......... Excision of rectal lesion ................................. Y ................. .................... A2 ............... $446.00 23.2282 $961.65 $574.91
45190 .......... Destruction, rectal tumor ................................ Y ................. .................... A2 ............... $1,339.00 23.2282 $961.65 $1,244.66
45300 .......... Proctosigmoidoscopy dx ................................ Y ................. .................... P3 ............... .................... 1.4345 $59.39 $59.39
45303 .......... Proctosigmoidoscopy dilate ............................ Y ................. .................... P2 ............... .................... 8.8611 $366.85 $366.85
45305 .......... Proctosigmoidoscopy w/bx ............................. Y ................. .................... A2 ............... $333.00 8.8611 $366.85 $341.46
45307 .......... Proctosigmoidoscopy fb ................................. Y ................. .................... A2 ............... $333.00 21.8923 $906.34 $476.34
45308 .......... Proctosigmoidoscopy removal ....................... Y ................. .................... A2 ............... $333.00 8.8611 $366.85 $341.46
45317 .......... Proctosigmoidoscopy bleed ........................... Y ................. .................... A2 ............... $333.00 8.8611 $366.85 $341.46
45320 .......... Proctosigmoidoscopy ablate .......................... Y ................. .................... A2 ............... $333.00 21.8923 $906.34 $476.34
45321 .......... Proctosigmoidoscopy volvul ........................... Y ................. .................... A2 ............... $333.00 21.8923 $906.34 $476.34
45327 .......... Proctosigmoidoscopy w/stent ......................... Y ................. .................... A2 ............... $333.00 25.2289 $1,044.48 $510.87
45330 .......... Diagnostic sigmoidoscopy .............................. Y ................. .................... P3 ............... .................... 1.9705 $81.58 $81.58
45331 .......... Sigmoidoscopy and biopsy ............................ Y ................. .................... A2 ............... $299.24 5.1441 $212.97 $277.67
45332 .......... Sigmoidoscopy w/fb removal ......................... Y ................. .................... A2 ............... $299.24 5.1441 $212.97 $277.67
45333 .......... Sigmoidoscopy & polypectomy ...................... Y ................. .................... A2 ............... $333.00 8.8611 $366.85 $341.46
45334 .......... Sigmoidoscopy for bleeding ........................... Y ................. .................... A2 ............... $333.00 8.8611 $366.85 $341.46
45335 .......... Sigmoidoscopy w/submuc inj ......................... Y ................. .................... A2 ............... $299.24 5.1441 $212.97 $277.67
45337 .......... Sigmoidoscopy & decompress ....................... Y ................. .................... A2 ............... $299.24 5.1441 $212.97 $277.67
45338 .......... Sigmoidoscopy w/tumr remove ...................... Y ................. .................... A2 ............... $333.00 8.8611 $366.85 $341.46
45339 .......... Sigmoidoscopy w/ablate tumr ........................ Y ................. .................... A2 ............... $333.00 8.8611 $366.85 $341.46
45340 .......... Sig w/balloon dilation ..................................... Y ................. .................... A2 ............... $333.00 8.8611 $366.85 $341.46
45341 .......... Sigmoidoscopy w/ultrasound .......................... Y ................. .................... A2 ............... $333.00 8.8611 $366.85 $341.46
45342 .......... Sigmoidoscopy w/us guide bx ........................ Y ................. .................... A2 ............... $333.00 8.8611 $366.85 $341.46
45345 .......... Sigmoidoscopy w/stent ................................... Y ................. .................... A2 ............... $333.00 25.2289 $1,044.48 $510.87
45355 .......... Surgical colonoscopy ..................................... Y ................. .................... A2 ............... $333.00 9.0360 $374.09 $343.27
45378 .......... Diagnostic colonoscopy .................................. Y ................. .................... A2 ............... $446.00 9.0360 $374.09 $428.02
45379 .......... Colonoscopy w/fb removal ............................. Y ................. .................... A2 ............... $446.00 9.0360 $374.09 $428.02
45380 .......... Colonoscopy and biopsy ................................ Y ................. .................... A2 ............... $446.00 9.0360 $374.09 $428.02
45381 .......... Colonoscopy, submucous inj ......................... Y ................. .................... A2 ............... $446.00 9.0360 $374.09 $428.02
45382 .......... Colonoscopy/control bleeding ........................ Y ................. .................... A2 ............... $446.00 9.0360 $374.09 $428.02
45383 .......... Lesion removal colonoscopy .......................... Y ................. .................... A2 ............... $446.00 9.0360 $374.09 $428.02
45384 .......... Lesion remove colonoscopy ........................... Y ................. .................... A2 ............... $446.00 9.0360 $374.09 $428.02
45385 .......... Lesion removal colonoscopy .......................... Y ................. .................... A2 ............... $446.00 9.0360 $374.09 $428.02
45386 .......... Colonoscopy dilate stricture ........................... Y ................. .................... A2 ............... $446.00 9.0360 $374.09 $428.02
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
45387 .......... Colonoscopy w/stent ...................................... Y ................. .................... A2 ............... $333.00 25.2289 $1,044.48 $510.87
45391 .......... Colonoscopy w/endoscope us ....................... Y ................. .................... A2 ............... $446.00 9.0360 $374.09 $428.02
45392 .......... Colonoscopy w/endoscopic fnb ...................... Y ................. .................... A2 ............... $446.00 9.0360 $374.09 $428.02
45500 .......... Repair of rectum ............................................. Y ................. .................... A2 ............... $446.00 23.2282 $961.65 $574.91
45505 .......... Repair of rectum ............................................. Y ................. .................... A2 ............... $446.00 30.5544 $1,264.95 $650.74
45520 .......... Treatment of rectal prolapse .......................... Y ................. .................... P2 ............... .................... 0.8046 $33.31 $33.31
45560 .......... Repair of rectocele ......................................... Y ................. .................... A2 ............... $446.00 30.5544 $1,264.95 $650.74
45900 .......... Reduction of rectal prolapse .......................... Y ................. .................... A2 ............... $312.07 4.5189 $187.08 $280.82
45905 .......... Dilation of anal sphincter ................................ Y ................. .................... A2 ............... $333.00 23.2282 $961.65 $490.16
45910 .......... Dilation of rectal narrowing ............................ Y ................. .................... A2 ............... $333.00 23.2282 $961.65 $490.16
45915 .......... Remove rectal obstruction ............................. Y ................. .................... A2 ............... $312.07 11.6524 $482.41 $354.66
45990 .......... Surg dx exam, anorectal ................................ Y ................. .................... A2 ............... $312.07 23.2282 $961.65 $474.47
46020 .......... Placement of seton ........................................ Y ................. .................... A2 ............... $510.00 23.2282 $961.65 $622.91
46030 .......... Removal of rectal marker ............................... Y ................. .................... A2 ............... $312.07 4.5189 $187.08 $280.82
46040 .......... Incision of rectal abscess ............................... Y ................. .................... A2 ............... $510.00 23.2282 $961.65 $622.91
46050 .......... Incision of anal abscess ................................. Y ................. .................... A2 ............... $312.07 11.6524 $482.41 $354.66
46070 .......... Incision of anal septum .................................. Y ................. .................... G2 .............. .................... 11.6524 $482.41 $482.41
46080 .......... Incision of anal sphincter ............................... Y ................. .................... A2 ............... $510.00 23.2282 $961.65 $622.91
46083 .......... Incise external hemorrhoid ............................. Y ................. .................... P3 ............... .................... 2.0036 $82.95 $82.95
46200 .......... Removal of anal fissure ................................. Y ................. .................... A2 ............... $446.00 23.2282 $961.65 $574.91
46210 .......... Removal of anal crypt .................................... Y ................. .................... A2 ............... $446.00 23.2282 $961.65 $574.91
46211 .......... Removal of anal crypts .................................. Y ................. .................... A2 ............... $446.00 23.2282 $961.65 $574.91
46220 .......... Removal of anal tag ....................................... Y ................. .................... A2 ............... $333.00 23.2282 $961.65 $490.16
46221 .......... Ligation of hemorrhoid(s) ............................... Y ................. .................... P3 ............... .................... 2.6138 $108.21 $108.21
46230 .......... Removal of anal tags ..................................... Y ................. .................... A2 ............... $333.00 23.2282 $961.65 $490.16
46250 .......... Hemorrhoidectomy ......................................... Y ................. .................... A2 ............... $510.00 23.2282 $961.65 $622.91
46257 .......... Remove hemorrhoids & fissure ...................... Y ................. .................... A2 ............... $510.00 23.2282 $961.65 $622.91
46258 .......... Remove hemorrhoids & fistula ....................... Y ................. .................... A2 ............... $510.00 23.2282 $961.65 $622.91
46261 .......... Remove hemorrhoids & fissure ...................... Y ................. .................... A2 ............... $630.00 23.2282 $961.65 $712.91
46262 .......... Remove hemorrhoids & fistula ....................... Y ................. .................... A2 ............... $630.00 23.2282 $961.65 $712.91
46270 .......... Removal of anal fistula ................................... Y ................. .................... A2 ............... $510.00 23.2282 $961.65 $622.91
46288 .......... Repair anal fistula .......................................... Y ................. .................... A2 ............... $630.00 23.2282 $961.65 $712.91
46320 .......... Removal of hemorrhoid clot ........................... Y ................. .................... P3 ............... .................... 1.8635 $77.15 $77.15
46500 .......... Injection into hemorrhoid(s) ............................ Y ................. .................... P3 ............... .................... 2.3498 $97.28 $97.28
46505 .......... Chemodenervation anal musc ....................... Y ................. CH .............. P3 ............... .................... 2.5973 $107.53 $107.53
46600 .......... Diagnostic anoscopy ...................................... N ................. .................... P2 ............... .................... 0.6416 $26.56 $26.56
46604 .......... Anoscopy and dilation .................................... Y ................. .................... P2 ............... .................... 8.8611 $366.85 $366.85
46606 .......... Anoscopy and biopsy ..................................... Y ................. .................... P3 ............... .................... 3.1498 $130.40 $130.40
46608 .......... Anoscopy, remove for body ........................... Y ................. .................... A2 ............... $333.00 8.8611 $366.85 $341.46
46610 .......... Anoscopy, remove lesion ............................... Y ................. .................... A2 ............... $333.00 21.8923 $906.34 $476.34
46611 .......... Anoscopy ........................................................ Y ................. .................... A2 ............... $333.00 8.8611 $366.85 $341.46
46612 .......... Anoscopy, remove lesions ............................. Y ................. .................... A2 ............... $333.00 21.8923 $906.34 $476.34
46614 .......... Anoscopy, control bleeding ............................ Y ................. .................... P3 ............... .................... 1.8386 $76.12 $76.12
46615 .......... Anoscopy ........................................................ Y ................. .................... A2 ............... $446.00 21.8923 $906.34 $561.09
46700 .......... Repair of anal stricture ................................... Y ................. .................... A2 ............... $510.00 23.2282 $961.65 $622.91
46706 .......... Repr of anal fistula w/glue ............................. Y ................. .................... A2 ............... $333.00 30.5544 $1,264.95 $565.99
46750 .......... Repair of anal sphincter ................................. Y ................. .................... A2 ............... $510.00 30.5544 $1,264.95 $698.74
46753 .......... Reconstruction of anus .................................. Y ................. .................... A2 ............... $510.00 23.2282 $961.65 $622.91
46754 .......... Removal of suture from anus ......................... Y ................. .................... A2 ............... $446.00 23.2282 $961.65 $574.91
46762 .......... Implant artificial sphincter ............................... Y ................. .................... A2 ............... $995.00 30.5544 $1,264.95 $1,062.49
46900 .......... Destruction, anal lesion(s) .............................. Y ................. .................... P3 ............... .................... 2.5560 $105.82 $105.82
46910 .......... Destruction, anal lesion(s) .............................. Y ................. .................... P3 ............... .................... 2.7870 $115.38 $115.38
46916 .......... Cryosurgery, anal lesion(s) ............................ Y ................. .................... P2 ............... .................... 1.5119 $62.59 $62.59
46917 .......... Laser surgery, anal lesions ............................ Y ................. .................... A2 ............... $333.00 20.0977 $832.04 $457.76
46922 .......... Excision of anal lesion(s) ............................... Y ................. .................... A2 ............... $333.00 20.0977 $832.04 $457.76
46924 .......... Destruction, anal lesion(s) .............................. Y ................. .................... A2 ............... $333.00 20.0977 $832.04 $457.76
46934 .......... Destruction of hemorrhoids ............................ Y ................. .................... P3 ............... .................... 4.3534 $180.23 $180.23
46937 .......... Cryotherapy of rectal lesion ........................... Y ................. .................... A2 ............... $446.00 23.2282 $961.65 $574.91
46938 .......... Cryotherapy of rectal lesion ........................... Y ................. .................... A2 ............... $446.00 30.5544 $1,264.95 $650.74
46940 .......... Treatment of anal fissure ............................... Y ................. .................... P3 ............... .................... 1.9872 $82.27 $82.27
46942 .......... Treatment of anal fissure ............................... Y ................. .................... P3 ............... .................... 1.9046 $78.85 $78.85
46945 .......... Ligation of hemorrhoids .................................. Y ................. .................... P3 ............... .................... 3.3145 $137.22 $137.22
46946 .......... Ligation of hemorrhoids .................................. Y ................. .................... A2 ............... $333.00 11.6524 $482.41 $370.35
46947 .......... Hemorrhoidopexy by stapling ......................... Y ................. .................... A2 ............... $995.00 30.5544 $1,264.95 $1,062.49
47000 .......... Needle biopsy of liver ..................................... Y ................. .................... A2 ............... $333.00 9.5741 $396.37 $348.84
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
47001 .......... Needle biopsy, liver add-on ........................... N ................. .................... N1 ............... .................... .................... .................... ....................
47382 .......... Percut ablate liver rf ....................................... Y ................. .................... G2 .............. .................... 44.1192 $1,826.53 $1,826.53
47500 .......... Injection for liver x-rays .................................. N ................. .................... N1 .............. .................... .................... .................... ....................
47505 .......... Injection for liver x-rays .................................. N ................. .................... N1 .............. .................... .................... .................... ....................
47510 .......... Insert catheter, bile duct ................................. Y ................. .................... A2 ............... $446.00 28.7304 $1,189.44 $631.86
47511 .......... Insert bile duct drain ....................................... Y ................. .................... A2 ............... $1,245.85 28.7304 $1,189.44 $1,231.75
47525 .......... Change bile duct catheter .............................. Y ................. .................... A2 ............... $333.00 14.8912 $616.50 $403.88
47530 .......... Revise/reinsert bile tube ................................. Y ................. .................... A2 ............... $333.00 14.8912 $616.50 $403.88
47552 .......... Biliary endoscopy thru skin ............................ Y ................. .................... A2 ............... $446.00 28.7304 $1,189.44 $631.86
47556 .......... Biliary endoscopy thru skin ............................ Y ................. .................... A2 ............... $1,245.85 28.7304 $1,189.44 $1,231.75
47560 .......... Laparoscopy w/cholangio ............................... Y ................. .................... A2 ............... $510.00 34.8153 $1,441.35 $742.84
47561 .......... Laparo w/cholangio/biopsy ............................. Y ................. .................... A2 ............... $510.00 34.8153 $1,441.35 $742.84
47562 .......... Laparoscopic cholecystectomy ...................... Y ................. .................... G2 .............. .................... 46.1201 $1,909.37 $1,909.37
47563 .......... Laparo cholecystectomy/graph ...................... Y ................. .................... G2 .............. .................... 46.1201 $1,909.37 $1,909.37
47564 .......... Laparo cholecystectomy/explr ........................ Y ................. .................... G2 .............. .................... 46.1201 $1,909.37 $1,909.37
47630 .......... Remove bile duct stone ................................. Y ................. .................... A2 ............... $510.00 28.7304 $1,189.44 $679.86
48102 .......... Needle biopsy, pancreas ................................ Y ................. .................... A2 ............... $333.00 9.5741 $396.37 $348.84
49080 .......... Puncture, peritoneal cavity ............................. Y ................. .................... A2 ............... $222.78 5.3095 $219.81 $222.04
49081 .......... Removal of abdominal fluid ............................ Y ................. .................... A2 ............... $222.78 5.3095 $219.81 $222.04
49180 .......... Biopsy, abdominal mass ................................ Y ................. .................... A2 ............... $333.00 9.5741 $396.37 $348.84
49250 .......... Excision of umbilicus ...................................... Y ................. .................... A2 ............... $630.00 25.4636 $1,054.19 $736.05
49320 .......... Diag laparo separate proc .............................. Y ................. .................... A2 ............... $510.00 34.8153 $1,441.35 $742.84
49321 .......... Laparoscopy, biopsy ...................................... Y ................. .................... A2 ............... $630.00 34.8153 $1,441.35 $832.84
49322 .......... Laparoscopy, aspiration ................................. Y ................. .................... A2 ............... $630.00 34.8153 $1,441.35 $832.84
49400 .......... Air injection into abdomen .............................. N ................. .................... N1 ............... .................... .................... .................... ....................
49402 .......... Remove foreign body, adbomen .................... Y ................. .................... A2 ............... $446.00 25.4636 $1,054.19 $598.05
49419 .......... Insrt abdom cath for chemotx ........................ Y ................. .................... A2 ............... $333.00 30.5379 $1,264.27 $565.82
49420 .......... Insert abdom drain, temp ............................... Y ................. .................... A2 ............... $333.00 31.7598 $1,314.86 $578.47
49421 .......... Insert abdom drain, perm ............................... Y ................. .................... A2 ............... $333.00 31.7598 $1,314.86 $578.47
49422 .......... Remove perm cannula/catheter ..................... Y ................. .................... A2 ............... $333.00 24.7274 $1,023.71 $505.68
49423 .......... Exchange drainage catheter .......................... Y ................. .................... G2 .............. .................... 14.8912 $616.50 $616.50
49424 .......... Assess cyst, contrast inject ............................ N ................. .................... N1 ............... .................... .................... .................... ....................
49426 .......... Revise abdomen-venous shunt ...................... Y ................. .................... A2 ............... $446.00 25.4636 $1,054.19 $598.05
49427 .......... Injection, abdominal shunt ............................. N ................. .................... N1 ............... .................... .................... .................... ....................
49429 .......... Removal of shunt ........................................... Y ................. .................... G2 .............. .................... 24.7274 $1,023.71 $1,023.71
49495 .......... Rpr ing hernia baby, reduc ............................ Y ................. .................... A2 ............... $630.00 31.1722 $1,290.53 $795.13
49496 .......... Rpr ing hernia baby, blocked ......................... Y ................. .................... A2 ............... $630.00 31.1722 $1,290.53 $795.13
49500 .......... Rpr ing hernia, init, reduce ............................. Y ................. .................... A2 ............... $630.00 31.1722 $1,290.53 $795.13
49501 .......... Rpr ing hernia, init blocked ............................ Y ................. .................... A2 ............... $1,339.00 31.1722 $1,290.53 $1,326.88
49505 .......... Prp i/hern init reduc >5 yr .............................. Y ................. .................... A2 ............... $630.00 31.1722 $1,290.53 $795.13
49507 .......... Prp i/hern init block >5 yr ............................... Y ................. .................... A2 ............... $1,339.00 31.1722 $1,290.53 $1,326.88
49520 .......... Rerepair ing hernia, reduce ........................... Y ................. .................... A2 ............... $995.00 31.1722 $1,290.53 $1,068.88
49521 .......... Rerepair ing hernia, blocked .......................... Y ................. .................... A2 ............... $1,339.00 31.1722 $1,290.53 $1,326.88
49525 .......... Repair ing hernia, sliding ............................... Y ................. .................... A2 ............... $630.00 31.1722 $1,290.53 $795.13
49540 .......... Repair lumbar hernia ...................................... Y ................. .................... A2 ............... $446.00 31.1722 $1,290.53 $657.13
49550 .......... Rpr rem hernia, init, reduce ........................... Y ................. .................... A2 ............... $717.00 31.1722 $1,290.53 $860.38
49553 .......... Rpr fem hernia, init blocked ........................... Y ................. .................... A2 ............... $1,339.00 31.1722 $1,290.53 $1,326.88
49555 .......... Rerepair fem hernia, reduce .......................... Y ................. .................... A2 ............... $717.00 31.1722 $1,290.53 $860.38
49557 .......... Rerepair fem hernia, blocked ......................... Y ................. .................... A2 ............... $1,339.00 31.1722 $1,290.53 $1,326.88
49560 .......... Rpr ventral hern init, reduc ............................ Y ................. .................... A2 ............... $630.00 31.1722 $1,290.53 $795.13
49561 .......... Rpr ventral hern init, block ............................. Y ................. .................... A2 ............... $1,339.00 31.1722 $1,290.53 $1,326.88
49565 .......... Rerepair ventrl hern, reduce .......................... Y ................. .................... A2 ............... $630.00 31.1722 $1,290.53 $795.13
49566 .......... Rerepair ventrl hern, block ............................. Y ................. .................... A2 ............... $1,339.00 31.1722 $1,290.53 $1,326.88
49568 .......... Hernia repair w/mesh ..................................... Y ................. .................... A2 ............... $995.00 31.1722 $1,290.53 $1,068.88
49570 .......... Rpr epigastric hern, reduce ............................ Y ................. .................... A2 ............... $630.00 31.1722 $1,290.53 $795.13
49572 .......... Rpr epigastric hern, blocked .......................... Y ................. .................... A2 ............... $1,339.00 31.1722 $1,290.53 $1,326.88
49580 .......... Rpr umbil hern, reduc < 5 yr .......................... Y ................. .................... A2 ............... $630.00 31.1722 $1,290.53 $795.13
49582 .......... Rpr umbil hern, block < 5 yr .......................... Y ................. .................... A2 ............... $1,339.00 31.1722 $1,290.53 $1,326.88
49585 .......... Rpr umbil hern, reduc > 5 yr .......................... Y ................. .................... A2 ............... $630.00 31.1722 $1,290.53 $795.13
49587 .......... Rpr umbil hern, block > 5 yr .......................... Y ................. .................... A2 ............... $1,339.00 31.1722 $1,290.53 $1,326.88
49590 .......... Repair spigelian hernia .................................. Y ................. .................... A2 ............... $510.00 31.1722 $1,290.53 $705.13
49600 .......... Repair umbilical lesion ................................... Y ................. .................... A2 ............... $630.00 31.1722 $1,290.53 $795.13
49650 .......... Laparo hernia repair initial ............................. Y ................. .................... A2 ............... $630.00 46.1201 $1,909.37 $949.84
49651 .......... Laparo hernia repair recur ............................. Y ................. .................... A2 ............... $995.00 46.1201 $1,909.37 $1,223.59
50200 .......... Biopsy of kidney ............................................. Y ................. .................... A2 ............... $333.00 9.5741 $396.37 $348.84
50382 .......... Change ureter stent, percut ........................... Y ................. .................... G2 .............. .................... 25.2775 $1,046.49 $1,046.49
50384 .......... Remove ureter stent, percut .......................... Y ................. .................... G2 .............. .................... 18.1376 $750.90 $750.90
50387 .......... Change ext/int ureter stent ............................. Y ................. .................... G2 .............. .................... 14.8912 $616.50 $616.50
50389 .......... Remove renal tube w/fluoro ........................... Y ................. .................... G2 .............. .................... 6.1077 $252.86 $252.86
50390 .......... Drainage of kidney lesion ............................... Y ................. .................... A2 ............... $333.00 9.5741 $396.37 $348.84
50391 .......... Instll rx agnt into rnal tub ............................... Y ................. .................... P2 ............... .................... 1.0850 $44.92 $44.92
50392 .......... Insert kidney drain .......................................... Y ................. .................... A2 ............... $333.00 18.1376 $750.90 $437.48
50393 .......... Insert ureteral tube ......................................... Y ................. .................... A2 ............... $333.00 25.2775 $1,046.49 $511.37
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
50394 .......... Injection for kidney x-ray ................................ N ................. .................... N1 ............... .................... .................... .................... ....................
50395 .......... Create passage to kidney .............................. Y ................. .................... A2 ............... $333.00 18.1376 $750.90 $437.48
50396 .......... Measure kidney pressure ............................... Y ................. .................... A2 ............... $131.50 2.1659 $89.67 $121.04
50398 .......... Change kidney tube ....................................... Y ................. .................... A2 ............... $333.00 14.8912 $616.50 $403.88
50551 .......... Kidney endoscopy .......................................... Y ................. .................... A2 ............... $333.00 6.1077 $252.86 $312.97
50553 .......... Kidney endoscopy .......................................... Y ................. .................... A2 ............... $333.00 25.2775 $1,046.49 $511.37
50555 .......... Kidney endoscopy & biopsy ........................... Y ................. .................... A2 ............... $333.00 6.1077 $252.86 $312.97
50557 .......... Kidney endoscopy & treatment ...................... Y ................. .................... A2 ............... $333.00 25.2775 $1,046.49 $511.37
50561 .......... Kidney endoscopy & treatment ...................... Y ................. .................... A2 ............... $333.00 25.2775 $1,046.49 $511.37
50562 .......... Renal scope w/tumor resect .......................... Y ................. .................... G2 .............. .................... 6.1077 $252.86 $252.86
50570 .......... Kidney endoscopy .......................................... Y ................. .................... G2 .............. .................... 6.1077 $252.86 $252.86
50572 .......... Kidney endoscopy .......................................... Y ................. .................... G2 .............. .................... 6.1077 $252.86 $252.86
50574 .......... Kidney endoscopy & biopsy ........................... Y ................. .................... G2 .............. .................... 6.1077 $252.86 $252.86
50575 .......... Kidney endoscopy .......................................... Y ................. .................... G2 .............. .................... 36.9175 $1,528.38 $1,528.38
50576 .......... Kidney endoscopy & treatment ...................... Y ................. .................... G2 .............. .................... 18.1376 $750.90 $750.90
50580 .......... Kidney endoscopy & treatment ...................... Y ................. CH .............. G2 .............. .................... 18.1376 $750.90 $750.90
50590 .......... Fragmenting of kidney stone .......................... Y ................. .................... G2 .............. .................... 43.0352 $1,781.66 $1,781.66
50592 .......... Perc rf ablate renal tumor .............................. Y ................. .................... G2 .............. .................... 44.1192 $1,826.53 $1,826.53
50684 .......... Injection for ureter x-ray ................................. N ................. .................... N1 ............... .................... .................... .................... ....................
50686 .......... Measure ureter pressure ................................ Y ................. .................... P2 ............... .................... 1.0850 $44.92 $44.92
50688 .......... Change of ureter tube/stent ........................... Y ................. .................... A2 ............... $333.00 14.8912 $616.50 $403.88
50690 .......... Injection for ureter x-ray ................................. N ................. .................... N1 ............... .................... .................... .................... ....................
50947 .......... Laparo new ureter/bladder ............................. Y ................. .................... A2 ............... $1,339.00 46.1201 $1,909.37 $1,481.59
50948 .......... Laparo new ureter/bladder ............................. Y ................. .................... A2 ............... $1,339.00 46.1201 $1,909.37 $1,481.59
50951 .......... Endoscopy of ureter ....................................... Y ................. .................... A2 ............... $333.00 6.1077 $252.86 $312.97
50953 .......... Endoscopy of ureter ....................................... Y ................. .................... A2 ............... $333.00 6.1077 $252.86 $312.97
50955 .......... Ureter endoscopy & biopsy ............................ Y ................. .................... A2 ............... $333.00 25.2775 $1,046.49 $511.37
50957 .......... Ureter endoscopy & treatment ....................... Y ................. .................... A2 ............... $333.00 25.2775 $1,046.49 $511.37
50970 .......... Ureter endoscopy ........................................... Y ................. .................... A2 ............... $333.00 6.1077 $252.86 $312.97
50972 .......... Ureter endoscopy & catheter ......................... Y ................. .................... A2 ............... $333.00 6.1077 $252.86 $312.97
50974 .......... Ureter endoscopy & biopsy ............................ Y ................. .................... A2 ............... $333.00 18.1376 $750.90 $437.48
50976 .......... Ureter endoscopy & treatment ....................... Y ................. .................... A2 ............... $333.00 18.1376 $750.90 $437.48
51000 .......... Drainage of bladder ........................................ Y ................. .................... P3 ............... .................... 1.1790 $48.81 $48.81
51005 .......... Drainage of bladder ........................................ Y ................. .................... P2 ............... .................... 1.0850 $44.92 $44.92
51010 .......... Drainage of bladder ........................................ Y ................. .................... A2 ............... $333.00 19.6126 $811.96 $452.74
51020 .......... Incise & treat bladder ..................................... Y ................. .................... A2 ............... $630.00 25.2775 $1,046.49 $734.12
51030 .......... Incise & treat bladder ..................................... Y ................. .................... A2 ............... $630.00 25.2775 $1,046.49 $734.12
51040 .......... Incise & drain bladder .................................... Y ................. .................... A2 ............... $630.00 25.2775 $1,046.49 $734.12
51045 .......... Incise bladder/drain ureter ............................. Y ................. .................... A2 ............... $399.24 6.1077 $252.86 $362.65
51050 .......... Removal of bladder stone .............................. Y ................. .................... A2 ............... $630.00 25.2775 $1,046.49 $734.12
51065 .......... Remove ureter calculus ................................. Y ................. .................... A2 ............... $630.00 25.2775 $1,046.49 $734.12
51080 .......... Drainage of bladder abscess ......................... Y ................. .................... A2 ............... $333.00 19.0457 $788.49 $446.87
51500 .......... Removal of bladder cyst ................................ Y ................. .................... A2 ............... $630.00 31.1722 $1,290.53 $795.13
51520 .......... Removal of bladder lesion ............................. Y ................. .................... A2 ............... $630.00 25.2775 $1,046.49 $734.12
51600 .......... Injection for bladder x-ray .............................. N ................. .................... N1 ............... .................... .................... .................... ....................
51605 .......... Preparation for bladder xray .......................... N ................. .................... N1 ............... .................... .................... .................... ....................
51610 .......... Injection for bladder x-ray .............................. N ................. .................... N1 ............... .................... .................... .................... ....................
51700 .......... Irrigation of bladder ........................................ Y ................. .................... P3 ............... .................... 1.2780 $52.91 $52.91
51701 .......... Insert bladder catheter ................................... N ................. .................... P2 ............... .................... 0.6416 $26.56 $26.56
51702 .......... Insert temp bladder cath ................................ N ................. .................... P2 ............... .................... 0.6416 $26.56 $26.56
51703 .......... Insert bladder cath, complex .......................... Y ................. .................... P2 ............... .................... 1.0850 $44.92 $44.92
51705 .......... Change of bladder tube ................................. Y ................. .................... P3 ............... .................... 1.7727 $73.39 $73.39
51710 .......... Change of bladder tube ................................. Y ................. .................... A2 ............... $333.00 14.8912 $616.50 $403.88
51715 .......... Endoscopic injection/implant .......................... Y ................. .................... A2 ............... $510.00 30.1994 $1,250.26 $695.07
51720 .......... Treatment of bladder lesion ........................... Y ................. .................... P3 ............... .................... 1.3935 $57.69 $57.69
51725 .......... Simple cystometrogram .................................. Y ................. .................... P2 ............... .................... 3.0601 $126.69 $126.69
51726 .......... Complex cystometrogram .............................. Y ................. .................... A2 ............... $209.48 3.0601 $126.69 $188.78
51736 .......... Urine flow measurement ................................ Y ................. .................... P3 ............... .................... 0.4452 $18.43 $18.43
51741 .......... Electro-uroflowmetry, first ............................... Y ................. .................... P3 ............... .................... 0.5111 $21.16 $21.16
51772 .......... Urethra pressure profile ................................. Y ................. .................... A2 ............... $131.50 2.1659 $89.67 $121.04
51784 .......... Anal/urinary muscle study .............................. Y ................. .................... P2 ............... .................... 1.0850 $44.92 $44.92
51785 .......... Anal/urinary muscle study .............................. Y ................. .................... A2 ............... $66.92 1.0850 $44.92 $61.42
51792 .......... Urinary reflex study ........................................ Y ................. .................... P2 ............... .................... 1.0850 $44.92 $44.92
51795 .......... Urine voiding pressure study ......................... Y ................. .................... P2 ............... .................... 2.1659 $89.67 $89.67
51797 .......... Intraabdominal pressure test .......................... Y ................. .................... P2 ............... .................... 2.1659 $89.67 $89.67
51798 .......... Us urine capacity measure ............................ N ................. .................... P3 ............... .................... 0.3792 $15.70 $15.70
51880 .......... Repair of bladder opening .............................. Y ................. .................... A2 ............... $333.00 25.2775 $1,046.49 $511.37
51992 .......... Laparo sling operation .................................... Y ................. .................... A2 ............... $717.00 46.1201 $1,909.37 $1,015.09
52000 .......... Cystoscopy ..................................................... Y ................. .................... A2 ............... $333.00 6.1077 $252.86 $312.97
52001 .......... Cystoscopy, removal of clots ......................... Y ................. .................... A2 ............... $399.24 18.1376 $750.90 $487.16
52005 .......... Cystoscopy & ureter catheter ......................... Y ................. .................... A2 ............... $446.00 18.1376 $750.90 $522.23
52007 .......... Cystoscopy and biopsy .................................. Y ................. .................... A2 ............... $446.00 25.2775 $1,046.49 $596.12
52010 .......... Cystoscopy & duct catheter ........................... Y ................. .................... A2 ............... $399.24 6.1077 $252.86 $362.65
52204 .......... Cystoscopy w/biopsy(s) .................................. Y ................. .................... A2 ............... $446.00 18.1376 $750.90 $522.23
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
52214 .......... Cystoscopy and treatment ............................. Y ................. .................... A2 ............... $446.00 25.2775 $1,046.49 $596.12
52250 .......... Cystoscopy and radiotracer ........................... Y ................. .................... A2 ............... $630.00 25.2775 $1,046.49 $734.12
52260 .......... Cystoscopy and treatment ............................. Y ................. .................... A2 ............... $446.00 18.1376 $750.90 $522.23
52265 .......... Cystoscopy and treatment ............................. Y ................. .................... P2 ............... .................... 6.1077 $252.86 $252.86
52270 .......... Cystoscopy & revise urethra .......................... Y ................. .................... A2 ............... $446.00 18.1376 $750.90 $522.23
52275 .......... Cystoscopy & revise urethra .......................... Y ................. .................... A2 ............... $446.00 25.2775 $1,046.49 $596.12
52282 .......... Cystoscopy, implant stent .............................. Y ................. .................... A2 ............... $1,339.00 36.9175 $1,528.38 $1,386.35
52317 .......... Remove bladder stone ................................... Y ................. .................... A2 ............... $333.00 25.2775 $1,046.49 $511.37
52318 .......... Remove bladder stone ................................... Y ................. .................... A2 ............... $446.00 25.2775 $1,046.49 $596.12
52325 .......... Cystoscopy, stone removal ............................ Y ................. .................... A2 ............... $630.00 25.2775 $1,046.49 $734.12
52327 .......... Cystoscopy, inject material ............................ Y ................. .................... A2 ............... $446.00 25.2775 $1,046.49 $596.12
52334 .......... Create passage to kidney .............................. Y ................. .................... A2 ............... $510.00 25.2775 $1,046.49 $644.12
52341 .......... Cysto w/ureter stricture tx .............................. Y ................. .................... A2 ............... $510.00 25.2775 $1,046.49 $644.12
52342 .......... Cysto w/up stricture tx .................................... Y ................. .................... A2 ............... $510.00 25.2775 $1,046.49 $644.12
52343 .......... Cysto w/renal stricture tx ................................ Y ................. .................... A2 ............... $510.00 25.2775 $1,046.49 $644.12
52344 .......... Cysto/uretero, stricture tx ............................... Y ................. .................... A2 ............... $510.00 25.2775 $1,046.49 $644.12
52345 .......... Cysto/uretero w/up stricture ........................... Y ................. .................... A2 ............... $510.00 25.2775 $1,046.49 $644.12
52346 .......... Cystouretero w/renal strict ............................. Y ................. .................... A2 ............... $510.00 25.2775 $1,046.49 $644.12
52351 .......... Cystouretero & or pyeloscope ........................ Y ................. .................... A2 ............... $510.00 25.2775 $1,046.49 $644.12
52352 .......... Cystouretero w/stone remove ........................ Y ................. .................... A2 ............... $630.00 25.2775 $1,046.49 $734.12
52353 .......... Cystouretero w/lithotripsy ............................... Y ................. .................... A2 ............... $630.00 36.9175 $1,528.38 $854.60
52354 .......... Cystouretero w/biopsy .................................... Y ................. .................... A2 ............... $630.00 25.2775 $1,046.49 $734.12
52355 .......... Cystouretero w/excise tumor .......................... Y ................. .................... A2 ............... $630.00 25.2775 $1,046.49 $734.12
52400 .......... Cystouretero w/congen repr ........................... Y ................. .................... A2 ............... $510.00 25.2775 $1,046.49 $644.12
52402 .......... Cystourethro cut ejacul duct .......................... Y ................. .................... A2 ............... $510.00 25.2775 $1,046.49 $644.12
52450 .......... Incision of prostate ......................................... Y ................. .................... A2 ............... $510.00 25.2775 $1,046.49 $644.12
52500 .......... Revision of bladder neck ................................ Y ................. .................... A2 ............... $510.00 25.2775 $1,046.49 $644.12
52510 .......... Dilation prostatic urethra ................................ Y ................. .................... A2 ............... $510.00 25.2775 $1,046.49 $644.12
52601 .......... Prostatectomy (TURP) ................................... Y ................. .................... A2 ............... $630.00 36.9175 $1,528.38 $854.60
52606 .......... Control postop bleeding ................................. Y ................. .................... A2 ............... $333.00 25.2775 $1,046.49 $511.37
52612 .......... Prostatectomy, first stage ............................... Y ................. .................... A2 ............... $446.00 36.9175 $1,528.38 $716.60
52614 .......... Prostatectomy, second stage ......................... Y ................. .................... A2 ............... $333.00 36.9175 $1,528.38 $631.85
52620 .......... Remove residual prostate .............................. Y ................. .................... A2 ............... $333.00 36.9175 $1,528.38 $631.85
52630 .......... Remove prostate regrowth ............................. Y ................. .................... A2 ............... $446.00 36.9175 $1,528.38 $716.60
52640 .......... Relieve bladder contracture ........................... Y ................. .................... A2 ............... $446.00 25.2775 $1,046.49 $596.12
52647 .......... Laser surgery of prostate ............................... Y ................. .................... A2 ............... $1,339.00 45.9021 $1,900.35 $1,479.34
52648 .......... Laser surgery of prostate ............................... Y ................. .................... A2 ............... $1,339.00 45.9021 $1,900.35 $1,479.34
52700 .......... Drainage of prostate abscess ........................ Y ................. .................... A2 ............... $446.00 25.2775 $1,046.49 $596.12
53000 .......... Incision of urethra ........................................... Y ................. .................... A2 ............... $333.00 19.6570 $813.80 $453.20
53025 .......... Incision of urethra ........................................... Y ................. .................... R2 ............... .................... 19.6570 $813.80 $813.80
53040 .......... Drainage of urethra abscess .......................... Y ................. .................... A2 ............... $446.00 19.6570 $813.80 $537.95
53060 .......... Drainage of urethra abscess .......................... Y ................. .................... P3 ............... .................... 1.7068 $70.66 $70.66
53080 .......... Drainage of urinary leakage ........................... Y ................. .................... A2 ............... $510.00 19.6570 $813.80 $585.95
53085 .......... Drainage of urinary leakage ........................... Y ................. .................... G2 .............. .................... 19.6570 $813.80 $813.80
53200 .......... Biopsy of urethra ............................................ Y ................. .................... A2 ............... $333.00 19.6570 $813.80 $453.20
53210 .......... Removal of urethra ......................................... Y ................. .................... A2 ............... $717.00 30.1994 $1,250.26 $850.32
53215 .......... Removal of urethra ......................................... Y ................. .................... A2 ............... $717.00 19.6570 $813.80 $741.20
53220 .......... Treatment of urethra lesion ............................ Y ................. .................... A2 ............... $446.00 30.1994 $1,250.26 $647.07
53230 .......... Removal of urethra lesion .............................. Y ................. .................... A2 ............... $446.00 30.1994 $1,250.26 $647.07
53235 .......... Removal of urethra lesion .............................. Y ................. .................... A2 ............... $510.00 19.6570 $813.80 $585.95
53240 .......... Surgery for urethra pouch .............................. Y ................. .................... A2 ............... $446.00 30.1994 $1,250.26 $647.07
53250 .......... Removal of urethra gland ............................... Y ................. .................... A2 ............... $446.00 19.6570 $813.80 $537.95
53260 .......... Treatment of urethra lesion ............................ Y ................. .................... A2 ............... $446.00 19.6570 $813.80 $537.95
53265 .......... Treatment of urethra lesion ............................ Y ................. .................... A2 ............... $446.00 19.6570 $813.80 $537.95
53270 .......... Removal of urethra gland ............................... Y ................. .................... A2 ............... $446.00 19.6570 $813.80 $537.95
53275 .......... Repair of urethra defect ................................. Y ................. .................... A2 ............... $446.00 19.6570 $813.80 $537.95
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
53400 .......... Revise urethra, stage 1 .................................. Y ................. .................... A2 ............... $510.00 30.1994 $1,250.26 $695.07
53405 .......... Revise urethra, stage 2 .................................. Y ................. .................... A2 ............... $446.00 30.1994 $1,250.26 $647.07
53410 .......... Reconstruction of urethra ............................... Y ................. .................... A2 ............... $446.00 30.1994 $1,250.26 $647.07
53420 .......... Reconstruct urethra, stage 1 .......................... Y ................. .................... A2 ............... $510.00 30.1994 $1,250.26 $695.07
53425 .......... Reconstruct urethra, stage 2 .......................... Y ................. .................... A2 ............... $446.00 30.1994 $1,250.26 $647.07
53431 .......... Reconstruct urethra/bladder ........................... Y ................. .................... A2 ............... $446.00 30.1994 $1,250.26 $647.07
53440 .......... Male sling procedure ...................................... N ................. CH .............. H8 ............... $446.00 109.0807 $4,515.94 $3,569.83
53442 .......... Remove/revise male sling .............................. Y ................. .................... A2 ............... $333.00 30.1994 $1,250.26 $562.32
53444 .......... Insert tandem cuff .......................................... N ................. CH .............. H8 ............... $446.00 109.0807 $4,515.94 $3,569.83
53445 .......... Insert uro/ves nck sphincter ........................... N ................. .................... H8 ............... $333.00 191.7932 $7,940.24 $6,492.40
53446 .......... Remove uro sphincter .................................... Y ................. .................... A2 ............... $333.00 30.1994 $1,250.26 $562.32
53447 .......... Remove/replace ur sphincter ......................... N ................. .................... H8 ............... $333.00 191.7932 $7,940.24 $6,492.40
53449 .......... Repair uro sphincter ....................................... Y ................. .................... A2 ............... $333.00 30.1994 $1,250.26 $562.32
53450 .......... Revision of urethra ......................................... Y ................. .................... A2 ............... $333.00 30.1994 $1,250.26 $562.32
53460 .......... Revision of urethra ......................................... Y ................. .................... A2 ............... $333.00 19.6570 $813.80 $453.20
53502 .......... Repair of urethra injury .................................. Y ................. .................... A2 ............... $446.00 19.6570 $813.80 $537.95
53505 .......... Repair of urethra injury .................................. Y ................. .................... A2 ............... $446.00 30.1994 $1,250.26 $647.07
53510 .......... Repair of urethra injury .................................. Y ................. .................... A2 ............... $446.00 19.6570 $813.80 $537.95
53515 .......... Repair of urethra injury .................................. Y ................. .................... A2 ............... $446.00 30.1994 $1,250.26 $647.07
53520 .......... Repair of urethra defect ................................. Y ................. .................... A2 ............... $446.00 30.1994 $1,250.26 $647.07
53600 .......... Dilate urethra stricture .................................... Y ................. .................... P3 ............... .................... 0.9483 $39.26 $39.26
53601 .......... Dilate urethra stricture .................................... Y ................. CH .............. P2 ............... .................... 1.0850 $44.92 $44.92
53605 .......... Dilate urethra stricture .................................... Y ................. .................... A2 ............... $446.00 18.1376 $750.90 $522.23
53660 .......... Dilation of urethra ........................................... Y ................. .................... P3 ............... .................... 1.0802 $44.72 $44.72
53661 .......... Dilation of urethra ........................................... Y ................. .................... P3 ............... .................... 1.0720 $44.38 $44.38
53665 .......... Dilation of urethra ........................................... Y ................. .................... A2 ............... $333.00 19.6570 $813.80 $453.20
53850 .......... Prostatic microwave thermotx ........................ Y ................. .................... P2 ............... .................... 36.9175 $1,528.38 $1,528.38
53852 .......... Prostatic rf thermotx ....................................... Y ................. .................... P2 ............... .................... 36.9175 $1,528.38 $1,528.38
53853 .......... Prostatic water thermother ............................. Y ................. .................... P2 ............... .................... 25.2775 $1,046.49 $1,046.49
54000 .......... Slitting of prepuce .......................................... Y ................. .................... A2 ............... $446.00 19.6570 $813.80 $537.95
54001 .......... Slitting of prepuce .......................................... Y ................. .................... A2 ............... $446.00 19.6570 $813.80 $537.95
54015 .......... Drain penis lesion ........................................... Y ................. .................... A2 ............... $630.00 19.0457 $788.49 $669.62
54050 .......... Destruction, penis lesion(s) ............................ Y ................. .................... P2 ............... .................... 1.5119 $62.59 $62.59
54055 .......... Destruction, penis lesion(s) ............................ Y ................. .................... P3 ............... .................... 1.4676 $60.76 $60.76
54056 .......... Cryosurgery, penis lesion(s) .......................... Y ................. .................... P2 ............... .................... 0.8046 $33.31 $33.31
54057 .......... Laser surg, penis lesion(s) ............................. Y ................. .................... A2 ............... $333.00 20.0977 $832.04 $457.76
54060 .......... Excision of penis lesion(s) ............................. Y ................. .................... A2 ............... $333.00 20.0977 $832.04 $457.76
54065 .......... Destruction, penis lesion(s) ............................ Y ................. .................... A2 ............... $333.00 20.0977 $832.04 $457.76
54100 .......... Biopsy of penis ............................................... Y ................. .................... A2 ............... $333.00 16.5832 $686.54 $421.39
54105 .......... Biopsy of penis ............................................... Y ................. .................... A2 ............... $333.00 21.4534 $888.17 $471.79
54110 .......... Treatment of penis lesion ............................... Y ................. .................... A2 ............... $446.00 35.1574 $1,455.52 $698.38
54111 .......... Treat penis lesion, graft ................................. Y ................. .................... A2 ............... $446.00 35.1574 $1,455.52 $698.38
54112 .......... Treat penis lesion, graft ................................. Y ................. .................... A2 ............... $446.00 35.1574 $1,455.52 $698.38
54115 .......... Treatment of penis lesion ............................... Y ................. .................... A2 ............... $333.00 19.0457 $788.49 $446.87
54120 .......... Partial removal of penis ................................. Y ................. .................... A2 ............... $446.00 35.1574 $1,455.52 $698.38
54150 .......... Circumcision w/regionl block .......................... Y ................. .................... A2 ............... $333.00 22.7802 $943.10 $485.53
54160 .......... Circumcision, neonate .................................... Y ................. .................... A2 ............... $446.00 22.7802 $943.10 $570.28
54161 .......... Circum 28 days or older ................................. Y ................. .................... A2 ............... $446.00 22.7802 $943.10 $570.28
54162 .......... Lysis penil circumic lesion .............................. Y ................. .................... A2 ............... $446.00 22.7802 $943.10 $570.28
54163 .......... Repair of circumcision .................................... Y ................. .................... A2 ............... $446.00 22.7802 $943.10 $570.28
54164 .......... Frenulotomy of penis ...................................... Y ................. .................... A2 ............... $446.00 22.7802 $943.10 $570.28
54200 .......... Treatment of penis lesion ............................... Y ................. .................... P3 ............... .................... 1.5667 $64.86 $64.86
54205 .......... Treatment of penis lesion ............................... Y ................. .................... A2 ............... $630.00 35.1574 $1,455.52 $836.38
54220 .......... Treatment of penis lesion ............................... Y ................. .................... A2 ............... $131.50 2.1659 $89.67 $121.04
54230 .......... Prepare penis study ....................................... N ................. .................... N1 ............... .................... .................... .................... ....................
54231 .......... Dynamic cavernosometry ............................... Y ................. .................... P3 ............... .................... 1.3686 $56.66 $56.66
54235 .......... Penile injection ............................................... Y ................. .................... P3 ............... .................... 0.9729 $40.28 $40.28
54240 .......... Penis study ..................................................... Y ................. .................... P3 ............... .................... 0.6679 $27.65 $27.65
54250 .......... Penis study ..................................................... Y ................. .................... P3 ............... .................... 0.2309 $9.56 $9.56
54300 .......... Revision of penis ............................................ Y ................. .................... A2 ............... $510.00 35.1574 $1,455.52 $746.38
54328 .......... Revise penis/urethra ...................................... Y ................. .................... A2 ............... $510.00 35.1574 $1,455.52 $746.38
54340 .......... Secondary urethral surgery ............................ Y ................. .................... A2 ............... $510.00 35.1574 $1,455.52 $746.38
54352 .......... Reconstruct urethra/penis .............................. Y ................. .................... A2 ............... $510.00 35.1574 $1,455.52 $746.38
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
54360 .......... Penis plastic surgery ...................................... Y ................. .................... A2 ............... $510.00 35.1574 $1,455.52 $746.38
54380 .......... Repair penis ................................................... Y ................. .................... A2 ............... $510.00 35.1574 $1,455.52 $746.38
54385 .......... Repair penis ................................................... Y ................. .................... A2 ............... $510.00 35.1574 $1,455.52 $746.38
54400 .......... Insert semi-rigid prosthesis ............................ N ................. CH .............. H8 ............... $510.00 109.0807 $4,515.94 $3,617.83
54401 .......... Insert self-contd prosthesis ............................ N ................. .................... H8 .............. $510.00 191.7932 $7,940.24 $6,625.15
54405 .......... Insert multi-comp penis pros .......................... N ................. .................... H8 ............... $510.00 191.7932 $7,940.24 $6,625.15
54406 .......... Remove muti-comp penis pros ...................... Y ................. .................... A2 ............... $510.00 35.1574 $1,455.52 $746.38
54408 .......... Repair multi-comp penis pros ........................ Y ................. .................... A2 ............... $510.00 35.1574 $1,455.52 $746.38
54410 .......... Remove/replace penis prosth ........................ N ................. .................... H8 ............... $510.00 191.7932 $7,940.24 $6,625.15
54415 .......... Remove self-contd penis pros ....................... Y ................. .................... A2 ............... $510.00 35.1574 $1,455.52 $746.38
54416 .......... Remv/repl penis contain pros ........................ N ................. .................... H8 .............. $510.00 191.7932 $7,940.24 $6,625.15
54440 .......... Repair of penis ............................................... Y ................. .................... A2 ............... $630.00 35.1574 $1,455.52 $836.38
54450 .......... Preputial stretching ......................................... Y ................. .................... A2 ............... $209.48 3.0601 $126.69 $188.78
54500 .......... Biopsy of testis ............................................... Y ................. .................... A2 ............... $333.00 13.9599 $577.94 $394.24
54505 .......... Biopsy of testis ............................................... Y ................. .................... A2 ............... $333.00 22.7802 $943.10 $485.53
54512 .......... Excise lesion testis ......................................... Y ................. .................... A2 ............... $446.00 22.7802 $943.10 $570.28
54520 .......... Removal of testis ............................................ Y ................. .................... A2 ............... $510.00 22.7802 $943.10 $618.28
54522 .......... Orchiectomy, partial ....................................... Y ................. .................... A2 ............... $510.00 22.7802 $943.10 $618.28
54530 .......... Removal of testis ............................................ Y ................. .................... A2 ............... $630.00 31.1722 $1,290.53 $795.13
54550 .......... Exploration for testis ....................................... Y ................. .................... A2 ............... $630.00 31.1722 $1,290.53 $795.13
54560 .......... Exploration for testis ....................................... Y ................. .................... G2 .............. .................... 22.7802 $943.10 $943.10
54600 .......... Reduce testis torsion ...................................... Y ................. .................... A2 ............... $630.00 22.7802 $943.10 $708.28
54620 .......... Suspension of testis ....................................... Y ................. .................... A2 ............... $510.00 22.7802 $943.10 $618.28
54640 .......... Suspension of testis ....................................... Y ................. .................... A2 ............... $630.00 31.1722 $1,290.53 $795.13
54660 .......... Revision of testis ............................................ Y ................. .................... A2 ............... $446.00 22.7802 $943.10 $570.28
54670 .......... Repair testis injury .......................................... Y ................. .................... A2 ............... $510.00 22.7802 $943.10 $618.28
54680 .......... Relocation of testis(es) ................................... Y ................. .................... A2 ............... $510.00 22.7802 $943.10 $618.28
54690 .......... Laparoscopy, orchiectomy ............................. Y ................. .................... A2 ............... $1,339.00 46.1201 $1,909.37 $1,481.59
54692 .......... Laparoscopy, orchiopexy ............................... Y ................. .................... G2 .............. .................... 71.0022 $2,939.49 $2,939.49
54700 .......... Drainage of scrotum ....................................... Y ................. .................... A2 ............... $446.00 22.7802 $943.10 $570.28
54800 .......... Biopsy of epididymis ...................................... Y ................. .................... A2 ............... $127.16 4.5062 $186.56 $142.01
54830 .......... Remove epididymis lesion ............................. Y ................. .................... A2 ............... $510.00 22.7802 $943.10 $618.28
54840 .......... Remove epididymis lesion ............................. Y ................. .................... A2 ............... $630.00 22.7802 $943.10 $708.28
54860 .......... Removal of epididymis ................................... Y ................. .................... A2 ............... $510.00 22.7802 $943.10 $618.28
54861 .......... Removal of epididymis ................................... Y ................. .................... A2 ............... $630.00 22.7802 $943.10 $708.28
54865 .......... Explore epididymis ......................................... Y ................. .................... A2 ............... $333.00 22.7802 $943.10 $485.53
54900 .......... Fusion of spermatic ducts .............................. Y ................. .................... A2 ............... $630.00 22.7802 $943.10 $708.28
54901 .......... Fusion of spermatic ducts .............................. Y ................. .................... A2 ............... $630.00 22.7802 $943.10 $708.28
55000 .......... Drainage of hydrocele .................................... Y ................. .................... P3 ............... .................... 1.6159 $66.90 $66.90
55040 .......... Removal of hydrocele .................................... Y ................. .................... A2 ............... $510.00 31.1722 $1,290.53 $705.13
55041 .......... Removal of hydroceles ................................... Y ................. .................... A2 ............... $717.00 31.1722 $1,290.53 $860.38
55060 .......... Repair of hydrocele ........................................ Y ................. .................... A2 ............... $630.00 22.7802 $943.10 $708.28
55100 .......... Drainage of scrotum abscess ........................ Y ................. .................... A2 ............... $333.00 12.5792 $520.78 $379.95
55110 .......... Explore scrotum ............................................. Y ................. .................... A2 ............... $446.00 22.7802 $943.10 $570.28
55120 .......... Removal of scrotum lesion ............................. Y ................. .................... A2 ............... $446.00 22.7802 $943.10 $570.28
55150 .......... Removal of scrotum ....................................... Y ................. .................... A2 ............... $333.00 22.7802 $943.10 $485.53
55175 .......... Revision of scrotum ........................................ Y ................. .................... A2 ............... $333.00 22.7802 $943.10 $485.53
55180 .......... Revision of scrotum ........................................ Y ................. .................... A2 ............... $446.00 22.7802 $943.10 $570.28
55200 .......... Incision of sperm duct .................................... Y ................. .................... A2 ............... $446.00 22.7802 $943.10 $570.28
55250 .......... Removal of sperm duct(s) .............................. Y ................. .................... A2 ............... $446.00 22.7802 $943.10 $570.28
55300 .......... Prepare, sperm duct x-ray ............................. N ................. .................... N1 ............... .................... .................... .................... ....................
55400 .......... Repair of sperm duct ...................................... Y ................. .................... A2 ............... $333.00 22.7802 $943.10 $485.53
55450 .......... Ligation of sperm duct .................................... Y ................. .................... P3 ............... .................... 5.2027 $215.39 $215.39
55500 .......... Removal of hydrocele .................................... Y ................. .................... A2 ............... $510.00 22.7802 $943.10 $618.28
55520 .......... Removal of sperm cord lesion ....................... Y ................. .................... A2 ............... $630.00 22.7802 $943.10 $708.28
55530 .......... Revise spermatic cord veins .......................... Y ................. .................... A2 ............... $630.00 22.7802 $943.10 $708.28
55535 .......... Revise spermatic cord veins .......................... Y ................. .................... A2 ............... $630.00 31.1722 $1,290.53 $795.13
55540 .......... Revise hernia & sperm veins ......................... Y ................. .................... A2 ............... $717.00 31.1722 $1,290.53 $860.38
55550 .......... Laparo ligate spermatic vein .......................... Y ................. .................... A2 ............... $1,339.00 46.1201 $1,909.37 $1,481.59
55600 .......... Incise sperm duct pouch ................................ Y ................. .................... R2 .............. .................... 22.7802 $943.10 $943.10
55680 .......... Remove sperm pouch lesion ......................... Y ................. .................... A2 ............... $333.00 22.7802 $943.10 $485.53
55700 .......... Biopsy of prostate .......................................... Y ................. .................... A2 ............... $345.83 11.3168 $468.52 $376.50
55705 .......... Biopsy of prostate .......................................... Y ................. .................... A2 ............... $345.83 11.3168 $468.52 $376.50
55860 .......... Surgical exposure, prostate ........................... Y ................. .................... G2 .............. .................... 19.6126 $811.96 $811.96
55870 .......... Electroejaculation ........................................... Y ................. .................... P3 ............... .................... 1.6572 $68.61 $68.61
55873 .......... Cryoablate prostate ........................................ Y ................. CH .............. H8 .............. $1,339.00 163.2548 $6,758.75 $6,201.03
55875 .......... Transperi needle place, pros ......................... N ................. CH .............. A2 ............... $1,339.00 36.9175 $1,528.38 $1,386.35
55876* ........ Place rt device/marker, pros .......................... Y ................. .................... P3 ............... .................... 1.6903 $69.98 $69.98
56405 .......... I & D of vulva/perineum ................................. Y ................. .................... P3 ............... .................... 1.0307 $42.67 $42.67
56420 .......... Drainage of gland abscess ............................ Y ................. .................... P2 ............... .................... 1.4138 $58.53 $58.53
56440 .......... Surgery for vulva lesion ................................. Y ................. .................... A2 ............... $446.00 19.2052 $795.10 $533.28
56441 .......... Lysis of labial lesion(s) ................................... Y ................. .................... A2 ............... $333.00 19.2052 $795.10 $448.53
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
56442 .......... Hymenotomy .................................................. Y ................. .................... A2 ............... $333.00 19.2052 $795.10 $448.53
56501 .......... Destroy, vulva lesions, sim ............................ Y ................. .................... P3 ............... .................... 1.4017 $58.03 $58.03
56515 .......... Destroy vulva lesion/s compl ......................... Y ................. .................... A2 ............... $510.00 20.0977 $832.04 $590.51
56605 .......... Biopsy of vulva/perineum ............................... Y ................. .................... P3 ............... .................... 0.8162 $33.79 $33.79
56606 .......... Biopsy of vulva/perineum ............................... Y ................. .................... P3 ............... .................... 0.3546 $14.68 $14.68
56620 .......... Partial removal of vulva .................................. Y ................. .................... A2 ............... $717.00 19.2052 $795.10 $736.53
56625 .......... Complete removal of vulva ............................ Y ................. .................... A2 ............... $995.00 19.2052 $795.10 $945.03
56700 .......... Partial removal of hymen ............................... Y ................. .................... A2 ............... $333.00 19.2052 $795.10 $448.53
56740 .......... Remove vagina gland lesion .......................... Y ................. .................... A2 ............... $510.00 19.2052 $795.10 $581.28
56800 .......... Repair of vagina ............................................. Y ................. .................... A2 ............... $510.00 19.2052 $795.10 $581.28
56805 .......... Repair clitoris .................................................. Y ................. .................... G2 .............. .................... 19.2052 $795.10 $795.10
56810 .......... Repair of perineum ......................................... Y ................. .................... A2 ............... $717.00 19.2052 $795.10 $736.53
56820 .......... Exam of vulva w/scope .................................. Y ................. .................... P3 ............... .................... 1.0307 $42.67 $42.67
56821 .......... Exam/biopsy of vulva w/scope ....................... Y ................. .................... P3 ............... .................... 1.3522 $55.98 $55.98
57000 .......... Exploration of vagina ...................................... Y ................. .................... A2 ............... $333.00 19.2052 $795.10 $448.53
57010 .......... Drainage of pelvic abscess ............................ Y ................. .................... A2 ............... $446.00 19.2052 $795.10 $533.28
57020 .......... Drainage of pelvic fluid ................................... Y ................. .................... A2 ............... $409.33 7.4497 $308.42 $384.10
57022 .......... I & d vaginal hematoma, pp ........................... Y ................. .................... G2 .............. .................... 12.5792 $520.78 $520.78
57023 .......... I & d vag hematoma, non-ob ......................... Y ................. .................... A2 ............... $333.00 19.0457 $788.49 $446.87
57061 .......... Destroy vag lesions, simple ........................... Y ................. .................... P3 ............... .................... 1.3027 $53.93 $53.93
57065 .......... Destroy vag lesions, complex ........................ Y ................. .................... A2 ............... $333.00 19.2052 $795.10 $448.53
57100 .......... Biopsy of vagina ............................................. Y ................. .................... P3 ............... .................... 0.8329 $34.48 $34.48
57105 .......... Biopsy of vagina ............................................. Y ................. .................... A2 ............... $446.00 19.2052 $795.10 $533.28
57130 .......... Remove vagina lesion .................................... Y ................. .................... A2 ............... $446.00 19.2052 $795.10 $533.28
57135 .......... Remove vagina lesion .................................... Y ................. .................... A2 ............... $446.00 19.2052 $795.10 $533.28
57150 .......... Treat vagina infection ..................................... Y ................. .................... P3 ............... .................... 0.6925 $28.67 $28.67
57155 .......... Insert uteri tandems/ovoids ............................ Y ................. .................... A2 ............... $409.33 7.4497 $308.42 $384.10
57160 .......... Insert pessary/other device ............................ Y ................. .................... P3 ............... .................... 0.8493 $35.16 $35.16
57170 .......... Fitting of diaphragm/cap ................................. Y ................. .................... P2 ............... .................... 0.1414 $5.85 $5.85
57180 .......... Treat vaginal bleeding .................................... Y ................. .................... A2 ............... $178.05 1.4138 $58.53 $148.17
57200 .......... Repair of vagina ............................................. Y ................. .................... A2 ............... $333.00 19.2052 $795.10 $448.53
57210 .......... Repair vagina/perineum ................................. Y ................. .................... A2 ............... $446.00 19.2052 $795.10 $533.28
57220 .......... Revision of urethra ......................................... Y ................. .................... A2 ............... $510.00 43.2255 $1,789.54 $829.89
57230 .......... Repair of urethral lesion ................................. Y ................. .................... A2 ............... $510.00 32.9713 $1,365.01 $723.75
57240 .......... Repair bladder & vagina ................................ Y ................. .................... A2 ............... $717.00 32.9713 $1,365.01 $879.00
57250 .......... Repair rectum & vagina ................................. Y ................. .................... A2 ............... $717.00 32.9713 $1,365.01 $879.00
57260 .......... Repair of vagina ............................................. Y ................. .................... A2 ............... $717.00 32.9713 $1,365.01 $879.00
57265 .......... Extensive repair of vagina .............................. Y ................. .................... A2 ............... $995.00 43.2255 $1,789.54 $1,193.64
57267 .......... Insert mesh/pelvic flr addon ........................... Y ................. .................... A2 ............... $995.00 32.9713 $1,365.01 $1,087.50
57268 .......... Repair of bowel bulge .................................... Y ................. .................... A2 ............... $510.00 32.9713 $1,365.01 $723.75
57287 .......... Revise/remove sling repair ............................. Y ................. .................... G2 .............. .................... 32.9713 $1,365.01 $1,365.01
57288 .......... Repair bladder defect ..................................... Y ................. .................... A2 ............... $717.00 43.2255 $1,789.54 $985.14
57289 .......... Repair bladder & vagina ................................ Y ................. .................... A2 ............... $717.00 32.9713 $1,365.01 $879.00
57291 .......... Construction of vagina ................................... Y ................. .................... A2 ............... $717.00 32.9713 $1,365.01 $879.00
57300 .......... Repair rectum-vagina fistula .......................... Y ................. .................... A2 ............... $510.00 32.9713 $1,365.01 $723.75
57320 .......... Repair bladder-vagina lesion ......................... Y ................. .................... G2 .............. .................... 32.9713 $1,365.01 $1,365.01
57400 .......... Dilation of vagina ............................................ Y ................. .................... A2 ............... $446.00 19.2052 $795.10 $533.28
57410 .......... Pelvic examination ......................................... Y ................. .................... A2 ............... $446.00 19.2052 $795.10 $533.28
57415 .......... Remove vaginal foreign body ........................ Y ................. .................... A2 ............... $446.00 19.2052 $795.10 $533.28
57420 .......... Exam of vagina w/scope ................................ Y ................. .................... P3 ............... .................... 1.0635 $44.03 $44.03
57421 .......... Exam/biopsy of vag w/scope ......................... Y ................. .................... P3 ............... .................... 1.4181 $58.71 $58.71
57452 .......... Exam of cervix w/scope ................................. Y ................. .................... P3 ............... .................... 1.0143 $41.99 $41.99
57454 .......... Bx/curett of cervix w/scope ............................ Y ................. .................... P3 ............... .................... 1.2534 $51.89 $51.89
57455 .......... Biopsy of cervix w/scope ................................ Y ................. .................... P3 ............... .................... 1.3275 $54.96 $54.96
57456 .......... Endocerv curettage w/scope .......................... Y ................. .................... P3 ............... .................... 1.2780 $52.91 $52.91
57460 .......... Bx of cervix w/scope, leep ............................. Y ................. .................... P3 ............... .................... 4.1638 $172.38 $172.38
57461 .......... Conz of cervix w/scope, leep ......................... Y ................. .................... P3 ............... .................... 4.3865 $181.60 $181.60
57500 .......... Biopsy of cervix .............................................. Y ................. .................... P3 ............... .................... 1.8717 $77.49 $77.49
57505 .......... Endocervical curettage ................................... Y ................. .................... P3 ............... .................... 1.1461 $47.45 $47.45
57510 .......... Cauterization of cervix .................................... Y ................. .................... P3 ............... .................... 1.1872 $49.15 $49.15
57511 .......... Cryocautery of cervix ..................................... Y ................. CH .............. P3 ............... .................... 1.4099 $58.37 $58.37
57513 .......... Laser surgery of cervix ................................... Y ................. .................... A2 ............... $446.00 19.2052 $795.10 $533.28
57520 .......... Conization of cervix ........................................ Y ................. .................... A2 ............... $446.00 19.2052 $795.10 $533.28
57522 .......... Conization of cervix ........................................ Y ................. .................... A2 ............... $446.00 19.2052 $795.10 $533.28
57530 .......... Removal of cervix ........................................... Y ................. .................... A2 ............... $510.00 32.9713 $1,365.01 $723.75
57550 .......... Removal of residual cervix ............................. Y ................. .................... A2 ............... $510.00 32.9713 $1,365.01 $723.75
57556 .......... Remove cervix, repair bowel .......................... Y ................. .................... A2 ............... $717.00 43.2255 $1,789.54 $985.14
57558 .......... D&c of cervical stump .................................... Y ................. .................... A2 ............... $510.00 19.2052 $795.10 $581.28
57700 .......... Revision of cervix ........................................... Y ................. .................... A2 ............... $333.00 19.2052 $795.10 $448.53
57800 .......... Dilation of cervical canal ................................ Y ................. .................... P3 ............... .................... 0.6101 $25.26 $25.26
58100 .......... Biopsy of uterus lining .................................... Y ................. .................... P3 ............... .................... 1.0143 $41.99 $41.99
58110 .......... Bx done w/colposcopy add-on ....................... N ................. CH .............. N1 ............... .................... .................... .................... ....................
58120 .......... Dilation and curettage .................................... Y ................. .................... A2 ............... $446.00 19.2052 $795.10 $533.28
58145 .......... Myomectomy vag method .............................. Y ................. .................... A2 ............... $717.00 32.9713 $1,365.01 $879.00
58301 .......... Remove intrauterine device ........................... Y ................. .................... P3 ............... .................... 0.9729 $40.28 $40.28
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
58321 .......... Artificial insemination ...................................... Y ................. .................... P3 ............... .................... 0.8575 $35.50 $35.50
58322 .......... Artificial insemination ...................................... Y ................. .................... P3 ............... .................... 0.9234 $38.23 $38.23
58323 .......... Sperm washing ............................................... Y ................. .................... P3 ............... .................... 0.2886 $11.95 $11.95
58340 .......... Catheter for hysterography ............................ N ................. .................... N1 ............... .................... .................... .................... ....................
58345 .......... Reopen fallopian tube .................................... Y ................. .................... R2 ............... .................... 19.2052 $795.10 $795.10
58346 .......... Insert heyman uteri capsule ........................... Y ................. .................... A2 ............... $446.00 19.2052 $795.10 $533.28
58350 .......... Reopen fallopian tube .................................... Y ................. .................... A2 ............... $510.00 32.9713 $1,365.01 $723.75
58353 .......... Endometr ablate, thermal ............................... Y ................. .................... A2 ............... $995.00 32.9713 $1,365.01 $1,087.50
58356 .......... Endometrial cryoablation ................................ Y ................. .................... P3 ............... .................... 43.0481 $1,782.19 $1,782.19
58545 .......... Laparoscopic myomectomy ............................ Y ................. .................... A2 ............... $1,339.00 34.8153 $1,441.35 $1,364.59
58546 .......... Laparo-myomectomy, complex ...................... Y ................. .................... A2 ............... $1,339.00 46.1201 $1,909.37 $1,481.59
58550 .......... Laparo-asst vag hysterectomy ....................... Y ................. .................... A2 ............... $1,339.00 71.0022 $2,939.49 $1,739.12
58552 .......... Laparo-vag hyst incl t/o .................................. Y ................. .................... G2 .............. .................... 46.1201 $1,909.37 $1,909.37
58555 .......... Hysteroscopy, dx, sep proc ............................ Y ................. .................... A2 ............... $333.00 22.1171 $915.65 $478.66
58558 .......... Hysteroscopy, biopsy ..................................... Y ................. .................... A2 ............... $510.00 22.1171 $915.65 $611.41
58559 .......... Hysteroscopy, lysis ......................................... Y ................. .................... A2 ............... $446.00 22.1171 $915.65 $563.41
58560 .......... Hysteroscopy, resect septum ......................... Y ................. .................... A2 ............... $510.00 34.8162 $1,441.39 $742.85
58561 .......... Hysteroscopy, remove myoma ....................... Y ................. .................... A2 ............... $510.00 34.8162 $1,441.39 $742.85
58562 .......... Hysteroscopy, remove fb ............................... Y ................. .................... A2 ............... $510.00 22.1171 $915.65 $611.41
58563 .......... Hysteroscopy, ablation ................................... Y ................. .................... A2 ............... $1,339.00 34.8162 $1,441.39 $1,364.60
58565 .......... Hysteroscopy, sterilization .............................. Y ................. .................... A2 ............... $1,339.00 43.2255 $1,789.54 $1,451.64
58600 .......... Division of fallopian tube ................................ Y ................. .................... G2 .............. .................... 32.9713 $1,365.01 $1,365.01
58615 .......... Occlude fallopian tube(s) ............................... Y ................. .................... G2 .............. .................... 19.2052 $795.10 $795.10
58660 .......... Laparoscopy, lysis .......................................... Y ................. .................... A2 ............... $717.00 46.1201 $1,909.37 $1,015.09
58661 .......... Laparoscopy, remove adnexa ........................ Y ................. .................... A2 ............... $717.00 46.1201 $1,909.37 $1,015.09
58662 .......... Laparoscopy, excise lesions .......................... Y ................. .................... A2 ............... $717.00 46.1201 $1,909.37 $1,015.09
58670 .......... Laparoscopy, tubal cautery ............................ Y ................. .................... A2 ............... $510.00 46.1201 $1,909.37 $859.84
58671 .......... Laparoscopy, tubal block ............................... Y ................. .................... A2 ............... $510.00 46.1201 $1,909.37 $859.84
58672 .......... Laparoscopy, fimbrioplasty ............................. Y ................. .................... A2 ............... $717.00 46.1201 $1,909.37 $1,015.09
58673 .......... Laparoscopy, salpingostomy .......................... Y ................. .................... A2 ............... $717.00 46.1201 $1,909.37 $1,015.09
58800 .......... Drainage of ovarian cyst(s) ............................ Y ................. .................... A2 ............... $510.00 19.2052 $795.10 $581.28
58805 .......... Drainage of ovarian cyst(s) ............................ Y ................. CH .............. G2 .............. .................... 32.9713 $1,365.01 $1,365.01
58820 .......... Drain ovary abscess, open ............................ Y ................. .................... A2 ............... $510.00 32.9713 $1,365.01 $723.75
58900 .......... Biopsy of ovary(s) .......................................... Y ................. .................... A2 ............... $510.00 19.2052 $795.10 $581.28
58970 .......... Retrieval of oocyte ......................................... Y ................. .................... A2 ............... $245.92 3.0466 $126.13 $215.97
58974 .......... Transfer of embryo ......................................... Y ................. .................... A2 ............... $245.92 3.0466 $126.13 $215.97
58976 .......... Transfer of embryo ......................................... Y ................. .................... A2 ............... $245.92 3.0466 $126.13 $215.97
59000 .......... Amniocentesis, diagnostic .............................. Y ................. CH .............. P3 ............... .................... 1.5667 $64.86 $64.86
59001 .......... Amniocentesis, therapeutic ............................ Y ................. .................... R2 ............... .................... 7.4497 $308.42 $308.42
59012 .......... Fetal cord puncture,prenatal .......................... Y ................. .................... G2 .............. .................... 3.0466 $126.13 $126.13
59015 .......... Chorion biopsy ............................................... Y ................. .................... P3 ............... .................... 1.2285 $50.86 $50.86
59020 .......... Fetal contract stress test ................................ Y ................. .................... P3 ............... .................... 0.5771 $23.89 $23.89
59025 .......... Fetal non-stress test ....................................... Y ................. .................... P3 ............... .................... 0.2886 $11.95 $11.95
59070 .......... Transabdom amnioinfus w/us ........................ Y ................. .................... G2 .............. .................... 3.0466 $126.13 $126.13
59072 .......... Umbilical cord occlud w/us ............................. Y ................. .................... G2 .............. .................... 3.0466 $126.13 $126.13
59076 .......... Fetal shunt placement, w/us .......................... Y ................. .................... G2 .............. .................... 3.0466 $126.13 $126.13
59100 .......... Remove uterus lesion .................................... Y ................. .................... R2 .............. .................... 32.9713 $1,365.01 $1,365.01
59150 .......... Treat ectopic pregnancy ................................. Y ................. .................... G2 .............. .................... 46.1201 $1,909.37 $1,909.37
59151 .......... Treat ectopic pregnancy ................................. Y ................. .................... G2 .............. .................... 46.1201 $1,909.37 $1,909.37
59160 .......... D& c after delivery .......................................... Y ................. .................... A2 ............... $510.00 19.2052 $795.10 $581.28
59200 .......... Insert cervical dilator ...................................... Y ................. .................... P3 ............... .................... 0.8821 $36.52 $36.52
59300 .......... Episiotomy or vaginal repair ........................... Y ................. .................... P3 ............... .................... 1.7973 $74.41 $74.41
59412 .......... Antepartum manipulation ............................... Y ................. .................... G2 .............. .................... 19.2052 $795.10 $795.10
59414 .......... Deliver placenta .............................................. Y ................. .................... G2 .............. .................... 19.2052 $795.10 $795.10
59812 .......... Treatment of miscarriage ............................... Y ................. .................... A2 ............... $717.00 19.2052 $795.10 $736.53
59820 .......... Care of miscarriage ........................................ Y ................. .................... A2 ............... $717.00 19.2052 $795.10 $736.53
59821 .......... Treatment of miscarriage ............................... Y ................. .................... A2 ............... $717.00 19.2052 $795.10 $736.53
59840 .......... Abortion .......................................................... Y ................. .................... A2 ............... $717.00 19.2052 $795.10 $736.53
59841 .......... Abortion .......................................................... Y ................. .................... A2 ............... $717.00 19.2052 $795.10 $736.53
59866 .......... Abortion (mpr) ................................................ Y ................. .................... G2 .............. .................... 3.0466 $126.13 $126.13
59870 .......... Evacuate mole of uterus ................................ Y ................. .................... A2 ............... $717.00 19.2052 $795.10 $736.53
59871 .......... Remove cerclage suture ................................ Y ................. .................... A2 ............... $717.00 19.2052 $795.10 $736.53
60000 .......... Drain thyroid/tongue cyst ............................... Y ................. .................... A2 ............... $333.00 7.6539 $316.87 $328.97
60001 .......... Aspirate/inject thyriod cyst ............................. Y ................. .................... P3 ............... .................... 1.3686 $56.66 $56.66
60100 .......... Biopsy of thyroid ............................................. Y ................. .................... P3 ............... .................... 1.1048 $45.74 $45.74
60200 .......... Remove thyroid lesion .................................... Y ................. .................... A2 ............... $446.00 45.1729 $1,870.16 $802.04
60280 .......... Remove thyroid duct lesion ............................ Y ................. .................... A2 ............... $630.00 45.1729 $1,870.16 $940.04
60281 .......... Remove thyroid duct lesion ............................ Y ................. .................... A2 ............... $630.00 45.1729 $1,870.16 $940.04
61000 .......... Remove cranial cavity fluid ............................ Y ................. .................... R2 ............... .................... 8.6797 $359.34 $359.34
61001 .......... Remove cranial cavity fluid ............................ Y ................. .................... R2 ............... .................... 8.6797 $359.34 $359.34
61020 .......... Remove brain cavity fluid ............................... Y ................. .................... A2 ............... $183.83 8.6797 $359.34 $227.71
61026 .......... Injection into brain canal ................................ Y ................. .................... A2 ............... $183.83 8.6797 $359.34 $227.71
61050 .......... Remove brain canal fluid ............................... Y ................. .................... A2 ............... $183.83 8.6797 $359.34 $227.71
61055 .......... Injection into brain canal ................................ Y ................. .................... A2 ............... $183.83 8.6797 $359.34 $227.71
61070 .......... Brain canal shunt procedure .......................... Y ................. .................... A2 ............... $183.83 3.2914 $136.26 $171.94
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
61215 .......... Insert brain-fluid device .................................. Y ................. .................... A2 ............... $510.00 37.1117 $1,536.42 $766.61
61330 .......... Decompress eye socket ................................. Y ................. .................... G2 .............. .................... 40.5598 $1,679.18 $1,679.18
61334 .......... Explore orbit/remove object ........................... Y ................. .................... G2 .............. .................... 40.5598 $1,679.18 $1,679.18
61790 .......... Treat trigeminal nerve .................................... Y ................. .................... A2 ............... $510.00 18.5069 $766.19 $574.05
61791 .......... Treat trigeminal tract ...................................... Y ................. .................... A2 ............... $351.92 15.5687 $644.54 $425.08
61795 .......... Brain surgery using computer ........................ N ................. CH .............. N1 ............... $302.04 .................... .................... ....................
61880 .......... Revise/remove neuroelectrode ...................... Y ................. .................... G2 .............. .................... 24.1752 $1,000.85 $1,000.85
61885 .......... Insrt/redo neurostim 1 array ........................... N ................. .................... H8 ............... $446.00 284.8210 $11,791.59 $11,031.64
61886 .......... Implant neurostim arrays ................................ Y ................. .................... H8 ............... $510.00 384.8428 $15,932.49 $15,191.32
61888 .......... Revise/remove neuroreceiver ........................ Y ................. .................... A2 ............... $333.00 35.7248 $1,479.01 $619.50
62194 .......... Replace/irrigate catheter ................................ Y ................. .................... A2 ............... $333.00 8.6797 $359.34 $339.59
62225 .......... Replace/irrigate catheter ................................ Y ................. .................... A2 ............... $333.00 14.8912 $616.50 $403.88
62230 .......... Replace/revise brain shunt ............................. Y ................. .................... A2 ............... $446.00 37.1117 $1,536.42 $718.61
62252 .......... Csf shunt reprogram ...................................... N ................. .................... P3 ............... .................... 1.0720 $44.38 $44.38
62263 .......... Epidural lysis mult sessions ........................... Y ................. .................... A2 ............... $333.00 15.5687 $644.54 $410.89
62264 .......... Epidural lysis on single day ........................... Y ................. .................... A2 ............... $333.00 15.5687 $644.54 $410.89
62268 .......... Drain spinal cord cyst ..................................... Y ................. .................... A2 ............... $183.83 8.6797 $359.34 $227.71
62269 .......... Needle biopsy, spinal cord ............................. Y ................. .................... A2 ............... $333.00 9.5741 $396.37 $348.84
62270 .......... Spinal fluid tap, diagnostic ............................. Y ................. .................... A2 ............... $139.00 4.1589 $172.18 $147.30
62272 .......... Drain cerebro spinal fluid ............................... Y ................. .................... A2 ............... $139.00 4.1589 $172.18 $147.30
62273 .......... Inject epidural patch ....................................... Y ................. .................... A2 ............... $333.00 4.1589 $172.18 $292.80
62280 .......... Treat spinal cord lesion .................................. Y ................. .................... A2 ............... $333.00 7.1370 $295.47 $323.62
62281 .......... Treat spinal cord lesion .................................. Y ................. .................... A2 ............... $333.00 7.1370 $295.47 $323.62
62282 .......... Treat spinal canal lesion ................................ Y ................. .................... A2 ............... $333.00 7.1370 $295.47 $323.62
62284 .......... Injection for myelogram .................................. N ................. .................... N1 .............. .................... .................... .................... ....................
62287 .......... Percutaneous diskectomy .............................. Y ................. .................... A2 ............... $1,339.00 32.0518 $1,326.94 $1,335.99
62290 .......... Inject for spine disk x-ray ............................... N ................. .................... N1 ............... .................... .................... .................... ....................
62291 .......... Inject for spine disk x-ray ............................... N ................. .................... N1 ............... .................... .................... .................... ....................
62292 .......... Injection into disk lesion ................................. Y ................. CH .............. R2 .............. .................... 8.6797 $359.34 $359.34
62294 .......... Injection into spinal artery .............................. Y ................. .................... A2 ............... $183.83 8.6797 $359.34 $227.71
62310 .......... Inject spine c/t ................................................ Y ................. .................... A2 ............... $333.00 7.1370 $295.47 $323.62
62311 .......... Inject spine l/s (cd) ......................................... Y ................. .................... A2 ............... $333.00 7.1370 $295.47 $323.62
62318 .......... Inject spine w/cath, c/t .................................... Y ................. .................... A2 ............... $333.00 7.1370 $295.47 $323.62
62319 .......... Inject spine w/cath l/s (cd) ............................. Y ................. .................... A2 ............... $333.00 7.1370 $295.47 $323.62
62350 .......... Implant spinal canal cath ............................... Y ................. .................... A2 ............... $446.00 37.1117 $1,536.42 $718.61
62355 .......... Remove spinal canal catheter ........................ Y ................. .................... A2 ............... $446.00 15.5687 $644.54 $495.64
62360 .......... Insert spine infusion device ............................ Y ................. .................... A2 ............... $446.00 37.1117 $1,536.42 $718.61
62361 .......... Implant spine infusion pump .......................... Y ................. .................... H8 .............. $446.00 255.4150 $10,574.18 $9,781.61
62362 .......... Implant spine infusion pump .......................... Y ................. .................... H8 .............. $446.00 255.4150 $10,574.18 $9,781.61
62365 .......... Remove spine infusion device ....................... Y ................. .................... A2 ............... $446.00 32.0518 $1,326.94 $666.24
62367 .......... Analyze spine infusion pump ......................... N ................. .................... P3 ............... .................... 0.4205 $17.41 $17.41
62368 .......... Analyze spine infusion pump ......................... N ................. .................... P3 ............... .................... 0.5278 $21.85 $21.85
63600 .......... Remove spinal cord lesion ............................. Y ................. .................... A2 ............... $446.00 18.5069 $766.19 $526.05
63610 .......... Stimulation of spinal cord ............................... Y ................. .................... A2 ............... $333.00 18.5069 $766.19 $441.30
63615 .......... Remove lesion of spinal cord ......................... Y ................. .................... R2 .............. .................... 18.5069 $766.19 $766.19
63650 .......... Implant neuroelectrodes ................................. N ................. .................... H8 ............... $446.00 82.9543 $3,434.31 $2,896.42
63655 .......... Implant neuroelectrodes ................................. N ................. .................... J8 ............... .................... 107.3027 $4,442.33 $4,442.33
63660 .......... Revise/remove neuroelectrode ...................... Y ................. .................... A2 ............... $333.00 24.1752 $1,000.85 $499.96
63685 .......... Insrt/redo spine n generator ........................... Y ................. .................... H8 .............. $446.00 280.0420 $11,593.74 $10,925.15
63688 .......... Revise/remove neuroreceiver ........................ Y ................. .................... A2 ............... $333.00 35.7248 $1,479.01 $619.50
63744 .......... Revision of spinal shunt ................................. Y ................. .................... A2 ............... $510.00 37.1117 $1,536.42 $766.61
63746 .......... Removal of spinal shunt ................................. Y ................. .................... A2 ............... $446.00 6.1077 $252.86 $397.72
64400 .......... Nblock inj, trigeminal ...................................... Y ................. .................... P3 ............... .................... 1.3604 $56.32 $56.32
64402 .......... Nblock inj, facial ............................................. Y ................. .................... P3 ............... .................... 1.2449 $51.54 $51.54
64405 .......... Nblock inj, occipital ......................................... Y ................. .................... P3 ............... .................... 1.0802 $44.72 $44.72
64408 .......... Nblock inj, vagus ............................................ Y ................. .................... P3 ............... .................... 1.2449 $51.54 $51.54
64410 .......... Nblock inj, phrenic .......................................... Y ................. .................... A2 ............... $333.00 7.1370 $295.47 $323.62
64412 .......... Nblock inj, spinal accessor ............................. Y ................. .................... P3 ............... .................... 1.9541 $80.90 $80.90
64413 .......... Nblock inj, cervical plexus .............................. Y ................. .................... P3 ............... .................... 1.2944 $53.59 $53.59
64415 .......... Nblock inj, brachial plexus ............................. Y ................. .................... A2 ............... $139.00 4.1589 $172.18 $147.30
64416 .......... Nblock cont infuse, b plex .............................. Y ................. .................... G2 .............. .................... 7.1370 $295.47 $295.47
64417 .......... Nblock inj, axillary .......................................... Y ................. .................... A2 ............... $139.00 4.1589 $172.18 $147.30
64418 .......... Nblock inj, suprascapular ............................... Y ................. .................... P3 ............... .................... 1.8551 $76.80 $76.80
64420 .......... Nblock inj, intercost, sng ................................ Y ................. .................... A2 ............... $139.00 4.1589 $172.18 $147.30
64421 .......... Nblock inj, intercost, mlt ................................. Y ................. .................... A2 ............... $333.00 4.1589 $172.18 $292.80
64425 .......... Nblock inj, ilio-ing/hypogi ................................ Y ................. .................... P3 ............... .................... 1.2203 $50.52 $50.52
64430 .......... Nblock inj, pudendal ....................................... Y ................. .................... A2 ............... $139.00 7.1370 $295.47 $178.12
64435 .......... Nblock inj, paracervical .................................. Y ................. .................... P3 ............... .................... 1.8551 $76.80 $76.80
64445 .......... Nblock inj, sciatic, sng .................................... Y ................. .................... P3 ............... .................... 1.7727 $73.39 $73.39
64446 .......... Nblk inj, sciatic, cont inf ................................. Y ................. .................... G2 .............. .................... 15.5687 $644.54 $644.54
64447 .......... Nblock inj fem, single ..................................... Y ................. CH .............. R2 ............... .................... 4.1589 $172.18 $172.18
64450 .......... Nblock, other peripheral ................................. Y ................. .................... P3 ............... .................... 1.0307 $42.67 $42.67
64470 .......... Inj paravertebral c/t ........................................ Y ................. .................... A2 ............... $333.00 7.1370 $295.47 $323.62
64472 .......... Inj paravertebral c/t add-on ............................ Y ................. .................... A2 ............... $333.00 4.1589 $172.18 $292.80
64475 .......... Inj paravertebral l/s ......................................... Y ................. .................... A2 ............... $333.00 7.1370 $295.47 $323.62
64476 .......... Inj paravertebral l/s add-on ............................ Y ................. .................... A2 ............... $333.00 4.1589 $172.18 $292.80
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
64479 .......... Inj foramen epidural c/t .................................. Y ................. .................... A2 ............... $333.00 7.1370 $295.47 $323.62
64480 .......... Inj foramen epidural add-on ........................... Y ................. .................... A2 ............... $333.00 4.1589 $172.18 $292.80
64483 .......... Inj foramen epidural l/s ................................... Y ................. .................... A2 ............... $333.00 7.1370 $295.47 $323.62
64484 .......... Inj foramen epidural add-on ........................... Y ................. .................... A2 ............... $333.00 7.1370 $295.47 $323.62
64505 .......... Nblock, spenopalatine gangl .......................... Y ................. .................... P3 ............... .................... 0.9729 $40.28 $40.28
64508 .......... Nblock, carotid sinus s/p ................................ Y ................. .................... P3 ............... .................... 2.1768 $90.12 $90.12
64510 .......... Nblock, stellate ganglion ................................ Y ................. .................... A2 ............... $333.00 7.1370 $295.47 $323.62
64517 .......... Nblock inj, hypogas plxs ................................ Y ................. .................... A2 ............... $139.00 7.1370 $295.47 $178.12
64520 .......... Nblock, lumbar/thoracic .................................. Y ................. .................... A2 ............... $333.00 7.1370 $295.47 $323.62
64530 .......... Nblock inj, celiac pelus ................................... Y ................. .................... A2 ............... $333.00 7.1370 $295.47 $323.62
64585 .......... Revise/remove neuroelectrode ...................... Y ................. .................... A2 ............... $333.00 24.1752 $1,000.85 $499.96
64590 .......... Insrt/redo pn/gastr stimul ................................ Y ................. .................... H8 .............. $446.00 280.0420 $11,593.74 $10,925.15
64595 .......... Revise/rmv pn/gastr stimul ............................. Y ................. .................... A2 ............... $333.00 35.7248 $1,479.01 $619.50
64600 .......... Injection treatment of nerve ........................... Y ................. .................... A2 ............... $333.00 15.5687 $644.54 $410.89
64612 .......... Destroy nerve, face muscle ........................... Y ................. .................... P3 ............... .................... 1.6821 $69.64 $69.64
64613 .......... Destroy nerve, neck muscle ........................... Y ................. .................... P3 ............... .................... 1.7727 $73.39 $73.39
64614 .......... Destroy nerve, extrem musc .......................... Y ................. .................... P3 ............... .................... 1.9954 $82.61 $82.61
64622 .......... Destr paravertebrl nerve l/s ............................ Y ................. .................... A2 ............... $333.00 7.1370 $295.47 $323.62
64623 .......... Destr paravertebral n add-on ......................... Y ................. .................... A2 ............... $333.00 7.1370 $295.47 $323.62
64626 .......... Destr paravertebrl nerve c/t ........................... Y ................. .................... A2 ............... $333.00 7.1370 $295.47 $323.62
64627 .......... Destr paravertebral n add-on ......................... Y ................. .................... A2 ............... $333.00 2.3254 $96.27 $273.82
64640 .......... Injection treatment of nerve ........................... Y ................. .................... P3 ............... .................... 2.7126 $112.30 $112.30
64650 .......... Chemodenerv eccrine glands ........................ Y ................. CH .............. P3 ............... .................... 0.6597 $27.31 $27.31
64653 .......... Chemodenerv eccrine glands ........................ Y ................. CH .............. P3 ............... .................... 0.7007 $29.01 $29.01
64702 .......... Revise finger/toe nerve .................................. Y ................. .................... A2 ............... $333.00 18.5069 $766.19 $441.30
64704 .......... Revise hand/foot nerve .................................. Y ................. .................... A2 ............... $333.00 18.5069 $766.19 $441.30
64708 .......... Revise arm/leg nerve ..................................... Y ................. .................... A2 ............... $446.00 18.5069 $766.19 $526.05
64712 .......... Revision of sciatic nerve ................................ Y ................. .................... A2 ............... $446.00 18.5069 $766.19 $526.05
64713 .......... Revision of arm nerve(s) ................................ Y ................. .................... A2 ............... $446.00 18.5069 $766.19 $526.05
64714 .......... Revise low back nerve(s) ............................... Y ................. .................... A2 ............... $446.00 18.5069 $766.19 $526.05
64716 .......... Revision of cranial nerve ................................ Y ................. .................... A2 ............... $510.00 18.5069 $766.19 $574.05
64718 .......... Revise ulnar nerve at elbow .......................... Y ................. .................... A2 ............... $446.00 18.5069 $766.19 $526.05
64719 .......... Revise ulnar nerve at wrist ............................ Y ................. .................... A2 ............... $446.00 18.5069 $766.19 $526.05
64721 .......... Carpal tunnel surgery ..................................... Y ................. .................... A2 ............... $446.00 18.5069 $766.19 $526.05
64722 .......... Relieve pressure on nerve(s) ......................... Y ................. .................... A2 ............... $333.00 18.5069 $766.19 $441.30
64726 .......... Release foot/toe nerve ................................... Y ................. .................... A2 ............... $333.00 18.5069 $766.19 $441.30
64727 .......... Internal nerve revision .................................... Y ................. .................... A2 ............... $333.00 18.5069 $766.19 $441.30
64732 .......... Incision of brow nerve .................................... Y ................. .................... A2 ............... $446.00 18.5069 $766.19 $526.05
64734 .......... Incision of cheek nerve .................................. Y ................. .................... A2 ............... $446.00 18.5069 $766.19 $526.05
64736 .......... Incision of chin nerve ..................................... Y ................. .................... A2 ............... $446.00 18.5069 $766.19 $526.05
64738 .......... Incision of jaw nerve ...................................... Y ................. .................... A2 ............... $446.00 18.5069 $766.19 $526.05
64740 .......... Incision of tongue nerve ................................. Y ................. .................... A2 ............... $446.00 18.5069 $766.19 $526.05
64742 .......... Incision of facial nerve ................................... Y ................. .................... A2 ............... $446.00 18.5069 $766.19 $526.05
64744 .......... Incise nerve, back of head ............................. Y ................. .................... A2 ............... $446.00 18.5069 $766.19 $526.05
64746 .......... Incise diaphragm nerve .................................. Y ................. .................... A2 ............... $446.00 18.5069 $766.19 $526.05
64761 .......... Incision of pelvis nerve ................................... Y ................. .................... G2 .............. .................... 18.5069 $766.19 $766.19
64763 .......... Incise hip/thigh nerve ..................................... Y ................. .................... G2 .............. .................... 18.5069 $766.19 $766.19
64766 .......... Incise hip/thigh nerve ..................................... Y ................. .................... G2 .............. .................... 32.0518 $1,326.94 $1,326.94
64771 .......... Sever cranial nerve ........................................ Y ................. .................... A2 ............... $446.00 18.5069 $766.19 $526.05
64772 .......... Incision of spinal nerve .................................. Y ................. .................... A2 ............... $446.00 18.5069 $766.19 $526.05
64774 .......... Remove skin nerve lesion .............................. Y ................. .................... A2 ............... $446.00 18.5069 $766.19 $526.05
64776 .......... Remove digit nerve lesion .............................. Y ................. .................... A2 ............... $510.00 18.5069 $766.19 $574.05
64778 .......... Digit nerve surgery add-on ............................. Y ................. .................... A2 ............... $446.00 18.5069 $766.19 $526.05
64782 .......... Remove limb nerve lesion .............................. Y ................. .................... A2 ............... $510.00 18.5069 $766.19 $574.05
64783 .......... Limb nerve surgery add-on ............................ Y ................. .................... A2 ............... $446.00 18.5069 $766.19 $526.05
64784 .......... Remove nerve lesion ..................................... Y ................. .................... A2 ............... $510.00 18.5069 $766.19 $574.05
64786 .......... Remove sciatic nerve lesion .......................... Y ................. .................... A2 ............... $510.00 32.0518 $1,326.94 $714.24
64787 .......... Implant nerve end .......................................... Y ................. .................... A2 ............... $446.00 18.5069 $766.19 $526.05
64788 .......... Remove skin nerve lesion .............................. Y ................. .................... A2 ............... $510.00 18.5069 $766.19 $574.05
64790 .......... Removal of nerve lesion ................................ Y ................. .................... A2 ............... $510.00 18.5069 $766.19 $574.05
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
64792 .......... Removal of nerve lesion ................................ Y ................. .................... A2 ............... $510.00 32.0518 $1,326.94 $714.24
64795 .......... Biopsy of nerve .............................................. Y ................. .................... A2 ............... $446.00 18.5069 $766.19 $526.05
64802 .......... Remove sympathetic nerves .......................... Y ................. .................... A2 ............... $446.00 18.5069 $766.19 $526.05
64820 .......... Remove sympathetic nerves .......................... Y ................. .................... G2 .............. .................... 18.5069 $766.19 $766.19
64821 .......... Remove sympathetic nerves .......................... Y ................. .................... A2 ............... $630.00 26.7322 $1,106.71 $749.18
64822 .......... Remove sympathetic nerves .......................... Y ................. .................... G2 .............. .................... 26.7322 $1,106.71 $1,106.71
64823 .......... Remove sympathetic nerves .......................... Y ................. .................... G2 .............. .................... 26.7322 $1,106.71 $1,106.71
64831 .......... Repair of digit nerve ....................................... Y ................. .................... A2 ............... $630.00 32.0518 $1,326.94 $804.24
64832 .......... Repair nerve add-on ...................................... Y ................. .................... A2 ............... $333.00 32.0518 $1,326.94 $581.49
64834 .......... Repair of hand or foot nerve .......................... Y ................. .................... A2 ............... $446.00 32.0518 $1,326.94 $666.24
64837 .......... Repair nerve add-on ...................................... Y ................. .................... A2 ............... $333.00 32.0518 $1,326.94 $581.49
64840 .......... Repair of leg nerve ......................................... Y ................. .................... A2 ............... $446.00 32.0518 $1,326.94 $666.24
64856 .......... Repair/transpose nerve .................................. Y ................. .................... A2 ............... $446.00 32.0518 $1,326.94 $666.24
64857 .......... Repair arm/leg nerve ...................................... Y ................. .................... A2 ............... $446.00 32.0518 $1,326.94 $666.24
64858 .......... Repair sciatic nerve ........................................ Y ................. .................... A2 ............... $446.00 32.0518 $1,326.94 $666.24
64859 .......... Nerve surgery ................................................. Y ................. .................... A2 ............... $333.00 32.0518 $1,326.94 $581.49
64861 .......... Repair of arm nerves ..................................... Y ................. .................... A2 ............... $510.00 32.0518 $1,326.94 $714.24
64862 .......... Repair of low back nerves ............................. Y ................. .................... A2 ............... $510.00 32.0518 $1,326.94 $714.24
64864 .......... Repair of facial nerve ..................................... Y ................. .................... A2 ............... $510.00 32.0518 $1,326.94 $714.24
64865 .......... Repair of facial nerve ..................................... Y ................. .................... A2 ............... $630.00 32.0518 $1,326.94 $804.24
64870 .......... Fusion of facial/other nerve ............................ Y ................. .................... A2 ............... $630.00 32.0518 $1,326.94 $804.24
64872 .......... Subsequent repair of nerve ............................ Y ................. .................... A2 ............... $446.00 32.0518 $1,326.94 $666.24
64874 .......... Repair & revise nerve add-on ........................ Y ................. .................... A2 ............... $510.00 32.0518 $1,326.94 $714.24
64876 .......... Repair nerve/shorten bone ............................. Y ................. .................... A2 ............... $510.00 32.0518 $1,326.94 $714.24
64885 .......... Nerve graft, head or neck .............................. Y ................. .................... A2 ............... $446.00 32.0518 $1,326.94 $666.24
64886 .......... Nerve graft, head or neck .............................. Y ................. .................... A2 ............... $446.00 32.0518 $1,326.94 $666.24
64890 .......... Nerve graft, hand or foot ................................ Y ................. .................... A2 ............... $446.00 32.0518 $1,326.94 $666.24
64892 .......... Nerve graft, arm or leg ................................... Y ................. .................... A2 ............... $446.00 32.0518 $1,326.94 $666.24
64901 .......... Nerve graft add-on ......................................... Y ................. .................... A2 ............... $446.00 32.0518 $1,326.94 $666.24
64902 .......... Nerve graft add-on ......................................... Y ................. .................... A2 ............... $446.00 32.0518 $1,326.94 $666.24
64905 .......... Nerve pedicle transfer .................................... Y ................. .................... A2 ............... $446.00 32.0518 $1,326.94 $666.24
64907 .......... Nerve pedicle transfer .................................... Y ................. .................... A2 ............... $333.00 32.0518 $1,326.94 $581.49
65091 .......... Revise eye ...................................................... Y ................. .................... A2 ............... $510.00 37.3504 $1,546.31 $769.08
65093 .......... Revise eye with implant ................................. Y ................. .................... A2 ............... $510.00 37.3504 $1,546.31 $769.08
65101 .......... Removal of eye .............................................. Y ................. .................... A2 ............... $510.00 37.3504 $1,546.31 $769.08
65103 .......... Remove eye/insert implant ............................. Y ................. .................... A2 ............... $510.00 37.3504 $1,546.31 $769.08
65105 .......... Remove eye/attach implant ............................ Y ................. .................... A2 ............... $630.00 37.3504 $1,546.31 $859.08
65110 .......... Removal of eye .............................................. Y ................. .................... A2 ............... $717.00 37.3504 $1,546.31 $924.33
65112 .......... Remove eye/revise socket ............................. Y ................. .................... A2 ............... $995.00 37.3504 $1,546.31 $1,132.83
65114 .......... Remove eye/revise socket ............................. Y ................. .................... A2 ............... $995.00 37.3504 $1,546.31 $1,132.83
65125 .......... Revise ocular implant ..................................... Y ................. .................... G2 .............. .................... 19.2280 $796.04 $796.04
65130 .......... Insert ocular implant ....................................... Y ................. .................... A2 ............... $510.00 24.8916 $1,030.51 $640.13
65135 .......... Insert ocular implant ....................................... Y ................. .................... A2 ............... $446.00 24.8916 $1,030.51 $592.13
65140 .......... Attach ocular implant ...................................... Y ................. .................... A2 ............... $510.00 37.3504 $1,546.31 $769.08
65150 .......... Revise ocular implant ..................................... Y ................. .................... A2 ............... $446.00 24.8916 $1,030.51 $592.13
65155 .......... Reinsert ocular implant .................................. Y ................. .................... A2 ............... $510.00 37.3504 $1,546.31 $769.08
65175 .......... Removal of ocular implant ............................. Y ................. .................... A2 ............... $333.00 19.2280 $796.04 $448.76
65205 .......... Remove foreign body from eye ...................... N ................. .................... P3 ............... .................... 0.5029 $20.82 $20.82
65220 .......... Remove foreign body from eye ...................... N ................. .................... G2 .............. .................... 1.1576 $47.92 $47.92
65235 .......... Remove foreign body from eye ...................... Y ................. .................... A2 ............... $446.00 16.5252 $684.14 $505.54
65260 .......... Remove foreign body from eye ...................... Y ................. .................... A2 ............... $510.00 18.8779 $781.55 $577.89
65265 .......... Remove foreign body from eye ...................... Y ................. .................... A2 ............... $630.00 29.0019 $1,200.68 $772.67
65270 .......... Repair of eye wound ...................................... Y ................. .................... A2 ............... $446.00 19.2280 $796.04 $533.51
65285 .......... Repair of eye wound ...................................... Y ................. .................... A2 ............... $630.00 38.1121 $1,577.84 $866.96
65286 .......... Repair of eye wound ...................................... Y ................. .................... P2 ............... .................... 5.1145 $211.74 $211.74
65290 .......... Repair of eye socket wound .......................... Y ................. .................... A2 ............... $510.00 24.3920 $1,009.83 $634.96
65400 .......... Removal of eye lesion .................................... Y ................. .................... A2 ............... $333.00 16.5252 $684.14 $420.79
65410 .......... Biopsy of cornea ............................................ Y ................. .................... A2 ............... $446.00 16.5252 $684.14 $505.54
65430 .......... Corneal smear ................................................ N ................. .................... P3 ............... .................... 0.9894 $40.96 $40.96
65435 .......... Curette/treat cornea ....................................... Y ................. .................... P3 ............... .................... 0.7669 $31.75 $31.75
65436 .......... Curette/treat cornea ....................................... Y ................. .................... G2 .............. .................... 16.5252 $684.14 $684.14
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
65450 .......... Treatment of corneal lesion ........................... N ................. .................... G2 .............. .................... 2.3117 $95.70 $95.70
65600 .......... Revision of cornea ......................................... Y ................. .................... P3 ............... .................... 3.9164 $162.14 $162.14
65710 .......... Corneal transplant .......................................... Y ................. .................... A2 ............... $995.00 38.2919 $1,585.28 $1,142.57
65770 .......... Revise cornea with implant ............................ Y ................. .................... A2 ............... $995.00 83.0605 $3,438.70 $1,605.93
65772 .......... Correction of astigmatism .............................. Y ................. .................... A2 ............... $630.00 16.5252 $684.14 $643.54
65775 .......... Correction of astigmatism .............................. Y ................. .................... A2 ............... $630.00 16.5252 $684.14 $643.54
65780 .......... Ocular reconst, transplant .............................. Y ................. .................... A2 ............... $717.00 38.2919 $1,585.28 $934.07
65800 .......... Drainage of eye .............................................. Y ................. .................... A2 ............... $333.00 16.5252 $684.14 $420.79
65820 .......... Relieve inner eye pressure ............................ Y ................. .................... A2 ............... $333.00 5.1145 $211.74 $302.69
65850 .......... Incision of eye ................................................ Y ................. .................... A2 ............... $630.00 24.0821 $997.00 $721.75
65855 .......... Laser surgery of eye ...................................... Y ................. .................... P3 ............... .................... 3.2403 $134.15 $134.15
65860 .......... Incise inner eye adhesions ............................ Y ................. .................... P3 ............... .................... 3.0343 $125.62 $125.62
65865 .......... Incise inner eye adhesions ............................ Y ................. .................... A2 ............... $333.00 16.5252 $684.14 $420.79
65900 .......... Remove eye lesion ......................................... Y ................. .................... A2 ............... $717.00 16.5252 $684.14 $708.79
65920 .......... Remove implant of eye .................................. Y ................. .................... A2 ............... $995.00 24.0821 $997.00 $995.50
65930 .......... Remove blood clot from eye .......................... Y ................. .................... A2 ............... $717.00 24.0821 $997.00 $787.00
66020 .......... Injection treatment of eye ............................... Y ................. .................... A2 ............... $333.00 16.5252 $684.14 $420.79
66030 .......... Injection treatment of eye ............................... Y ................. .................... A2 ............... $333.00 5.1145 $211.74 $302.69
66130 .......... Remove eye lesion ......................................... Y ................. .................... A2 ............... $995.00 24.0821 $997.00 $995.50
66150 .......... Glaucoma surgery .......................................... Y ................. .................... A2 ............... $630.00 24.0821 $997.00 $721.75
66172 .......... Incision of eye ................................................ Y ................. .................... A2 ............... $630.00 24.0821 $997.00 $721.75
66180 .......... Implant eye shunt ........................................... Y ................. .................... A2 ............... $717.00 40.8481 $1,691.11 $960.53
66185 .......... Revise eye shunt ............................................ Y ................. .................... A2 ............... $446.00 40.8481 $1,691.11 $757.28
66220 .......... Repair eye lesion ........................................... Y ................. .................... A2 ............... $510.00 38.1121 $1,577.84 $776.96
66225 .......... Repair/graft eye lesion ................................... Y ................. .................... A2 ............... $630.00 40.8481 $1,691.11 $895.28
66250 .......... Follow-up surgery of eye ................................ Y ................. .................... A2 ............... $446.00 16.5252 $684.14 $505.54
66500 .......... Incision of iris ................................................. Y ................. .................... A2 ............... $333.00 5.1145 $211.74 $302.69
66505 .......... Incision of iris ................................................. Y ................. .................... A2 ............... $333.00 5.1145 $211.74 $302.69
66600 .......... Remove iris and lesion ................................... Y ................. .................... A2 ............... $510.00 24.0821 $997.00 $631.75
66605 .......... Removal of iris ............................................... Y ................. .................... A2 ............... $510.00 24.0821 $997.00 $631.75
66680 .......... Repair iris & ciliary body ................................ Y ................. .................... A2 ............... $510.00 24.0821 $997.00 $631.75
66682 .......... Repair iris & ciliary body ................................ Y ................. .................... A2 ............... $446.00 24.0821 $997.00 $583.75
66700 .......... Destruction, ciliary body ................................. Y ................. .................... A2 ............... $446.00 16.5252 $684.14 $505.54
66710 .......... Ciliary transsleral therapy ............................... Y ................. .................... A2 ............... $446.00 16.5252 $684.14 $505.54
66711 .......... Ciliary endoscopic ablation ............................ Y ................. .................... A2 ............... $446.00 16.5252 $684.14 $505.54
66761 .......... Revision of iris ................................................ Y ................. .................... P3 ............... .................... 4.4029 $182.28 $182.28
66762 .......... Revision of iris ................................................ Y ................. .................... P3 ............... .................... 4.4606 $184.67 $184.67
66770 .......... Removal of inner eye lesion .......................... Y ................. .................... P3 ............... .................... 4.8234 $199.69 $199.69
66820 .......... Incision, secondary cataract ........................... Y ................. .................... G2 .............. .................... 5.1145 $211.74 $211.74
66821 .......... After cataract laser surgery ............................ Y ................. .................... A2 ............... $312.50 5.2389 $216.89 $288.60
66825 .......... Reposition intraocular lens ............................. Y ................. .................... A2 ............... $630.00 24.0821 $997.00 $721.75
66830 .......... Removal of lens lesion ................................... Y ................. .................... A2 ............... $372.94 5.1145 $211.74 $332.64
66840 .......... Removal of lens material ............................... Y ................. .................... A2 ............... $630.00 14.9022 $616.95 $626.74
66850 .......... Removal of lens material ............................... Y ................. .................... A2 ............... $995.00 29.7487 $1,231.60 $1,054.15
66852 .......... Removal of lens material ............................... Y ................. .................... A2 ............... $630.00 29.7487 $1,231.60 $780.40
66920 .......... Extraction of lens ............................................ Y ................. .................... A2 ............... $630.00 29.7487 $1,231.60 $780.40
66930 .......... Extraction of lens ............................................ Y ................. .................... A2 ............... $717.00 29.7487 $1,231.60 $845.65
66940 .......... Extraction of lens ............................................ Y ................. .................... A2 ............... $717.00 14.9022 $616.95 $691.99
66982 .......... Cataract surgery, complex ............................. Y ................. .................... A2 ............... $973.00 24.2197 $1,002.70 $980.43
66983 .......... Cataract surg w/iol, 1 stage ........................... Y ................. .................... A2 ............... $973.00 24.2197 $1,002.70 $980.43
66984 .......... Cataract surg w/iol, 1 stage ........................... Y ................. .................... A2 ............... $973.00 24.2197 $1,002.70 $980.43
66985 .......... Insert lens prosthesis ..................................... Y ................. .................... A2 ............... $826.00 24.2197 $1,002.70 $870.18
66986 .......... Exchange lens prosthesis .............................. Y ................. .................... A2 ............... $826.00 24.2197 $1,002.70 $870.18
66990 .......... Ophthalmic endoscope add-on ...................... N ................. .................... N1 ............... .................... .................... .................... ....................
67005 .......... Partial removal of eye fluid ............................ Y ................. .................... A2 ............... $630.00 29.0019 $1,200.68 $772.67
67010 .......... Partial removal of eye fluid ............................ Y ................. .................... A2 ............... $630.00 29.0019 $1,200.68 $772.67
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
67015 .......... Release of eye fluid ....................................... Y ................. .................... A2 ............... $333.00 29.0019 $1,200.68 $549.92
67025 .......... Replace eye fluid ............................................ Y ................. .................... A2 ............... $333.00 29.0019 $1,200.68 $549.92
67027 .......... Implant eye drug system ................................ Y ................. .................... A2 ............... $630.00 38.1121 $1,577.84 $866.96
67028 .......... Injection eye drug ........................................... N ................. .................... P3 ............... .................... 2.0200 $83.63 $83.63
67030 .......... Incise inner eye strands ................................. Y ................. .................... A2 ............... $333.00 18.8779 $781.55 $445.14
67031 .......... Laser surgery, eye strands ............................ Y ................. .................... A2 ............... $312.50 5.2389 $216.89 $288.60
67036 .......... Removal of inner eye fluid ............................. Y ................. .................... A2 ............... $630.00 38.1121 $1,577.84 $866.96
67038 .......... Strip retinal membrane ................................... Y ................. .................... A2 ............... $717.00 38.1121 $1,577.84 $932.21
67039 .......... Laser treatment of retina ................................ Y ................. .................... A2 ............... $995.00 38.1121 $1,577.84 $1,140.71
67040 .......... Laser treatment of retina ................................ Y ................. .................... A2 ............... $995.00 38.1121 $1,577.84 $1,140.71
67101 .......... Repair detached retina ................................... Y ................. .................... P3 ............... .................... 7.3135 $302.78 $302.78
67107 .......... Repair detached retina ................................... Y ................. .................... A2 ............... $717.00 38.1121 $1,577.84 $932.21
67108 .......... Repair detached retina ................................... Y ................. .................... A2 ............... $995.00 38.1121 $1,577.84 $1,140.71
67112 .......... Rerepair detached retina ................................ Y ................. .................... A2 ............... $995.00 38.1121 $1,577.84 $1,140.71
67115 .......... Release encircling material ............................ Y ................. .................... A2 ............... $446.00 18.8779 $781.55 $529.89
67120 .......... Remove eye implant material ........................ Y ................. .................... A2 ............... $446.00 18.8779 $781.55 $529.89
67121 .......... Remove eye implant material ........................ Y ................. .................... A2 ............... $446.00 29.0019 $1,200.68 $634.67
67141 .......... Treatment of retina ......................................... Y ................. .................... A2 ............... $241.77 4.0100 $166.01 $222.83
67145 .......... Treatment of retina ......................................... Y ................. .................... P3 ............... .................... 4.6007 $190.47 $190.47
67208 .......... Treatment of retinal lesion ............................. Y ................. .................... P3 ............... .................... 4.8976 $202.76 $202.76
67218 .......... Treatment of retinal lesion ............................. Y ................. .................... A2 ............... $717.00 18.8779 $781.55 $733.14
67220 .......... Treatment of choroid lesion ........................... Y ................. .................... P2 ............... .................... 4.0100 $166.01 $166.01
67221 .......... Ocular photodynamic ther .............................. Y ................. .................... P3 ............... .................... 3.0094 $124.59 $124.59
67225 .......... Eye photodynamic ther add-on ...................... Y ................. .................... P3 ............... .................... 0.1978 $8.19 $8.19
67227 .......... Treatment of retinal lesion ............................. Y ................. .................... A2 ............... $333.00 29.0019 $1,200.68 $549.92
67250 .......... Reinforce eye wall .......................................... Y ................. .................... A2 ............... $510.00 19.2280 $796.04 $581.51
67255 .......... Reinforce/graft eye wall .................................. Y ................. .................... A2 ............... $510.00 29.0019 $1,200.68 $682.67
67311 .......... Revise eye muscle ......................................... Y ................. .................... A2 ............... $510.00 24.3920 $1,009.83 $634.96
67312 .......... Revise two eye muscles ................................ Y ................. .................... A2 ............... $630.00 24.3920 $1,009.83 $724.96
67314 .......... Revise eye muscle ......................................... Y ................. .................... A2 ............... $630.00 24.3920 $1,009.83 $724.96
67316 .......... Revise two eye muscles ................................ Y ................. .................... A2 ............... $630.00 24.3920 $1,009.83 $724.96
67318 .......... Revise eye muscle(s) ..................................... Y ................. .................... A2 ............... $630.00 24.3920 $1,009.83 $724.96
67320 .......... Revise eye muscle(s) add-on ........................ Y ................. .................... A2 ............... $630.00 24.3920 $1,009.83 $724.96
67331 .......... Eye surgery follow-up add-on ........................ Y ................. .................... A2 ............... $630.00 24.3920 $1,009.83 $724.96
67332 .......... Rerevise eye muscles add-on ........................ Y ................. .................... A2 ............... $630.00 24.3920 $1,009.83 $724.96
67334 .......... Revise eye muscle w/suture .......................... Y ................. .................... A2 ............... $630.00 24.3920 $1,009.83 $724.96
67335 .......... Eye suture during surgery .............................. Y ................. .................... A2 ............... $630.00 24.3920 $1,009.83 $724.96
67340 .......... Revise eye muscle add-on ............................. Y ................. .................... A2 ............... $630.00 24.3920 $1,009.83 $724.96
67343 .......... Release eye tissue ......................................... Y ................. .................... A2 ............... $995.00 24.3920 $1,009.83 $998.71
67345 .......... Destroy nerve of eye muscle ......................... Y ................. .................... P3 ............... .................... 1.9787 $81.92 $81.92
67346 .......... Biopsy, eye muscle ........................................ Y ................. .................... A2 ............... $333.00 14.2784 $591.13 $397.53
67400 .......... Explore/biopsy eye socket ............................. Y ................. .................... A2 ............... $510.00 24.8916 $1,030.51 $640.13
67405 .......... Explore/drain eye socket ................................ Y ................. .................... A2 ............... $630.00 24.8916 $1,030.51 $730.13
67412 .......... Explore/treat eye socket ................................. Y ................. .................... A2 ............... $717.00 24.8916 $1,030.51 $795.38
67414 .......... Explr/decompress eye socket ........................ Y ................. .................... G2 .............. .................... 37.3504 $1,546.31 $1,546.31
67415 .......... Aspiration, orbital contents ............................. Y ................. .................... A2 ............... $333.00 19.2280 $796.04 $448.76
67440 .......... Explore/drain eye socket ................................ Y ................. .................... A2 ............... $717.00 37.3504 $1,546.31 $924.33
67445 .......... Explr/decompress eye socket ........................ Y ................. .................... A2 ............... $717.00 37.3504 $1,546.31 $924.33
67450 .......... Explore/biopsy eye socket ............................. Y ................. .................... A2 ............... $717.00 37.3504 $1,546.31 $924.33
67500 .......... Inject/treat eye socket .................................... N ................. .................... G2 .............. .................... 2.3117 $95.70 $95.70
67505 .......... Inject/treat eye socket .................................... Y ................. .................... G2 .............. .................... 2.8636 $118.55 $118.55
67515 .......... Inject/treat eye socket .................................... Y ................. .................... P3 ............... .................... 0.5688 $23.55 $23.55
67550 .......... Insert eye socket implant ............................... Y ................. .................... A2 ............... $630.00 37.3504 $1,546.31 $859.08
67560 .......... Revise eye socket implant ............................. Y ................. .................... A2 ............... $446.00 24.8916 $1,030.51 $592.13
67570 .......... Decompress optic nerve ................................ Y ................. .................... A2 ............... $630.00 37.3504 $1,546.31 $859.08
67700 .......... Drainage of eyelid abscess ............................ Y ................. .................... P2 ............... .................... 2.8636 $118.55 $118.55
67710 .......... Incision of eyelid ............................................. Y ................. .................... P3 ............... .................... 3.7432 $154.97 $154.97
67715 .......... Incision of eyelid fold ...................................... Y ................. .................... A2 ............... $333.00 19.2280 $796.04 $448.76
67800 .......... Remove eyelid lesion ..................................... Y ................. .................... P3 ............... .................... 1.2534 $51.89 $51.89
67801 .......... Remove eyelid lesions ................................... Y ................. .................... P3 ............... .................... 1.5089 $62.47 $62.47
67805 .......... Remove eyelid lesions ................................... Y ................. .................... P3 ............... .................... 1.9541 $80.90 $80.90
67808 .......... Remove eyelid lesion(s) ................................. Y ................. .................... A2 ............... $446.00 19.2280 $796.04 $533.51
67810 .......... Biopsy of eyelid .............................................. Y ................. .................... P2 ............... .................... 2.8636 $118.55 $118.55
67820 .......... Revise eyelashes ........................................... N ................. .................... P3 ............... .................... 0.4370 $18.09 $18.09
67825 .......... Revise eyelashes ........................................... Y ................. .................... P3 ............... .................... 1.2944 $53.59 $53.59
67830 .......... Revise eyelashes ........................................... Y ................. .................... A2 ............... $446.00 7.1099 $294.35 $408.09
67835 .......... Revise eyelashes ........................................... Y ................. .................... A2 ............... $446.00 19.2280 $796.04 $533.51
67840 .......... Remove eyelid lesion ..................................... Y ................. .................... P3 ............... .................... 3.8751 $160.43 $160.43
67850 .......... Treat eyelid lesion .......................................... Y ................. .................... P3 ............... .................... 2.7457 $113.67 $113.67
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
67875 .......... Closure of eyelid by suture ............................ Y ................. .................... G2 .............. .................... 7.1099 $294.35 $294.35
67900 .......... Repair brow defect ......................................... Y ................. .................... A2 ............... $630.00 19.2280 $796.04 $671.51
67901 .......... Repair eyelid defect ....................................... Y ................. .................... A2 ............... $717.00 19.2280 $796.04 $736.76
67909 .......... Revise eyelid defect ....................................... Y ................. .................... A2 ............... $630.00 19.2280 $796.04 $671.51
67911 .......... Revise eyelid defect ....................................... Y ................. .................... A2 ............... $510.00 19.2280 $796.04 $581.51
67912 .......... Correction eyelid w/implant ............................ Y ................. .................... A2 ............... $510.00 19.2280 $796.04 $581.51
67915 .......... Repair eyelid defect ....................................... Y ................. .................... P3 ............... .................... 4.2792 $177.16 $177.16
67922 .......... Repair eyelid defect ....................................... Y ................. .................... P3 ............... .................... 4.1969 $173.75 $173.75
67930 .......... Repair eyelid wound ....................................... Y ................. .................... P3 ............... .................... 4.1720 $172.72 $172.72
67935 .......... Repair eyelid wound ....................................... Y ................. .................... A2 ............... $446.00 19.2280 $796.04 $533.51
67938 .......... Remove eyelid foreign body .......................... N ................. .................... P2 ............... .................... 1.1576 $47.92 $47.92
67971 .......... Reconstruction of eyelid ................................. Y ................. .................... A2 ............... $510.00 24.8916 $1,030.51 $640.13
67975 .......... Reconstruction of eyelid ................................. Y ................. .................... A2 ............... $510.00 19.2280 $796.04 $581.51
68020 .......... Incise/drain eyelid lining ................................. Y ................. .................... P3 ............... .................... 1.0966 $45.40 $45.40
68040 .......... Treatment of eyelid lesions ............................ N ................. .................... P3 ............... .................... 0.5442 $22.53 $22.53
68100 .......... Biopsy of eyelid lining .................................... Y ................. .................... P3 ............... .................... 2.3169 $95.92 $95.92
68110 .......... Remove eyelid lining lesion ........................... Y ................. .................... P3 ............... .................... 2.9684 $122.89 $122.89
68115 .......... Remove eyelid lining lesion ........................... Y ................. .................... A2 ............... $446.00 19.2280 $796.04 $533.51
68130 .......... Remove eyelid lining lesion ........................... Y ................. .................... A2 ............... $446.00 16.5252 $684.14 $505.54
68135 .......... Remove eyelid lining lesion ........................... Y ................. .................... P3 ............... .................... 1.4099 $58.37 $58.37
68200 .......... Treat eyelid by injection ................................. N ................. .................... P3 ............... .................... 0.4123 $17.07 $17.07
68320 .......... Revise/graft eyelid lining ................................ Y ................. .................... A2 ............... $630.00 19.2280 $796.04 $671.51
68325 .......... Revise/graft eyelid lining ................................ Y ................. .................... A2 ............... $630.00 24.8916 $1,030.51 $730.13
68330 .......... Revise eyelid lining ........................................ Y ................. .................... A2 ............... $630.00 24.0821 $997.00 $721.75
68340 .......... Separate eyelid adhesions ............................. Y ................. .................... A2 ............... $630.00 19.2280 $796.04 $671.51
68371 .......... Harvest eye tissue, alograft ........................... Y ................. .................... A2 ............... $446.00 16.5252 $684.14 $505.54
68400 .......... Incise/drain tear gland .................................... Y ................. .................... P2 ............... .................... 2.8636 $118.55 $118.55
68420 .......... Incise/drain tear sac ....................................... Y ................. .................... P3 ............... .................... 4.4606 $184.67 $184.67
68440 .......... Incise tear duct opening ................................. Y ................. .................... P3 ............... .................... 1.3771 $57.01 $57.01
68500 .......... Removal of tear gland .................................... Y ................. .................... A2 ............... $510.00 24.8916 $1,030.51 $640.13
68505 .......... Partial removal, tear gland ............................. Y ................. .................... A2 ............... $510.00 24.8916 $1,030.51 $640.13
68510 .......... Biopsy of tear gland ....................................... Y ................. .................... A2 ............... $333.00 19.2280 $796.04 $448.76
68520 .......... Removal of tear sac ....................................... Y ................. .................... A2 ............... $510.00 24.8916 $1,030.51 $640.13
68525 .......... Biopsy of tear sac .......................................... Y ................. .................... A2 ............... $333.00 19.2280 $796.04 $448.76
68530 .......... Clearance of tear duct .................................... Y ................. .................... P3 ............... .................... 5.6973 $235.87 $235.87
68540 .......... Remove tear gland lesion .............................. Y ................. .................... A2 ............... $510.00 24.8916 $1,030.51 $640.13
68550 .......... Remove tear gland lesion .............................. Y ................. .................... A2 ............... $510.00 24.8916 $1,030.51 $640.13
68700 .......... Repair tear ducts ............................................ Y ................. .................... A2 ............... $446.00 24.8916 $1,030.51 $592.13
68705 .......... Revise tear duct opening ............................... Y ................. .................... P2 ............... .................... 2.8636 $118.55 $118.55
68720 .......... Create tear sac drain ..................................... Y ................. .................... A2 ............... $630.00 24.8916 $1,030.51 $730.13
68745 .......... Create tear duct drain .................................... Y ................. .................... A2 ............... $630.00 24.8916 $1,030.51 $730.13
68750 .......... Create tear duct drain .................................... Y ................. .................... A2 ............... $630.00 24.8916 $1,030.51 $730.13
68760 .......... Close tear duct opening ................................. N ................. .................... P2 ............... .................... 2.3117 $95.70 $95.70
68761 .......... Close tear duct opening ................................. N ................. .................... P3 ............... .................... 1.6986 $70.32 $70.32
68770 .......... Close tear system fistula ................................ Y ................. .................... A2 ............... $630.00 19.2280 $796.04 $671.51
68801 .......... Dilate tear duct opening ................................. N ................. .................... P2 ............... .................... 1.1576 $47.92 $47.92
68810 .......... Probe nasolacrimal duct ................................. N ................. .................... A2 ............... $131.86 2.3117 $95.70 $122.82
68811 .......... Probe nasolacrimal duct ................................. Y ................. .................... A2 ............... $446.00 19.2280 $796.04 $533.51
68815 .......... Probe nasolacrimal duct ................................. Y ................. .................... A2 ............... $446.00 19.2280 $796.04 $533.51
68840 .......... Explore/irrigate tear ducts .............................. N ................. .................... P2 ............... .................... 1.1576 $47.92 $47.92
68850 .......... Injection for tear sac x-ray ............................. N ................. .................... N1 ............... .................... .................... .................... ....................
69000 .......... Drain external ear lesion ................................ Y ................. .................... P2 ............... .................... 1.4630 $60.57 $60.57
69005 .......... Drain external ear lesion ................................ Y ................. .................... P3 ............... .................... 2.4075 $99.67 $99.67
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
69020 .......... Drain outer ear canal lesion ........................... Y ................. .................... P2 ............... .................... 1.4630 $60.57 $60.57
69100 .......... Biopsy of external ear .................................... Y ................. .................... P3 ............... .................... 1.4676 $60.76 $60.76
69105 .......... Biopsy of external ear canal .......................... Y ................. .................... P3 ............... .................... 2.0283 $83.97 $83.97
69110 .......... Remove external ear, partial .......................... Y ................. .................... A2 ............... $333.00 16.5832 $686.54 $421.39
69120 .......... Removal of external ear ................................. Y ................. .................... A2 ............... $446.00 24.3535 $1,008.23 $586.56
69140 .......... Remove ear canal lesion(s) ........................... Y ................. .................... A2 ............... $446.00 24.3535 $1,008.23 $586.56
69145 .......... Remove ear canal lesion(s) ........................... Y ................. .................... A2 ............... $446.00 16.5832 $686.54 $506.14
69150 .......... Extensive ear canal surgery ........................... Y ................. .................... A2 ............... $464.15 7.6539 $316.87 $427.33
69200 .......... Clear outer ear canal ..................................... N ................. .................... P2 ............... .................... 0.6416 $26.56 $26.56
69205 .......... Clear outer ear canal ..................................... Y ................. .................... A2 ............... $333.00 21.4534 $888.17 $471.79
69210 .......... Remove impacted ear wax ............................ N ................. .................... P3 ............... .................... 0.4947 $20.48 $20.48
69220 .......... Clean out mastoid cavity ................................ Y ................. .................... P2 ............... .................... 0.8046 $33.31 $33.31
69222 .......... Clean out mastoid cavity ................................ Y ................. .................... P3 ............... .................... 3.1826 $131.76 $131.76
69300 .......... Revise external ear ........................................ Y ................. .................... A2 ............... $510.00 24.3535 $1,008.23 $634.56
69310 .......... Rebuild outer ear canal .................................. Y ................. .................... A2 ............... $510.00 40.5598 $1,679.18 $802.30
69320 .......... Rebuild outer ear canal .................................. Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
69400 .......... Inflate middle ear canal .................................. Y ................. .................... P3 ............... .................... 2.0200 $83.63 $83.63
69401 .......... Inflate middle ear canal .................................. Y ................. .................... P3 ............... .................... 1.1295 $46.76 $46.76
69405 .......... Catheterize middle ear canal ......................... Y ................. .................... P3 ............... .................... 2.9188 $120.84 $120.84
69420 .......... Incision of eardrum ......................................... Y ................. .................... P2 ............... .................... 2.5765 $106.67 $106.67
69421 .......... Incision of eardrum ......................................... Y ................. .................... A2 ............... $510.00 16.6341 $688.65 $554.66
69424 .......... Remove ventilating tube ................................. Y ................. .................... P3 ............... .................... 1.8386 $76.12 $76.12
69433 .......... Create eardrum opening ................................ Y ................. .................... P3 ............... .................... 2.6056 $107.87 $107.87
69436 .......... Create eardrum opening ................................ Y ................. .................... A2 ............... $510.00 16.6341 $688.65 $554.66
69440 .......... Exploration of middle ear ............................... Y ................. .................... A2 ............... $510.00 24.3535 $1,008.23 $634.56
69450 .......... Eardrum revision ............................................ Y ................. .................... A2 ............... $333.00 40.5598 $1,679.18 $669.55
69501 .......... Mastoidectomy ............................................... Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
69502 .......... Mastoidectomy ............................................... Y ................. .................... A2 ............... $995.00 24.3535 $1,008.23 $998.31
69505 .......... Remove mastoid structures ........................... Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
69511 .......... Extensive mastoid surgery ............................. Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
69530 .......... Extensive mastoid surgery ............................. Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
69540 .......... Remove ear lesion ......................................... Y ................. .................... P3 ............... .................... 3.1085 $128.69 $128.69
69550 .......... Remove ear lesion ......................................... Y ................. .................... A2 ............... $717.00 40.5598 $1,679.18 $957.55
69552 .......... Remove ear lesion ......................................... Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
69601 .......... Mastoid surgery revision ................................ Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
69610 .......... Repair of eardrum .......................................... Y ................. .................... P3 ............... .................... 4.2546 $176.14 $176.14
69620 .......... Repair of eardrum .......................................... Y ................. .................... A2 ............... $446.00 24.3535 $1,008.23 $586.56
69631 .......... Repair eardrum structures ............................. Y ................. .................... A2 ............... $717.00 40.5598 $1,679.18 $957.55
69632 .......... Rebuild eardrum structures ............................ Y ................. .................... A2 ............... $717.00 40.5598 $1,679.18 $957.55
69633 .......... Rebuild eardrum structures ............................ Y ................. .................... A2 ............... $717.00 40.5598 $1,679.18 $957.55
69635 .......... Repair eardrum structures ............................. Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
69636 .......... Rebuild eardrum structures ............................ Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
69637 .......... Rebuild eardrum structures ............................ Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
69641 .......... Revise middle ear & mastoid ......................... Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
69650 .......... Release middle ear bone ............................... Y ................. .................... A2 ............... $995.00 24.3535 $1,008.23 $998.31
69660 .......... Revise middle ear bone ................................. Y ................. .................... A2 ............... $717.00 40.5598 $1,679.18 $957.55
69666 .......... Repair middle ear structures .......................... Y ................. .................... A2 ............... $630.00 40.5598 $1,679.18 $892.30
69667 .......... Repair middle ear structures .......................... Y ................. .................... A2 ............... $630.00 40.5598 $1,679.18 $892.30
69670 .......... Remove mastoid air cells ............................... Y ................. .................... A2 ............... $510.00 40.5598 $1,679.18 $802.30
69676 .......... Remove middle ear nerve .............................. Y ................. .................... A2 ............... $510.00 40.5598 $1,679.18 $802.30
69700 .......... Close mastoid fistula ...................................... Y ................. .................... A2 ............... $510.00 40.5598 $1,679.18 $802.30
69711 .......... Remove/repair hearing aid ............................. Y ................. .................... A2 ............... $333.00 40.5598 $1,679.18 $669.55
69714 .......... Implant temple bone w/stimul ........................ Y ................. .................... A2 ............... $1,339.00 40.5598 $1,679.18 $1,424.05
69715 .......... Temple bne implnt w/stimulat ........................ Y ................. .................... A2 ............... $1,339.00 40.5598 $1,679.18 $1,424.05
69717 .......... Temple bone implant revision ........................ Y ................. .................... A2 ............... $1,339.00 40.5598 $1,679.18 $1,424.05
69718 .......... Revise temple bone implant ........................... Y ................. .................... A2 ............... $1,339.00 40.5598 $1,679.18 $1,424.05
69720 .......... Release facial nerve ....................................... Y ................. .................... A2 ............... $717.00 40.5598 $1,679.18 $957.55
69740 .......... Repair facial nerve ......................................... Y ................. .................... A2 ............... $717.00 40.5598 $1,679.18 $957.55
69745 .......... Repair facial nerve ......................................... Y ................. .................... A2 ............... $717.00 40.5598 $1,679.18 $957.55
69801 .......... Incise inner ear ............................................... Y ................. .................... A2 ............... $717.00 40.5598 $1,679.18 $957.55
69802 .......... Incise inner ear ............................................... Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
69805 .......... Explore inner ear ............................................ Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
69806 .......... Explore inner ear ............................................ Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
69820 .......... Establish inner ear window ............................ Y ................. .................... A2 ............... $717.00 40.5598 $1,679.18 $957.55
69840 .......... Revise inner ear window ................................ Y ................. .................... A2 ............... $717.00 40.5598 $1,679.18 $957.55
Proposed Proposed
Subject to Proposed
CY 2007 CY 2008 CY 2008
69905 .......... Remove inner ear ........................................... Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
69910 .......... Remove inner ear & mastoid ......................... Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
69915 .......... Incise inner ear nerve .................................... Y ................. .................... A2 ............... $995.00 40.5598 $1,679.18 $1,166.05
69930 .......... Implant cochlear device ................................. Y ................. .................... H8 .............. $995.00 585.1167 $24,223.83 $22,839.55
69990 .......... Microsurgery add-on ...................................... N ................. .................... N1 .............. .................... .................... .................... ....................
C9716 ......... Radiofrequency energy to anu ....................... Y ................. .................... G2 .............. .................... 30.5544 $1,264.95 $1,264.95
C9724 ......... EPS gast cardia plic ....................................... Y ................. .................... G2 .............. .................... 24.6480 $1,020.43 $1,020.43
C9725 ......... Place endorectal app ..................................... N ................. .................... G2 .............. .................... 8.6353 $357.50 $357.50
C9726 ......... Rxt breast appl place/remov .......................... N ................. .................... G2 .............. .................... 10.2053 $422.50 $422.50
C9727 ......... Insert palate implants ..................................... N ................. .................... G2 .............. .................... 13.3454 $552.50 $552.50
G0104 ......... CA screen;flexi sigmoidscope ........................ N ................. .................... P3 ............... .................... 1.9705 $81.58 $81.58
G0105 ......... Colorectal scrn; hi risk ind .............................. Y ................. .................... A2 ............... $446.00 8.0134 $331.75 $417.44
G0121 ......... Colon ca scrn not hi rsk ind ........................... Y ................. .................... A2 ............... $446.00 8.0134 $331.75 $417.44
G0127 ......... Trim nail(s) ..................................................... Y ................. .................... P3 ............... .................... 0.2556 $10.58 $10.58
G0186 ......... Dstry eye lesn,fdr vssl tech ............................ Y ................. .................... R2 .............. .................... 4.0100 $166.01 $166.01
G0247 ......... Routine footcare pt w lops ............................. Y ................. .................... P3 ............... .................... 0.4865 $20.14 $20.14
G0260 ......... Inj for sacroiliac jt anesth ............................... Y ................. .................... A2 ............... $333.00 7.1370 $295.47 $323.62
G0268 ......... Removal of impacted wax md ........................ N ................. CH .............. N1 ............... .................... .................... .................... ....................
G0364 ......... Bone marrow aspirate &biopsy ...................... Y ................. .................... P3 ............... .................... 0.1237 $5.12 $5.12
G0392 ......... AV fistula or graft arterial ............................... Y ................. .................... A2 ............... $1,339.00 46.0685 $1,907.24 $1,481.06
G0393 ......... AV fistula or graft venous ............................... Y ................. .................... A2 ............... $1,339.00 46.0685 $1,907.24 $1,481.06
ADDENDUM B.—PROPOSED OPPS PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION FOR CY 2008
National Minimum
HCPCS Relative Payment
Short descriptor CI SI APC unadjusted unadjusted
code weight rate copayment copayment
00100 ......... Anesth, salivary gland ..................................... .................... N ................. .................... .................... .................... .................... ....................
00102 ......... Anesth, repair of cleft lip ................................. .................... N ................. .................... .................... .................... .................... ....................
00103 ......... Anesth, blepharoplasty .................................... .................... N ................. .................... .................... .................... .................... ....................
00104 ......... Anesth, electroshock ....................................... .................... N ................. .................... .................... .................... .................... ....................
00120 ......... Anesth, ear surgery ......................................... .................... N ................. .................... .................... .................... .................... ....................
00124 ......... Anesth, ear exam ............................................ .................... N ................. .................... .................... .................... .................... ....................
00126 ......... Anesth, tympanotomy ...................................... .................... N ................. .................... .................... .................... .................... ....................
0012F ......... Cap bacterial assess ....................................... .................... M ................ .................... .................... .................... .................... ....................
00140 ......... Anesth, procedures on eye ............................. .................... N ................. .................... .................... .................... .................... ....................
00142 ......... Anesth, lens surgery ....................................... .................... N ................. .................... .................... .................... .................... ....................
00144 ......... Anesth, corneal transplant .............................. .................... N ................. .................... .................... .................... .................... ....................
00145 ......... Anesth, vitreoretinal surg ................................ .................... N ................. .................... .................... .................... .................... ....................
00147 ......... Anesth, iridectomy ........................................... .................... N ................. .................... .................... .................... .................... ....................
00148 ......... Anesth, eye exam ........................................... .................... N ................. .................... .................... .................... .................... ....................
00160 ......... Anesth, nose/sinus surgery ............................. .................... N ................. .................... .................... .................... .................... ....................
00162 ......... Anesth, nose/sinus surgery ............................. .................... N ................. .................... .................... .................... .................... ....................
00164 ......... Anesth, biopsy of nose .................................... .................... N ................. .................... .................... .................... .................... ....................
0016T ......... Thermotx choroid vasc lesion ......................... .................... T ................. 0235 4.01 $255.41 $58.90 $51.08
00170 ......... Anesth, procedure on mouth ........................... .................... N ................. .................... .................... .................... .................... ....................
00172 ......... Anesth, cleft palate repair ............................... .................... N ................. .................... .................... .................... .................... ....................
00174 ......... Anesth, pharyngeal surgery ............................ .................... N ................. .................... .................... .................... .................... ....................
00176 ......... Anesth, pharyngeal surgery ............................ .................... C ................. .................... .................... .................... .................... ....................
0017T ......... Photocoagulat macular drusen ....................... .................... T ................. 0235 4.01 $255.41 $58.90 $51.08
00190 ......... Anesth, face/skull bone surg ........................... .................... N ................. .................... .................... .................... .................... ....................
00192 ......... Anesth, facial bone surgery ............................ .................... C ................. .................... .................... .................... .................... ....................
0019T ......... Extracorp shock wv tx,ms nos ........................ .................... A ................. .................... .................... .................... .................... ....................
00210 ......... Anesth, open head surgery ............................. .................... N ................. .................... .................... .................... .................... ....................
00212 ......... Anesth, skull drainage ..................................... .................... N ................. .................... .................... .................... .................... ....................
00214 ......... Anesth, skull drainage ..................................... .................... C ................. .................... .................... .................... .................... ....................
00215 ......... Anesth, skull repair/fract .................................. .................... C ................. .................... .................... .................... .................... ....................
00216 ......... Anesth, head vessel surgery ........................... .................... N ................. .................... .................... .................... .................... ....................
00218 ......... Anesth, special head surgery .......................... .................... N ................. .................... .................... .................... .................... ....................
00220 ......... Anesth, intrcrn nerve ....................................... .................... N ................. .................... .................... .................... .................... ....................
00222 ......... Anesth, head nerve surgery ............................ .................... N ................. .................... .................... .................... .................... ....................
0024T ......... Transcath cardiac reduction ............................ .................... C ................. .................... .................... .................... .................... ....................
0026T ......... Measure remnant lipoproteins ......................... .................... A ................. .................... .................... .................... .................... ....................
0027T ......... Endoscopic epidural lysis ................................ .................... T ................. 0220 18.5069 $1,178.76 .................... $235.75
0028T ......... Dexa body composition study ......................... .................... N ................. .................... .................... .................... .................... ....................
0029T ......... Magnetic tx for incontinence ........................... .................... A ................. .................... .................... .................... .................... ....................
00300 ......... Anesth, head/neck/ptrunk ................................ .................... N ................. .................... .................... .................... .................... ....................
0030T ......... Antiprothrombin antibody ................................ .................... A ................. .................... .................... .................... .................... ....................
0031T ......... Speculoscopy .................................................. .................... N ................. .................... .................... .................... .................... ....................
00320 ......... Anesth, neck organ, 1 & over ......................... .................... N ................. .................... .................... .................... .................... ....................
00322 ......... Anesth, biopsy of thyroid ................................. .................... N ................. .................... .................... .................... .................... ....................
00326 ......... Anesth, larynx/trach, < 1 yr ............................. .................... N ................. .................... .................... .................... .................... ....................
0032T ......... Speculoscopy w/direct sample ........................ .................... N ................. .................... .................... .................... .................... ....................
00350 ......... Anesth, neck vessel surgery ........................... .................... N ................. .................... .................... .................... .................... ....................
00352 ......... Anesth, neck vessel surgery ........................... .................... N ................. .................... .................... .................... .................... ....................
00400 ......... Anesth, skin, ext/per/atrunk ............................. .................... N ................. .................... .................... .................... .................... ....................
00402 ......... Anesth, surgery of breast ................................ .................... N ................. .................... .................... .................... .................... ....................
00410 ......... Anesth, correct heart rhythm ........................... .................... N ................. .................... .................... .................... .................... ....................
0041T ......... Detect ur infect agnt w/cpas ........................... .................... A ................. .................... .................... .................... .................... ....................
0042T ......... Ct perfusion w/contrast, cbf ............................ .................... N ................. .................... .................... .................... .................... ....................
0043T ......... Co expired gas analysis .................................. .................... A ................. .................... .................... .................... .................... ....................
00450 ......... Anesth, surgery of shoulder ............................ .................... N ................. .................... .................... .................... .................... ....................
00452 ......... Anesth, surgery of shoulder ............................ .................... C ................. .................... .................... .................... .................... ....................
00454 ......... Anesth, collar bone biopsy .............................. .................... N ................. .................... .................... .................... .................... ....................
0046T ......... Cath lavage, mammary duct(s) ....................... .................... T ................. 0021 16.5832 $1,056.23 $219.40 $211.25
00470 ......... Anesth, removal of rib ..................................... .................... N ................. .................... .................... .................... .................... ....................
00472 ......... Anesth, chest wall repair ................................. .................... N ................. .................... .................... .................... .................... ....................
00474 ......... Anesth, surgery of rib(s) .................................. .................... C ................. .................... .................... .................... .................... ....................
0047T ......... Cath lavage, mammary duct(s) ....................... .................... T ................. 0021 16.5832 $1,056.23 $219.40 $211.25
0048T ......... Implant ventricular device ............................... .................... C ................. .................... .................... .................... .................... ....................
0049T ......... External circulation assist ................................ .................... C ................. .................... .................... .................... .................... ....................
00500 ......... Anesth, esophageal surgery ........................... .................... N ................. .................... .................... .................... .................... ....................
0050T ......... Removal circulation assist ............................... .................... C ................. .................... .................... .................... .................... ....................
0051T ......... Implant total heart system ............................... .................... C ................. .................... .................... .................... .................... ....................
00520 ......... Anesth, chest procedure ................................. .................... N ................. .................... .................... .................... .................... ....................
00522 ......... Anesth, chest lining biopsy ............................. .................... N ................. .................... .................... .................... .................... ....................
00524 ......... Anesth, chest drainage ................................... .................... C ................. .................... .................... .................... .................... ....................
00528 ......... Anesth, chest partition view ............................ .................... N ................. .................... .................... .................... .................... ....................
00529 ......... Anesth, chest partition view ............................ .................... N ................. .................... .................... .................... .................... ....................
0052T ......... Replace component heart syst ....................... .................... C ................. .................... .................... .................... .................... ....................
00530 ......... Anesth, pacemaker insertion ........................... .................... N ................. .................... .................... .................... .................... ....................
00532 ......... Anesth, vascular access ................................. .................... N ................. .................... .................... .................... .................... ....................
00534 ......... Anesth, cardioverter/defib ............................... .................... N ................. .................... .................... .................... .................... ....................
00537 ......... Anesth, cardiac electrophys ............................ .................... N ................. .................... .................... .................... .................... ....................
00539 ......... Anesth, trach-bronch reconst .......................... .................... N ................. .................... .................... .................... .................... ....................
ADDENDUM B.—PROPOSED OPPS PAYMENT STATUS BY HCPCS CODE AND RELATED INFORMATION FOR CY 2008—
Continued
National Minimum
0053T ......... Replace component heart syst ....................... .................... C ................. .................... .................... .................... .................... ....................
00540 ......... Anesth, chest surgery ..................................... .................... C ................. .................... .................... .................... .................... ....................
00541 ......... Anesth, one lung ventilation ............................ .................... N ................. .................... .................... .................... .................... ....................
00542 ......... Anesth, release of lung ................................... .................... C ................. .................... .................... .................... .................... ....................
00546 ......... Anesth, lung,chest wall surg ........................... .................... C ................. .................... .................... .................... .................... ....................
00548 ......... Anesth, trachea,bronchi surg .......................... .................... N ................. .................... .................... .................... .................... ....................
0054T ......... Bone surgery using computer ......................... CH .............. N ................. .................... .................... .................... .................... ....................
00550 ......... Anesth, sternal debridement ........................... .................... N ................. .................... .................... .................... .................... ....................
00560 ......... Anesth, heart surg w/o pump .......................... .................... C ................. .................... .................... .................... .................... ....................
00561 ......... Anesth, heart surg < age 1 ............................. .................... C ................. .................... .................... .................... .................... ....................
00562 ......... Anesth, heart surg w/pump ............................. .................... C ................. .................... .................... .................... .................... ....................
00563 ......... Anesth, heart surg w/arrest ............................. .................... N ................. .................... .................... .................... .................... ....................
00566 ......... Anesth, cabg w/o pump .................................. .................... N ................. .................... .................... .................... .................... ....................
00580 ......... Anesth, heart/lung transplnt ............................ .................... C ................. .................... .................... .................... .................... ....................
0058T ......... Cryopreservation, ovary tiss ............................ CH .............. X ................. 0344 0.8586 $54.69 $15.60 $10.94
0059T ......... Cryopreservation, oocyte ................................ CH .............. X ................. 0344 0.8586 $54.69 $15.60 $10.94
00600 ......... Anesth, spine, cord surgery ............................ .................... N ................. .................... .................... .................... .................... ....................
00604 ......... Anesth, sitting procedure ................................ .................... C ................. .................... .................... .................... .................... ....................
0060T ......... Electrical impedance scan .............................. .................... B ................. .................... .................... .................... .................... ....................
0061T ......... Destruction of tumor, breast ............................ .................... B ................. .................... .................... .................... .................... ....................
00622 ......... Anesth, removal of nerves .............................. .................... C ................. .................... .................... .................... .................... ....................
00625 ......... Anes spine tranthor w/o vent .......................... .................... N ................. .................... .................... .................... .................... ....................
00626 ......... Anes, spine transthor w/vent ........................... .................... N ................. .................... .................... .................... .................... ....................
0062T ......... Rep intradisc annulus;1 lev ............................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
00632 ......... Anesth, removal of nerves .............................. .................... C ................. .................... .................... .................... .................... ....................
00634 ......... Anesth for chemonucleolysis .......................... .................... N ................. .................... .................... .................... .................... ....................
00635 ......... Anesth, lumbar puncture ................................. .................... N ................. .................... .................... .................... .................... ....................
0063T ......... Rep intradisc annulus;>1lev ............................ .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
00640 ......... Anesth, spine manipulation ............................. .................... N ................. .................... .................... .................... .................... ....................
0064T ......... Spectroscop eval expired gas ......................... .................... X ................. 0367 0.5955 $37.93 $14.38 $7.59
0065T ......... Ocular photoscreen bilat ................................. .................... E ................. .................... .................... .................... .................... ....................
0066T ......... Ct colonography;screen .................................. .................... E ................. .................... .................... .................... .................... ....................
00670 ......... Anesth, spine, cord surgery ............................ .................... C ................. .................... .................... .................... .................... ....................
0067T ......... Ct colonography;dx ......................................... CH .............. S ................. 0332 3.1487 $200.55 $75.20 $40.11
0068T ......... Interp/rept heart sound .................................... .................... B ................. .................... .................... .................... .................... ....................
0069T ......... Analysis only heart sound ............................... .................... N ................. .................... .................... .................... .................... ....................
00700 ......... Anesth, abdominal wall surg ........................... .................... N ................. .................... .................... .................... .................... ....................
00702 ......... Anesth, for liver biopsy .................................... .................... N ................. .................... .................... .................... .................... ....................
0070T ......... Interp only heart sound ................................... .................... B ................. .................... .................... .................... .................... ....................
0071T ......... U/s leiomyomata ablate <200 ......................... CH .............. S ................. 0067 61.5205 $3,918.43 .................... $783.69
0072T ......... U/s leiomyomata ablate >200 ......................... CH .............. S ................. 0067 61.5205 $3,918.43 .................... $783.69
0073T ......... Delivery, comp imrt ......................................... .................... S ................. 0412 5.7275 $364.80 .................... $72.96
00740 ......... Anesth, upper gi visualize ............................... .................... N ................. .................... .................... .................... .................... ....................
0074T ......... Online physician e/m ....................................... .................... E ................. .................... .................... .................... .................... ....................
00750 ......... Anesth, repair of hernia ................................... .................... N ................. .................... .................... .................... .................... ....................
0075T ......... Perq stent/chest vert art .................................. .................... C ................. .................... .................... .................... .................... ....................
0076T ......... S&i stent/chest vert art .................................... .................... C ................. .................... .................... .................... .................... ....................
00770 ......... Anesth, blood vessel repair ............................. .................... N ................. .................... .................... .................... .................... ....................
0077T ......... Cereb therm perfusion probe .......................... .................... C ................. .................... .................... .................... .................... ....................
0078T ......... Endovasc aort repr w/device ........................... .................... C ................. .................... .................... .................... .................... ....................
00790 ......... Anesth, surg upper abdomen .......................... .................... N ................. .................... .................... .................... .................... ....................
00792 ......... Anesth, hemorr/excise liver ............................. .................... C ................. .................... .................... .................... .................... ....................
00794 ......... Anesth, pancreas removal .............................. .................... C ................. .................... .................... .................... .................... ....................
00796 ......... Anesth, for liver transplant .............................. .................... C ................. .................... .................... .................... .................... ....................
00797 ......... Anesth, surgery for obesity ............................. .................... N ................. .................... .................... .................... .................... ....................
0079T ......... Endovasc visc extnsn repr .............................. .................... C ................. .................... .................... .................... .................... ....................
00802 ......... Anesth, fat layer removal ................................ .................... C ................. .................... .................... .................... .................... ....................
0080T ......... Endovasc aort repr rad s&i ............................. .................... C ................. .................... .................... .................... .................... ....................
00810 ......... Anesth, low intestine scope ............................ .................... N ................. .................... .................... .................... .................... ....................
0081T ......... Endovasc visc extnsn s&i ............................... .................... C ................. .................... .................... .................... .................... ....................
00834 ......... Anesth, hernia repair< 1 yr ............................. .................... N ................. .................... .................... .................... .................... ....................
00836 ......... Anesth hernia repair preemie .......................... .................... N ................. .................... .................... .................... .................... ....................
00840 ......... Anesth, surg lower abdomen .......................... .................... N ................. .................... .................... .................... .................... ....................
00842 ......... Anesth, amniocentesis .................................... .................... N ................. .................... .................... .................... .................... ....................
00844 ......... Anesth, pelvis surgery ..................................... .................... C ................. .................... .................... .................... .................... ....................
00846 ......... Anesth, hysterectomy ...................................... .................... C ................. .................... .................... .................... .................... ....................
Continued
National Minimum
00848 ......... Anesth, pelvic organ surg ............................... .................... C ................. .................... .................... .................... .................... ....................
0084T ......... Temp prostate urethral stent ........................... .................... T ................. 0164 2.1659 $137.95 .................... $27.59
00851 ......... Anesth, tubal ligation ....................................... .................... N ................. .................... .................... .................... .................... ....................
0085T ......... Breath test heart reject .................................... .................... X ................. 0340 0.6416 $40.87 .................... $8.17
00860 ......... Anesth, surgery of abdomen ........................... .................... N ................. .................... .................... .................... .................... ....................
00862 ......... Anesth, kidney/ureter surg .............................. .................... N ................. .................... .................... .................... .................... ....................
00864 ......... Anesth, removal of bladder ............................. .................... C ................. .................... .................... .................... .................... ....................
00865 ......... Anesth, removal of prostate ............................ .................... C ................. .................... .................... .................... .................... ....................
00866 ......... Anesth, removal of adrenal ............................. .................... C ................. .................... .................... .................... .................... ....................
00868 ......... Anesth, kidney transplant ................................ .................... C ................. .................... .................... .................... .................... ....................
0086T ......... L ventricle fill pressure .................................... .................... N ................. .................... .................... .................... .................... ....................
00870 ......... Anesth, bladder stone surg ............................. .................... N ................. .................... .................... .................... .................... ....................
00872 ......... Anesth kidney stone destruct .......................... .................... N ................. .................... .................... .................... .................... ....................
00873 ......... Anesth kidney stone destruct .......................... .................... N ................. .................... .................... .................... .................... ....................
0087T ......... Sperm eval hyaluronan ................................... CH .............. X ................. 0344 0.8586 $54.69 $15.60 $10.94
00880 ......... Anesth, abdomen vessel surg ......................... .................... N ................. .................... .................... .................... .................... ....................
00882 ......... Anesth, major vein ligation .............................. .................... C ................. .................... .................... .................... .................... ....................
0088T ......... Rf tongue base vol reduxn .............................. .................... T ................. 0253 16.6341 $1,059.48 $282.20 $211.90
0089T ......... Actigraphy testing, 3-day ................................. .................... S ................. 0218 1.1861 $75.55 .................... $15.11
00902 ......... Anesth, anorectal surgery ............................... .................... N ................. .................... .................... .................... .................... ....................
00904 ......... Anesth, perineal surgery ................................. .................... C ................. .................... .................... .................... .................... ....................
00906 ......... Anesth, removal of vulva ................................. .................... N ................. .................... .................... .................... .................... ....................
00908 ......... Anesth, removal of prostate ............................ .................... C ................. .................... .................... .................... .................... ....................
0090T ......... Cervical artific disc .......................................... .................... C ................. .................... .................... .................... .................... ....................
00910 ......... Anesth, bladder surgery .................................. .................... N ................. .................... .................... .................... .................... ....................
00912 ......... Anesth, bladder tumor surg ............................. .................... N ................. .................... .................... .................... .................... ....................
00914 ......... Anesth, removal of prostate ............................ .................... N ................. .................... .................... .................... .................... ....................
00916 ......... Anesth, bleeding control .................................. .................... N ................. .................... .................... .................... .................... ....................
00918 ......... Anesth, stone removal .................................... .................... N ................. .................... .................... .................... .................... ....................
00920 ......... Anesth, genitalia surgery ................................. .................... N ................. .................... .................... .................... .................... ....................
00921 ......... Anesth, vasectomy .......................................... .................... N ................. .................... .................... .................... .................... ....................
00922 ......... Anesth, sperm duct surgery ............................ .................... N ................. .................... .................... .................... .................... ....................
00924 ......... Anesth, testis exploration ................................ .................... N ................. .................... .................... .................... .................... ....................
00926 ......... Anesth, removal of testis ................................. .................... N ................. .................... .................... .................... .................... ....................
00928 ......... Anesth, removal of testis ................................. .................... N ................. .................... .................... .................... .................... ....................
0092T ......... Artific disc addl ................................................ .................... C ................. .................... .................... .................... .................... ....................
00930 ......... Anesth, testis suspension ............................... .................... N ................. .................... .................... .................... .................... ....................
00932 ......... Anesth, amputation of penis ........................... .................... C ................. .................... .................... .................... .................... ....................
00934 ......... Anesth, penis, nodes removal ......................... .................... C ................. .................... .................... .................... .................... ....................
00936 ......... Anesth, penis, nodes removal ......................... .................... C ................. .................... .................... .................... .................... ....................
00938 ......... Anesth, insert penis device ............................. .................... N ................. .................... .................... .................... .................... ....................
0093T ......... Cervical artific diskectomy ............................... .................... C ................. .................... .................... .................... .................... ....................
00940 ......... Anesth, vaginal procedures ............................. .................... N ................. .................... .................... .................... .................... ....................
00942 ......... Anesth, surg on vag/urethral ........................... .................... N ................. .................... .................... .................... .................... ....................
00944 ......... Anesth, vaginal hysterectomy ......................... .................... C ................. .................... .................... .................... .................... ....................
00948 ......... Anesth, repair of cervix ................................... .................... N ................. .................... .................... .................... .................... ....................
00950 ......... Anesth, vaginal endoscopy ............................. .................... N ................. .................... .................... .................... .................... ....................
00952 ......... Anesth, hysteroscope/graph ............................ .................... N ................. .................... .................... .................... .................... ....................
0095T ......... Artific diskectomy addl .................................... .................... C ................. .................... .................... .................... .................... ....................
0096T ......... Rev cervical artific disc ................................... .................... C ................. .................... .................... .................... .................... ....................
0098T ......... Rev artific disc addl ......................................... .................... C ................. .................... .................... .................... .................... ....................
0099T ......... Implant corneal ring ......................................... .................... T ................. 0233 16.5252 $1,052.54 $266.30 $210.51
0100T ......... Prosth retina receive&gen ............................... .................... T ................. 0672 38.1121 $2,427.47 .................... $485.49
0101T ......... Extracorp shockwv tx,hi enrg .......................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
0102T ......... Extracorp shockwv tx,anesth .......................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
0103T ......... Holotranscobalamin ......................................... .................... A ................. .................... .................... .................... .................... ....................
0104T ......... At rest cardio gas rebreathe ........................... .................... A ................. .................... .................... .................... .................... ....................
0105T ......... Exerc cardio gas rebreathe ............................. .................... A ................. .................... .................... .................... .................... ....................
0106T ......... Touch quant sensory test ................................ .................... X ................. 0341 0.0879 $5.60 $2.20 $1.12
0107T ......... Vibrate quant sensory test .............................. .................... X ................. 0341 0.0879 $5.60 $2.20 $1.12
0108T ......... Cool quant sensory test .................................. .................... X ................. 0341 0.0879 $5.60 $2.20 $1.12
0109T ......... Heat quant sensory test .................................. .................... X ................. 0341 0.0879 $5.60 $2.20 $1.12
0110T ......... Nos quant sensory test ................................... .................... X ................. 0341 0.0879 $5.60 $2.20 $1.12
01112 ......... Anesth, bone aspirate/bx ................................ .................... N ................. .................... .................... .................... .................... ....................
0111T ......... Rbc membranes fatty acids ............................ .................... A ................. .................... .................... .................... .................... ....................
01120 ......... Anesth, pelvis surgery ..................................... .................... N ................. .................... .................... .................... .................... ....................
01130 ......... Anesth, body cast procedure .......................... .................... N ................. .................... .................... .................... .................... ....................
01140 ......... Anesth, amputation at pelvis ........................... .................... C ................. .................... .................... .................... .................... ....................
01150 ......... Anesth, pelvic tumor surgery .......................... .................... C ................. .................... .................... .................... .................... ....................
0115T ......... Med tx mngmt 15 min ..................................... .................... B ................. .................... .................... .................... .................... ....................
01160 ......... Anesth, pelvis procedure ................................. .................... N ................. .................... .................... .................... .................... ....................
0116T ......... Med tx mngmt subsqt ...................................... .................... B ................. .................... .................... .................... .................... ....................
01170 ......... Anesth, pelvis surgery ..................................... .................... N ................. .................... .................... .................... .................... ....................
01173 ......... Anesth, fx repair, pelvis ................................... .................... N ................. .................... .................... .................... .................... ....................
0117T ......... Med tx mngmt addl 15 min ............................. .................... B ................. .................... .................... .................... .................... ....................
01180 ......... Anesth, pelvis nerve removal .......................... .................... N ................. .................... .................... .................... .................... ....................
01190 ......... Anesth, pelvis nerve removal .......................... .................... N ................. .................... .................... .................... .................... ....................
01200 ......... Anesth, hip joint procedure ............................. .................... N ................. .................... .................... .................... .................... ....................
Continued
National Minimum
01202 ......... Anesth, arthroscopy of hip .............................. .................... N ................. .................... .................... .................... .................... ....................
01210 ......... Anesth, hip joint surgery ................................. .................... N ................. .................... .................... .................... .................... ....................
01212 ......... Anesth, hip disarticulation ............................... .................... C ................. .................... .................... .................... .................... ....................
01214 ......... Anesth, hip arthroplasty .................................. .................... C ................. .................... .................... .................... .................... ....................
01215 ......... Anesth, revise hip repair ................................. .................... N ................. .................... .................... .................... .................... ....................
01220 ......... Anesth, procedure on femur ........................... .................... N ................. .................... .................... .................... .................... ....................
01230 ......... Anesth, surgery of femur ................................. .................... N ................. .................... .................... .................... .................... ....................
01232 ......... Anesth, amputation of femur ........................... .................... C ................. .................... .................... .................... .................... ....................
01234 ......... Anesth, radical femur surg .............................. .................... C ................. .................... .................... .................... .................... ....................
0123T ......... Scleral fistulization ........................................... .................... T ................. 0234 24.0821 $1,533.86 $511.30 $306.77
0124T ......... Conjunctival drug placement ........................... .................... T ................. 0232 5.1145 $325.76 $81.59 $65.15
01250 ......... Anesth, upper leg surgery ............................... .................... N ................. .................... .................... .................... .................... ....................
01260 ......... Anesth, upper leg veins surg .......................... .................... N ................. .................... .................... .................... .................... ....................
0126T ......... Chd risk imt study ........................................... CH .............. Q ................ 0340 0.6416 $40.87 .................... $8.17
01270 ......... Anesth, thigh arteries surg .............................. .................... N ................. .................... .................... .................... .................... ....................
01272 ......... Anesth, femoral artery surg ............................. .................... C ................. .................... .................... .................... .................... ....................
01274 ......... Anesth, femoral embolectomy ......................... .................... C ................. .................... .................... .................... .................... ....................
0130T ......... Chron care drug investigatn ............................ .................... B ................. .................... .................... .................... .................... ....................
01320 ......... Anesth, knee area surgery .............................. .................... N ................. .................... .................... .................... .................... ....................
0133T ......... Esophageal implant injexn .............................. .................... T ................. 0422 24.648 $1,569.91 $445.06 $313.98
01340 ......... Anesth, knee area procedure .......................... .................... N ................. .................... .................... .................... .................... ....................
0135T ......... Perq cryoablate renal tumor ............................ .................... T ................. 0423 44.1192 $2,810.08 .................... $562.02
0137T ......... Prostate saturation sampling ........................... .................... T ................. 0184 11.3168 $720.80 .................... $144.16
01380 ......... Anesth, knee joint procedure .......................... .................... N ................. .................... .................... .................... .................... ....................
01382 ......... Anesth, dx knee arthroscopy .......................... .................... N ................. .................... .................... .................... .................... ....................
01390 ......... Anesth, knee area procedure .......................... .................... N ................. .................... .................... .................... .................... ....................
01400 ......... Anesth, knee joint surgery .............................. .................... N ................. .................... .................... .................... .................... ....................
01402 ......... Anesth, knee arthroplasty ............................... .................... C ................. .................... .................... .................... .................... ....................
01404 ......... Anesth, amputation at knee ............................ .................... C ................. .................... .................... .................... .................... ....................
0140T ......... Exhaled breath condensate ph ....................... .................... A ................. .................... .................... .................... .................... ....................
0141T ......... Perq islet transplant ........................................ .................... E ................. .................... .................... .................... .................... ....................
01420 ......... Anesth, knee joint casting ............................... .................... N ................. .................... .................... .................... .................... ....................
0142T ......... Open islet transplant ....................................... .................... E ................. .................... .................... .................... .................... ....................
01430 ......... Anesth, knee veins surgery ............................. .................... N ................. .................... .................... .................... .................... ....................
01432 ......... Anesth, knee vessel surg ................................ .................... N ................. .................... .................... .................... .................... ....................
0143T ......... Laparoscopic islet transplnt ............................. .................... E ................. .................... .................... .................... .................... ....................
01440 ......... Anesth, knee arteries surg .............................. .................... N ................. .................... .................... .................... .................... ....................
01442 ......... Anesth, knee artery surg ................................. .................... C ................. .................... .................... .................... .................... ....................
01444 ......... Anesth, knee artery repair ............................... .................... C ................. .................... .................... .................... .................... ....................
0144T ......... CT heart wo dye; qual calc ............................. CH .............. S ................. 0282 1.6768 $106.80 $37.80 $21.36
0145T ......... CT heart w/wo dye funct ................................. CH .............. S ................. 0383 4.9887 $317.75 $124.17 $63.55
01462 ......... Anesth, lower leg procedure ........................... .................... N ................. .................... .................... .................... .................... ....................
01464 ......... Anesth, ankle/ft arthroscopy ............................ .................... N ................. .................... .................... .................... .................... ....................
0146T ......... CCTA w/wo dye .............................................. CH .............. S ................. 0383 4.9887 $317.75 $124.17 $63.55
01470 ......... Anesth, lower leg surgery ............................... .................... N ................. .................... .................... .................... .................... ....................
01472 ......... Anesth, achilles tendon surg ........................... .................... N ................. .................... .................... .................... .................... ....................
01474 ......... Anesth, lower leg surgery ............................... .................... N ................. .................... .................... .................... .................... ....................
0147T ......... CCTA w/wo, quan calcium .............................. CH .............. S ................. 0383 4.9887 $317.75 $124.17 $63.55
01480 ......... Anesth, lower leg bone surg ........................... .................... N ................. .................... .................... .................... .................... ....................
01482 ......... Anesth, radical leg surgery ............................. .................... N ................. .................... .................... .................... .................... ....................
01484 ......... Anesth, lower leg revision ............................... .................... N ................. .................... .................... .................... .................... ....................
01486 ......... Anesth, ankle replacement .............................. .................... C ................. .................... .................... .................... .................... ....................
0148T ......... CCTA w/wo, strxr ............................................ CH .............. S ................. 0383 4.9887 $317.75 $124.17 $63.55
01490 ......... Anesth, lower leg casting ................................ .................... N ................. .................... .................... .................... .................... ....................
0149T ......... CCTA w/wo, strxr quan calc ........................... CH .............. S ................. 0383 4.9887 $317.75 $124.17 $63.55
01500 ......... Anesth, leg arteries surg ................................. .................... N ................. .................... .................... .................... .................... ....................
01502 ......... Anesth, lwr leg embolectomy .......................... .................... C ................. .................... .................... .................... .................... ....................
0150T ......... CCTA w/wo, disease strxr ............................... CH .............. S ................. 0383 4.9887 $317.75 $124.17 $63.55
0151T ......... CT heart funct add-on ..................................... .................... S ................. 0282 1.6768 $106.80 $37.80 $21.36
01520 ......... Anesth, lower leg vein surg ............................. .................... N ................. .................... .................... .................... .................... ....................
01522 ......... Anesth, lower leg vein surg ............................. .................... N ................. .................... .................... .................... .................... ....................
0153T ......... Tcath sensor aneurysm sac ............................ .................... C ................. .................... .................... .................... .................... ....................
0154T ......... Study sensor aneurysm sac ............................ .................... X ................. 0097 1.0396 $66.22 $23.70 $13.24
0155T ......... Lap impl gast curve electrd ............................. .................... T ................. 0130 34.8153 $2,217.49 $659.50 $443.50
0156T ......... Lap remv gast curve electrd ........................... .................... T ................. 0130 34.8153 $2,217.49 $659.50 $443.50
0157T ......... Open impl gast curve electrd .......................... .................... C ................. .................... .................... .................... .................... ....................
0158T ......... Open remv gast curve electrd ......................... .................... C ................. .................... .................... .................... .................... ....................
0159T ......... Cad breast mri ................................................. .................... N ................. .................... .................... .................... .................... ....................
0160T ......... Tcranial magn stim tx plan .............................. .................... S ................. 0216 2.768 $176.30 .................... $35.26
0161T ......... Tcranial magn stim tx deliv ............................. .................... S ................. 0216 2.768 $176.30 .................... $35.26
01620 ......... Anesth, shoulder procedure ............................ .................... N ................. .................... .................... .................... .................... ....................
01622 ......... Anes dx shoulder arthroscopy ........................ .................... N ................. .................... .................... .................... .................... ....................
0162T ......... Anal program gast neurostim .......................... .................... S ................. 0692 1.9206 $122.33 $30.10 $24.47
01632 ......... Anesth, surgery of shoulder ............................ .................... C ................. .................... .................... .................... .................... ....................
Continued
National Minimum
01634 ......... Anesth, shoulder joint amput .......................... .................... C ................. .................... .................... .................... .................... ....................
01636 ......... Anesth, forequarter amput .............................. .................... C ................. .................... .................... .................... .................... ....................
01638 ......... Anesth, shoulder replacement ........................ .................... C ................. .................... .................... .................... .................... ....................
0163T ......... Lumb artif diskectomy addl ............................. .................... C ................. .................... .................... .................... .................... ....................
0164T ......... Remove lumb artif disc addl ........................... .................... C ................. .................... .................... .................... .................... ....................
01650 ......... Anesth, shoulder artery surg ........................... .................... N ................. .................... .................... .................... .................... ....................
01652 ......... Anesth, shoulder vessel surg .......................... .................... C ................. .................... .................... .................... .................... ....................
01654 ......... Anesth, shoulder vessel surg .......................... .................... C ................. .................... .................... .................... .................... ....................
01656 ......... Anesth, arm-leg vessel surg ........................... .................... C ................. .................... .................... .................... .................... ....................
0165T ......... Revise lumb artif disc addl .............................. .................... C ................. .................... .................... .................... .................... ....................
0166T ......... Tcath vsd close w/o bypass ............................ .................... C ................. .................... .................... .................... .................... ....................
01670 ......... Anesth, shoulder vein surg ............................. .................... N ................. .................... .................... .................... .................... ....................
0167T ......... Tcath vsd close w bypass ............................... .................... C ................. .................... .................... .................... .................... ....................
01680 ......... Anesth, shoulder casting ................................. .................... N ................. .................... .................... .................... .................... ....................
01682 ......... Anesth, airplane cast ....................................... .................... N ................. .................... .................... .................... .................... ....................
0168T ......... Rhinophototx light app bilat ............................. .................... T ................. 0251 2.5765 $164.11 .................... $32.82
0169T ......... Place stereo cath brain ................................... .................... C ................. .................... .................... .................... .................... ....................
0170T ......... Anorectal fistula plug rpr ................................. .................... T ................. 0150 30.5544 $1,946.10 $437.10 $389.22
01710 ......... Anesth, elbow area surgery ............................ .................... N ................. .................... .................... .................... .................... ....................
01712 ......... Anesth, uppr arm tendon surg ........................ .................... N ................. .................... .................... .................... .................... ....................
01714 ......... Anesth, uppr arm tendon surg ........................ .................... N ................. .................... .................... .................... .................... ....................
01716 ......... Anesth, biceps tendon repair .......................... .................... N ................. .................... .................... .................... .................... ....................
0171T ......... Lumbar spine proces distract .......................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
0172T ......... Lumbar spine proces addl ............................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
01730 ......... Anesth, uppr arm procedure ........................... .................... N ................. .................... .................... .................... .................... ....................
01732 ......... Anesth, dx elbow arthroscopy ......................... .................... N ................. .................... .................... .................... .................... ....................
0173T ......... Iop monit io pressure ...................................... .................... N ................. .................... .................... .................... .................... ....................
01740 ......... Anesth, upper arm surgery ............................. .................... N ................. .................... .................... .................... .................... ....................
01742 ......... Anesth, humerus surgery ................................ .................... N ................. .................... .................... .................... .................... ....................
01744 ......... Anesth, humerus repair ................................... .................... N ................. .................... .................... .................... .................... ....................
0174T ......... Cad cxr with interp .......................................... .................... N ................. .................... .................... .................... .................... ....................
01756 ......... Anesth, radical humerus surg ......................... .................... C ................. .................... .................... .................... .................... ....................
01758 ......... Anesth, humeral lesion surg ........................... .................... N ................. .................... .................... .................... .................... ....................
0175T ......... Cad cxr remote ................................................ .................... N ................. .................... .................... .................... .................... ....................
01760 ......... Anesth, elbow replacement ............................. .................... N ................. .................... .................... .................... .................... ....................
0176T ......... Aqu canal dilat w/o retent ............................... .................... T ................. 0673 40.8481 $2,601.74 $649.50 $520.35
01770 ......... Anesth, uppr arm artery surg .......................... .................... N ................. .................... .................... .................... .................... ....................
01772 ......... Anesth, uppr arm embolectomy ...................... .................... N ................. .................... .................... .................... .................... ....................
0177T ......... Aqu canal dilat w retent .................................. .................... T ................. 0673 40.8481 $2,601.74 $649.50 $520.35
01780 ......... Anesth, upper arm vein surg ........................... .................... N ................. .................... .................... .................... .................... ....................
01782 ......... Anesth, uppr arm vein repair .......................... .................... N ................. .................... .................... .................... .................... ....................
01810 ......... Anesth, lower arm surgery .............................. .................... N ................. .................... .................... .................... .................... ....................
01820 ......... Anesth, lower arm procedure .......................... .................... N ................. .................... .................... .................... .................... ....................
01829 ......... Anesth, dx wrist arthroscopy ........................... .................... N ................. .................... .................... .................... .................... ....................
01830 ......... Anesth, lower arm surgery .............................. .................... N ................. .................... .................... .................... .................... ....................
01832 ......... Anesth, wrist replacement ............................... .................... N ................. .................... .................... .................... .................... ....................
01840 ......... Anesth, lwr arm artery surg ............................. .................... N ................. .................... .................... .................... .................... ....................
01842 ......... Anesth, lwr arm embolectomy ......................... .................... N ................. .................... .................... .................... .................... ....................
01844 ......... Anesth, vascular shunt surg ............................ .................... N ................. .................... .................... .................... .................... ....................
01850 ......... Anesth, lower arm vein surg ........................... .................... N ................. .................... .................... .................... .................... ....................
01852 ......... Anesth, lwr arm vein repair ............................. .................... N ................. .................... .................... .................... .................... ....................
01860 ......... Anesth, lower arm casting ............................... .................... N ................. .................... .................... .................... .................... ....................
01905 ......... Anes, spine inject, x-ray/re .............................. .................... N ................. .................... .................... .................... .................... ....................
01916 ......... Anesth, dx arteriography ................................. .................... N ................. .................... .................... .................... .................... ....................
01920 ......... Anesth, catheterize heart ................................ .................... N ................. .................... .................... .................... .................... ....................
01922 ......... Anesth, cat or MRI scan ................................. .................... N ................. .................... .................... .................... .................... ....................
01924 ......... Anes, ther interven rad, art ............................. .................... N ................. .................... .................... .................... .................... ....................
01925 ......... Anes, ther interven rad, car ............................ .................... N ................. .................... .................... .................... .................... ....................
01926 ......... Anes, tx interv rad hrt/cran .............................. .................... N ................. .................... .................... .................... .................... ....................
01930 ......... Anes, ther interven rad, vei ............................. .................... N ................. .................... .................... .................... .................... ....................
01931 ......... Anes, ther interven rad, tip .............................. .................... N ................. .................... .................... .................... .................... ....................
01932 ......... Anes, tx interv rad, th vein .............................. .................... N ................. .................... .................... .................... .................... ....................
01933 ......... Anes, tx interv rad, cran v ............................... .................... N ................. .................... .................... .................... .................... ....................
01951 ......... Anesth, burn, less 4 percent ........................... .................... N ................. .................... .................... .................... .................... ....................
01952 ......... Anesth, burn, 4-9 percent ............................... .................... N ................. .................... .................... .................... .................... ....................
01953 ......... Anesth, burn, each 9 percent .......................... .................... N ................. .................... .................... .................... .................... ....................
01958 ......... Anesth, antepartum manipul ........................... .................... N ................. .................... .................... .................... .................... ....................
01960 ......... Anesth, vaginal delivery .................................. .................... N ................. .................... .................... .................... .................... ....................
01961 ......... Anesth, cs delivery .......................................... .................... N ................. .................... .................... .................... .................... ....................
01962 ......... Anesth, emer hysterectomy ............................ .................... N ................. .................... .................... .................... .................... ....................
01963 ......... Anesth, cs hysterectomy ................................. .................... N ................. .................... .................... .................... .................... ....................
01965 ......... Anesth, inc/missed ab proc ............................. .................... N ................. .................... .................... .................... .................... ....................
01966 ......... Anesth, induced ab procedure ........................ .................... N ................. .................... .................... .................... .................... ....................
01967 ......... Anesth/analg, vag delivery .............................. .................... N ................. .................... .................... .................... .................... ....................
01968 ......... Anes/analg cs deliver add-on .......................... .................... N ................. .................... .................... .................... .................... ....................
01969 ......... Anesth/analg cs hyst add-on ........................... .................... N ................. .................... .................... .................... .................... ....................
01990 ......... Support for organ donor .................................. .................... C ................. .................... .................... .................... .................... ....................
01991 ......... Anesth, nerve block/inj .................................... .................... N ................. .................... .................... .................... .................... ....................
Continued
National Minimum
01992 ......... Anesth, n block/inj, prone ................................ .................... N ................. .................... .................... .................... .................... ....................
01996 ......... Hosp manage cont drug admin ....................... .................... N ................. .................... .................... .................... .................... ....................
01999 ......... Unlisted anesth procedure .............................. .................... N ................. .................... .................... .................... .................... ....................
0500F ......... Initial prenatal care visit .................................. .................... M ................ .................... .................... .................... .................... ....................
0501F ......... Prenatal flow sheet .......................................... .................... M ................ .................... .................... .................... .................... ....................
0502F ......... Subsequent prenatal care ............................... .................... M ................ .................... .................... .................... .................... ....................
0503F ......... Postpartum care visit ....................................... .................... M ................ .................... .................... .................... .................... ....................
0505F ......... Hemodialysis plan doc’d ................................. .................... M ................ .................... .................... .................... .................... ....................
0507F ......... Periton dialysis plan doc’d .............................. .................... M ................ .................... .................... .................... .................... ....................
0509F ......... Urine incon plan doc ....................................... .................... M ................ .................... .................... .................... .................... ....................
1000F ......... Tobacco use assessed ................................... .................... M ................ .................... .................... .................... .................... ....................
10021 ......... Fna w/o image ................................................. .................... T ................. 0002 1.1915 $75.89 .................... $15.18
10022 ......... Fna w/image .................................................... CH .............. T ................. 0004 4.5062 $287.01 .................... $57.40
1002F ......... Assess anginal symptom/level ........................ .................... M ................ .................... .................... .................... .................... ....................
1003F ......... Level of activity assess ................................... .................... M ................ .................... .................... .................... .................... ....................
10040 ......... Acne surgery ................................................... CH .............. T ................. 0013 0.8046 $51.25 .................... $10.25
1004F ......... Clin symp vol ovrld assess ............................. .................... M ................ .................... .................... .................... .................... ....................
1005F ......... Asthma symptoms evaluate ............................ .................... M ................ .................... .................... .................... .................... ....................
10060 ......... Drainage of skin abscess ................................ .................... T ................. 0006 1.463 $93.18 .................... $18.64
10061 ......... Drainage of skin abscess ................................ .................... T ................. 0006 1.463 $93.18 .................... $18.64
1006F ......... Osteoarthritis assess ....................................... .................... M ................ .................... .................... .................... .................... ....................
1007F ......... Anti-inflm/anlgsc otc assess ............................ .................... M ................ .................... .................... .................... .................... ....................
10080 ......... Drainage of pilonidal cyst ................................ .................... T ................. 0006 1.463 $93.18 .................... $18.64
10081 ......... Drainage of pilonidal cyst ................................ .................... T ................. 0007 12.5792 $801.21 .................... $160.24
1008F ......... Gi/renal risk assess ......................................... .................... M ................ .................... .................... .................... .................... ....................
10120 ......... Remove foreign body ...................................... .................... T ................. 0006 1.463 $93.18 .................... $18.64
10121 ......... Remove foreign body ...................................... .................... T ................. 0021 16.5832 $1,056.23 $219.40 $211.25
10140 ......... Drainage of hematoma/fluid ............................ .................... T ................. 0007 12.5792 $801.21 .................... $160.24
1015F ......... Copd symptoms assess .................................. .................... M ................ .................... .................... .................... .................... ....................
10160 ......... Puncture drainage of lesion ............................ CH .............. T ................. 0006 1.463 $93.18 .................... $18.64
10180 ......... Complex drainage, wound .............................. .................... T ................. 0008 19.0457 $1,213.08 .................... $242.62
1018F ......... Assess dyspnea not present ........................... .................... M ................ .................... .................... .................... .................... ....................
1019F ......... Assess dyspnea present ................................. .................... M ................ .................... .................... .................... .................... ....................
1022F ......... Pneumo imm status assess ............................ .................... M ................ .................... .................... .................... .................... ....................
1026F ......... Co-morbid condition assess ............................ .................... M ................ .................... .................... .................... .................... ....................
1030F ......... Influenza imm status assess ........................... .................... M ................ .................... .................... .................... .................... ....................
1034F ......... Current tobacco smoker .................................. .................... M ................ .................... .................... .................... .................... ....................
1035F ......... Smokeless tobacco user ................................. .................... M ................ .................... .................... .................... .................... ....................
1036F ......... Tobacco non-user ........................................... .................... M ................ .................... .................... .................... .................... ....................
1038F ......... Persistent asthma ............................................ .................... M ................ .................... .................... .................... .................... ....................
1039F ......... Intermittent asthma .......................................... .................... M ................ .................... .................... .................... .................... ....................
1040F ......... Dsm-iv info mdd doc’d .................................... .................... M ................ .................... .................... .................... .................... ....................
1050F ......... History of mole changes ................................. .................... M ................ .................... .................... .................... .................... ....................
1055F ......... Visual funct status assess ............................... .................... M ................ .................... .................... .................... .................... ....................
1060F ......... Doc perm/cont/parox atr. fib ............................ .................... M ................ .................... .................... .................... .................... ....................
1061F ......... Doc lack perm+cont+parox fib ........................ .................... M ................ .................... .................... .................... .................... ....................
1065F ......... Ischm stroke symp <3 hrs b/4 ........................ .................... M ................ .................... .................... .................... .................... ....................
1066F ......... Ischm stroke symp ?3 hrs b/4 ......................... .................... M ................ .................... .................... .................... .................... ....................
1070F ......... Alarm symp assessed-absent ......................... .................... M ................ .................... .................... .................... .................... ....................
1071F ......... Alarm symp assessed-1+ prsnt ...................... .................... M ................ .................... .................... .................... .................... ....................
1080F ......... Decis mkr/advncd plan doc’d .......................... .................... M ................ .................... .................... .................... .................... ....................
1090F ......... Pres/absn urine incon assess ......................... .................... M ................ .................... .................... .................... .................... ....................
1091F ......... Urine incon characterized ............................... .................... M ................ .................... .................... .................... .................... ....................
11000 ......... Debride infected skin ....................................... .................... T ................. 0013 0.8046 $51.25 .................... $10.25
11001 ......... Debride infected skin add-on .......................... CH .............. T ................. 0013 0.8046 $51.25 .................... $10.25
11004 ......... Debride genitalia & perineum .......................... .................... C ................. .................... .................... .................... .................... ....................
11005 ......... Debride abdom wall ........................................ .................... C ................. .................... .................... .................... .................... ....................
11006 ......... Debride genit/per/abdom wall ......................... .................... C ................. .................... .................... .................... .................... ....................
11008 ......... Remove mesh from abd wall .......................... .................... C ................. .................... .................... .................... .................... ....................
1100F ......... Pt falls assess-doc’d?2+/yr ............................. .................... M ................ .................... .................... .................... .................... ....................
11010 ......... Debride skin, fx ............................................... .................... T ................. 0019 4.4463 $283.20 $71.80 $56.64
11011 ......... Debride skin/muscle, fx ................................... .................... T ................. 0019 4.4463 $283.20 $71.80 $56.64
11012 ......... Debride skin/muscle/bone, fx .......................... .................... T ................. 0019 4.4463 $283.20 $71.80 $56.64
1101F ......... Pt falls assessed-doc’d?1/yr ........................... .................... M ................ .................... .................... .................... .................... ....................
11040 ......... Debride skin, partial ........................................ .................... T ................. 0015 1.5119 $96.30 .................... $19.26
11041 ......... Debride skin, full .............................................. .................... T ................. 0015 1.5119 $96.30 .................... $19.26
11042 ......... Debride skin/tissue .......................................... .................... T ................. 0016 2.7493 $175.11 .................... $35.02
11043 ......... Debride tissue/muscle ..................................... .................... T ................. 0016 2.7493 $175.11 .................... $35.02
11044 ......... Debride tissue/muscle/bone ............................ .................... T ................. 0682 7.1126 $453.02 $158.60 $90.60
11055 ......... Trim skin lesion ............................................... CH .............. T ................. 0013 0.8046 $51.25 .................... $10.25
11056 ......... Trim skin lesions, 2 to 4 .................................. CH .............. T ................. 0013 0.8046 $51.25 .................... $10.25
11057 ......... Trim skin lesions, over 4 ................................. CH .............. T ................. 0015 1.5119 $96.30 .................... $19.26
11100 ......... Biopsy, skin lesion ........................................... CH .............. T ................. 0013 0.8046 $51.25 .................... $10.25
11101 ......... Biopsy, skin add-on ......................................... CH .............. T ................. 0013 0.8046 $51.25 .................... $10.25
1110F ......... Pt lft inpt fac w/in 60 days ............................... .................... M ................ .................... .................... .................... .................... ....................
1111F ......... Dschrg med/current med merge ..................... .................... M ................ .................... .................... .................... .................... ....................
11200 ......... Removal of skin tags ....................................... .................... T ................. 0013 0.8046 $51.25 .................... $10.25
11201 ......... Remove skin tags add-on ............................... .................... T ................. 0015 1.5119 $96.30 .................... $19.26
Continued
National Minimum
11300 ......... Shave skin lesion ............................................ CH .............. T ................. 0013 0.8046 $51.25 .................... $10.25
11302 ......... Shave skin lesion ............................................ .................... T ................. 0013 0.8046 $51.25 .................... $10.25
11400 ......... Exc tr-ext b9+marg 0.5 < cm .......................... .................... T ................. 0019 4.4463 $283.20 $71.80 $56.64
11401 ......... Exc tr-ext b9+marg 0.6-1 cm .......................... .................... T ................. 0019 4.4463 $283.20 $71.80 $56.64
11402 ......... Exc tr-ext b9+marg 1.1-2 cm .......................... .................... T ................. 0019 4.4463 $283.20 $71.80 $56.64
11403 ......... Exc tr-ext b9+marg 2.1-3 cm .......................... .................... T ................. 0020 8.7155 $555.12 .................... $111.02
11404 ......... Exc tr-ext b9+marg 3.1-4 cm .......................... .................... T ................. 0021 16.5832 $1,056.23 $219.40 $211.25
11406 ......... Exc tr-ext b9+marg > 4.0 cm .......................... .................... T ................. 0021 16.5832 $1,056.23 $219.40 $211.25
11420 ......... Exc h-f-nk-sp b9+marg 0.5 < .......................... .................... T ................. 0020 8.7155 $555.12 .................... $111.02
11421 ......... Exc h-f-nk-sp b9+marg 0.6-1 .......................... .................... T ................. 0020 8.7155 $555.12 .................... $111.02
11422 ......... Exc h-f-nk-sp b9+marg 1.1-2 .......................... .................... T ................. 0020 8.7155 $555.12 .................... $111.02
11423 ......... Exc h-f-nk-sp b9+marg 2.1-3 .......................... .................... T ................. 0021 16.5832 $1,056.23 $219.40 $211.25
11424 ......... Exc h-f-nk-sp b9+marg 3.1-4 .......................... .................... T ................. 0021 16.5832 $1,056.23 $219.40 $211.25
11426 ......... Exc h-f-nk-sp b9+marg > 4 cm ....................... .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
11440 ......... Exc face-mm b9+marg 0.5 < cm .................... .................... T ................. 0019 4.4463 $283.20 $71.80 $56.64
11441 ......... Exc face-mm b9+marg 0.6-1 cm ..................... .................... T ................. 0019 4.4463 $283.20 $71.80 $56.64
11442 ......... Exc face-mm b9+marg 1.1-2 cm ..................... .................... T ................. 0020 8.7155 $555.12 .................... $111.02
11446 ......... Exc face-mm b9+marg > 4 cm ....................... .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
11450 ......... Removal, sweat gland lesion .......................... .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
11600 ......... Exc tr-ext mlg+marg 0.5 < cm ........................ .................... T ................. 0019 4.4463 $283.20 $71.80 $56.64
11601 ......... Exc tr-ext mlg+marg 0.6-1 cm ........................ .................... T ................. 0019 4.4463 $283.20 $71.80 $56.64
11602 ......... Exc tr-ext mlg+marg 1.1-2 cm ........................ .................... T ................. 0019 4.4463 $283.20 $71.80 $56.64
11603 ......... Exc tr-ext mlg+marg 2.1-3 cm ........................ .................... T ................. 0020 8.7155 $555.12 .................... $111.02
11604 ......... Exc tr-ext mlg+marg 3.1-4 cm ........................ .................... T ................. 0020 8.7155 $555.12 .................... $111.02
11606 ......... Exc tr-ext mlg+marg > 4 cm ........................... .................... T ................. 0021 16.5832 $1,056.23 $219.40 $211.25
11620 ......... Exc h-f-nk-sp mlg+marg 0.5 < ........................ .................... T ................. 0020 8.7155 $555.12 .................... $111.02
11621 ......... Exc h-f-nk-sp mlg+marg 0.6-1 ........................ .................... T ................. 0019 4.4463 $283.20 $71.80 $56.64
11622 ......... Exc h-f-nk-sp mlg+marg 1.1-2 ........................ .................... T ................. 0020 8.7155 $555.12 .................... $111.02
11623 ......... Exc h-f-nk-sp mlg+marg 2.1-3 ........................ CH .............. T ................. 0020 8.7155 $555.12 .................... $111.02
11624 ......... Exc h-f-nk-sp mlg+marg 3.1-4 ........................ .................... T ................. 0021 16.5832 $1,056.23 $219.40 $211.25
11626 ......... Exc h-f-nk-sp mlg+mar > 4 cm ....................... .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
11640 ......... Exc face-mm malig+marg 0.5 < ...................... CH .............. T ................. 0019 4.4463 $283.20 $71.80 $56.64
11641 ......... Exc face-mm malig+marg 0.6-1 ...................... CH .............. T ................. 0019 4.4463 $283.20 $71.80 $56.64
11642 ......... Exc face-mm malig+marg 1.1-2 ...................... .................... T ................. 0020 8.7155 $555.12 .................... $111.02
11643 ......... Exc face-mm malig+marg 2.1-3 ...................... .................... T ................. 0020 8.7155 $555.12 .................... $111.02
11644 ......... Exc face-mm malig+marg 3.1-4 ...................... .................... T ................. 0021 16.5832 $1,056.23 $219.40 $211.25
11646 ......... Exc face-mm mlg+marg > 4 cm ...................... .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
11719 ......... Trim nail(s) ...................................................... CH .............. T ................. 0013 0.8046 $51.25 .................... $10.25
11720 ......... Debride nail, 1-5 .............................................. CH .............. T ................. 0013 0.8046 $51.25 .................... $10.25
11721 ......... Debride nail, 6 or more ................................... CH .............. T ................. 0013 0.8046 $51.25 .................... $10.25
11730 ......... Removal of nail plate ...................................... .................... T ................. 0013 0.8046 $51.25 .................... $10.25
11732 ......... Remove nail plate, add-on .............................. CH .............. T ................. 0013 0.8046 $51.25 .................... $10.25
11740 ......... Drain blood from under nail ............................ CH .............. T ................. 0012 0.2682 $17.08 .................... $3.42
11750 ......... Removal of nail bed ........................................ .................... T ................. 0019 4.4463 $283.20 $71.80 $56.64
11752 ......... Remove nail bed/finger tip .............................. .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
11755 ......... Biopsy, nail unit ............................................... .................... T ................. 0019 4.4463 $283.20 $71.80 $56.64
11760 ......... Repair of nail bed ............................................ CH .............. T ................. 0134 2.1114 $134.48 $42.36 $26.90
11762 ......... Reconstruction of nail bed .............................. CH .............. T ................. 0136 15.4399 $983.41 .................... $196.68
11765 ......... Excision of nail fold, toe .................................. .................... T ................. 0015 1.5119 $96.30 .................... $19.26
11770 ......... Removal of pilonidal lesion ............................. .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
11900 ......... Injection into skin lesions ................................ CH .............. T ................. 0013 0.8046 $51.25 .................... $10.25
11901 ......... Added skin lesions injection ............................ CH .............. T ................. 0013 0.8046 $51.25 .................... $10.25
11920 ......... Correct skin color defects ............................... CH .............. T ................. 0134 2.1114 $134.48 $42.36 $26.90
11950 ......... Therapy for contour defects ............................ CH .............. T ................. 0133 1.334 $84.97 $26.76 $16.99
Continued
National Minimum
11960 ......... Insert tissue expander(s) ................................. CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
11970 ......... Replace tissue expander ................................. .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
11971 ......... Remove tissue expander(s) ............................ .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
11975 ......... Insert contraceptive cap .................................. .................... E ................. .................... .................... .................... .................... ....................
11976 ......... Removal of contraceptive cap ......................... .................... T ................. 0019 4.4463 $283.20 $71.80 $56.64
11977 ......... Removal/reinsert contra cap ........................... .................... E ................. .................... .................... .................... .................... ....................
11980 ......... Implant hormone pellet(s) ............................... .................... X ................. 0340 0.6416 $40.87 .................... $8.17
11981 ......... Insert drug implant device ............................... .................... X ................. 0340 0.6416 $40.87 .................... $8.17
11982 ......... Remove drug implant device .......................... .................... X ................. 0340 0.6416 $40.87 .................... $8.17
11983 ......... Remove/insert drug implant ............................ .................... X ................. 0340 0.6416 $40.87 .................... $8.17
12001 ......... Repair superficial wound(s) ............................. CH .............. T ................. 0133 1.334 $84.97 $26.76 $16.99
12020 ......... Closure of split wound ..................................... CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
12021 ......... Closure of split wound ..................................... CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
12031 ......... Layer closure of wound(s) ............................... CH .............. T ................. 0134 2.1114 $134.48 $42.36 $26.90
13100 ......... Repair of wound or lesion ............................... CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
13102 ......... Repair wound/lesion add-on ........................... CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
13120 ......... Repair of wound or lesion ............................... CH .............. T ................. 0134 2.1114 $134.48 $42.36 $26.90
13122 ......... Repair wound/lesion add-on ........................... CH .............. T ................. 0134 2.1114 $134.48 $42.36 $26.90
13133 ......... Repair wound/lesion add-on ........................... CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
13153 ......... Repair wound/lesion add-on ........................... CH .............. T ................. 0134 2.1114 $134.48 $42.36 $26.90
13160 ......... Late closure of wound ..................................... CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
14000 ......... Skin tissue rearrangement .............................. CH .............. T ................. 0136 15.4399 $983.41 .................... $196.68
14300 ......... Skin tissue rearrangement .............................. CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
14350 ......... Skin tissue rearrangement .............................. CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15002 ......... Wnd prep, ch/inf, trk/arm/lg ............................. CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15003 ......... Wnd prep, ch/inf addl 100 cm ......................... CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15004 ......... Wnd prep ch/inf, f/n/hf/g .................................. CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15005 ......... Wnd prep, f/n/hf/g, addl cm ............................. CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15040 ......... Harvest cultured skin graft .............................. CH .............. T ................. 0134 2.1114 $134.48 $42.36 $26.90
15050 ......... Skin pinch graft ............................................... CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15100 ......... Skin splt grft, trnk/arm/leg ............................... CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15101 ......... Skin splt grft t/a/l, add-on ................................ CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15110 ......... Epidrm autogrft trnk/arm/leg ............................ CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15111 ......... Epidrm autogrft t/a/l add-on ............................ CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
Continued
National Minimum
15115 ......... Epidrm a-grft face/nck/hf/g .............................. CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15116 ......... Epidrm a-grft f/n/hf/g addl ............................... CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15120 ......... Skn splt a-grft fac/nck/hf/g .............................. CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15121 ......... Skn splt a-grft f/n/hf/g add ............................... CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15130 ......... Derm autograft, trnk/arm/leg ........................... CH .............. T ................. 0136 15.4399 $983.41 .................... $196.68
15131 ......... Derm autograft t/a/l add-on ............................. CH .............. T ................. 0136 15.4399 $983.41 .................... $196.68
15135 ......... Derm autograft face/nck/hf/g ........................... CH .............. T ................. 0136 15.4399 $983.41 .................... $196.68
15136 ......... Derm autograft, f/n/hf/g add ............................ CH .............. T ................. 0136 15.4399 $983.41 .................... $196.68
15150 ......... Cult epiderm grft t/arm/leg .............................. CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15151 ......... Cult epiderm grft t/a/l addl ............................... CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15152 ......... Cult epiderm graft t/a/l +% .............................. CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15155 ......... Cult epiderm graft, f/n/hf/g .............................. CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15156 ......... Cult epidrm grft f/n/hfg add ............................. CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15157 ......... Cult epiderm grft f/n/hfg +% ............................ CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15170 ......... Acell graft trunk/arms/legs ............................... CH .............. T ................. 0134 2.1114 $134.48 $42.36 $26.90
15171 ......... Acell graft t/arm/leg add-on ............................. CH .............. T ................. 0134 2.1114 $134.48 $42.36 $26.90
15175 ......... Acellular graft, f/n/hf/g ..................................... CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15176 ......... Acell graft, f/n/hf/g add-on ............................... CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15200 ......... Skin full graft, trunk ......................................... CH .............. T ................. 0136 15.4399 $983.41 .................... $196.68
15201 ......... Skin full graft trunk add-on .............................. CH .............. T ................. 0136 15.4399 $983.41 .................... $196.68
15220 ......... Skin full graft sclp/arm/leg ............................... CH .............. T ................. 0136 15.4399 $983.41 .................... $196.68
15221 ......... Skin full graft add-on ....................................... CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15240 ......... Skin full grft face/genit/hf ................................. CH .............. T ................. 0136 15.4399 $983.41 .................... $196.68
15260 ......... Skin full graft een & lips .................................. CH .............. T ................. 0136 15.4399 $983.41 .................... $196.68
15300 ......... Apply skinallogrft, t/arm/lg ............................... CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15301 ......... Apply sknallogrft t/a/l addl ............................... CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15320 ......... Apply skin allogrft f/n/hf/g ................................ CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15321 ......... Aply sknallogrft f/n/hfg add .............................. CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15330 ......... Aply acell alogrft t/arm/leg ............................... CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15331 ......... Aply acell grft t/a/l add-on ............................... CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15335 ......... Apply acell graft, f/n/hf/g ................................. CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15336 ......... Aply acell grft f/n/hf/g add ............................... CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15340 ......... Apply cult skin substitute ................................. CH .............. T ................. 0134 2.1114 $134.48 $42.36 $26.90
15341 ......... Apply cult skin sub add-on .............................. CH .............. T ................. 0134 2.1114 $134.48 $42.36 $26.90
15360 ......... Apply cult derm sub, t/a/l ................................ CH .............. T ................. 0134 2.1114 $134.48 $42.36 $26.90
15361 ......... Aply cult derm sub t/a/l add ............................ CH .............. T ................. 0134 2.1114 $134.48 $42.36 $26.90
15365 ......... Apply cult derm sub f/n/hf/g ............................ CH .............. T ................. 0134 2.1114 $134.48 $42.36 $26.90
15366 ......... Apply cult derm f/hf/g add ............................... CH .............. T ................. 0134 2.1114 $134.48 $42.36 $26.90
15400 ......... Apply skin xenograft, t/a/l ................................ CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15401 ......... Apply skn xenogrft t/a/l add ............................ CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15420 ......... Apply skin xgraft, f/n/hf/g ................................. CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15421 ......... Apply skn xgrft f/n/hf/g add ............................. CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15430 ......... Apply acellular xenograft ................................. CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15431 ......... Apply acellular xgraft add ................................ CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
15570 ......... Form skin pedicle flap ..................................... CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15600 ......... Skin graft ......................................................... CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15610 ......... Skin graft ......................................................... CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15620 ......... Skin graft ......................................................... CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15630 ......... Skin graft ......................................................... CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15650 ......... Transfer skin pedicle flap ................................ CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15731 ......... Forehead flap w/vasc pedicle ......................... CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15732 ......... Muscle-skin graft, head/neck .......................... CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15734 ......... Muscle-skin graft, trunk ................................... CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15736 ......... Muscle-skin graft, arm ..................................... CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15738 ......... Muscle-skin graft, leg ...................................... CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15740 ......... Island pedicle flap graft ................................... CH .............. T ................. 0136 15.4399 $983.41 .................... $196.68
15750 ......... Neurovascular pedicle graft ............................ CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15756 ......... Free myo/skin flap microvasc ......................... .................... C ................. .................... .................... .................... .................... ....................
15757 ......... Free skin flap, microvasc ................................ .................... C ................. .................... .................... .................... .................... ....................
15758 ......... Free fascial flap, microvasc ............................ .................... C ................. .................... .................... .................... .................... ....................
15760 ......... Composite skin graft ....................................... CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15770 ......... Derma-fat-fascia graft ...................................... CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15775 ......... Hair transplant punch grafts ............................ CH .............. T ................. 0133 1.334 $84.97 $26.76 $16.99
15776 ......... Hair transplant punch grafts ............................ CH .............. T ................. 0133 1.334 $84.97 $26.76 $16.99
15780 ......... Abrasion treatment of skin .............................. .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
15781 ......... Abrasion treatment of skin .............................. .................... T ................. 0019 4.4463 $283.20 $71.80 $56.64
15782 ......... Abrasion treatment of skin .............................. .................... T ................. 0019 4.4463 $283.20 $71.80 $56.64
15783 ......... Abrasion treatment of skin .............................. .................... T ................. 0016 2.7493 $175.11 .................... $35.02
15786 ......... Abrasion, lesion, single ................................... .................... T ................. 0013 0.8046 $51.25 .................... $10.25
15787 ......... Abrasion, lesions, add-on ................................ .................... T ................. 0013 0.8046 $51.25 .................... $10.25
15788 ......... Chemical peel, face, epiderm ......................... CH .............. T ................. 0013 0.8046 $51.25 .................... $10.25
15789 ......... Chemical peel, face, dermal ........................... .................... T ................. 0015 1.5119 $96.30 .................... $19.26
15792 ......... Chemical peel, nonfacial ................................. CH .............. T ................. 0015 1.5119 $96.30 .................... $19.26
Continued
National Minimum
15793 ......... Chemical peel, nonfacial ................................. CH .............. T ................. 0013 0.8046 $51.25 .................... $10.25
15819 ......... Plastic surgery, neck ....................................... CH .............. T ................. 0134 2.1114 $134.48 $42.36 $26.90
15820 ......... Revision of lower eyelid .................................. CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15821 ......... Revision of lower eyelid .................................. CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15822 ......... Revision of upper eyelid .................................. CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15823 ......... Revision of upper eyelid .................................. CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15824 ......... Removal of forehead wrinkles ......................... CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15825 ......... Removal of neck wrinkles ............................... CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15826 ......... Removal of brow wrinkles ............................... CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15828 ......... Removal of face wrinkles ................................ CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15829 ......... Removal of skin wrinkles ................................ CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15830 ......... Exc skin abd .................................................... .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
15832 ......... Excise excessive skin tissue ........................... .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
15835 ......... Excise excessive skin tissue ........................... CH .............. T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
15840 ......... Graft for face nerve palsy ............................... CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15841 ......... Graft for face nerve palsy ............................... CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15842 ......... Flap for face nerve palsy ................................ CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15845 ......... Skin and muscle repair, face .......................... CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15847 ......... Exc skin abd add-on ....................................... .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
15850 ......... Removal of sutures ......................................... .................... T ................. 0016 2.7493 $175.11 .................... $35.02
15851 ......... Removal of sutures ......................................... .................... T ................. 0016 2.7493 $175.11 .................... $35.02
15852 ......... Dressing change not for burn ......................... .................... X ................. 0340 0.6416 $40.87 .................... $8.17
15860 ......... Test for blood flow in graft .............................. .................... X ................. 0340 0.6416 $40.87 .................... $8.17
15876 ......... Suction assisted lipectomy .............................. CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15920 ......... Removal of tail bone ulcer .............................. .................... T ................. 0019 4.4463 $283.20 $71.80 $56.64
15922 ......... Removal of tail bone ulcer .............................. CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15931 ......... Remove sacrum pressure sore ....................... .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
15933 ......... Remove sacrum pressure sore ....................... .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
15934 ......... Remove sacrum pressure sore ....................... CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15936 ......... Remove sacrum pressure sore ....................... CH .............. T ................. 0136 15.4399 $983.41 .................... $196.68
15940 ......... Remove hip pressure sore .............................. .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
15941 ......... Remove hip pressure sore .............................. .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
15944 ......... Remove hip pressure sore .............................. CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
15950 ......... Remove thigh pressure sore ........................... .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
15951 ......... Remove thigh pressure sore ........................... .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
15952 ......... Remove thigh pressure sore ........................... CH .............. T ................. 0136 15.4399 $983.41 .................... $196.68
15999 ......... Removal of pressure sore ............................... .................... T ................. 0019 4.4463 $283.20 $71.80 $56.64
16000 ......... Initial treatment of burn(s) ............................... CH .............. T ................. 0013 0.8046 $51.25 .................... $10.25
16020 ......... Dress/debrid p-thick burn, s ............................ CH .............. T ................. 0015 1.5119 $96.30 .................... $19.26
16025 ......... Dress/debrid p-thick burn, m ........................... CH .............. T ................. 0016 2.7493 $175.11 .................... $35.02
16030 ......... Dress/debrid p-thick burn, l ............................. CH .............. T ................. 0016 2.7493 $175.11 .................... $35.02
16035 ......... Incision of burn scab, initi ............................... .................... T ................. 0016 2.7493 $175.11 .................... $35.02
16036 ......... Escharotomy; add’l incision ............................. .................... C ................. .................... .................... .................... .................... ....................
17000 ......... Destruct premalg lesion .................................. CH .............. T ................. 0013 0.8046 $51.25 .................... $10.25
17003 ......... Destruct premalg les, 2-14 .............................. CH .............. T ................. 0012 0.2682 $17.08 .................... $3.42
17004 ......... Destroy premlg lesions 15+ ............................ CH .............. T ................. 0016 2.7493 $175.11 .................... $35.02
17106 ......... Destruction of skin lesions .............................. CH .............. T ................. 0016 2.7493 $175.11 .................... $35.02
17110 ......... Destruct b9 lesion, 1-14 .................................. CH .............. T ................. 0013 0.8046 $51.25 .................... $10.25
17111 ......... Destruct lesion, 15 or more ............................. CH .............. T ................. 0015 1.5119 $96.30 .................... $19.26
17250 ......... Chemical cautery, tissue ................................. CH .............. T ................. 0015 1.5119 $96.30 .................... $19.26
17260 ......... Destruction of skin lesions .............................. .................... T ................. 0015 1.5119 $96.30 .................... $19.26
Continued
National Minimum
17311 ......... Mohs, 1 stage, h/n/hf/g ................................... .................... T ................. 0694 3.9713 $252.94 $91.60 $50.59
17312 ......... Mohs addl stage .............................................. .................... T ................. 0694 3.9713 $252.94 $91.60 $50.59
17313 ......... Mohs, 1 stage, t/a/l .......................................... .................... T ................. 0694 3.9713 $252.94 $91.60 $50.59
17314 ......... Mohs, addl stage, t/a/l ..................................... .................... T ................. 0694 3.9713 $252.94 $91.60 $50.59
17315 ......... Mohs surg, addl block ..................................... .................... T ................. 0694 3.9713 $252.94 $91.60 $50.59
17340 ......... Cryotherapy of skin ......................................... CH .............. T ................. 0013 0.8046 $51.25 .................... $10.25
17360 ......... Skin peel therapy ............................................ .................... T ................. 0013 0.8046 $51.25 .................... $10.25
17380 ......... Hair removal by electrolysis ............................ .................... T ................. 0013 0.8046 $51.25 .................... $10.25
17999 ......... Skin tissue procedure ...................................... .................... T ................. 0012 0.2682 $17.08 .................... $3.42
19000 ......... Drainage of breast lesion ................................ .................... T ................. 0004 4.5062 $287.01 .................... $57.40
19001 ......... Drain breast lesion add-on .............................. .................... T ................. 0002 1.1915 $75.89 .................... $15.18
19020 ......... Incision of breast lesion .................................. .................... T ................. 0008 19.0457 $1,213.08 .................... $242.62
19030 ......... Injection for breast x-ray ................................. .................... N ................. .................... .................... .................... .................... ....................
19100 ......... Bx breast percut w/o image ............................ CH .............. T ................. 0004 4.5062 $287.01 .................... $57.40
19101 ......... Biopsy of breast, open .................................... .................... T ................. 0028 20.998 $1,337.43 $303.70 $267.49
19102 ......... Bx breast percut w/image ............................... .................... T ................. 0005 7.3012 $465.04 .................... $93.01
19103 ......... Bx breast percut w/device ............................... CH .............. T ................. 0037 13.9599 $889.15 $228.70 $177.83
19105 ......... Cryosurg ablate fa, each ................................. .................... T ................. 0029 32.494 $2,069.64 $581.50 $413.93
19110 ......... Nipple exploration ............................................ .................... T ................. 0028 20.998 $1,337.43 $303.70 $267.49
19112 ......... Excise breast duct fistula ................................ .................... T ................. 0028 20.998 $1,337.43 $303.70 $267.49
19120 ......... Removal of breast lesion ................................ .................... T ................. 0028 20.998 $1,337.43 $303.70 $267.49
19125 ......... Excision, breast lesion .................................... .................... T ................. 0028 20.998 $1,337.43 $303.70 $267.49
19126 ......... Excision, addl breast lesion ............................ .................... T ................. 0028 20.998 $1,337.43 $303.70 $267.49
19260 ......... Removal of chest wall lesion .......................... .................... T ................. 0021 16.5832 $1,056.23 $219.40 $211.25
19271 ......... Revision of chest wall ..................................... .................... C ................. .................... .................... .................... .................... ....................
19272 ......... Extensive chest wall surgery ........................... .................... C ................. .................... .................... .................... .................... ....................
19290 ......... Place needle wire, breast ................................ .................... N ................. .................... .................... .................... .................... ....................
19291 ......... Place needle wire, breast ................................ .................... N ................. .................... .................... .................... .................... ....................
19295 ......... Place breast clip, percut .................................. CH .............. N ................. .................... .................... .................... .................... ....................
19296 ......... Place po breast cath for rad ........................... .................... T ................. 0648 52.9438 $3,372.15 .................... $674.43
19297 ......... Place breast cath for rad ................................. .................... T ................. 0648 52.9438 $3,372.15 .................... $674.43
19298 ......... Place breast rad tube/caths ............................ CH .............. T ................. 0648 52.9438 $3,372.15 .................... $674.43
19300 ......... Removal of breast tissue ................................ .................... T ................. 0028 20.998 $1,337.43 $303.70 $267.49
19301 ......... Partical mastectomy ........................................ .................... T ................. 0028 20.998 $1,337.43 $303.70 $267.49
19302 ......... P-mastectomy w/ln removal ............................ CH .............. T ................. 0030 40.4634 $2,577.24 $747.00 $515.45
19303 ......... Mast, simple, complete ................................... .................... T ................. 0029 32.494 $2,069.64 $581.50 $413.93
19304 ......... Mast, subq ....................................................... .................... T ................. 0029 32.494 $2,069.64 $581.50 $413.93
19305 ......... Mast, radical .................................................... .................... C ................. .................... .................... .................... .................... ....................
19306 ......... Mast, rad, urban type ...................................... .................... C ................. .................... .................... .................... .................... ....................
19307 ......... Mast, mod rad ................................................. .................... T ................. 0030 40.4634 $2,577.24 $747.00 $515.45
19316 ......... Suspension of breast ...................................... .................... T ................. 0029 32.494 $2,069.64 $581.50 $413.93
19318 ......... Reduction of large breast ................................ CH .............. T ................. 0030 40.4634 $2,577.24 $747.00 $515.45
19324 ......... Enlarge breast ................................................. CH .............. T ................. 0030 40.4634 $2,577.24 $747.00 $515.45
19325 ......... Enlarge breast with implant ............................. .................... T ................. 0648 52.9438 $3,372.15 .................... $674.43
19328 ......... Removal of breast implant .............................. .................... T ................. 0029 32.494 $2,069.64 $581.50 $413.93
19330 ......... Removal of implant material ........................... .................... T ................. 0029 32.494 $2,069.64 $581.50 $413.93
19340 ......... Immediate breast prosthesis ........................... .................... T ................. 0030 40.4634 $2,577.24 $747.00 $515.45
19342 ......... Delayed breast prosthesis ............................... .................... T ................. 0648 52.9438 $3,372.15 .................... $674.43
19350 ......... Breast reconstruction ...................................... .................... T ................. 0028 20.998 $1,337.43 $303.70 $267.49
19355 ......... Correct inverted nipple(s) ................................ .................... T ................. 0029 32.494 $2,069.64 $581.50 $413.93
19357 ......... Breast reconstruction ...................................... .................... T ................. 0648 52.9438 $3,372.15 .................... $674.43
19361 ......... Breast reconstr w/lat flap ................................ .................... C ................. .................... .................... .................... .................... ....................
19364 ......... Breast reconstruction ...................................... .................... C ................. .................... .................... .................... .................... ....................
19366 ......... Breast reconstruction ...................................... .................... T ................. 0029 32.494 $2,069.64 $581.50 $413.93
19370 ......... Surgery of breast capsule ............................... .................... T ................. 0029 32.494 $2,069.64 $581.50 $413.93
19371 ......... Removal of breast capsule ............................. .................... T ................. 0029 32.494 $2,069.64 $581.50 $413.93
19380 ......... Revise breast reconstruction ........................... .................... T ................. 0030 40.4634 $2,577.24 $747.00 $515.45
19396 ......... Design custom breast implant ......................... .................... T ................. 0029 32.494 $2,069.64 $581.50 $413.93
19499 ......... Breast surgery procedure ................................ .................... T ................. 0028 20.998 $1,337.43 $303.70 $267.49
20000 ......... Incision of abscess .......................................... .................... T ................. 0006 1.463 $93.18 .................... $18.64
20005 ......... Incision of deep abscess ................................. .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
2000F ......... Blood pressure measure ................................. .................... M ................ .................... .................... .................... .................... ....................
2001F ......... Weight record .................................................. .................... M ................ .................... .................... .................... .................... ....................
2002F ......... Clin sign vol ovrld assess ............................... .................... M ................ .................... .................... .................... .................... ....................
2004F ......... Initial exam involved joints .............................. .................... M ................ .................... .................... .................... .................... ....................
20100 ......... Explore wound, neck ....................................... .................... T ................. 0023 9.5721 $609.68 .................... $121.94
20101 ......... Explore wound, chest ...................................... CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
Continued
National Minimum
20102 ......... Explore wound, abdomen ............................... CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
20103 ......... Explore wound, extremity ................................ .................... T ................. 0023 9.5721 $609.68 .................... $121.94
2010F ......... Vital signs recorded ......................................... .................... M ................ .................... .................... .................... .................... ....................
2014F ......... Mental status assess ....................................... .................... M ................ .................... .................... .................... .................... ....................
20150 ......... Excise epiphyseal bar ..................................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
2018F ......... Hydration status assess .................................. .................... M ................ .................... .................... .................... .................... ....................
2019F ......... Dilated macul exam done ............................... .................... M ................ .................... .................... .................... .................... ....................
20200 ......... Muscle biopsy .................................................. .................... T ................. 0021 16.5832 $1,056.23 $219.40 $211.25
20205 ......... Deep muscle biopsy ........................................ .................... T ................. 0021 16.5832 $1,056.23 $219.40 $211.25
20206 ......... Needle biopsy, muscle .................................... .................... T ................. 0005 7.3012 $465.04 .................... $93.01
2020F ......... Dilated fundus eval done ................................ .................... M ................ .................... .................... .................... .................... ....................
2021F ......... Dilat macul+exam done .................................. .................... M ................ .................... .................... .................... .................... ....................
20220 ......... Bone biopsy, trocar/needle ............................. CH .............. T ................. 0020 8.7155 $555.12 .................... $111.02
20225 ......... Bone biopsy, trocar/needle ............................. .................... T ................. 0020 8.7155 $555.12 .................... $111.02
2022F ......... Dil retina exam interp rev ................................ .................... M ................ .................... .................... .................... .................... ....................
20240 ......... Bone biopsy, excisional ................................... .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
20245 ......... Bone biopsy, excisional ................................... .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
2024F ......... 7 field photo interp doc rev ............................. .................... M ................ .................... .................... .................... .................... ....................
20250 ......... Open bone biopsy ........................................... .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
20251 ......... Open bone biopsy ........................................... .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
2026F ......... Eye image valid to dx rev ............................... .................... M ................ .................... .................... .................... .................... ....................
2027F ......... Optic nerve head eval done ............................ .................... M ................ .................... .................... .................... .................... ....................
2028F ......... Foot exam performed ...................................... .................... M ................ .................... .................... .................... .................... ....................
2029F ......... Complete phys skin exam done ...................... .................... M ................ .................... .................... .................... .................... ....................
2030F ......... H2O stat doc’d, normal ................................... .................... M ................ .................... .................... .................... .................... ....................
2031F ......... H2O stat doc’d, dehydrated ............................ .................... M ................ .................... .................... .................... .................... ....................
20500 ......... Injection of sinus tract ..................................... .................... T ................. 0251 2.5765 $164.11 .................... $32.82
20501 ......... Inject sinus tract for x-ray ................................ .................... N ................. .................... .................... .................... .................... ....................
20520 ......... Removal of foreign body ................................. .................... T ................. 0019 4.4463 $283.20 $71.80 $56.64
20525 ......... Removal of foreign body ................................. .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
20526 ......... Ther injection, carp tunnel ............................... .................... T ................. 0204 2.3254 $148.11 $40.10 $29.62
20550 ......... Inj tendon sheath/ligament .............................. .................... T ................. 0204 2.3254 $148.11 $40.10 $29.62
20551 ......... Inj tendon origin/insertion ................................ .................... T ................. 0204 2.3254 $148.11 $40.10 $29.62
20552 ......... Inj trigger point, 1/2 muscl ............................... .................... T ................. 0204 2.3254 $148.11 $40.10 $29.62
20553 ......... Inject trigger points, =/> 3 ............................... .................... T ................. 0204 2.3254 $148.11 $40.10 $29.62
20600 ......... Drain/inject, joint/bursa .................................... .................... T ................. 0204 2.3254 $148.11 $40.10 $29.62
20612 ......... Aspirate/inj ganglion cyst ................................ .................... T ................. 0204 2.3254 $148.11 $40.10 $29.62
20615 ......... Treatment of bone cyst ................................... .................... T ................. 0004 4.5062 $287.01 .................... $57.40
20650 ......... Insert and remove bone pin ............................ .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
20660 ......... Apply, rem fixation device ............................... .................... C ................. .................... .................... .................... .................... ....................
20661 ......... Application of head brace ............................... .................... C ................. .................... .................... .................... .................... ....................
20662 ......... Application of pelvis brace .............................. .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
20663 ......... Application of thigh brace ................................ .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
20664 ......... Halo brace application ..................................... .................... C ................. .................... .................... .................... .................... ....................
20665 ......... Removal of fixation device .............................. .................... X ................. 0340 0.6416 $40.87 .................... $8.17
20670 ......... Removal of support implant ............................ .................... T ................. 0021 16.5832 $1,056.23 $219.40 $211.25
20680 ......... Removal of support implant ............................ .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
20690 ......... Apply bone fixation device .............................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
20692 ......... Apply bone fixation device .............................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
20693 ......... Adjust bone fixation device ............................. .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
20694 ......... Remove bone fixation device .......................... .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
20802 ......... Replantation, arm, complete ........................... .................... C ................. .................... .................... .................... .................... ....................
20805 ......... Replant forearm, complete .............................. .................... C ................. .................... .................... .................... .................... ....................
20808 ......... Replantation hand, complete .......................... .................... C ................. .................... .................... .................... .................... ....................
20816 ......... Replantation digit, complete ............................ .................... C ................. .................... .................... .................... .................... ....................
20822 ......... Replantation digit, complete ............................ .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
20824 ......... Replantation thumb, complete ........................ .................... C ................. .................... .................... .................... .................... ....................
20827 ......... Replantation thumb, complete ........................ .................... C ................. .................... .................... .................... .................... ....................
20838 ......... Replantation foot, complete ............................ .................... C ................. .................... .................... .................... .................... ....................
20900 ......... Removal of bone for graft ............................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
20902 ......... Removal of bone for graft ............................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
20910 ......... Remove cartilage for graft ............................... CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
20912 ......... Remove cartilage for graft ............................... CH .............. T ................. 0137 20.9338 $1,333.34 .................... $266.67
20920 ......... Removal of fascia for graft .............................. CH .............. T ................. 0136 15.4399 $983.41 .................... $196.68
20922 ......... Removal of fascia for graft .............................. CH .............. T ................. 0136 15.4399 $983.41 .................... $196.68
20924 ......... Removal of tendon for graft ............................ .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
20926 ......... Removal of tissue for graft .............................. CH .............. T ................. 0135 4.6816 $298.19 .................... $59.64
20930 ......... Spinal bone allograft ....................................... .................... C ................. .................... .................... .................... .................... ....................
20931 ......... Spinal bone allograft ....................................... .................... C ................. .................... .................... .................... .................... ....................
20936 ......... Spinal bone autograft ...................................... .................... C ................. .................... .................... .................... .................... ....................
20950 ......... Fluid pressure, muscle .................................... .................... T ................. 0006 1.463 $93.18 .................... $18.64
20955 ......... Fibula bone graft, microvasc ........................... .................... C ................. .................... .................... .................... .................... ....................
20956 ......... Iliac bone graft, microvasc .............................. .................... C ................. .................... .................... .................... .................... ....................
20957 ......... Mt bone graft, microvasc ................................. .................... C ................. .................... .................... .................... .................... ....................
Continued
National Minimum
20962 ......... Other bone graft, microvasc ............................ .................... C ................. .................... .................... .................... .................... ....................
20969 ......... Bone/skin graft, microvasc .............................. .................... C ................. .................... .................... .................... .................... ....................
20970 ......... Bone/skin graft, iliac crest ............................... .................... C ................. .................... .................... .................... .................... ....................
20972 ......... Bone/skin graft, metatarsal ............................. .................... T ................. 0056 44.471 $2,832.49 .................... $566.50
20973 ......... Bone/skin graft, great toe ................................ .................... T ................. 0056 44.471 $2,832.49 .................... $566.50
20974 ......... Electrical bone stimulation .............................. .................... A ................. .................... .................... .................... .................... ....................
20975 ......... Electrical bone stimulation .............................. CH .............. N ................. .................... .................... .................... .................... ....................
20979 ......... Us bone stimulation ......................................... .................... X ................. 0340 0.6416 $40.87 .................... $8.17
20982 ......... Ablate, bone tumor(s) perq ............................. .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
20999 ......... Musculoskeletal surgery .................................. .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
21010 ......... Incision of jaw joint .......................................... .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
21015 ......... Resection of facial tumor ................................ .................... T ................. 0253 16.6341 $1,059.48 $282.20 $211.90
21025 ......... Excision of bone, lower jaw ............................ .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21026 ......... Excision of facial bone(s) ................................ .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21029 ......... Contour of face bone lesion ............................ .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21030 ......... Excise max/zygoma b9 tumor ......................... .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
21031 ......... Remove exostosis, mandible .......................... .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
21032 ......... Remove exostosis, maxilla .............................. .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
21034 ......... Excise max/zygoma mlg tumor ....................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21040 ......... Excise mandible lesion .................................... .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
21044 ......... Removal of jaw bone lesion ............................ .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21045 ......... Extensive jaw surgery ..................................... .................... C ................. .................... .................... .................... .................... ....................
21046 ......... Remove mandible cyst complex ..................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21047 ......... Excise lwr jaw cyst w/repair ............................ .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21048 ......... Remove maxilla cyst complex ......................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21049 ......... Excis uppr jaw cyst w/repair ........................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21050 ......... Removal of jaw joint ........................................ .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21060 ......... Remove jaw joint cartilage .............................. .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21070 ......... Remove coronoid process .............................. .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21076 ......... Prepare face/oral prosthesis ........................... .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
21077 ......... Prepare face/oral prosthesis ........................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21085 ......... Prepare face/oral prosthesis ........................... .................... T ................. 0253 16.6341 $1,059.48 $282.20 $211.90
21089 ......... Prepare face/oral prosthesis ........................... .................... T ................. 0251 2.5765 $164.11 .................... $32.82
21100 ......... Maxillofacial fixation ........................................ .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21110 ......... Interdental fixation ........................................... .................... T ................. 0252 7.6539 $487.50 $109.10 $97.50
21116 ......... Injection, jaw joint x-ray ................................... .................... N ................. .................... .................... .................... .................... ....................
21120 ......... Reconstruction of chin ..................................... .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
21125 ......... Augmentation, lower jaw bone ........................ .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
21127 ......... Augmentation, lower jaw bone ........................ .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21137 ......... Reduction of forehead ..................................... .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
21138 ......... Reduction of forehead ..................................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21139 ......... Reduction of forehead ..................................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21141 ......... Reconstruct midface, lefort ............................. .................... C ................. .................... .................... .................... .................... ....................
21150 ......... Reconstruct midface, lefort ............................. .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21172 ......... Reconstruct orbit/forehead .............................. .................... C ................. .................... .................... .................... .................... ....................
21175 ......... Reconstruct orbit/forehead .............................. .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21179 ......... Reconstruct entire forehead ............................ .................... C ................. .................... .................... .................... .................... ....................
21180 ......... Reconstruct entire forehead ............................ .................... C ................. .................... .................... .................... .................... ....................
21181 ......... Contour cranial bone lesion ............................ .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
21182 ......... Reconstruct cranial bone ................................ .................... C ................. .................... .................... .................... .................... ....................
21188 ......... Reconstruction of midface ............................... .................... C ................. .................... .................... .................... .................... ....................
21193 ......... Reconst lwr jaw w/o graft ................................ .................... C ................. .................... .................... .................... .................... ....................
21194 ......... Reconst lwr jaw w/graft ................................... .................... C ................. .................... .................... .................... .................... ....................
21195 ......... Reconst lwr jaw w/o fixation ............................ .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
Continued
National Minimum
21196 ......... Reconst lwr jaw w/fixation ............................... .................... C ................. .................... .................... .................... .................... ....................
21198 ......... Reconstr lwr jaw segment ............................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21199 ......... Reconstr lwr jaw w/advance ........................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21206 ......... Reconstruct upper jaw bone ........................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21208 ......... Augmentation of facial bones .......................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21209 ......... Reduction of facial bones ................................ .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21210 ......... Face bone graft ............................................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21215 ......... Lower jaw bone graft ....................................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21230 ......... Rib cartilage graft ............................................ .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21235 ......... Ear cartilage graft ............................................ .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
21240 ......... Reconstruction of jaw joint .............................. .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21244 ......... Reconstruction of lower jaw ............................ .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21245 ......... Reconstruction of jaw ...................................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21247 ......... Reconstruct lower jaw bone ............................ .................... C ................. .................... .................... .................... .................... ....................
21255 ......... Reconstruct lower jaw bone ............................ .................... C ................. .................... .................... .................... .................... ....................
21256 ......... Reconstruction of orbit .................................... .................... C ................. .................... .................... .................... .................... ....................
21260 ......... Revise eye sockets ......................................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21268 ......... Revise eye sockets ......................................... .................... C ................. .................... .................... .................... .................... ....................
21270 ......... Augmentation, cheek bone ............................. .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21275 ......... Revision, orbitofacial bones ............................ .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21280 ......... Revision of eyelid ............................................ .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21282 ......... Revision of eyelid ............................................ .................... T ................. 0253 16.6341 $1,059.48 $282.20 $211.90
21295 ......... Revision of jaw muscle/bone .......................... .................... T ................. 0252 7.6539 $487.50 $109.10 $97.50
21296 ......... Revision of jaw muscle/bone .......................... .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
21299 ......... Cranio/maxillofacial surgery ............................ .................... T ................. 0251 2.5765 $164.11 .................... $32.82
21310 ......... Treatment of nose fracture .............................. .................... T ................. 0251 2.5765 $164.11 .................... $32.82
21315 ......... Treatment of nose fracture .............................. .................... T ................. 0251 2.5765 $164.11 .................... $32.82
21320 ......... Treatment of nose fracture .............................. CH .............. T ................. 0253 16.6341 $1,059.48 $282.20 $211.90
21325 ......... Treatment of nose fracture .............................. .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
21336 ......... Treat nasal septal fracture .............................. .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
21337 ......... Treat nasal septal fracture .............................. .................... T ................. 0253 16.6341 $1,059.48 $282.20 $211.90
21338 ......... Treat nasoethmoid fracture ............................. .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
21339 ......... Treat nasoethmoid fracture ............................. .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
21340 ......... Treatment of nose fracture .............................. .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21343 ......... Treatment of sinus fracture ............................. .................... C ................. .................... .................... .................... .................... ....................
21344 ......... Treatment of sinus fracture ............................. .................... C ................. .................... .................... .................... .................... ....................
21345 ......... Treat nose/jaw fracture ................................... .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
21346 ......... Treat nose/jaw fracture ................................... .................... C ................. .................... .................... .................... .................... ....................
21355 ......... Treat cheek bone fracture ............................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21356 ......... Treat cheek bone fracture ............................... .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
21360 ......... Treat cheek bone fracture ............................... CH .............. T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
21365 ......... Treat cheek bone fracture ............................... CH .............. T ................. 0256 40.5598 $2,583.38 .................... $516.68
21366 ......... Treat cheek bone fracture ............................... .................... C ................. .................... .................... .................... .................... ....................
21385 ......... Treat eye socket fracture ................................ CH .............. T ................. 0256 40.5598 $2,583.38 .................... $516.68
21386 ......... Treat eye socket fracture ................................ .................... C ................. .................... .................... .................... .................... ....................
21390 ......... Treat eye socket fracture ................................ .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21400 ......... Treat eye socket fracture ................................ .................... T ................. 0252 7.6539 $487.50 $109.10 $97.50
21401 ......... Treat eye socket fracture ................................ .................... T ................. 0253 16.6341 $1,059.48 $282.20 $211.90
21421 ......... Treat mouth roof fracture ................................ .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
21422 ......... Treat mouth roof fracture ................................ .................... C ................. .................... .................... .................... .................... ....................
21423 ......... Treat mouth roof fracture ................................ .................... C ................. .................... .................... .................... .................... ....................
21431 ......... Treat craniofacial fracture ............................... .................... C ................. .................... .................... .................... .................... ....................
21440 ......... Treat dental ridge fracture ............................... .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
21445 ......... Treat dental ridge fracture ............................... .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
21450 ......... Treat lower jaw fracture .................................. .................... T ................. 0251 2.5765 $164.11 .................... $32.82
21451 ......... Treat lower jaw fracture .................................. .................... T ................. 0252 7.6539 $487.50 $109.10 $97.50
21452 ......... Treat lower jaw fracture .................................. .................... T ................. 0253 16.6341 $1,059.48 $282.20 $211.90
Continued
National Minimum
21453 ......... Treat lower jaw fracture .................................. .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21454 ......... Treat lower jaw fracture .................................. .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
21480 ......... Reset dislocated jaw ....................................... .................... T ................. 0251 2.5765 $164.11 .................... $32.82
21485 ......... Reset dislocated jaw ....................................... .................... T ................. 0253 16.6341 $1,059.48 $282.20 $211.90
21490 ......... Repair dislocated jaw ...................................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
21495 ......... Treat hyoid bone fracture ................................ .................... T ................. 0253 16.6341 $1,059.48 $282.20 $211.90
21497 ......... Interdental wiring ............................................. .................... T ................. 0253 16.6341 $1,059.48 $282.20 $211.90
21499 ......... Head surgery procedure ................................. .................... T ................. 0251 2.5765 $164.11 .................... $32.82
21501 ......... Drain neck/chest lesion ................................... .................... T ................. 0008 19.0457 $1,213.08 .................... $242.62
21502 ......... Drain chest lesion ............................................ .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
21510 ......... Drainage of bone lesion .................................. .................... C ................. .................... .................... .................... .................... ....................
21550 ......... Biopsy of neck/chest ....................................... .................... T ................. 0020 8.7155 $555.12 .................... $111.02
21555 ......... Remove lesion, neck/chest ............................. .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
21556 ......... Remove lesion, neck/chest ............................. .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
21557 ......... Remove tumor, neck/chest ............................. .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
21600 ......... Partial removal of rib ....................................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
21610 ......... Partial removal of rib ....................................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
21615 ......... Removal of rib ................................................. .................... C ................. .................... .................... .................... .................... ....................
21616 ......... Removal of rib and nerves .............................. .................... C ................. .................... .................... .................... .................... ....................
21620 ......... Partial removal of sternum .............................. .................... C ................. .................... .................... .................... .................... ....................
21627 ......... Sternal debridement ........................................ .................... C ................. .................... .................... .................... .................... ....................
21630 ......... Extensive sternum surgery .............................. .................... C ................. .................... .................... .................... .................... ....................
21632 ......... Extensive sternum surgery .............................. .................... C ................. .................... .................... .................... .................... ....................
21685 ......... Hyoid myotomy & suspension ......................... .................... T ................. 0252 7.6539 $487.50 $109.10 $97.50
21700 ......... Revision of neck muscle ................................. .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
21705 ......... Revision of neck muscle/rib ............................ .................... C ................. .................... .................... .................... .................... ....................
21720 ......... Revision of neck muscle ................................. .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
21725 ......... Revision of neck muscle ................................. .................... T ................. 0006 1.463 $93.18 .................... $18.64
21740 ......... Reconstruction of sternum .............................. .................... C ................. .................... .................... .................... .................... ....................
21742 ......... Repair stern/nuss w/o scope ........................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
21743 ......... Repair sternum/nuss w/scope ......................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
21750 ......... Repair of sternum separation .......................... .................... C ................. .................... .................... .................... .................... ....................
21800 ......... Treatment of rib fracture ................................. .................... T ................. 0043 1.8742 $119.37 .................... $23.87
21805 ......... Treatment of rib fracture ................................. .................... T ................. 0062 26.3092 $1,675.71 $372.80 $335.14
21810 ......... Treatment of rib fracture(s) ............................. .................... C ................. .................... .................... .................... .................... ....................
21820 ......... Treat sternum fracture ..................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
21825 ......... Treat sternum fracture ..................................... .................... C ................. .................... .................... .................... .................... ....................
21899 ......... Neck/chest surgery procedure ........................ .................... T ................. 0251 2.5765 $164.11 .................... $32.82
21920 ......... Biopsy soft tissue of back ............................... .................... T ................. 0020 8.7155 $555.12 .................... $111.02
21925 ......... Biopsy soft tissue of back ............................... .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
21930 ......... Remove lesion, back or flank .......................... .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
21935 ......... Remove tumor, back ....................................... .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
22010 ......... I&d, p-spine, c/t/cerv-thor ................................ .................... C ................. .................... .................... .................... .................... ....................
22015 ......... I&d, p-spine, l/s/ls ............................................ .................... C ................. .................... .................... .................... .................... ....................
22100 ......... Remove part of neck vertebra ........................ .................... T ................. 0208 47.6714 $3,036.33 .................... $607.27
22101 ......... Remove part, thorax vertebra ......................... .................... T ................. 0208 47.6714 $3,036.33 .................... $607.27
22102 ......... Remove part, lumbar vertebra ........................ .................... T ................. 0208 47.6714 $3,036.33 .................... $607.27
22103 ......... Remove extra spine segment ......................... .................... T ................. 0208 47.6714 $3,036.33 .................... $607.27
22110 ......... Remove part of neck vertebra ........................ .................... C ................. .................... .................... .................... .................... ....................
22112 ......... Remove part, thorax vertebra ......................... .................... C ................. .................... .................... .................... .................... ....................
22114 ......... Remove part, lumbar vertebra ........................ .................... C ................. .................... .................... .................... .................... ....................
22116 ......... Remove extra spine segment ......................... .................... C ................. .................... .................... .................... .................... ....................
22210 ......... Revision of neck spine .................................... .................... C ................. .................... .................... .................... .................... ....................
22212 ......... Revision of thorax spine .................................. .................... C ................. .................... .................... .................... .................... ....................
22214 ......... Revision of lumbar spine ................................. .................... C ................. .................... .................... .................... .................... ....................
22216 ......... Revise, extra spine segment ........................... .................... C ................. .................... .................... .................... .................... ....................
22220 ......... Revision of neck spine .................................... .................... C ................. .................... .................... .................... .................... ....................
22222 ......... Revision of thorax spine .................................. .................... T ................. 0208 47.6714 $3,036.33 .................... $607.27
22224 ......... Revision of lumbar spine ................................. .................... C ................. .................... .................... .................... .................... ....................
22226 ......... Revise, extra spine segment ........................... .................... C ................. .................... .................... .................... .................... ....................
22305 ......... Treat spine process fracture ........................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
22310 ......... Treat spine fracture ......................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
22315 ......... Treat spine fracture ......................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
22318 ......... Treat odontoid fx w/o graft .............................. .................... C ................. .................... .................... .................... .................... ....................
22319 ......... Treat odontoid fx w/graft ................................. .................... C ................. .................... .................... .................... .................... ....................
22325 ......... Treat spine fracture ......................................... .................... C ................. .................... .................... .................... .................... ....................
22326 ......... Treat neck spine fracture ................................ .................... C ................. .................... .................... .................... .................... ....................
22327 ......... Treat thorax spine fracture .............................. .................... C ................. .................... .................... .................... .................... ....................
22328 ......... Treat each add spine fx .................................. .................... C ................. .................... .................... .................... .................... ....................
22505 ......... Manipulation of spine ...................................... .................... T ................. 0045 15.0176 $956.52 $268.40 $191.30
22520 ......... Percut vertebroplasty thor ............................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
22521 ......... Percut vertebroplasty lumb ............................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
22522 ......... Percut vertebroplasty add’l .............................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
22523 ......... Percut kyphoplasty, thor .................................. .................... T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
Continued
National Minimum
22524 ......... Percut kyphoplasty, lumbar ............................. .................... T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
22525 ......... Percut kyphoplasty, add-on ............................. .................... T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
22526 ......... Idet, single level .............................................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
22527 ......... Idet, 1 or more levels ...................................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
22532 ......... Lat thorax spine fusion .................................... .................... C ................. .................... .................... .................... .................... ....................
22533 ......... Lat lumbar spine fusion ................................... .................... C ................. .................... .................... .................... .................... ....................
22534 ......... Lat thor/lumb, add’l seg ................................... .................... C ................. .................... .................... .................... .................... ....................
22548 ......... Neck spine fusion ............................................ .................... C ................. .................... .................... .................... .................... ....................
22556 ......... Thorax spine fusion ......................................... .................... C ................. .................... .................... .................... .................... ....................
22558 ......... Lumbar spine fusion ........................................ .................... C ................. .................... .................... .................... .................... ....................
22585 ......... Additional spinal fusion ................................... .................... C ................. .................... .................... .................... .................... ....................
22590 ......... Spine & skull spinal fusion .............................. .................... C ................. .................... .................... .................... .................... ....................
22595 ......... Neck spinal fusion ........................................... .................... C ................. .................... .................... .................... .................... ....................
22610 ......... Thorax spine fusion ......................................... .................... C ................. .................... .................... .................... .................... ....................
22612 ......... Lumbar spine fusion ........................................ .................... T ................. 0208 47.6714 $3,036.33 .................... $607.27
22614 ......... Spine fusion, extra segment ........................... .................... T ................. 0208 47.6714 $3,036.33 .................... $607.27
22630 ......... Lumbar spine fusion ........................................ .................... C ................. .................... .................... .................... .................... ....................
22632 ......... Spine fusion, extra segment ........................... .................... C ................. .................... .................... .................... .................... ....................
22800 ......... Fusion of spine ................................................ .................... C ................. .................... .................... .................... .................... ....................
22802 ......... Fusion of spine ................................................ .................... C ................. .................... .................... .................... .................... ....................
22804 ......... Fusion of spine ................................................ .................... C ................. .................... .................... .................... .................... ....................
22808 ......... Fusion of spine ................................................ .................... C ................. .................... .................... .................... .................... ....................
22810 ......... Fusion of spine ................................................ .................... C ................. .................... .................... .................... .................... ....................
22812 ......... Fusion of spine ................................................ .................... C ................. .................... .................... .................... .................... ....................
22818 ......... Kyphectomy, 1-2 segments ............................. .................... C ................. .................... .................... .................... .................... ....................
22819 ......... Kyphectomy, 3 or more ................................... .................... C ................. .................... .................... .................... .................... ....................
22830 ......... Exploration of spinal fusion ............................. .................... C ................. .................... .................... .................... .................... ....................
22840 ......... Insert spine fixation device .............................. .................... C ................. .................... .................... .................... .................... ....................
22848 ......... Insert pelv fixation device ................................ .................... C ................. .................... .................... .................... .................... ....................
22849 ......... Reinsert spinal fixation .................................... .................... C ................. .................... .................... .................... .................... ....................
22850 ......... Remove spine fixation device ......................... .................... C ................. .................... .................... .................... .................... ....................
22851 ......... Apply spine prosth device ............................... .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
22857 ......... Lumbar artif diskectomy .................................. .................... C ................. .................... .................... .................... .................... ....................
22862 ......... Revise lumbar artif disc ................................... .................... C ................. .................... .................... .................... .................... ....................
22865 ......... Remove lumb artif disc ................................... .................... C ................. .................... .................... .................... .................... ....................
22899 ......... Spine surgery procedure ................................. .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
22900 ......... Remove abdominal wall lesion ....................... .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
22999 ......... Abdomen surgery procedure ........................... .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
23000 ......... Removal of calcium deposits .......................... .................... T ................. 0021 16.5832 $1,056.23 $219.40 $211.25
23020 ......... Release shoulder joint ..................................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
23030 ......... Drain shoulder lesion ...................................... .................... T ................. 0008 19.0457 $1,213.08 .................... $242.62
23031 ......... Drain shoulder bursa ....................................... .................... T ................. 0008 19.0457 $1,213.08 .................... $242.62
23035 ......... Drain shoulder bone lesion ............................. .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
23040 ......... Exploratory shoulder surgery .......................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
23044 ......... Exploratory shoulder surgery .......................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
23065 ......... Biopsy shoulder tissues .................................. .................... T ................. 0020 8.7155 $555.12 .................... $111.02
23066 ......... Biopsy shoulder tissues .................................. .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
23075 ......... Removal of shoulder lesion ............................. .................... T ................. 0021 16.5832 $1,056.23 $219.40 $211.25
23076 ......... Removal of shoulder lesion ............................. .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
23077 ......... Remove tumor of shoulder .............................. .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
23100 ......... Biopsy of shoulder joint ................................... .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
23101 ......... Shoulder joint surgery ..................................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
23105 ......... Remove shoulder joint lining ........................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
23106 ......... Incision of collarbone joint ............................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
23107 ......... Explore treat shoulder joint ............................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
23120 ......... Partial removal, collar bone ............................ CH .............. T ................. 0050 29.3263 $1,867.88 .................... $373.58
23125 ......... Removal of collar bone ................................... CH .............. T ................. 0050 29.3263 $1,867.88 .................... $373.58
23130 ......... Remove shoulder bone, part ........................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
23140 ......... Removal of bone lesion .................................. .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
23150 ......... Removal of humerus lesion ............................ .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
23170 ......... Remove collar bone lesion .............................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
23172 ......... Remove shoulder blade lesion ........................ .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
23174 ......... Remove humerus lesion ................................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
Continued
National Minimum
23180 ......... Remove collar bone lesion .............................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
23182 ......... Remove shoulder blade lesion ........................ .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
23190 ......... Partial removal of scapula ............................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
23195 ......... Removal of head of humerus .......................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
23200 ......... Removal of collar bone ................................... .................... C ................. .................... .................... .................... .................... ....................
23210 ......... Removal of shoulder blade ............................. .................... C ................. .................... .................... .................... .................... ....................
23220 ......... Partial removal of humerus ............................. .................... C ................. .................... .................... .................... .................... ....................
23330 ......... Remove shoulder foreign body ....................... .................... T ................. 0020 8.7155 $555.12 .................... $111.02
23331 ......... Remove shoulder foreign body ....................... .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
23332 ......... Remove shoulder foreign body ....................... .................... C ................. .................... .................... .................... .................... ....................
23350 ......... Injection for shoulder x-ray .............................. .................... N ................. .................... .................... .................... .................... ....................
23395 ......... Muscle transfer,shoulder/arm .......................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
23397 ......... Muscle transfers .............................................. .................... T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
23400 ......... Fixation of shoulder blade ............................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
23405 ......... Incision of tendon & muscle ............................ .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
23406 ......... Incise tendon(s) & muscle(s) .......................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
23410 ......... Repair rotator cuff, acute ................................ .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
23412 ......... Repair rotator cuff, chronic .............................. .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
23415 ......... Release of shoulder ligament ......................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
23420 ......... Repair of shoulder ........................................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
23430 ......... Repair biceps tendon ...................................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
23440 ......... Remove/transplant tendon .............................. .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
23450 ......... Repair shoulder capsule ................................. .................... T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
23462 ......... Repair shoulder capsule ................................. .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
23466 ......... Repair shoulder capsule ................................. .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
23470 ......... Reconstruct shoulder joint ............................... .................... T ................. 0425 113.6713 $7,240.07 .................... $1,448.01
23472 ......... Reconstruct shoulder joint ............................... .................... C ................. .................... .................... .................... .................... ....................
23480 ......... Revision of collar bone .................................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
23485 ......... Revision of collar bone .................................... .................... T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
23490 ......... Reinforce clavicle ............................................ .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
23491 ......... Reinforce shoulder bones ............................... .................... T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
23500 ......... Treat clavicle fracture ...................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
23505 ......... Treat clavicle fracture ...................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
23515 ......... Treat clavicle fracture ...................................... .................... T ................. 0064 60.0595 $3,825.37 $835.70 $765.07
23520 ......... Treat clavicle dislocation ................................. .................... T ................. 0043 1.8742 $119.37 .................... $23.87
23530 ......... Treat clavicle dislocation ................................. .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
23570 ......... Treat shoulder blade fx ................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
23575 ......... Treat shoulder blade fx ................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
23585 ......... Treat scapula fracture ..................................... .................... T ................. 0064 60.0595 $3,825.37 $835.70 $765.07
23600 ......... Treat humerus fracture .................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
23615 ......... Treat humerus fracture .................................... .................... T ................. 0064 60.0595 $3,825.37 $835.70 $765.07
23650 ......... Treat shoulder dislocation ............................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
23655 ......... Treat shoulder dislocation ............................... .................... T ................. 0045 15.0176 $956.52 $268.40 $191.30
23660 ......... Treat shoulder dislocation ............................... .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
23665 ......... Treat dislocation/fracture ................................. .................... T ................. 0043 1.8742 $119.37 .................... $23.87
23670 ......... Treat dislocation/fracture ................................. .................... T ................. 0064 60.0595 $3,825.37 $835.70 $765.07
23675 ......... Treat dislocation/fracture ................................. .................... T ................. 0043 1.8742 $119.37 .................... $23.87
23680 ......... Treat dislocation/fracture ................................. .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
23700 ......... Fixation of shoulder ......................................... .................... T ................. 0045 15.0176 $956.52 $268.40 $191.30
23800 ......... Fusion of shoulder joint ................................... .................... T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
23802 ......... Fusion of shoulder joint ................................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
23900 ......... Amputation of arm & girdle ............................. .................... C ................. .................... .................... .................... .................... ....................
23920 ......... Amputation at shoulder joint ........................... .................... C ................. .................... .................... .................... .................... ....................
23921 ......... Amputation follow-up surgery .......................... CH .............. T ................. 0136 15.4399 $983.41 .................... $196.68
23929 ......... Shoulder surgery procedure ............................ .................... T ................. 0043 1.8742 $119.37 .................... $23.87
23930 ......... Drainage of arm lesion .................................... .................... T ................. 0008 19.0457 $1,213.08 .................... $242.62
23931 ......... Drainage of arm bursa .................................... .................... T ................. 0008 19.0457 $1,213.08 .................... $242.62
23935 ......... Drain arm/elbow bone lesion .......................... .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
24000 ......... Exploratory elbow surgery ............................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
24006 ......... Release elbow joint ......................................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
24065 ......... Biopsy arm/elbow soft tissue .......................... .................... T ................. 0021 16.5832 $1,056.23 $219.40 $211.25
Continued
National Minimum
24066 ......... Biopsy arm/elbow soft tissue .......................... .................... T ................. 0021 16.5832 $1,056.23 $219.40 $211.25
24075 ......... Remove arm/elbow lesion ............................... .................... T ................. 0021 16.5832 $1,056.23 $219.40 $211.25
24076 ......... Remove arm/elbow lesion ............................... .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
24077 ......... Remove tumor of arm/elbow ........................... .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
24100 ......... Biopsy elbow joint lining .................................. .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
24101 ......... Explore/treat elbow joint .................................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
24102 ......... Remove elbow joint lining ............................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
24105 ......... Removal of elbow bursa ................................. .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
24115 ......... Remove/graft bone lesion ............................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
24120 ......... Remove elbow lesion ...................................... .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
24130 ......... Removal of head of radius .............................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
24134 ......... Removal of arm bone lesion ........................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
24136 ......... Remove radius bone lesion ............................ .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
24138 ......... Remove elbow bone lesion ............................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
24140 ......... Partial removal of arm bone ............................ .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
24145 ......... Partial removal of radius ................................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
24147 ......... Partial removal of elbow .................................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
24149 ......... Radical resection of elbow .............................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
24150 ......... Extensive humerus surgery ............................. .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
24151 ......... Extensive humerus surgery ............................. .................... T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
24152 ......... Extensive radius surgery ................................. .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
24153 ......... Extensive radius surgery ................................. .................... T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
24155 ......... Removal of elbow joint .................................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
24160 ......... Remove elbow joint implant ............................ .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
24164 ......... Remove radius head implant .......................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
24200 ......... Removal of arm foreign body .......................... .................... T ................. 0019 4.4463 $283.20 $71.80 $56.64
24201 ......... Removal of arm foreign body .......................... .................... T ................. 0021 16.5832 $1,056.23 $219.40 $211.25
24220 ......... Injection for elbow x-ray .................................. .................... N ................. .................... .................... .................... .................... ....................
24300 ......... Manipulate elbow w/anesth ............................. .................... T ................. 0045 15.0176 $956.52 $268.40 $191.30
24301 ......... Muscle/tendon transfer .................................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
24305 ......... Arm tendon lengthening .................................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
24310 ......... Revision of arm tendon ................................... .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
24320 ......... Repair of arm tendon ...................................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
24330 ......... Revision of arm muscles ................................. .................... T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
24331 ......... Revision of arm muscles ................................. .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
24332 ......... Tenolysis, triceps ............................................. .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
24340 ......... Repair of biceps tendon .................................. .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
24341 ......... Repair arm tendon/muscle .............................. .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
24342 ......... Repair of ruptured tendon ............................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
24343 ......... Repr elbow lat ligmnt w/tiss ............................ .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
24344 ......... Reconstruct elbow lat ligmnt ........................... .................... T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
24345 ......... Repr elbw med ligmnt w/tissu ......................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
24346 ......... Reconstruct elbow med ligmnt ........................ .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
24350 ......... Repair of tennis elbow .................................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
24356 ......... Revision of tennis elbow ................................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
24360 ......... Reconstruct elbow joint ................................... .................... T ................. 0047 35.9249 $2,288.16 $537.00 $457.63
24361 ......... Reconstruct elbow joint ................................... .................... T ................. 0425 113.6713 $7,240.07 .................... $1,448.01
24362 ......... Reconstruct elbow joint ................................... .................... T ................. 0048 51.0431 $3,251.09 .................... $650.22
24363 ......... Replace elbow joint ......................................... .................... T ................. 0425 113.6713 $7,240.07 .................... $1,448.01
24365 ......... Reconstruct head of radius ............................. .................... T ................. 0047 35.9249 $2,288.16 $537.00 $457.63
24366 ......... Reconstruct head of radius ............................. .................... T ................. 0425 113.6713 $7,240.07 .................... $1,448.01
24400 ......... Revision of humerus ....................................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
24430 ......... Repair of humerus ........................................... .................... T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
24435 ......... Repair humerus with graft ............................... .................... T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
24470 ......... Revision of elbow joint .................................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
24495 ......... Decompression of forearm .............................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
24498 ......... Reinforce humerus .......................................... .................... T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
Continued
National Minimum
24586 ......... Treat elbow fracture ........................................ .................... T ................. 0064 60.0595 $3,825.37 $835.70 $765.07
24600 ......... Treat elbow dislocation ................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
24605 ......... Treat elbow dislocation ................................... .................... T ................. 0045 15.0176 $956.52 $268.40 $191.30
24615 ......... Treat elbow dislocation ................................... .................... T ................. 0064 60.0595 $3,825.37 $835.70 $765.07
24620 ......... Treat elbow fracture ........................................ .................... T ................. 0043 1.8742 $119.37 .................... $23.87
24640 ......... Treat elbow dislocation ................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
24650 ......... Treat radius fracture ........................................ .................... T ................. 0043 1.8742 $119.37 .................... $23.87
24655 ......... Treat radius fracture ........................................ .................... T ................. 0043 1.8742 $119.37 .................... $23.87
24665 ......... Treat radius fracture ........................................ .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
24666 ......... Treat radius fracture ........................................ .................... T ................. 0064 60.0595 $3,825.37 $835.70 $765.07
24670 ......... Treat ulnar fracture .......................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
24675 ......... Treat ulnar fracture .......................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
24685 ......... Treat ulnar fracture .......................................... .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
24800 ......... Fusion of elbow joint ....................................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
24802 ......... Fusion/graft of elbow joint ............................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
24900 ......... Amputation of upper arm ................................ .................... C ................. .................... .................... .................... .................... ....................
24920 ......... Amputation of upper arm ................................ .................... C ................. .................... .................... .................... .................... ....................
24925 ......... Amputation follow-up surgery .......................... .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
24930 ......... Amputation follow-up surgery .......................... .................... C ................. .................... .................... .................... .................... ....................
24931 ......... Amputate upper arm & implant ....................... .................... C ................. .................... .................... .................... .................... ....................
24935 ......... Revision of amputation .................................... .................... T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
24940 ......... Revision of upper arm ..................................... .................... C ................. .................... .................... .................... .................... ....................
24999 ......... Upper arm/elbow surgery ................................ .................... T ................. 0043 1.8742 $119.37 .................... $23.87
25000 ......... Incision of tendon sheath ................................ .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
25001 ......... Incise flexor carpi radialis ................................ .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
25020 ......... Decompress forearm 1 space ......................... .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
25023 ......... Decompress forearm 1 space ......................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
25024 ......... Decompress forearm 2 spaces ....................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
25025 ......... Decompress forearm 2 spaces ....................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
25028 ......... Drainage of forearm lesion .............................. .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
25031 ......... Drainage of forearm bursa .............................. .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
25035 ......... Treat forearm bone lesion ............................... .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
25040 ......... Explore/treat wrist joint .................................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
25065 ......... Biopsy forearm soft tissues ............................. .................... T ................. 0020 8.7155 $555.12 .................... $111.02
25066 ......... Biopsy forearm soft tissues ............................. .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
25075 ......... Removal forearm lesion subcu ....................... .................... T ................. 0021 16.5832 $1,056.23 $219.40 $211.25
25076 ......... Removal forearm lesion deep ......................... .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
25077 ......... Remove tumor, forearm/wrist .......................... .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
25085 ......... Incision of wrist capsule .................................. .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
25100 ......... Biopsy of wrist joint ......................................... .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
25101 ......... Explore/treat wrist joint .................................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
25105 ......... Remove wrist joint lining ................................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
25107 ......... Remove wrist joint cartilage ............................ .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
25109 ......... Excise tendon forearm/wrist ............................ .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
25110 ......... Remove wrist tendon lesion ............................ .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
25111 ......... Remove wrist tendon lesion ............................ .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
25112 ......... Reremove wrist tendon lesion ......................... .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
25115 ......... Remove wrist/forearm lesion ........................... .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
25116 ......... Remove wrist/forearm lesion ........................... .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
25118 ......... Excise wrist tendon sheath ............................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
25119 ......... Partial removal of ulna .................................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
25120 ......... Removal of forearm lesion .............................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
25125 ......... Remove/graft forearm lesion ........................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
25126 ......... Remove/graft forearm lesion ........................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
25130 ......... Removal of wrist lesion ................................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
25135 ......... Remove & graft wrist lesion ............................ .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
25136 ......... Remove & graft wrist lesion ............................ .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
25145 ......... Remove forearm bone lesion .......................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
25170 ......... Extensive forearm surgery .............................. .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
25210 ......... Removal of wrist bone .................................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
25215 ......... Removal of wrist bones ................................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
25246 ......... Injection for wrist x-ray .................................... .................... N ................. .................... .................... .................... .................... ....................
25248 ......... Remove forearm foreign body ........................ .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
25250 ......... Removal of wrist prosthesis ............................ .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
25251 ......... Removal of wrist prosthesis ............................ .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
25259 ......... Manipulate wrist w/anesthes ........................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
25260 ......... Repair forearm tendon/muscle ........................ .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
Continued
National Minimum
25275 ......... Repair forearm tendon sheath ........................ .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
25280 ......... Revise wrist/forearm tendon ........................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
25290 ......... Incise wrist/forearm tendon ............................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
25295 ......... Release wrist/forearm tendon ......................... .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
25300 ......... Fusion of tendons at wrist ............................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
25301 ......... Fusion of tendons at wrist ............................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
25310 ......... Transplant forearm tendon .............................. .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
25312 ......... Transplant forearm tendon .............................. .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
25315 ......... Revise palsy hand tendon(s) .......................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
25316 ......... Revise palsy hand tendon(s) .......................... .................... T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
25320 ......... Repair/revise wrist joint ................................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
25332 ......... Revise wrist joint ............................................. .................... T ................. 0047 35.9249 $2,288.16 $537.00 $457.63
25335 ......... Realignment of hand ....................................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
25337 ......... Reconstruct ulna/radioulnar ............................ .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
25350 ......... Revision of radius ............................................ .................... T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
25355 ......... Revision of radius ............................................ .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
25360 ......... Revision of ulna ............................................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
25365 ......... Revise radius & ulna ....................................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
25370 ......... Revise radius or ulna ...................................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
25375 ......... Revise radius & ulna ....................................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
25390 ......... Shorten radius or ulna ..................................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
25391 ......... Lengthen radius or ulna .................................. .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
25392 ......... Shorten radius & ulna ..................................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
25393 ......... Lengthen radius & ulna ................................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
25394 ......... Repair carpal bone, shorten ............................ .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
25400 ......... Repair radius or ulna ....................................... CH .............. T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
25405 ......... Repair/graft radius or ulna .............................. CH .............. T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
25415 ......... Repair radius & ulna ....................................... CH .............. T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
25420 ......... Repair/graft radius & ulna ............................... .................... T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
25425 ......... Repair/graft radius or ulna .............................. .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
25426 ......... Repair/graft radius & ulna ............................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
25430 ......... Vasc graft into carpal bone ............................. .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
25431 ......... Repair nonunion carpal bone .......................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
25440 ......... Repair/graft wrist bone .................................... .................... T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
25441 ......... Reconstruct wrist joint ..................................... .................... T ................. 0425 113.6713 $7,240.07 .................... $1,448.01
25442 ......... Reconstruct wrist joint ..................................... .................... T ................. 0425 113.6713 $7,240.07 .................... $1,448.01
25443 ......... Reconstruct wrist joint ..................................... .................... T ................. 0048 51.0431 $3,251.09 .................... $650.22
25446 ......... Wrist replacement ........................................... .................... T ................. 0425 113.6713 $7,240.07 .................... $1,448.01
25447 ......... Repair wrist joint(s) ......................................... .................... T ................. 0047 35.9249 $2,288.16 $537.00 $457.63
25449 ......... Remove wrist joint implant .............................. .................... T ................. 0047 35.9249 $2,288.16 $537.00 $457.63
25450 ......... Revision of wrist joint ...................................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
25455 ......... Revision of wrist joint ...................................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
25490 ......... Reinforce radius .............................................. .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
25491 ......... Reinforce ulna ................................................. .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
25492 ......... Reinforce radius and ulna ............................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
25500 ......... Treat fracture of radius .................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
25515 ......... Treat fracture of radius .................................... .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
25530 ......... Treat fracture of ulna ....................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
25535 ......... Treat fracture of ulna ....................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
25545 ......... Treat fracture of ulna ....................................... .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
25560 ......... Treat fracture radius & ulna ............................ .................... T ................. 0043 1.8742 $119.37 .................... $23.87
25565 ......... Treat fracture radius & ulna ............................ .................... T ................. 0043 1.8742 $119.37 .................... $23.87
25574 ......... Treat fracture radius & ulna ............................ .................... T ................. 0064 60.0595 $3,825.37 $835.70 $765.07
25575 ......... Treat fracture radius/ulna ................................ .................... T ................. 0064 60.0595 $3,825.37 $835.70 $765.07
25600 ......... Treat fracture radius/ulna ................................ .................... T ................. 0043 1.8742 $119.37 .................... $23.87
25605 ......... Treat fracture radius/ulna ................................ .................... T ................. 0043 1.8742 $119.37 .................... $23.87
25606 ......... Treat fx distal radial ......................................... .................... T ................. 0062 26.3092 $1,675.71 $372.80 $335.14
25607 ......... Treat fx rad extra-articul .................................. .................... T ................. 0064 60.0595 $3,825.37 $835.70 $765.07
25608 ......... Treat fx rad intra-articul ................................... .................... T ................. 0064 60.0595 $3,825.37 $835.70 $765.07
25609 ......... Treat fx radial 3+ frag ..................................... .................... T ................. 0064 60.0595 $3,825.37 $835.70 $765.07
25622 ......... Treat wrist bone fracture ................................. .................... T ................. 0043 1.8742 $119.37 .................... $23.87
25628 ......... Treat wrist bone fracture ................................. .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
25645 ......... Treat wrist bone fracture ................................. .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
Continued
National Minimum
25651 ......... Pin ulnar styloid fracture ................................. .................... T ................. 0062 26.3092 $1,675.71 $372.80 $335.14
25652 ......... Treat fracture ulnar styloid .............................. .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
25660 ......... Treat wrist dislocation ..................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
25670 ......... Treat wrist dislocation ..................................... .................... T ................. 0062 26.3092 $1,675.71 $372.80 $335.14
25671 ......... Pin radioulnar dislocation ................................ .................... T ................. 0062 26.3092 $1,675.71 $372.80 $335.14
25680 ......... Treat wrist fracture .......................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
25685 ......... Treat wrist fracture .......................................... .................... T ................. 0062 26.3092 $1,675.71 $372.80 $335.14
25800 ......... Fusion of wrist joint ......................................... .................... T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
25805 ......... Fusion/graft of wrist joint ................................. .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
25810 ......... Fusion/graft of wrist joint ................................. .................... T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
25820 ......... Fusion of hand bones ..................................... .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
25825 ......... Fuse hand bones with graft ............................ CH .............. T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
25830 ......... Fusion, radioulnar jnt/ulna ............................... .................... T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
25900 ......... Amputation of forearm ..................................... .................... C ................. .................... .................... .................... .................... ....................
25920 ......... Amputate hand at wrist ................................... .................... C ................. .................... .................... .................... .................... ....................
25922 ......... Amputate hand at wrist ................................... .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
25927 ......... Amputation of hand ......................................... .................... C ................. .................... .................... .................... .................... ....................
25929 ......... Amputation follow-up surgery .......................... CH .............. T ................. 0136 15.4399 $983.41 .................... $196.68
25931 ......... Amputation follow-up surgery .......................... CH .............. T ................. 0049 21.5761 $1,374.25 .................... $274.85
25999 ......... Forearm or wrist surgery ................................. .................... T ................. 0043 1.8742 $119.37 .................... $23.87
26010 ......... Drainage of finger abscess ............................. .................... T ................. 0006 1.463 $93.18 .................... $18.64
26011 ......... Drainage of finger abscess ............................. .................... T ................. 0007 12.5792 $801.21 .................... $160.24
26020 ......... Drain hand tendon sheath ............................... .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26025 ......... Drainage of palm bursa ................................... .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26030 ......... Drainage of palm bursa(s) .............................. .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26034 ......... Treat hand bone lesion ................................... .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26035 ......... Decompress fingers/hand ............................... .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26037 ......... Decompress fingers/hand ............................... .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26040 ......... Release palm contracture ............................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26055 ......... Incise finger tendon sheath ............................. .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26060 ......... Incision of finger tendon .................................. .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26070 ......... Explore/treat hand joint ................................... .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26075 ......... Explore/treat finger joint .................................. .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26080 ......... Explore/treat finger joint .................................. .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26100 ......... Biopsy hand joint lining ................................... .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26105 ......... Biopsy finger joint lining .................................. .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26110 ......... Biopsy finger joint lining .................................. .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26115 ......... Removal hand lesion subcut ........................... .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
26116 ......... Removal hand lesion, deep ............................ .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
26117 ......... Remove tumor, hand/finger ............................. .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
26125 ......... Release palm contracture ............................... .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26130 ......... Remove wrist joint lining ................................. .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26135 ......... Revise finger joint, each .................................. .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26140 ......... Revise finger joint, each .................................. .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26145 ......... Tendon excision, palm/finger .......................... .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26160 ......... Remove tendon sheath lesion ........................ .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26170 ......... Removal of palm tendon, each ....................... .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26180 ......... Removal of finger tendon ................................ .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26185 ......... Remove finger bone ........................................ .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26200 ......... Remove hand bone lesion .............................. .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26210 ......... Removal of finger lesion ................................. .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26215 ......... Remove/graft finger lesion .............................. .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26230 ......... Partial removal of hand bone .......................... .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26235 ......... Partial removal, finger bone ............................ .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26236 ......... Partial removal, finger bone ............................ .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26250 ......... Extensive hand surgery ................................... .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26255 ......... Extensive hand surgery ................................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26260 ......... Extensive finger surgery .................................. .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26261 ......... Extensive finger surgery .................................. .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26262 ......... Partial removal of finger .................................. .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26320 ......... Removal of implant from hand ........................ .................... T ................. 0021 16.5832 $1,056.23 $219.40 $211.25
26340 ......... Manipulate finger w/anesth ............................. .................... T ................. 0043 1.8742 $119.37 .................... $23.87
26350 ......... Repair finger/hand tendon ............................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26352 ......... Repair/graft hand tendon ................................ .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
Continued
National Minimum
26390 ......... Revise hand/finger tendon .............................. .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26410 ......... Repair hand tendon ......................................... .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26415 ......... Excision, hand/finger tendon ........................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26416 ......... Graft hand or finger tendon ............................. .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26418 ......... Repair finger tendon ........................................ .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26420 ......... Repair/graft finger tendon ............................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26437 ......... Realignment of tendons .................................. .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26440 ......... Release palm/finger tendon ............................ .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26442 ......... Release palm & finger tendon ........................ .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26445 ......... Release hand/finger tendon ............................ .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26449 ......... Release forearm/hand tendon ......................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26450 ......... Incision of palm tendon ................................... .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26455 ......... Incision of finger tendon .................................. .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26460 ......... Incise hand/finger tendon ................................ .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26471 ......... Fusion of finger tendons ................................. .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26474 ......... Fusion of finger tendons ................................. .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26476 ......... Tendon lengthening ......................................... .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26477 ......... Tendon shortening .......................................... .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26478 ......... Lengthening of hand tendon ........................... .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26479 ......... Shortening of hand tendon .............................. .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26480 ......... Transplant hand tendon .................................. .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26483 ......... Transplant/graft hand tendon .......................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26485 ......... Transplant palm tendon .................................. .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26489 ......... Transplant/graft palm tendon .......................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26490 ......... Revise thumb tendon ...................................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26492 ......... Tendon transfer with graft ............................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26494 ......... Hand tendon/muscle transfer .......................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26496 ......... Revise thumb tendon ...................................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26497 ......... Finger tendon transfer ..................................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26498 ......... Finger tendon transfer ..................................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26499 ......... Revision of finger ............................................ .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26500 ......... Hand tendon reconstruction ............................ .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26502 ......... Hand tendon reconstruction ............................ .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26508 ......... Release thumb contracture ............................. .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26510 ......... Thumb tendon transfer .................................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26516 ......... Fusion of knuckle joint .................................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26517 ......... Fusion of knuckle joints ................................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26518 ......... Fusion of knuckle joints ................................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26520 ......... Release knuckle contracture ........................... .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26525 ......... Release finger contracture .............................. .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26530 ......... Revise knuckle joint ........................................ .................... T ................. 0047 35.9249 $2,288.16 $537.00 $457.63
26531 ......... Revise knuckle with implant ............................ .................... T ................. 0048 51.0431 $3,251.09 .................... $650.22
26535 ......... Revise finger joint ............................................ .................... T ................. 0047 35.9249 $2,288.16 $537.00 $457.63
26536 ......... Revise/implant finger joint ............................... .................... T ................. 0048 51.0431 $3,251.09 .................... $650.22
26540 ......... Repair hand joint ............................................. .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26541 ......... Repair hand joint with graft ............................. .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26542 ......... Repair hand joint with graft ............................. .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26545 ......... Reconstruct finger joint ................................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26546 ......... Repair nonunion hand ..................................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26548 ......... Reconstruct finger joint ................................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26550 ......... Construct thumb replacement ......................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26551 ......... Great toe-hand transfer ................................... .................... C ................. .................... .................... .................... .................... ....................
26553 ......... Single transfer, toe-hand ................................. .................... C ................. .................... .................... .................... .................... ....................
26554 ......... Double transfer, toe-hand ............................... .................... C ................. .................... .................... .................... .................... ....................
26555 ......... Positional change of finger .............................. .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26556 ......... Toe joint transfer ............................................. .................... C ................. .................... .................... .................... .................... ....................
26560 ......... Repair of web finger ........................................ .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26561 ......... Repair of web finger ........................................ .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26562 ......... Repair of web finger ........................................ .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26565 ......... Correct metacarpal flaw .................................. .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26567 ......... Correct finger deformity ................................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26568 ......... Lengthen metacarpal/finger ............................. .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26580 ......... Repair hand deformity ..................................... .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26587 ......... Reconstruct extra finger .................................. .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26590 ......... Repair finger deformity .................................... .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26591 ......... Repair muscles of hand .................................. .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
Continued
National Minimum
26593 ......... Release muscles of hand ................................ .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26596 ......... Excision constricting tissue ............................. .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26600 ......... Treat metacarpal fracture ................................ .................... T ................. 0043 1.8742 $119.37 .................... $23.87
26608 ......... Treat metacarpal fracture ................................ .................... T ................. 0062 26.3092 $1,675.71 $372.80 $335.14
26615 ......... Treat metacarpal fracture ................................ .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
26641 ......... Treat thumb dislocation ................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
26645 ......... Treat thumb fracture ........................................ .................... T ................. 0043 1.8742 $119.37 .................... $23.87
26650 ......... Treat thumb fracture ........................................ .................... T ................. 0062 26.3092 $1,675.71 $372.80 $335.14
26665 ......... Treat thumb fracture ........................................ .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
26670 ......... Treat hand dislocation ..................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
26675 ......... Treat hand dislocation ..................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
26676 ......... Pin hand dislocation ........................................ .................... T ................. 0062 26.3092 $1,675.71 $372.80 $335.14
26685 ......... Treat hand dislocation ..................................... .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
26686 ......... Treat hand dislocation ..................................... .................... T ................. 0064 60.0595 $3,825.37 $835.70 $765.07
26700 ......... Treat knuckle dislocation ................................. .................... T ................. 0043 1.8742 $119.37 .................... $23.87
26705 ......... Treat knuckle dislocation ................................. .................... T ................. 0043 1.8742 $119.37 .................... $23.87
26706 ......... Pin knuckle dislocation .................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
26715 ......... Treat knuckle dislocation ................................. .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
26720 ......... Treat finger fracture, each ............................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
26727 ......... Treat finger fracture, each ............................... .................... T ................. 0062 26.3092 $1,675.71 $372.80 $335.14
26756 ......... Pin finger fracture, each .................................. .................... T ................. 0062 26.3092 $1,675.71 $372.80 $335.14
26770 ......... Treat finger dislocation .................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
26775 ......... Treat finger dislocation .................................... .................... T ................. 0045 15.0176 $956.52 $268.40 $191.30
26776 ......... Pin finger dislocation ....................................... .................... T ................. 0062 26.3092 $1,675.71 $372.80 $335.14
26785 ......... Treat finger dislocation .................................... .................... T ................. 0062 26.3092 $1,675.71 $372.80 $335.14
26820 ......... Thumb fusion with graft ................................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26841 ......... Fusion of thumb .............................................. .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26842 ......... Thumb fusion with graft ................................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26843 ......... Fusion of hand joint ......................................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26844 ......... Fusion/graft of hand joint ................................ .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26850 ......... Fusion of knuckle ............................................ .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26852 ......... Fusion of knuckle with graft ............................ .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26860 ......... Fusion of finger joint ........................................ .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26861 ......... Fusion of finger jnt, add-on ............................. .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26862 ......... Fusion/graft of finger joint ............................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26863 ......... Fuse/graft added joint ..................................... .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26910 ......... Amputate metacarpal bone ............................. .................... T ................. 0054 26.7322 $1,702.65 .................... $340.53
26951 ......... Amputation of finger/thumb ............................. .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26952 ......... Amputation of finger/thumb ............................. .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
26989 ......... Hand/finger surgery ......................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
26990 ......... Drainage of pelvis lesion ................................. .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
26991 ......... Drainage of pelvis bursa ................................. .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27000 ......... Incision of hip tendon ...................................... .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27005 ......... Incision of hip tendon ...................................... .................... C ................. .................... .................... .................... .................... ....................
27006 ......... Incision of hip tendons .................................... CH .............. T ................. 0050 29.3263 $1,867.88 .................... $373.58
27025 ......... Incision of hip/thigh fascia ............................... .................... C ................. .................... .................... .................... .................... ....................
27030 ......... Drainage of hip joint ........................................ .................... C ................. .................... .................... .................... .................... ....................
27033 ......... Exploration of hip joint ..................................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
27035 ......... Denervation of hip joint ................................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
27036 ......... Excision of hip joint/muscle ............................. .................... C ................. .................... .................... .................... .................... ....................
27040 ......... Biopsy of soft tissues ...................................... .................... T ................. 0020 8.7155 $555.12 .................... $111.02
27041 ......... Biopsy of soft tissues ...................................... .................... T ................. 0020 8.7155 $555.12 .................... $111.02
27047 ......... Remove hip/pelvis lesion ................................ .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
27048 ......... Remove hip/pelvis lesion ................................ .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
27049 ......... Remove tumor, hip/pelvis ................................ .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
27050 ......... Biopsy of sacroiliac joint .................................. .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27052 ......... Biopsy of hip joint ............................................ .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27054 ......... Removal of hip joint lining ............................... .................... C ................. .................... .................... .................... .................... ....................
27060 ......... Removal of ischial bursa ................................. .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27062 ......... Remove femur lesion/bursa ............................ .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27065 ......... Removal of hip bone lesion ............................ .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27066 ......... Removal of hip bone lesion ............................ .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27067 ......... Remove/graft hip bone lesion ......................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27070 ......... Partial removal of hip bone ............................. .................... C ................. .................... .................... .................... .................... ....................
27071 ......... Partial removal of hip bone ............................. .................... C ................. .................... .................... .................... .................... ....................
Continued
National Minimum
27075 ......... Extensive hip surgery ...................................... .................... C ................. .................... .................... .................... .................... ....................
27080 ......... Removal of tail bone ....................................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27086 ......... Remove hip foreign body ................................ .................... T ................. 0020 8.7155 $555.12 .................... $111.02
27087 ......... Remove hip foreign body ................................ .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27090 ......... Removal of hip prosthesis ............................... .................... C ................. .................... .................... .................... .................... ....................
27091 ......... Removal of hip prosthesis ............................... .................... C ................. .................... .................... .................... .................... ....................
27093 ......... Injection for hip x-ray ....................................... .................... N ................. .................... .................... .................... .................... ....................
27095 ......... Injection for hip x-ray ....................................... .................... N ................. .................... .................... .................... .................... ....................
27096 ......... Inject sacroiliac joint ........................................ .................... B ................. .................... .................... .................... .................... ....................
27097 ......... Revision of hip tendon .................................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27098 ......... Transfer tendon to pelvis ................................ .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27100 ......... Transfer of abdominal muscle ......................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
27105 ......... Transfer of spinal muscle ................................ .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
27110 ......... Transfer of iliopsoas muscle ........................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
27111 ......... Transfer of iliopsoas muscle ........................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
27120 ......... Reconstruction of hip socket ........................... .................... C ................. .................... .................... .................... .................... ....................
27122 ......... Reconstruction of hip socket ........................... .................... C ................. .................... .................... .................... .................... ....................
27125 ......... Partial hip replacement ................................... .................... C ................. .................... .................... .................... .................... ....................
27130 ......... Total hip arthroplasty ....................................... .................... C ................. .................... .................... .................... .................... ....................
27132 ......... Total hip arthroplasty ....................................... .................... C ................. .................... .................... .................... .................... ....................
27134 ......... Revise hip joint replacement ........................... .................... C ................. .................... .................... .................... .................... ....................
27140 ......... Transplant femur ridge .................................... .................... C ................. .................... .................... .................... .................... ....................
27146 ......... Incision of hip bone ......................................... .................... C ................. .................... .................... .................... .................... ....................
27147 ......... Revision of hip bone ....................................... .................... C ................. .................... .................... .................... .................... ....................
27151 ......... Incision of hip bones ....................................... .................... C ................. .................... .................... .................... .................... ....................
27156 ......... Revision of hip bones ...................................... .................... C ................. .................... .................... .................... .................... ....................
27158 ......... Revision of pelvis ............................................ .................... C ................. .................... .................... .................... .................... ....................
27161 ......... Incision of neck of femur ................................. .................... C ................. .................... .................... .................... .................... ....................
27165 ......... Incision/fixation of femur ................................. .................... C ................. .................... .................... .................... .................... ....................
27170 ......... Repair/graft femur head/neck .......................... .................... C ................. .................... .................... .................... .................... ....................
27175 ......... Treat slipped epiphysis ................................... .................... C ................. .................... .................... .................... .................... ....................
27179 ......... Revise head/neck of femur ............................. .................... C ................. .................... .................... .................... .................... ....................
27185 ......... Revision of femur epiphysis ............................ .................... C ................. .................... .................... .................... .................... ....................
27187 ......... Reinforce hip bones ........................................ .................... C ................. .................... .................... .................... .................... ....................
27193 ......... Treat pelvic ring fracture ................................. .................... T ................. 0043 1.8742 $119.37 .................... $23.87
27194 ......... Treat pelvic ring fracture ................................. .................... T ................. 0045 15.0176 $956.52 $268.40 $191.30
27200 ......... Treat tail bone fracture .................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
27202 ......... Treat tail bone fracture .................................... .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
27215 ......... Treat pelvic fracture(s) .................................... .................... C ................. .................... .................... .................... .................... ....................
27216 ......... Treat pelvic ring fracture ................................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27217 ......... Treat pelvic ring fracture ................................. .................... C ................. .................... .................... .................... .................... ....................
27218 ......... Treat pelvic ring fracture ................................. .................... C ................. .................... .................... .................... .................... ....................
27220 ......... Treat hip socket fracture ................................. .................... T ................. 0043 1.8742 $119.37 .................... $23.87
27222 ......... Treat hip socket fracture ................................. .................... C ................. .................... .................... .................... .................... ....................
27226 ......... Treat hip wall fracture ..................................... .................... C ................. .................... .................... .................... .................... ....................
27227 ......... Treat hip fracture(s) ......................................... .................... C ................. .................... .................... .................... .................... ....................
27228 ......... Treat hip fracture(s) ......................................... .................... C ................. .................... .................... .................... .................... ....................
27230 ......... Treat thigh fracture .......................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
27232 ......... Treat thigh fracture .......................................... .................... C ................. .................... .................... .................... .................... ....................
27235 ......... Treat thigh fracture .......................................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27250 ......... Treat hip dislocation ........................................ .................... T ................. 0043 1.8742 $119.37 .................... $23.87
27252 ......... Treat hip dislocation ........................................ .................... T ................. 0045 15.0176 $956.52 $268.40 $191.30
27253 ......... Treat hip dislocation ........................................ .................... C ................. .................... .................... .................... .................... ....................
27275 ......... Manipulation of hip joint .................................. .................... T ................. 0045 15.0176 $956.52 $268.40 $191.30
Continued
National Minimum
27280 ......... Fusion of sacroiliac joint .................................. .................... C ................. .................... .................... .................... .................... ....................
27282 ......... Fusion of pubic bones ..................................... .................... C ................. .................... .................... .................... .................... ....................
27284 ......... Fusion of hip joint ............................................ .................... C ................. .................... .................... .................... .................... ....................
27286 ......... Fusion of hip joint ............................................ .................... C ................. .................... .................... .................... .................... ....................
27290 ......... Amputation of leg at hip .................................. .................... C ................. .................... .................... .................... .................... ....................
27295 ......... Amputation of leg at hip .................................. .................... C ................. .................... .................... .................... .................... ....................
27299 ......... Pelvis/hip joint surgery .................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
27301 ......... Drain thigh/knee lesion .................................... .................... T ................. 0008 19.0457 $1,213.08 .................... $242.62
27305 ......... Incise thigh tendon & fascia ............................ .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27306 ......... Incision of thigh tendon ................................... .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27307 ......... Incision of thigh tendons ................................. .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27310 ......... Exploration of knee joint .................................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27323 ......... Biopsy, thigh soft tissues ................................ .................... T ................. 0020 8.7155 $555.12 .................... $111.02
27324 ......... Biopsy, thigh soft tissues ................................ .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
27325 ......... Neurectomy, hamstring ................................... .................... T ................. 0220 18.5069 $1,178.76 .................... $235.75
27326 ......... Neurectomy, popliteal ...................................... .................... T ................. 0220 18.5069 $1,178.76 .................... $235.75
27327 ......... Removal of thigh lesion ................................... .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
27328 ......... Removal of thigh lesion ................................... .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
27329 ......... Remove tumor, thigh/knee .............................. .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
27330 ......... Biopsy, knee joint lining .................................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27331 ......... Explore/treat knee joint ................................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27332 ......... Removal of knee cartilage .............................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27333 ......... Removal of knee cartilage .............................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27334 ......... Remove knee joint lining ................................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27335 ......... Remove knee joint lining ................................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27340 ......... Removal of kneecap bursa ............................. .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27345 ......... Removal of knee cyst ...................................... .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27347 ......... Remove knee cyst ........................................... .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27350 ......... Removal of kneecap ....................................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27355 ......... Remove femur lesion ...................................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27356 ......... Remove femur lesion/graft .............................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27357 ......... Remove femur lesion/graft .............................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27358 ......... Remove femur lesion/fixation .......................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27360 ......... Partial removal, leg bone(s) ............................ .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27365 ......... Extensive leg surgery ...................................... .................... C ................. .................... .................... .................... .................... ....................
27370 ......... Injection for knee x-ray .................................... .................... N ................. .................... .................... .................... .................... ....................
27372 ......... Removal of foreign body ................................. .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
27380 ......... Repair of kneecap tendon ............................... .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27381 ......... Repair/graft kneecap tendon ........................... .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27385 ......... Repair of thigh muscle .................................... .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27386 ......... Repair/graft of thigh muscle ............................ .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27390 ......... Incision of thigh tendon ................................... .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27393 ......... Lengthening of thigh tendon ........................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27394 ......... Lengthening of thigh tendons .......................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27395 ......... Lengthening of thigh tendons .......................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
27396 ......... Transplant of thigh tendon .............................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27397 ......... Transplants of thigh tendons ........................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
27400 ......... Revise thigh muscles/tendons ........................ .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
27403 ......... Repair of knee cartilage .................................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27405 ......... Repair of knee ligament .................................. .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
27407 ......... Repair of knee ligament .................................. .................... T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
27409 ......... Repair of knee ligaments ................................ .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
27412 ......... Autochondrocyte implant knee ........................ .................... T ................. 0042 47.7765 $3,043.03 $804.70 $608.61
27415 ......... Osteochondral knee allograft .......................... .................... T ................. 0042 47.7765 $3,043.03 $804.70 $608.61
27418 ......... Repair degenerated kneecap .......................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
27420 ......... Revision of unstable kneecap ......................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
27422 ......... Revision of unstable kneecap ......................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
27424 ......... Revision/removal of kneecap .......................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
27425 ......... Lat retinacular release open ........................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27427 ......... Reconstruction, knee ....................................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
27428 ......... Reconstruction, knee ....................................... .................... T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
27429 ......... Reconstruction, knee ....................................... .................... T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
27430 ......... Revision of thigh muscles ............................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
27435 ......... Incision of knee joint ....................................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
27437 ......... Revise kneecap ............................................... .................... T ................. 0047 35.9249 $2,288.16 $537.00 $457.63
27438 ......... Revise kneecap with implant .......................... .................... T ................. 0048 51.0431 $3,251.09 .................... $650.22
27440 ......... Revision of knee joint ...................................... .................... T ................. 0047 35.9249 $2,288.16 $537.00 $457.63
27445 ......... Revision of knee joint ...................................... .................... C ................. .................... .................... .................... .................... ....................
27446 ......... Revision of knee joint ...................................... .................... T ................. 0681 191.2387 $12,180.57 .................... $2,436.11
27447 ......... Total knee arthroplasty .................................... .................... C ................. .................... .................... .................... .................... ....................
27448 ......... Incision of thigh ............................................... .................... C ................. .................... .................... .................... .................... ....................
27450 ......... Incision of thigh ............................................... .................... C ................. .................... .................... .................... .................... ....................
Continued
National Minimum
27454 ......... Realignment of thigh bone .............................. .................... C ................. .................... .................... .................... .................... ....................
27455 ......... Realignment of knee ....................................... .................... C ................. .................... .................... .................... .................... ....................
27457 ......... Realignment of knee ....................................... .................... C ................. .................... .................... .................... .................... ....................
27465 ......... Shortening of thigh bone ................................. .................... C ................. .................... .................... .................... .................... ....................
27466 ......... Lengthening of thigh bone .............................. .................... C ................. .................... .................... .................... .................... ....................
27468 ......... Shorten/lengthen thighs .................................. .................... C ................. .................... .................... .................... .................... ....................
27470 ......... Repair of thigh ................................................. .................... C ................. .................... .................... .................... .................... ....................
27472 ......... Repair/graft of thigh ......................................... .................... C ................. .................... .................... .................... .................... ....................
27475 ......... Surgery to stop leg growth .............................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27477 ......... Surgery to stop leg growth .............................. .................... C ................. .................... .................... .................... .................... ....................
27486 ......... Revise/replace knee joint ................................ .................... C ................. .................... .................... .................... .................... ....................
27487 ......... Revise/replace knee joint ................................ .................... C ................. .................... .................... .................... .................... ....................
27488 ......... Removal of knee prosthesis ............................ .................... C ................. .................... .................... .................... .................... ....................
27495 ......... Reinforce thigh ................................................ .................... C ................. .................... .................... .................... .................... ....................
27496 ......... Decompression of thigh/knee .......................... .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27500 ......... Treatment of thigh fracture .............................. .................... T ................. 0043 1.8742 $119.37 .................... $23.87
27506 ......... Treatment of thigh fracture .............................. .................... C ................. .................... .................... .................... .................... ....................
27509 ......... Treatment of thigh fracture .............................. .................... T ................. 0062 26.3092 $1,675.71 $372.80 $335.14
27516 ......... Treat thigh fx growth plate .............................. .................... T ................. 0043 1.8742 $119.37 .................... $23.87
27517 ......... Treat thigh fx growth plate .............................. .................... T ................. 0043 1.8742 $119.37 .................... $23.87
27519 ......... Treat thigh fx growth plate .............................. .................... C ................. .................... .................... .................... .................... ....................
27520 ......... Treat kneecap fracture .................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
27524 ......... Treat kneecap fracture .................................... .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
27530 ......... Treat knee fracture .......................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
27532 ......... Treat knee fracture .......................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
27535 ......... Treat knee fracture .......................................... .................... C ................. .................... .................... .................... .................... ....................
27538 ......... Treat knee fracture(s) ...................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
27550 ......... Treat knee dislocation ..................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
27552 ......... Treat knee dislocation ..................................... .................... T ................. 0045 15.0176 $956.52 $268.40 $191.30
27556 ......... Treat knee dislocation ..................................... .................... C ................. .................... .................... .................... .................... ....................
27560 ......... Treat kneecap dislocation ............................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
27562 ......... Treat kneecap dislocation ............................... .................... T ................. 0045 15.0176 $956.52 $268.40 $191.30
27566 ......... Treat kneecap dislocation ............................... .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
27570 ......... Fixation of knee joint ....................................... .................... T ................. 0045 15.0176 $956.52 $268.40 $191.30
27580 ......... Fusion of knee ................................................. .................... C ................. .................... .................... .................... .................... ....................
27590 ......... Amputate leg at thigh ...................................... .................... C ................. .................... .................... .................... .................... ....................
27598 ......... Amputate lower leg at knee ............................ .................... C ................. .................... .................... .................... .................... ....................
27599 ......... Leg surgery procedure .................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
27600 ......... Decompression of lower leg ............................ .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27603 ......... Drain lower leg lesion ...................................... .................... T ................. 0008 19.0457 $1,213.08 .................... $242.62
27604 ......... Drain lower leg bursa ...................................... .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27605 ......... Incision of achilles tendon ............................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
27606 ......... Incision of achilles tendon ............................... .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27607 ......... Treat lower leg bone lesion ............................. .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27610 ......... Explore/treat ankle joint ................................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27612 ......... Exploration of ankle joint ................................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27613 ......... Biopsy lower leg soft tissue ............................ .................... T ................. 0020 8.7155 $555.12 .................... $111.02
27614 ......... Biopsy lower leg soft tissue ............................ .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
27615 ......... Remove tumor, lower leg ................................ .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27618 ......... Remove lower leg lesion ................................. .................... T ................. 0021 16.5832 $1,056.23 $219.40 $211.25
27619 ......... Remove lower leg lesion ................................. .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
27620 ......... Explore/treat ankle joint ................................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27625 ......... Remove ankle joint lining ................................ .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27626 ......... Remove ankle joint lining ................................ .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
Continued
National Minimum
27630 ......... Removal of tendon lesion ............................... .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27635 ......... Remove lower leg bone lesion ........................ .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27637 ......... Remove/graft leg bone lesion ......................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27638 ......... Remove/graft leg bone lesion ......................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27640 ......... Partial removal of tibia .................................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
27641 ......... Partial removal of fibula .................................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27645 ......... Extensive lower leg surgery ............................ .................... C ................. .................... .................... .................... .................... ....................
27646 ......... Extensive lower leg surgery ............................ .................... C ................. .................... .................... .................... .................... ....................
27647 ......... Extensive ankle/heel surgery .......................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
27648 ......... Injection for ankle x-ray ................................... .................... N ................. .................... .................... .................... .................... ....................
27650 ......... Repair achilles tendon ..................................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
27652 ......... Repair/graft achilles tendon ............................ .................... T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
27654 ......... Repair of achilles tendon ................................ .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
27656 ......... Repair leg fascia defect .................................. .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27658 ......... Repair of leg tendon, each .............................. .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27675 ......... Repair lower leg tendons ................................ .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27676 ......... Repair lower leg tendons ................................ .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27680 ......... Release of lower leg tendon ........................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27681 ......... Release of lower leg tendons ......................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27685 ......... Revision of lower leg tendon ........................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27686 ......... Revise lower leg tendons ................................ .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27687 ......... Revision of calf tendon .................................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27690 ......... Revise lower leg tendon .................................. .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
27691 ......... Revise lower leg tendon .................................. .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
27692 ......... Revise additional leg tendon ........................... .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
27695 ......... Repair of ankle ligament ................................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27696 ......... Repair of ankle ligaments ............................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27698 ......... Repair of ankle ligament ................................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27700 ......... Revision of ankle joint ..................................... .................... T ................. 0047 35.9249 $2,288.16 $537.00 $457.63
27702 ......... Reconstruct ankle joint .................................... .................... C ................. .................... .................... .................... .................... ....................
27703 ......... Reconstruction, ankle joint .............................. .................... C ................. .................... .................... .................... .................... ....................
27704 ......... Removal of ankle implant ................................ .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27705 ......... Incision of tibia ................................................ .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
27707 ......... Incision of fibula .............................................. .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27709 ......... Incision of tibia & fibula ................................... .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27712 ......... Realignment of lower leg ................................ .................... C ................. .................... .................... .................... .................... ....................
27715 ......... Revision of lower leg ....................................... .................... C ................. .................... .................... .................... .................... ....................
27720 ......... Repair of tibia .................................................. CH .............. T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
27722 ......... Repair/graft of tibia .......................................... CH .............. T ................. 0064 60.0595 $3,825.37 $835.70 $765.07
27724 ......... Repair/graft of tibia .......................................... .................... C ................. .................... .................... .................... .................... ....................
27725 ......... Repair of lower leg .......................................... .................... C ................. .................... .................... .................... .................... ....................
27727 ......... Repair of lower leg .......................................... .................... C ................. .................... .................... .................... .................... ....................
27730 ......... Repair of tibia epiphysis .................................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27732 ......... Repair of fibula epiphysis ................................ .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27734 ......... Repair lower leg epiphyses ............................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27740 ......... Repair of leg epiphyses .................................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27742 ......... Repair of leg epiphyses .................................. .................... T ................. 0051 43.5953 $2,776.72 .................... $555.34
27745 ......... Reinforce tibia ................................................. .................... T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
27750 ......... Treatment of tibia fracture ............................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
27752 ......... Treatment of tibia fracture ............................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
27756 ......... Treatment of tibia fracture ............................... .................... T ................. 0062 26.3092 $1,675.71 $372.80 $335.14
27760 ......... Treatment of ankle fracture ............................. .................... T ................. 0043 1.8742 $119.37 .................... $23.87
27766 ......... Treatment of ankle fracture ............................. .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
27780 ......... Treatment of fibula fracture ............................. .................... T ................. 0043 1.8742 $119.37 .................... $23.87
27781 ......... Treatment of fibula fracture ............................. .................... T ................. 0043 1.8742 $119.37 .................... $23.87
27784 ......... Treatment of fibula fracture ............................. .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
27824 ......... Treat lower leg fracture ................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
27825 ......... Treat lower leg fracture ................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
27826 ......... Treat lower leg fracture ................................... .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
27829 ......... Treat lower leg joint ......................................... .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
Continued
National Minimum
27830 ......... Treat lower leg dislocation .............................. .................... T ................. 0043 1.8742 $119.37 .................... $23.87
27831 ......... Treat lower leg dislocation .............................. .................... T ................. 0043 1.8742 $119.37 .................... $23.87
27832 ......... Treat lower leg dislocation .............................. .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
27840 ......... Treat ankle dislocation .................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
27842 ......... Treat ankle dislocation .................................... .................... T ................. 0045 15.0176 $956.52 $268.40 $191.30
27846 ......... Treat ankle dislocation .................................... .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
27848 ......... Treat ankle dislocation .................................... .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
27860 ......... Fixation of ankle joint ...................................... .................... T ................. 0045 15.0176 $956.52 $268.40 $191.30
27870 ......... Fusion of ankle joint, open .............................. .................... T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
27871 ......... Fusion of tibiofibular joint ................................ .................... T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
27880 ......... Amputation of lower leg .................................. .................... C ................. .................... .................... .................... .................... ....................
27888 ......... Amputation of foot at ankle ............................. .................... C ................. .................... .................... .................... .................... ....................
27889 ......... Amputation of foot at ankle ............................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
27892 ......... Decompression of leg ..................................... .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
27899 ......... Leg/ankle surgery procedure .......................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
28001 ......... Drainage of bursa of foot ................................ .................... T ................. 0007 12.5792 $801.21 .................... $160.24
28002 ......... Treatment of foot infection .............................. .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
28003 ......... Treatment of foot infection .............................. .................... T ................. 0049 21.5761 $1,374.25 .................... $274.85
28005 ......... Treat foot bone lesion ..................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28008 ......... Incision of foot fascia ...................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28010 ......... Incision of toe tendon ...................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28011 ......... Incision of toe tendons .................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28020 ......... Exploration of foot joint ................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28022 ......... Exploration of foot joint ................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28024 ......... Exploration of toe joint .................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28035 ......... Decompression of tibia nerve ......................... .................... T ................. 0220 18.5069 $1,178.76 .................... $235.75
28043 ......... Excision of foot lesion ..................................... .................... T ................. 0022 21.4534 $1,366.43 $354.40 $273.29
28045 ......... Excision of foot lesion ..................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28046 ......... Resection of tumor, foot .................................. .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28050 ......... Biopsy of foot joint lining ................................. .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28052 ......... Biopsy of foot joint lining ................................. .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28054 ......... Biopsy of toe joint lining .................................. .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28055 ......... Neurectomy, foot ............................................. .................... T ................. 0220 18.5069 $1,178.76 .................... $235.75
28060 ......... Partial removal, foot fascia .............................. .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28062 ......... Removal of foot fascia .................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28070 ......... Removal of foot joint lining .............................. .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28072 ......... Removal of foot joint lining .............................. .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28080 ......... Removal of foot lesion .................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28086 ......... Excise foot tendon sheath ............................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28088 ......... Excise foot tendon sheath ............................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28092 ......... Removal of toe lesions .................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28100 ......... Removal of ankle/heel lesion .......................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28102 ......... Remove/graft foot lesion ................................. .................... T ................. 0056 44.471 $2,832.49 .................... $566.50
28108 ......... Removal of toe lesions .................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28110 ......... Part removal of metatarsal .............................. .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28114 ......... Removal of metatarsal heads ......................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28116 ......... Revision of foot ............................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28118 ......... Removal of heel bone ..................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28119 ......... Removal of heel spur ...................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28120 ......... Part removal of ankle/heel .............................. .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28122 ......... Partial removal of foot bone ............................ .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28124 ......... Partial removal of toe ...................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28130 ......... Removal of ankle bone ................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28140 ......... Removal of metatarsal .................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28150 ......... Removal of toe ................................................ .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28171 ......... Extensive foot surgery ..................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28190 ......... Removal of foot foreign body .......................... .................... T ................. 0019 4.4463 $283.20 $71.80 $56.64
28192 ......... Removal of foot foreign body .......................... .................... T ................. 0021 16.5832 $1,056.23 $219.40 $211.25
28193 ......... Removal of foot foreign body .......................... .................... T ................. 0020 8.7155 $555.12 .................... $111.02
Continued
National Minimum
28200 ......... Repair of foot tendon ...................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28202 ......... Repair/graft of foot tendon .............................. .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28208 ......... Repair of foot tendon ...................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28210 ......... Repair/graft of foot tendon .............................. .................... T ................. 0056 44.471 $2,832.49 .................... $566.50
28220 ......... Release of foot tendon .................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28222 ......... Release of foot tendons .................................. .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28225 ......... Release of foot tendon .................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28226 ......... Release of foot tendons .................................. .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28230 ......... Incision of foot tendon(s) ................................. .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28232 ......... Incision of toe tendon ...................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28234 ......... Incision of foot tendon ..................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28238 ......... Revision of foot tendon ................................... .................... T ................. 0056 44.471 $2,832.49 .................... $566.50
28240 ......... Release of big toe ........................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28250 ......... Revision of foot fascia ..................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28260 ......... Release of midfoot joint .................................. .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28261 ......... Revision of foot tendon ................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28262 ......... Revision of foot and ankle .............................. .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28264 ......... Release of midfoot joint .................................. .................... T ................. 0056 44.471 $2,832.49 .................... $566.50
28270 ......... Release of foot contracture ............................. .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28272 ......... Release of toe joint, each ............................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28280 ......... Fusion of toes .................................................. .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28285 ......... Repair of hammertoe ...................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28286 ......... Repair of hammertoe ...................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28288 ......... Partial removal of foot bone ............................ .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28289 ......... Repair hallux rigidus ........................................ .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28290 ......... Correction of bunion ........................................ .................... T ................. 0057 29.8356 $1,900.32 $475.90 $380.06
28300 ......... Incision of heel bone ....................................... .................... T ................. 0056 44.471 $2,832.49 .................... $566.50
28302 ......... Incision of ankle bone ..................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28304 ......... Incision of midfoot bones ................................ .................... T ................. 0056 44.471 $2,832.49 .................... $566.50
28305 ......... Incise/graft midfoot bones ............................... .................... T ................. 0056 44.471 $2,832.49 .................... $566.50
28306 ......... Incision of metatarsal ...................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28309 ......... Incision of metatarsals .................................... .................... T ................. 0056 44.471 $2,832.49 .................... $566.50
28310 ......... Revision of big toe .......................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28312 ......... Revision of toe ................................................ .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28313 ......... Repair deformity of toe .................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28315 ......... Removal of sesamoid bone ............................ .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28320 ......... Repair of foot bones ........................................ .................... T ................. 0056 44.471 $2,832.49 .................... $566.50
28322 ......... Repair of metatarsals ...................................... .................... T ................. 0056 44.471 $2,832.49 .................... $566.50
28340 ......... Resect enlarged toe tissue ............................. .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28341 ......... Resect enlarged toe ........................................ .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28344 ......... Repair extra toe(s) .......................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28345 ......... Repair webbed toe(s) ...................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28360 ......... Reconstruct cleft foot ...................................... .................... T ................. 0056 44.471 $2,832.49 .................... $566.50
28400 ......... Treatment of heel fracture ............................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
28405 ......... Treatment of heel fracture ............................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
28406 ......... Treatment of heel fracture ............................... .................... T ................. 0062 26.3092 $1,675.71 $372.80 $335.14
28415 ......... Treat heel fracture ........................................... .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
28420 ......... Treat/graft heel fracture ................................... .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
28445 ......... Treat ankle fracture ......................................... .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
28450 ......... Treat midfoot fracture, each ............................ .................... T ................. 0043 1.8742 $119.37 .................... $23.87
28455 ......... Treat midfoot fracture, each ............................ .................... T ................. 0043 1.8742 $119.37 .................... $23.87
28456 ......... Treat midfoot fracture ...................................... .................... T ................. 0062 26.3092 $1,675.71 $372.80 $335.14
28465 ......... Treat midfoot fracture, each ............................ .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
28470 ......... Treat metatarsal fracture ................................. .................... T ................. 0043 1.8742 $119.37 .................... $23.87
28475 ......... Treat metatarsal fracture ................................. .................... T ................. 0043 1.8742 $119.37 .................... $23.87
28476 ......... Treat metatarsal fracture ................................. .................... T ................. 0062 26.3092 $1,675.71 $372.80 $335.14
28485 ......... Treat metatarsal fracture ................................. .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
28490 ......... Treat big toe fracture ....................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
28495 ......... Treat big toe fracture ....................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
28496 ......... Treat big toe fracture ....................................... .................... T ................. 0062 26.3092 $1,675.71 $372.80 $335.14
28505 ......... Treat big toe fracture ....................................... .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
28510 ......... Treatment of toe fracture ................................ .................... T ................. 0043 1.8742 $119.37 .................... $23.87
28515 ......... Treatment of toe fracture ................................ .................... T ................. 0043 1.8742 $119.37 .................... $23.87
28525 ......... Treat toe fracture ............................................. .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
28530 ......... Treat sesamoid bone fracture ......................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
28531 ......... Treat sesamoid bone fracture ......................... .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
Continued
National Minimum
28540 ......... Treat foot dislocation ....................................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
28545 ......... Treat foot dislocation ....................................... .................... T ................. 0062 26.3092 $1,675.71 $372.80 $335.14
28555 ......... Repair foot dislocation ..................................... .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
28630 ......... Treat toe dislocation ........................................ .................... T ................. 0043 1.8742 $119.37 .................... $23.87
28635 ......... Treat toe dislocation ........................................ .................... T ................. 0045 15.0176 $956.52 $268.40 $191.30
28636 ......... Treat toe dislocation ........................................ .................... T ................. 0062 26.3092 $1,675.71 $372.80 $335.14
28645 ......... Repair toe dislocation ...................................... .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
28660 ......... Treat toe dislocation ........................................ .................... T ................. 0043 1.8742 $119.37 .................... $23.87
28665 ......... Treat toe dislocation ........................................ .................... T ................. 0045 15.0176 $956.52 $268.40 $191.30
28666 ......... Treat toe dislocation ........................................ .................... T ................. 0062 26.3092 $1,675.71 $372.80 $335.14
28675 ......... Repair of toe dislocation ................................. .................... T ................. 0063 40.3466 $2,569.80 $548.30 $513.96
28705 ......... Fusion of foot bones ....................................... .................... T ................. 0056 44.471 $2,832.49 .................... $566.50
28715 ......... Fusion of foot bones ....................................... CH .............. T ................. 0052 78.6518 $5,009.57 .................... $1,001.91
28737 ......... Revision of foot bones .................................... .................... T ................. 0056 44.471 $2,832.49 .................... $566.50
28750 ......... Fusion of big toe joint ...................................... .................... T ................. 0056 44.471 $2,832.49 .................... $566.50
28755 ......... Fusion of big toe joint ...................................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28760 ......... Fusion of big toe joint ...................................... .................... T ................. 0056 44.471 $2,832.49 .................... $566.50
28800 ......... Amputation of midfoot ..................................... .................... C ................. .................... .................... .................... .................... ....................
28805 ......... Amputation thru metatarsal ............................. .................... C ................. .................... .................... .................... .................... ....................
28810 ......... Amputation toe & metatarsal ........................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28820 ......... Amputation of toe ............................................ .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28825 ......... Partial amputation of toe ................................. .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
28890 ......... High energy eswt, plantar f ............................. .................... T ................. 0050 29.3263 $1,867.88 .................... $373.58
28899 ......... Foot/toes surgery procedure ........................... .................... T ................. 0043 1.8742 $119.37 .................... $23.87
29000 ......... Application of body cast .................................. .................... S ................. 0058 1.1272 $71.79 .................... $14.36
29049 ......... Application of figure eight ................................ .................... S ................. 0058 1.1272 $71.79 .................... $14.36
29055 ......... Application of shoulder cast ............................ .................... S ................. 0426 2.2383 $142.56 .................... $28.51
29058 ......... Application of shoulder cast ............................ .................... S ................. 0058 1.1272 $71.79 .................... $14.36
29065 ......... Application of long arm cast ............................ .................... S ................. 0426 2.2383 $142.56 .................... $28.51
29075 ......... Application of forearm cast ............................. .................... S ................. 0426 2.2383 $142.56 .................... $28.51
29085 ......... Apply hand/wrist cast ...................................... .................... S ................. 0058 1.1272 $71.79 .................... $14.36
29086 ......... Apply finger cast .............................................. .................... S ................. 0058 1.1272 $71.79 .................... $14.36
29105 ......... Apply long arm splint ....................................... .................... S ................. 0058 1.1272 $71.79 .................... $14.36
29125 ......... Apply forearm splint ........................................ .................... S ................. 0058 1.1272 $71.79 .................... $14.36
29126 ......... Apply forearm splint ........................................ .................... S ................. 0058 1.1272 $71.79 .................... $14.36
29130 ......... Application of finger splint ............................... .................... S ................. 0058 1.1272 $71.79 .................... $14.36
29131 ......... Application of finger splint ............................... .................... S ................. 0058 1.1272 $71.79 .................... $14.36
29200 ......... Strapping of chest ........................................... .................... S ................. 0058 1.1272 $71.79 .................... $14.36
29220 ......... Strapping of low back ...................................... .................... S ................. 0058 1.1272 $71.79 .................... $14.36
29240 ......... Strapping of shoulder ...................................... .................... S ................. 0058 1.1272 $71.79 .................... $14.36
29260 ......... Strapping of elbow or wrist ............................. .................... S ................. 0058 1.1272 $71.79 .................... $14.36
29280 ......... Strapping of hand or finger ............................. .................... S ................. 0058 1.1272 $71.79 .................... $14.36
29305 ......... Application of hip cast ..................................... .................... S ................. 0426 2.2383 $142.56 .................... $28.51
29325 ......... Application of hip casts ................................... .................... S ................. 0426 2.2383 $142.56 .................... $28.51
29345 ......... Application of long leg cast ............................. .................... S ................. 0426 2.2383 $142.56 .................... $28.51
29358 ......... Apply long leg cast brace ................................ .................... S ................. 0426 2.2383 $142.56 .................... $28.51
29405 ......... Apply short leg cast ......................................... .................... S ................. 0426 2.2383 $142.56 .................... $28.51
29440 ......... Addition of walker to cast ................................ .................... S ................. 0058 1.1272 $71.79 .................... $14.36
29445 ......... Apply rigid leg cast .......................................... .................... S ................. 0426 2.2383 $142.56 .................... $28.51
29450 ......... Application of leg cast ..................................... .................... S ................. 0058 1.1272 $71.79 .................... $14.36
29505 ......... Application, long leg splint .............................. .................... S ................. 0058 1.1272 $71.79 .................... $14.36
29515 ......... Application lower leg splint .............................. .................... S ................. 0058 1.1272 $71.79 .................... $14.36
29520 ......... Strapping of hip ............................................... .................... S ................. 0058 1.1272 $71.79 .................... $14.36
Continued
National Minimum
29530 ......... Strapping of knee ............................................ .................... S ................. 0058 1.1272 $71.79 .................... $14.36
29540 ......... Strapping of ankle and/or ft ............................. .................... S ................. 0058 1.1272 $71.79 .................... $14.36
29550 ......... Strapping of toes ............................................. .................... S ................. 0058 1.1272 $71.79 .................... $14.36
29580 ......... Application of paste boot ................................. .................... S ................. 0058 1.1272 $71.79 .................... $14.36
29590 ......... Application of foot splint .................................. .................... S ................. 0058 1.1272 $71.79 .................... $14.36
29700 ......... Removal/revision of cast ................................. .................... S ................. 0058 1.1272 $71.79 .................... $14.36
29720 ......... Repair of body cast ......................................... .................... S ................. 0058 1.1272 $71.79 .................... $14.36
29730 ......... Windowing of cast ........................................... .................... S ................. 0058 1.1272 $71.79 .................... $14.36
29740 ......... Wedging of cast .............................................. .................... S ................. 0058 1.1272 $71.79 .................... $14.36
29750 ......... Wedging of clubfoot cast ................................. .................... S ................. 0058 1.1272 $71.79 .................... $14.36
29799 ......... Casting/strapping procedure ........................... .................... S ................. 0058 1.1272 $71.79 .................... $14.36
29800 ......... Jaw arthroscopy/surgery ................................. .................... T ................. 0041 29.4467 $1,875.55 .................... $375.11
29804 ......... Jaw arthroscopy/surgery ................................. .................... T ................. 0041 29.4467 $1,875.55 .................... $375.11
29805 ......... Shoulder arthroscopy, dx ................................ .................... T ................. 0041 29.4467 $1,875.55 .................... $375.11
29806 ......... Shoulder arthroscopy/surgery ......................... .................... T ................. 0042 47.7765 $3,043.03 $804.70 $608.61
29819 ......... Shoulder arthroscopy/surgery ......................... .................... T ................. 0041 29.4467 $1,875.55 .................... $375.11
29827 ......... Arthroscop rotator cuff repr ............................. .................... T ................. 0042 47.7765 $3,043.03 $804.70 $608.61
29830 ......... Elbow arthroscopy ........................................... .................... T ................. 0041 29.4467 $1,875.55 .................... $375.11
29834 ......... Elbow arthroscopy/surgery .............................. .................... T ................. 0041 29.4467 $1,875.55 .................... $375.11
29840 ......... Wrist arthroscopy ............................................ .................... T ................. 0041 29.4467 $1,875.55 .................... $375.11
29843 ......... Wrist arthroscopy/surgery ............................... .................... T ................. 0041 29.4467 $1,875.55 .................... $375.11
29848 ......... Wrist endoscopy/surgery ................................. .................... T ................. 0041 29.4467 $1,875.55 .................... $375.11
29850 ......... Knee arthroscopy/surgery ............................... .................... T ................. 0041 29.4467 $1,875.55 .................... $375.11
29851 ......... Knee arthroscopy/surgery ............................... .................... T ................. 0042 47.7765 $3,043.03 $804.70 $608.61
29855 ......... Tibial arthroscopy/surgery ............................... .................... T ................. 0042 47.7765 $3,043.03 $804.70 $608.61
29856 ......... Tibial arthroscopy/surgery ............................... .................... T ................. 0041 29.4467 $1,875.55 .................... $375.11
29860 ......... Hip arthroscopy, dx ......................................... .................... T ................. 0041 29.4467 $1,875.55 .................... $375.11
29861 ......... Hip arthroscopy/surgery .................................. .................... T ................. 0041 29.4467 $1,875.55 .................... $375.11
29862 ......... Hip arthroscopy/surgery .................................. .................... T ................. 0042 47.7765 $3,043.03 $804.70 $608.61
29863 ......... Hip arthroscopy/surgery .................................. .................... T ................. 0042 47.7765 $3,043.03 $804.70 $608.61
29866 ......... Autgrft implnt, knee w/scope ........................... .................... T ................. 0042 47.7765 $3,043.03 $804.70 $608.61
29867 ......... Allgrft implnt, knee w/scope ............................ .................... T ................. 0042 47.7765 $3,043.03 $804.70 $608.61
29868 ......... Meniscal trnspl, knee w/scpe .......................... .................... T ................. 0042 47.7765 $3,043.03 $804.70 $608.61
29870 ......... Knee arthroscopy, dx ...................................... .................... T ................. 0041 29.4467 $1,875.55 .................... $375.11
29871 ......... Knee arthroscopy/drainage ............................. .................... T ................. 0041 29.4467 $1,875.55 .................... $375.11
29891 ......... Ankle arthroscopy/surgery ............................... .................... T ................. 0041 29.4467 $1,875.55 .................... $375.11
29893 ......... Scope, plantar fasciotomy ............................... .................... T ................. 0055 21.1762 $1,348.78 $355.30 $269.76
29899 ......... Ankle arthroscopy/surgery ............................... .................... T ................. 0042 47.7765 $3,043.03 $804.70 $608.61
Continued
National Minimum
29900 ......... Mcp joint arthroscopy, dx ................................ .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
29901 ......... Mcp joint arthroscopy, surg ............................. .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
29902 ......... Mcp joint arthroscopy, surg ............................. .................... T ................. 0053 16.822 $1,071.44 $253.40 $214.29
29999 ......... Arthroscopy of joint ......................................... .................... T ................. 0041 29.4467 $1,875.55 .................... $375.11
30000 ......... Drainage of nose lesion .................................. .................... T ................. 0251 2.5765 $164.11 .................... $32.82
30020 ......... Drainage of nose lesion .................................. .................... T ................. 0251 2.5765 $164.11 .................... $32.82
3006F ......... Cxr doc rev ...................................................... .................... M ................ .................... .................... .................... .................... ....................
30100 ......... Intranasal biopsy ............................................. .................... T ................. 0252 7.6539 $487.50 $109.10 $97.50
30110 ......... Removal of nose polyp(s) ............................... .................... T ................. 0253 16.6341 $1,059.48 $282.20 $211.90
30115 ......... Removal of nose polyp(s) ............................... .................... T ................. 0253 16.6341 $1,059.48 $282.20 $211.90
30117 ......... Removal of intranasal lesion ........................... .................... T ................. 0253 16.6341 $1,059.48 $282.20 $211.90
30118 ......... Removal of intranasal lesion ........................... .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
3011F ......... Lipid panel doc rev .......................................... .................... M ................ .................... .................... .................... .................... ....................
30120 ......... Revision of nose .............................................. .................... T ................. 0253 16.6341 $1,059.48 $282.20 $211.90
30124 ......... Removal of nose lesion ................................... .................... T ................. 0252 7.6539 $487.50 $109.10 $97.50
30125 ......... Removal of nose lesion ................................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
30130 ......... Excise inferior turbinate ................................... .................... T ................. 0253 16.6341 $1,059.48 $282.20 $211.90
30140 ......... Resect inferior turbinate .................................. .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
3014F ......... Screen mammo doc rev .................................. .................... M ................ .................... .................... .................... .................... ....................
30150 ......... Partial removal of nose ................................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
30160 ......... Removal of nose ............................................. .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
3017F ......... Colorectal ca screen doc rev .......................... .................... M ................ .................... .................... .................... .................... ....................
30200 ......... Injection treatment of nose .............................. .................... T ................. 0252 7.6539 $487.50 $109.10 $97.50
3020F ......... Lvf assess ....................................................... .................... M ................ .................... .................... .................... .................... ....................
30210 ......... Nasal sinus therapy ......................................... .................... T ................. 0252 7.6539 $487.50 $109.10 $97.50
3021F ......... Lvef mod/sever deprs syst .............................. .................... M ................ .................... .................... .................... .................... ....................
30220 ......... Insert nasal septal button ................................ .................... T ................. 0252 7.6539 $487.50 $109.10 $97.50
3022F ......... Lvef =40% systolic .......................................... .................... M ................ .................... .................... .................... .................... ....................
3023F ......... Spirom doc rev ................................................ .................... M ................ .................... .................... .................... .................... ....................
3025F ......... Spirom fev/fvc<70% w copd ........................... .................... M ................ .................... .................... .................... .................... ....................
3027F ......... Spirom fev/fvc=70%/ w/o copd ....................... .................... M ................ .................... .................... .................... .................... ....................
3028F ......... O2 saturation doc rev ...................................... .................... M ................ .................... .................... .................... .................... ....................
30300 ......... Remove nasal foreign body ............................ .................... X ................. 0340 0.6416 $40.87 .................... $8.17
30310 ......... Remove nasal foreign body ............................ .................... T ................. 0253 16.6341 $1,059.48 $282.20 $211.90
30320 ......... Remove nasal foreign body ............................ .................... T ................. 0253 16.6341 $1,059.48 $282.20 $211.90
3035F ......... O2 saturation =88% /pa0 =55 ......................... .................... M ................ .................... .................... .................... .................... ....................
3037F ......... O2 saturation> 88% /pao>55 .......................... .................... M ................ .................... .................... .................... .................... ....................
30400 ......... Reconstruction of nose ................................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
3040F ......... Fev<40% predicted value ............................... .................... M ................ .................... .................... .................... .................... ....................
3042F ......... Fev=40% predicted value ............................... .................... M ................ .................... .................... .................... .................... ....................
30430 ......... Revision of nose .............................................. .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
30435 ......... Revision of nose .............................................. .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
3044F ......... HG a1c level < 7.0% ....................................... .................... M ................ .................... .................... .................... .................... ....................
3045F ......... HG a1c level 7.0-9.0% .................................... .................... M ................ .................... .................... .................... .................... ....................
30465 ......... Repair nasal stenosis ...................................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
3046F ......... Hemoglobin a1c level > 9.0% ......................... .................... M ................ .................... .................... .................... .................... ....................
3048F ......... LDL-C <100 mg/dL .......................................... .................... M ................ .................... .................... .................... .................... ....................
3049F ......... LDL-C 100-129 mg/dL ..................................... .................... M ................ .................... .................... .................... .................... ....................
3050F ......... LDL-C = 130 mg/dL ........................................ .................... M ................ .................... .................... .................... .................... ....................
30520 ......... Repair of nasal septum ................................... .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
30540 ......... Repair nasal defect ......................................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
30545 ......... Repair nasal defect ......................................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
30560 ......... Release of nasal adhesions ............................ .................... T ................. 0251 2.5765 $164.11 .................... $32.82
30580 ......... Repair upper jaw fistula .................................. .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
30600 ......... Repair mouth/nose fistula ............................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
3060F ......... Pos microalbuminuria rev ................................ .................... M ................ .................... .................... .................... .................... ....................
3061F ......... Neg microalbuminuria rev ............................... .................... M ................ .................... .................... .................... .................... ....................
30620 ......... Intranasal reconstruction ................................. .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
3062F ......... Pos macroalbuminuria rev .............................. .................... M ................ .................... .................... .................... .................... ....................
30630 ......... Repair nasal septum defect ............................ .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
3066F ......... Nephropathy doc tx ......................................... .................... M ................ .................... .................... .................... .................... ....................
3072F ......... Low risk for retinopathy ................................... .................... M ................ .................... .................... .................... .................... ....................
3073F ......... Pre-surg eye measures doc’d ......................... .................... M ................ .................... .................... .................... .................... ....................
3074F ......... Syst bp < 130 mm hg ..................................... .................... M ................ .................... .................... .................... .................... ....................
3075F ......... Syst bp ´130-139 mm hg ............................... .................... M ................ .................... .................... .................... .................... ....................
3077F ......... Syst bp = 140 mm hg ..................................... .................... M ................ .................... .................... .................... .................... ....................
3078F ......... Diast bp < 80 mm hg ...................................... .................... M ................ .................... .................... .................... .................... ....................
3079F ......... Diast bp 80-89 mm hg .................................... .................... M ................ .................... .................... .................... .................... ....................
30801 ......... Ablate inf turbinate, superf .............................. .................... T ................. 0252 7.6539 $487.50 $109.10 $97.50
30802 ......... Cauterization, inner nose ................................ .................... T ................. 0252 7.6539 $487.50 $109.10 $97.50
3080F ......... Diast bp = 90 mm hg ...................................... .................... M ................ .................... .................... .................... .................... ....................
3082F ......... Kt/v <1.2 .......................................................... .................... M ................ .................... .................... .................... .................... ....................
3083F ......... Kt/v ´ 1.2 and <1.7 ........................................ .................... M ................ .................... .................... .................... .................... ....................
Continued
National Minimum
3084F ......... Kt/v´1.7 .......................................................... .................... M ................ .................... .................... .................... .................... ....................
3085F ......... Suicide risk assessed ...................................... .................... M ................ .................... .................... .................... .................... ....................
3088F ......... MDD, mild ........................................................ .................... M ................ .................... .................... .................... .................... ....................
3089F ......... MDD, moderate ............................................... .................... M ................ .................... .................... .................... .................... ....................
30901 ......... Control of nosebleed ....................................... .................... T ................. 0250 1.1708 $74.57 $25.30 $14.91
30906 ......... Repeat control of nosebleed ........................... .................... T ................. 0250 1.1708 $74.57 $25.30 $14.91
3090F ......... MDD, severe; w/o psych ................................. .................... M ................ .................... .................... .................... .................... ....................
30915 ......... Ligation, nasal sinus artery ............................. .................... T ................. 0092 26.4396 $1,684.02 .................... $336.80
3091F ......... MDD, severe; w/ psych ................................... .................... M ................ .................... .................... .................... .................... ....................
30920 ......... Ligation, upper jaw artery ................................ .................... T ................. 0092 26.4396 $1,684.02 .................... $336.80
3092F ......... MDD, in remission ........................................... .................... M ................ .................... .................... .................... .................... ....................
30930 ......... Ther fx, nasal inf turbinate .............................. .................... T ................. 0253 16.6341 $1,059.48 $282.20 $211.90
3093F ......... Doc new diag 1st/addl. mdd ........................... .................... M ................ .................... .................... .................... .................... ....................
3095F ......... Central dexa results doc’d .............................. .................... M ................ .................... .................... .................... .................... ....................
3096F ......... Central dexa ordered ...................................... .................... M ................ .................... .................... .................... .................... ....................
30999 ......... Nasal surgery procedure ................................. .................... T ................. 0251 2.5765 $164.11 .................... $32.82
31000 ......... Irrigation, maxillary sinus ................................. .................... T ................. 0251 2.5765 $164.11 .................... $32.82
31002 ......... Irrigation, sphenoid sinus ................................ .................... T ................. 0252 7.6539 $487.50 $109.10 $97.50
3100F ......... Carot blk doc’d w/ carot ref ............................. .................... M ................ .................... .................... .................... .................... ....................
3101F ......... Intl carot blk 30-99% range ............................. .................... M ................ .................... .................... .................... .................... ....................
31020 ......... Exploration, maxillary sinus ............................. .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
3102F ......... Int carot blk < 30% .......................................... .................... M ................ .................... .................... .................... .................... ....................
31030 ......... Exploration, maxillary sinus ............................. .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
31032 ......... Explore sinus, remove polyps ......................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
31040 ......... Exploration behind upper jaw .......................... .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
31050 ......... Exploration, sphenoid sinus ............................ .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
31051 ......... Sphenoid sinus surgery ................................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
31070 ......... Exploration of frontal sinus .............................. .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
31075 ......... Exploration of frontal sinus .............................. .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
31080 ......... Removal of frontal sinus ................................. .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
31090 ......... Exploration of sinuses ..................................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
3110F ......... Pres/absn hmrhg/lesion doc’d ......................... .................... M ................ .................... .................... .................... .................... ....................
3111F ......... Ct/mri brain done w/in 24hrs ........................... .................... M ................ .................... .................... .................... .................... ....................
3112F ......... Ct/mri brain done > 24 hrs .............................. .................... M ................ .................... .................... .................... .................... ....................
31200 ......... Removal of ethmoid sinus ............................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
3120F ......... 12-lead ecg performed .................................... .................... M ................ .................... .................... .................... .................... ....................
31225 ......... Removal of upper jaw ..................................... .................... C ................. .................... .................... .................... .................... ....................
31230 ......... Removal of upper jaw ..................................... .................... C ................. .................... .................... .................... .................... ....................
31231 ......... Nasal endoscopy, dx ....................................... .................... T ................. 0072 1.573 $100.19 $21.20 $20.04
31233 ......... Nasal/sinus endoscopy, dx ............................. .................... T ................. 0072 1.573 $100.19 $21.20 $20.04
31235 ......... Nasal/sinus endoscopy, dx ............................. .................... T ................. 0074 17.4546 $1,111.74 $292.20 $222.35
31237 ......... Nasal/sinus endoscopy, surg .......................... .................... T ................. 0074 17.4546 $1,111.74 $292.20 $222.35
31254 ......... Revision of ethmoid sinus ............................... .................... T ................. 0075 23.2819 $1,482.89 $445.90 $296.58
31255 ......... Removal of ethmoid sinus ............................... .................... T ................. 0075 23.2819 $1,482.89 $445.90 $296.58
31256 ......... Exploration maxillary sinus .............................. .................... T ................. 0075 23.2819 $1,482.89 $445.90 $296.58
31267 ......... Endoscopy, maxillary sinus ............................. .................... T ................. 0075 23.2819 $1,482.89 $445.90 $296.58
31276 ......... Sinus endoscopy, surgical .............................. .................... T ................. 0075 23.2819 $1,482.89 $445.90 $296.58
31290 ......... Nasal/sinus endoscopy, surg .......................... .................... C ................. .................... .................... .................... .................... ....................
31291 ......... Nasal/sinus endoscopy, surg .......................... .................... C ................. .................... .................... .................... .................... ....................
31299 ......... Sinus surgery procedure ................................. .................... T ................. 0251 2.5765 $164.11 .................... $32.82
31300 ......... Removal of larynx lesion ................................. .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
3130F ......... Upper gi endoscopy performed ....................... .................... M ................ .................... .................... .................... .................... ....................
31320 ......... Diagnostic incision, larynx ............................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
3132F ......... Doc ref. upper gi endoscopy ........................... .................... M ................ .................... .................... .................... .................... ....................
31360 ......... Removal of larynx ........................................... .................... C ................. .................... .................... .................... .................... ....................
31365 ......... Removal of larynx ........................................... .................... C ................. .................... .................... .................... .................... ....................
31367 ......... Partial removal of larynx ................................. .................... C ................. .................... .................... .................... .................... ....................
Continued
National Minimum
31390 ......... Removal of larynx & pharynx .......................... .................... C ................. .................... .................... .................... .................... ....................
31395 ......... Reconstruct larynx & pharynx ......................... .................... C ................. .................... .................... .................... .................... ....................
31400 ......... Revision of larynx ............................................ .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
3140F ......... Forceps esoph biopsy done ............................ .................... M ................ .................... .................... .................... .................... ....................
3141F ......... Upper gi endo shows barrtt’s .......................... .................... M ................ .................... .................... .................... .................... ....................
31420 ......... Removal of epiglottis ....................................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
3142F ......... Upper gi endo not barrtt’s ............................... .................... M ................ .................... .................... .................... .................... ....................
3143F ......... Doc order barium swallow tst .......................... .................... M ................ .................... .................... .................... .................... ....................
31500 ......... Insert emergency airway ................................. .................... S ................. 0094 2.5547 $162.72 $46.20 $32.54
31502 ......... Change of windpipe airway ............................. CH .............. S ................. 0078 1.3636 $86.85 .................... $17.37
31505 ......... Diagnostic laryngoscopy ................................. .................... T ................. 0071 0.8256 $52.58 $11.20 $10.52
31510 ......... Laryngoscopy with biopsy ............................... .................... T ................. 0074 17.4546 $1,111.74 $292.20 $222.35
31511 ......... Remove foreign body, larynx .......................... .................... T ................. 0072 1.573 $100.19 $21.20 $20.04
31513 ......... Injection into vocal cord .................................. .................... T ................. 0072 1.573 $100.19 $21.20 $20.04
31515 ......... Laryngoscopy for aspiration ............................ .................... T ................. 0074 17.4546 $1,111.74 $292.20 $222.35
31520 ......... Dx laryngoscopy, newborn .............................. .................... T ................. 0072 1.573 $100.19 $21.20 $20.04
31525 ......... Dx laryngoscopy excl nb ................................. .................... T ................. 0074 17.4546 $1,111.74 $292.20 $222.35
31526 ......... Dx laryngoscopy w/oper scope ....................... .................... T ................. 0075 23.2819 $1,482.89 $445.90 $296.58
31527 ......... Laryngoscopy for treatment ............................ .................... T ................. 0075 23.2819 $1,482.89 $445.90 $296.58
31528 ......... Laryngoscopy and dilation .............................. .................... T ................. 0074 17.4546 $1,111.74 $292.20 $222.35
31529 ......... Laryngoscopy and dilation .............................. .................... T ................. 0074 17.4546 $1,111.74 $292.20 $222.35
31530 ......... Laryngoscopy w/fb removal ............................ .................... T ................. 0075 23.2819 $1,482.89 $445.90 $296.58
31531 ......... Laryngoscopy w/fb & op scope ....................... .................... T ................. 0075 23.2819 $1,482.89 $445.90 $296.58
31535 ......... Laryngoscopy w/biopsy ................................... .................... T ................. 0075 23.2819 $1,482.89 $445.90 $296.58
31536 ......... Laryngoscopy w/bx & op scope ...................... .................... T ................. 0075 23.2819 $1,482.89 $445.90 $296.58
31540 ......... Laryngoscopy w/exc of tumor ......................... .................... T ................. 0075 23.2819 $1,482.89 $445.90 $296.58
31541 ......... Larynscop w/tumr exc + scope ....................... .................... T ................. 0075 23.2819 $1,482.89 $445.90 $296.58
31545 ......... Remove vc lesion w/scope ............................. .................... T ................. 0075 23.2819 $1,482.89 $445.90 $296.58
31546 ......... Remove vc lesion scope/graft ......................... .................... T ................. 0075 23.2819 $1,482.89 $445.90 $296.58
31560 ......... Laryngoscop w/arytenoidectom ....................... .................... T ................. 0075 23.2819 $1,482.89 $445.90 $296.58
31561 ......... Larynscop, remve cart + scop ........................ .................... T ................. 0075 23.2819 $1,482.89 $445.90 $296.58
31570 ......... Laryngoscope w/vc inj ..................................... .................... T ................. 0074 17.4546 $1,111.74 $292.20 $222.35
31571 ......... Laryngoscop w/vc inj + scope ......................... .................... T ................. 0075 23.2819 $1,482.89 $445.90 $296.58
31576 ......... Laryngoscopy with biopsy ............................... .................... T ................. 0075 23.2819 $1,482.89 $445.90 $296.58
31577 ......... Remove foreign body, larynx .......................... .................... T ................. 0073 4.206 $267.89 $69.10 $53.58
31584 ......... Treat larynx fracture ........................................ .................... C ................. .................... .................... .................... .................... ....................
31587 ......... Revision of larynx ............................................ .................... C ................. .................... .................... .................... .................... ....................
31590 ......... Reinnervate larynx .......................................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
31595 ......... Larynx nerve surgery ...................................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
31599 ......... Larynx surgery procedure ............................... .................... T ................. 0251 2.5765 $164.11 .................... $32.82
31600 ......... Incision of windpipe ......................................... .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
31603 ......... Incision of windpipe ......................................... .................... T ................. 0252 7.6539 $487.50 $109.10 $97.50
31605 ......... Incision of windpipe ......................................... .................... T ................. 0252 7.6539 $487.50 $109.10 $97.50
31611 ......... Surgery/speech prosthesis .............................. .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
31612 ......... Puncture/clear windpipe .................................. .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
31613 ......... Repair windpipe opening ................................. .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
31614 ......... Repair windpipe opening ................................. .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
31615 ......... Visualization of windpipe ................................. .................... T ................. 0076 10.1732 $647.96 $189.80 $129.59
31620 ......... Endobronchial us add-on ................................ CH .............. N ................. .................... .................... .................... .................... ....................
31622 ......... Dx bronchoscope/wash ................................... .................... T ................. 0076 10.1732 $647.96 $189.80 $129.59
31623 ......... Dx bronchoscope/brush .................................. .................... T ................. 0076 10.1732 $647.96 $189.80 $129.59
31624 ......... Dx bronchoscope/lavage ................................. .................... T ................. 0076 10.1732 $647.96 $189.80 $129.59
31625 ......... Bronchoscopy w/biopsy(s) .............................. .................... T ................. 0076 10.1732 $647.96 $189.80 $129.59
31628 ......... Bronchoscopy/lung bx, each ........................... .................... T ................. 0076 10.1732 $647.96 $189.80 $129.59
31629 ......... Bronchoscopy/needle bx, each ....................... .................... T ................. 0076 10.1732 $647.96 $189.80 $129.59
31630 ......... Bronchoscopy dilate/fx repr ............................. .................... T ................. 0415 24.2882 $1,546.99 $459.90 $309.40
31631 ......... Bronchoscopy, dilate w/stent .......................... .................... T ................. 0415 24.2882 $1,546.99 $459.90 $309.40
31632 ......... Bronchoscopy/lung bx, add’l ........................... .................... T ................. 0076 10.1732 $647.96 $189.80 $129.59
31633 ......... Bronchoscopy/needle bx add’l ........................ .................... T ................. 0076 10.1732 $647.96 $189.80 $129.59
31635 ......... Bronchoscopy w/fb removal ............................ .................... T ................. 0076 10.1732 $647.96 $189.80 $129.59
31636 ......... Bronchoscopy, bronch stents .......................... .................... T ................. 0415 24.2882 $1,546.99 $459.90 $309.40
31637 ......... Bronchoscopy, stent add-on ........................... .................... T ................. 0076 10.1732 $647.96 $189.80 $129.59
31638 ......... Bronchoscopy, revise stent ............................. .................... T ................. 0415 24.2882 $1,546.99 $459.90 $309.40
31640 ......... Bronchoscopy w/tumor excise ........................ .................... T ................. 0415 24.2882 $1,546.99 $459.90 $309.40
31641 ......... Bronchoscopy, treat blockage ......................... .................... T ................. 0415 24.2882 $1,546.99 $459.90 $309.40
31643 ......... Diag bronchoscope/catheter ........................... .................... T ................. 0076 10.1732 $647.96 $189.80 $129.59
31645 ......... Bronchoscopy, clear airways .......................... .................... T ................. 0076 10.1732 $647.96 $189.80 $129.59
31646 ......... Bronchoscopy, reclear airway ......................... .................... T ................. 0076 10.1732 $647.96 $189.80 $129.59
Continued
National Minimum
31656 ......... Bronchoscopy, inj for x-ray ............................. .................... T ................. 0076 10.1732 $647.96 $189.80 $129.59
31715 ......... Injection for bronchus x-ray ............................. .................... N ................. .................... .................... .................... .................... ....................
31717 ......... Bronchial brush biopsy .................................... .................... T ................. 0073 4.206 $267.89 $69.10 $53.58
31720 ......... Clearance of airways ....................................... CH .............. S ................. 0077 0.3904 $24.87 $7.70 $4.97
31725 ......... Clearance of airways ....................................... .................... C ................. .................... .................... .................... .................... ....................
31730 ......... Intro, windpipe wire/tube ................................. .................... T ................. 0073 4.206 $267.89 $69.10 $53.58
31750 ......... Repair of windpipe .......................................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
31755 ......... Repair of windpipe .......................................... .................... T ................. 0256 40.5598 $2,583.38 .................... $516.68
31760 ......... Repair of windpipe .......................................... .................... C ................. .................... .................... .................... .................... ....................
31766 ......... Reconstruction of windpipe ............................. .................... C ................. .................... .................... .................... .................... ....................
31770 ......... Repair/graft of bronchus .................................. .................... C ................. .................... .................... .................... .................... ....................
31775 ......... Reconstruct bronchus ..................................... .................... C ................. .................... .................... .................... .................... ....................
31780 ......... Reconstruct windpipe ...................................... .................... C ................. .................... .................... .................... .................... ....................
31781 ......... Reconstruct windpipe ...................................... .................... C ................. .................... .................... .................... .................... ....................
31785 ......... Remove windpipe lesion ................................. .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
31786 ......... Remove windpipe lesion ................................. .................... C ................. .................... .................... .................... .................... ....................
31800 ......... Repair of windpipe injury ................................. .................... C ................. .................... .................... .................... .................... ....................
31805 ......... Repair of windpipe injury ................................. .................... C ................. .................... .................... .................... .................... ....................
31820 ......... Closure of windpipe lesion .............................. .................... T ................. 0253 16.6341 $1,059.48 $282.20 $211.90
31825 ......... Repair of windpipe defect ............................... .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
31830 ......... Revise windpipe scar ...................................... .................... T ................. 0254 24.3535 $1,551.15 $321.30 $310.23
31899 ......... Airways surgical procedure ............................. .................... T ................. 0076 10.1732 $647.96 $189.80 $129.59
32000 ......... Drainage of chest ............................................ .................... T ................. 0070 5.3095 $338.18 .................... $67.64
32002 ......... Treatment of collapsed lung ............................ .................... T ................. 0070 5.3095 $338.18 .................... $67.64
32005 ......... Treat lung lining chemically ............................. .................... T ................. 0070 5.3095 $338.18 .................... $67.64
32019 ......... Insert pleural catheter ..................................... .................... T ................. 0652 31.7598 $2,022.88 .................... $404.58
32020 ......... Insertion of chest tube ..................................... .................... T ................. 0070 5.3095 $338.18 .................... $67.64
32035 ......... Exploration of chest ......................................... .................... C ................. .................... .................... .................... .................... ....................
32036 ......... Exploration of chest ......................................... .................... C ................. .................... .................... .................... .................... ....................
32095 ......... Biopsy through chest wall ............................... .................... C ................. .................... .................... .................... .................... ....................
32100 ......... Exploration/biopsy of chest ............................. .................... C ................. .................... .................... .................... .................... ....................
32110 ......... Explore/repair chest ........................................ .................... C ................. .................... .................... .................... .................... ....................
32120 ......... Re-exploration of chest ................................... .................... C ................. .................... .................... .................... .................... ....................
32124 ......... Explore chest free adhesions .......................... .................... C ................. .................... .................... .................... .................... ....................
32140 ......... Removal of lung lesion(s) ............................... .................... C ................. .................... .................... .................... .................... ....................
32141 ......... Remove/treat lung lesions ............................... .................... C ................. .................... .................... .................... .................... ....................
32150 ......... Removal of lung lesion(s) ............................... .................... C ................. .................... .................... .................... .................... ....................
32151 ......... Remove lung foreign body .............................. .................... C ................. .................... .................... .................... .................... ....................
32160 ......... Open chest heart massage ............................. .................... C ................. .................... .................... .................... .................... ....................
32200 ......... Drain, open, lung lesion .................................. .................... C ................. .................... .................... .................... .................... ....................
32201 ......... Drain, percut, lung lesion ................................ .................... T ................. 0070 5.3095 $338.18 .................... $67.64
32215 ......... Treat chest lining ............................................. .................... C ................. .................... .................... .................... .................... ....................
32220 ......... Release of lung ............................................... .................... C ................. .................... .................... .................... .................... ....................
32225 ......... Partial release of lung ..................................... .................... C ................. .................... .................... .................... .................... ....................
32310 ......... Removal of chest lining ................................... .................... C ................. .................... .................... .................... .................... ....................
32320 ......... Free/remove chest lining ................................. .................... C ................. .................... .................... .................... .................... ....................
32400 ......... Needle biopsy chest lining .............................. .................... T ................. 0685 9.5741 $609.80 .................... $121.96
32402 ......... Open biopsy chest lining ................................. .................... C ................. .................... .................... .................... .................... ....................
32405 ......... Biopsy, lung or mediastinum ........................... .................... T ................. 0685 9.5741 $609.80 .................... $121.96
32420 ......... Puncture/clear lung ......................................... .................... T ................. 0070 5.3095 $338.18 .................... $67.64
32440 ......... Removal of lung .............................................. .................... C ................. .................... .................... .................... .................... ....................
32442 ......... Sleeve pneumonectomy .................................. .................... C ................. .................... .................... .................... .................... ....................
32445 ......... Removal of lung .............................................. .................... C ................. .................... .................... .................... .................... ....................
32480 ......... Partial removal of lung .................................... .................... C ................. .................... .................... .................... .................... ....................
32482 ......... Bilobectomy ..................................................... .................... C ................. .................... .................... .................... .................... ....................
32484 ......... Segmentectomy ............................................... .................... C ................. .................... .................... .................... .................... ....................
32486 ......... Sleeve lobectomy ............................................ .................... C ................. .................... .................... .................... .................... ....................
32488 ......... Completion pneumonectomy ........................... .................... C ................. .................... .................... .................... .................... ....................
32491 ......... Lung volume reduction .................................... .................... C ................. .................... .................... .................... .................... ....................
32500 ......... Partial removal of lung .................................... .................... C ................. .................... .................... .................... .................... ....................
32501 ......... Repair bronchus add-on .................................. .................... C ................. .................... .................... .................... .................... ....................
32503 ......... Resect apical lung tumor ................................ .................... C ................. .................... .................... .................... .................... ....................
32504 ......... Resect apical lung tum/chest .......................... .................... C ................. .................... .................... .................... .................... ....................
32540 ......... Removal of lung lesion .................................... .................... C ................. .................... .................... .................... .................... ....................
32601 ......... Thoracoscopy, diagnostic ................................ .................... T ................. 0069 33.1688 $2,112.62 $591.60 $422.52
32650 ......... Thoracoscopy, surgical ................................... .................... C ................. .................... .................... .................... .................... ....................
Continued
National Minimum
32662 ......... Thoracoscopy, surgical ................................... .................... C ................. .................... .................... .................... ............

Proposed Rule: Medicare: Hospital Outpatient Prospective Payment System and 2008 CY Payment Rates Ambulatory Service Center Procedures

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Proposed Rule: Medicare: Hospital Outpatient Prospective Payment System and 2008 CY Payment Rates Ambulatory Service Center Procedures

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42 CFR Parts 410, 411, 414 et al.

Testing Improvement, and Modernization Act 1. Authority of the APC Panel

4. Unfunded Mandates services and to encourage more efficient coinsurance, as an outpatient

Payment System who have exhausted their Part A Hospitals

HCPCS HCPCS HCPCS

Subset 1: ‘‘Hardcore’’ Multiple Claims with Only Drug Administration Codes

693,925 ............................................................................................................ 21.6 26.8 12.7 19.3

Subset 2: ‘‘Multiple’’ Claims with At Least One Drug Administration Code

4,816,338 ......................................................................................................... 13.2 19.4 5.8 10.0

2008. for standardization because we believe single bill representation in an APC is

TABLE 4.—PROPOSED CY 2008 PACKAGED REVENUE CODES

0250 ......... PHARMACY.

0683 ......... TRAUMA RESPONSE, LEVEL III.

TABLE 4.—PROPOSED CY 2008 PACKAGED REVENUE CODES—Continued

0721 ......... LABOR.

TABLE 5.—GROWTH IN EXPENDITURES UNDER OPPS FROM CY 2001–CY 2008

TABLE 6.—PERCENT INCREASE IN VOLUME AND INTENSITY OF HOSPITAL OUTPATIENT SERVICES

Total Payment .... .......................................................................................................................................... 2,369.51 2,810.08

TABLE 8.—GUIDANCE HCPCS CODES PROPOSED FOR PACKAGED PAYMENT IN CY 2008

19295 .......... Place breast clip, precut ........ S 0657 N n/a

Total Payment .... .......................................................................................................................................... 451.56 488.54

76125 ......... Cine/video x-rays add-on ....... X .................. 0260 ............ N

a broad search for possible supportive diagnostic testing or other

Total Payment .................................................................................................................................................. 104.80 54.41

TABLE 12.—INTRAOPERATIVE HCPCS CODES PROPOSED FOR PACKAGED PAYMENT IN CY 2008

20975 .......... Electrical bone stimulation ...................................................................................... X .................. 0340 N

31620 .......... Endobronchial us add-on ........................................................................................ S .................. 0670 N

TABLE 12.—INTRAOPERATIVE HCPCS CODES PROPOSED FOR PACKAGED PAYMENT IN CY 2008—Continued

74301 .......... X-rays at surgery add-on ........................................................................................ X .................. 0263 N

Total Payment .............................................. ................................................................................................ 472.14 751.09

(5) Diagnostic Radiopharmaceuticals radiopharmaceutical. At that time, we radiopharmaceuticals could provoke

A9552 ........................ F18 fdg (dependent service) ........................................................................................... *$279.29 0.00

Total Payment .................................................................................................................................................. 1,229.29 1,107.22

A4641 .......... Radiopharm dx agent noc ...................................................................................... N ................. n/a N

A9558 .......... Xe133 xenon 10mci ................................................................................................ N ................. n/a N*

A9568 .......... Tc99m arcitumomab ............................................................................................... H ................. 1648 N

Total Payment .................................................................................................................................................. 315.18 289.71

Q9945 .......... LOCM <=149 mg/ml iodine, 1 ml ........................................................................... K .................. 9157 N*

Q9948 .......... LOCM 250–299 mg/ml iodine, 1 ml ....................................................................... K .................. 9160 N*

Total Payment ....................................................... ....................................................................................... 768.07 348.81

TABLE 22.—TEN MOST FREQUENTLY OCCURRING UNIQUE OCCURRENCES OF CARDIAC ELECTROPHYSIOLOGIC

1 .......................... 763 93620 Electrophysiology evaluation ...................................................................... 0085 T

Ablate heart dysrhythm focus ................................................................................................................. 93652 0086 T

We believe that the circumstances in 1. Background providing partial hospitalization

to determine median cost by computing CMHCs using the outlier percentage

TABLE 25.—PROPOSED CY 2008 STATEWIDE AVERAGE CCRS

ALASKA .................................................................................................................................... RURAL ............. 0.5389 0.5337

MISSISSIPPI ............................................................................................................................. URBAN ............. 0.2300 0.2312

TABLE 25.—PROPOSED CY 2008 STATEWIDE AVERAGE CCRS—Continued

NEBRASKA .............................................................................................................................. URBAN ............. 0.2832 0.2899

correction notice to the FY 2008 IPPS OPPS. 3. Calculation of a Proposed Adjusted

TABLE 26A.—NEW NON-DRUG HCPCS CODES IMPLEMENTED IN JULY 2007

TABLE 26B.—NEW DRUG HCPCS CODES IMPLEMENTED IN JULY 2007

TABLE 27.—CATEGORY III CPT CODES IMPLEMENTED IN JULY 2007

B. Proposed Changes—Variations radiopharmaceuticals, and relative to the hospital median cost of

TABLE 30—PROPOSED CY 2008 SKIN REPAIR APC CONFIGURATIONS

11950 Therapy for contour defects ........................................................................................................................... 0133 $83.91

12007 Repair superficial wound(s).

TABLE 30—PROPOSED CY 2008 SKIN REPAIR APC CONFIGURATIONS—Continued

12031 Layer closure of wound(s).

15150 Cult epiderm grft t/arm/leg.

TABLE 30—PROPOSED CY 2008 SKIN REPAIR APC CONFIGURATIONS—Continued