### DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services 42 CFR Parts 405, 409, 410, 411, 413, 414, 415, and 424 [CMS-1503-P]

RINs 0938-AP79 Medicare Program; Payment Policies Under the Physician Fee Schedule and Other

Revisions to Part B for CY 2011

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

ACTION: Proposed rule.

SUMMARY: This proposed rule addresses proposed changes to the physician fee schedule and other Medicare Part B payment po licies to ensure that our payment systems are updated to reflect changes in medical prac tice and the relative value of services. It also addresses, impleme nts or discusses certain provisions of both the Affordable Care Act and the Medicare Improveme nts for Patients and Providers Act of 2008. In addition, this proposed rule discusses payments under the Ambulance Fee Schedule, Clinical Laboratory Fee Schedule, payments to ESRD facilities, and payments for Part B drugs. Finally, the proposed rule includes a disc ussion regarding the Chiropractic Services Demonstration program, the Competitive Bidding Program for Durable Medical Equipment and Provider and Supplier Enrollment Issues associated with Air Ambulances. (See the Table of Contents for a listing of the specific issues addressed in this proposed rule.)

DATES : To be assured consid eration, comments must be received at one of the addresses provided below, no later than 5 p.m. on [ O F R

— i n s e r t d a t e 6 0 d a y s a f t e r t h e

d a t e o f f i l i n g f o r p u b l i c i n s p e c t i o n a t O F R

. ]

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ADDRESSES: In commenting, please refer to file code CMS-1503-P. Because of staff and resource limitations, we cannot accept co mments by facsimile (FAX) transmission. You may submit comments in one of four ways (please choose only one of the ways listed): 1. Electronically . You may submit electronic comments on this regulation to http://www.regulations.gov . Follow the instructions for "submitting a comment." 2. By regular mail . You may mail written comments to the following address

ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1503-P, P.O. Box 8013, Baltimore, MD 21244-8013.

Please allow sufficient time for mailed comments to be received before the close of the comment period. 3. By express or overnight mail . You may send written comments to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1503-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.

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4. By hand or courier . If you prefer, you may deliver (by hand or courier) your written comments before the close of the comment period to either of the following

addresses: a. For delivery in Washington, DC-- Centers for Medicare & Medicaid Services, Department of Health and Human Services, Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC 20201 (Because access to the interior of the Hubert H. Humphrey Building is not readily available to persons without Federal g overnment identification, commenters are encouraged to leave their comments in the CMS drop slots located in the main lobby of the building. A stamp-in clock is available for persons wishing to retain a proof of filing by stamping in and retaining an extra copy of the comments being filed.) b. For delivery in Baltimore, MD-- Centers for Medicare & Medicaid Services, Department of Health and Human Services, 7500 Security Boulevard, Baltimore, MD 21244-1850. If you intend to deliver your comments to the Baltimore address, please call telephone number (410) 786-9994 in advance to schedule y our arrival with one of our

staff members.

Comments mailed to the addresses indica ted as appropriate for hand or courier delivery may be delayed and rece ived after the comment period.

FOR FURTHER INFORM ATION CONTACT:

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Rebecca Cole, (410) 786-4497, for issues re lated to physician payment and for all

other issues not identified below. Cheryl Gilbreath, (410)786-5919, for issues related to payment for covered outpatient drugs and biologicals. Roechel Kujawa, (410)786-9111, for issu es related to ambulance services. Glenn McGuirk, (410) 786-5723, for clinical laboratory issues. Randall Ricktor, (410) 786-4632, for Federa lly Qualified Health Center Issues. Pauline Lapin, (410)786-6883, for issues re lated to the chiropractic services

demonstration BN issue. Troy Barsky, (410)786-8873, or Kristin B ohl, (410)786-8680, for issues related to physician self-referral. Troy Barsky, (410)786-8873, or Fred Grabau (410)786-0206, for issues related to timely filing rules. Henry Richter, (410)786-4562, or Lisa Hubbard, (410)786-5472, for issues related to renal dialysis provisions and payments for end-stage renal disease facilities. Diane Stern, (410)786-1133 , for issues related to the physician quality reporting initiative and incentives for e-prescribing. Sheila Roman, 410-786-6004, or Pamela Cheetham, 410-786-2259, for issues related to the Physician Resource Use Fee dback Program and value-based purchasing. Joel Kaiser, (410)786-4499, for issues related to the DME provisions. Jim Bossenmeyer, (410)786-9317, for issues related to provider and supplier

enrollment issues.

SUPPLEMENTARY INFORMATION: Inspection of Public Comments: All comments received before the close of the comment period are available for viewing by the public , including any personally identifiable or

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confidential business information that is included in a comment. We post all comments received before the close of the comment pe riod on the following Web site as soon as possible after they have been received: http://www.regulations.gov . Follow the search instructions on that Web site to view public comments. Comments received timely will also be ava ilable for public inspection as they are received, generally beginning approximately 3 weeks after publication of a document, at the headquarters of the Centers for Medi care & Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 a.m. to 4 p.m. To schedule an appoin tment to view public comments, phone 1-800-743-

3951.

Table of Contents To assist readers in referencing secti ons contained in this preamble, we are providing a table of contents. Some of the issues discussed in this preamble affect the payment policies, but do not require changes to the regulations in the Code of Federal Regulations (CFR). Information on the regulation’s impact appears throughout the preamble, and therefore, is not discussed excl usively in section V. of this proposed rule. I. Background A. Development of the Relative Value System

1. Work RVUs 2. Practice Expense Relati ve Value Units (PE RVUs) 3. Resource-Based Malpractice (MP) RVUs

4. Refinements to the RVUs 5. Adjustments to RVUs Are Budget Neutral B. Components of the Fee Schedule Payment Amounts C. Most Recent Changes to Fee Schedule

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II. Provisions of the Proposed Rule for the Physician Fee Schedule A. Resource-Based Practice Expense (PE) Relative Value Units (RVUs)

1. Overview 2. Practice Expense Methodology a. Direct Practice Expense b. Indirect Practice Expense per Hour Data

c. Allocation of PE to Services (i) Direct costs (ii) Indirect costs d. Facility and Nonfacility Costs

e. Services with Technical Co mponents (TCs) and Pr ofessional Components (PCs)

f. Alternative Data Sources a nd Public Comments on Final Rule for 2010 g. PE RVU Methodology (i) Setup File (ii) Calculate the Direct Cost PE RVUs (iii) Create the Indirect Cost PE RVUs (iv) Calculate the Final PE RVUs (v) Setup File Information (vi) Equipment cost per minute 3. Proposed PE Revisions for CY 2011 a. Equipment Utilization Rate b. HCPCS Code-Specific PE Proposals (1) Biohazard Bags (2) PE Inputs for Professional Component (PC) Only and Technical

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Component (TC) Only Codes Summing to Global Only Codes (3) Equipment Time Inputs for Certain Diagnostic Tests (4) Cobalt-57 Flood Source (5) Venom Immunotherapy (6) Equipment Redundancy (7) Equipment Duplication (8) Establishing Overall Direct PE Supply Price Inputs Based on Unit Prices and Quantities c. AMA RUC Recommendations in CY 2010 for Changes to Direct PE Inputs (1) Electrogastrography and Esophageal Function Test (2) 64-Slice CT Scanner and Software (3) Cystometrogram (4) Breath Hydrogen Test (5) Radiographic Fluoroscopic Room d. Referral of Existing CPT Codes for AMA RUC Review e. Updating Equipment and Supply Price Inputs for Existing Codes B. Malpractice Relative Value Units (RVUs) 1. Background 2. Malpractice RVUs for New and Revise d Services Effective Before the Next 5

Year Review 3. Revised Malpractice RVUs for Sele cted Disc Arthroplasty Services C. Potentially Misvalued Codes Under the Physician Fee Schedule 1. Valuing Services Under the PFS 2. Identifying, Reviewing, and Validating the RVUs of Potentially Misvalued

Services under the PFS

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a. Background b. Progress in Identifying and Re viewing Potentially Misvalued Codes c. Validating RVUs of Potentially Misvalued Codes

3. CY 2011 Identification and Review of Potentially Misvalued Services a. Codes on the Multis-Specialty Points of Comparison List b. Codes with Low Work RVUs Commonly Billed in Multiple Units Per Single Encounter c. Codes with High Volume and Low Work RVUs

d. Codes with S ite-of-Service-Anomalies e. Codes with “23-hour” Stays 4. Expanding the Multiple Procedure Payment Reduction (MPPR) Policy to Additional Nonsurgical Services a. Background b. Proposed CY 2011 Expansion of the Imaging Technical Component MPPR Policy to Additional Combin ations of Imaging Services c. Proposed CY 2011 Expansion of the MPPR Policy to Therapy Services 5. High Cost Supplies a. Background b. Future Updates to the Prices of High-Cost Supplies D. Geographic Practice Cost Indices (GPCIs) 1. Background 2. GPCI Update a. Physician Work GPCIs b. Practice Expense GPCIs 1) The Affordable Care Act Requirements for PE GPCIs

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2) Summary of CY 2011 Proposed PE GPCIs c. Malpractice GPCIs d. General GPCI Update Process 3. Payment Localities E. Physician Fee Schedule Update for CY 2011 1. Rebasing the Medicare Economic Index (MEI) a. Background

b. Use of More Current Data c. Rebasing and Revising Expense Categories in the MEI (1) Developing the Weights for Use in the MEI (2) Physician’s Own Time (3) Physician’s Practice Expenses (A) Non-physician Employee Compensation (B) Office Expenses (C) Professional Liability Insurance (PLI) Expense (D) Medical Equipment Expenses (E) Medical Supplies Expenses (F) All Other Professional Expenses

d. Selection of Price Proxies for Use in the MEI (1) Expense Categories in the MEI (A) Physician’s Own Time (Physician Compensation) (B) Nonphysician Employee Compensation (C) Utilities (D) Chemicals (E) Paper

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(F) Rubber and Plastics (G) Telephone (H) Postage (I) All Other Labor-Intensive Services (J) Fixed Capital (K) Moveable Capital (L) Professional Liability Insurance (M) Medical Equipment (N) Other Professional Expenses (2) Productivity Adjustment to the MEI e. Results of Rebasing f. Adjustments to the RVU Shar es to Match the Proposed Rebased MEI Weights III. Code-Specific Issues for the PFS A. Therapy Services 1. Outpatient Therapy Caps for CY 2011 2. Alternatives to Therapy Caps a. Background

b. Current Activities

c. Potential Short-Term Approaches to Therapy Caps B. Diabetes Self-Management Training (DSMT) Services (HCPCS Codes G0108 and G0109) 1. Background 2. Proposed Payment for DSMT Services

C. End-State Renal Diseas e Related Services for Home Dialysis (CPT code 90963,

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90964, 90965, and 90966) 1. End-Stage Renal Disease Home Dialysis Monthly Capitation Payment Services (CPT codes 90963, 90964, 90965, and 90966) 2. Daily and Monthly ESRD-Related Services (CPT Codes 90951 through 90970) D. Portable X-Ray Se t-Up (HCPCS code Q0092) E. Pulmonary Rehabilitation Services (HCPCS Code G0424) F. Application of Tissue-Cultured Skin Substitutes to Lower Extremities (HCPCS Codes GXXX1 and GXXX2) G. Canalith Repositioning (CPT code 95992)

H. Intranasal/Oral Immunizati on Codes (CPT codes 90467, 90468, 90473, and 90474)

I. Refinement Panel Process J. Remote Cardiac Monitoring Services (CPT codes 93012, 93229, 93268, and 93271)

IV. Medicare Telehealth Services for the Physician Fee Schedule A. Billing and Payment for Telehealth Services 1. History 2. Current Telehealth Billing and Payment Policies B. Requests for Adding Services to th e List of Medicare Telehealth Services C. Submitted Requests for Addition to th e List of Telehealth Services for CY 2011 (1) Individual KDE Services (2) Individual DSMT Services (3) Group KDE, MNT, DSMT, and HBAI Services (4) Initial, Subsequent, and Discharge Day Management Hospital Care Services

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(5) Initial, Subsequent, Discharge Day Management, and Other Nursing Facility

Care Services (6) Neuropsychological Testing Services (7) Speech-Language Pathology Services (8) Home Wound Care Services D. Summary of CY 2011 Telehealth Proposals

V. Provisions of the Pa tient Protection and Afford able Care Act of 2010 A. Section 3002: Improvements to the Physician Quality Reporting System B. Section 3003: Improvements to th e Physician Feedback Program and Section 3007: Value-based payment modifier under the physician fee schedule 1. Background

2. Effect of the Patient Protection a nd Affordable Care Act on the Program 3. Implementation of Sections 3003 and 3007 of the Affordable Care Act 4. Comments Sought on Specific Po licy Topics Related to Both PPACA

Sections 3003 and 3007 a. Risk Adjustment

b. Attribution c. Benchmarking and Peer Groups d. Cost and Quality Meas ures and Composite Measurement

C. Section 3102: Extension of the Work Geographic Index Floor and Revisions to the Practice Expense Geographic Adjus tment under the Medicare Physician Fee Schedule, and Protections for Fron tier States as amended by Section

10324 of the Affordable Care Act D. Section 3103: Extension of Excepti ons Process for Medicare Therapy Caps E. Section 3104: Extension of Paym ent for Technical Component of Certain

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Physician Pathology Services

F. Section 3105: Extension of Ambulance Add-On G. Section 3107: Extension of Physic ian Fee Schedule Mental Health Add-On

H. Section 3108: Permittin g Physician Assistants to Order Post-Hospital Extended

Care Services I. Section 3111: Payment for Bone Density Tests J. Section 3114: Improved Access for Certified Nurse Midwife Services

K. Section 3122: Extension of Medicar e Reasonable Costs Payments for Certain Clinical Diagnostic Laboratory Tests Furnished to Hospital Patients in Certain

Rural Areas

L. Section 3134: Misvalued Code s Under the Physician Fee Schedule

M. Section 3135: Modification of E quipment Utilization Factor for Advanced Imaging Services 1. Adjustment in Practice Expense to Reflect Higher Presumed Utilization 2. Adjustment in Technical Component “Discount” on Single-Session Imaging to Consecutive Body Parts

N. Section 3136: Revision for Pa yment for Power-Driven Wheelchairs a. Payment Rules for Power Wheelchairs b. Elimination of Lump Sum Payment for Standard Power Wheelchairs c. Revision of Payment Amounts for Power Wheelchairs O. Section 3139: Payment for Biosimilar Biological Products

P. Section 3401: Revision of Certain Ma rket Basket Updates and Incorporation of Productivity Improvements into Market Ba sket Updates That Do Not Already Incorporate Such Improvements

1. ESRD Market Basket Discussion

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2. Productivity Adjustment regarding Ambulance and Clini cal Laboratory Fee

Schedules a. Ambulatory Surgery Centers (ASCs) b. Ambulance Fee Schedule (AFS)

c. Clinical Lab Fee Schedule Q. Section 4103: Medicare Coverage of Annual Wellness Visit Providing a

Personalized Prevention Plan 1. Background a. Medicare Coverage of Preven tive Physical Examinations and Routine Checkups b. Requirements for Coverage of an Annual Wellness Visit 2. Proposed Revisions a. Proposed Revisions to §411.15, Par ticular services excluded from coverage b. Proposed revisions to Part 410, Subpart B – Medical and Other Health

Services (1) Definitions (2) Requirements of the first visit for personalized prevention plan services (3) Requirements of subsequent visits for personalized prevention plan

services 3. Payment for the Annual Wellness Visit Providing Personalized Prevention Plan Services (PPPS)

R. Section 4104: Removal of Barriers to Preventive Services in Medicare

1. Definition of “Preventive Services”

2. Deductible and Coinsurance for Preventive Services

3. Extension of Waiver of Deductible to Services Furnished in Connection with

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or in relation to a Colorectal Cancer Screening Test that becomes Diagnostic or Therapeutic S. Section 5501: Expanding Access to Pr imary Care Services and General Surgery

Services 1. Section 5501(a): Incentive Payment Program for Primary Care Services a. Background b. Proposed Primary Care Incentive Payment Program (PCIP) 2. Section 5501(b): Incentive Payment Program for Major Surgical Procedures

Furnished in Health Prof essional Shortage Areas a. Background b. Proposed HPSA Surgical Incentive Payment Program (HSIP) 3. Sections 5501(a) and (b) of the Afford able Care Act and Payment for Critical Access Hospital Profe ssional Services Under the Optional Method T. Section 6003: Disclosure Require ments for In-Office Ancillary Services Exception to the Prohibition on Physician Self-Referral for Certain Imaging

Services 1. Background 2. Proposed Disc losure Requirement U. Section 6404: Maximum period for s ubmission of Medicare claims reduced to

not more than 12 months 1. Background

2. Provisions of Affordable Care Act V. Section 6410 and MIPPA: Adjustme nts to the Medicare Durable Medical Equipment, Prosthetics,Orthotics, and Supplies Competitive Acquisition Program

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1. Background 2. Subdividing Large MSAs under Round 2

3. Exclusions of Certain Areas after Round 2 and Prior to 2015 4. Expansion of Round 2 W. Section 10501(i)(3)—Proposed Collec tion of HCPCS data for Development and Implementation of a Prospective Payment System for the Medicare Federally Qualified Health Center Program VI. Other Provisions of the Proposed Regulation A. Part B Drug Payment: Average Sales Price (ASP) Issues 1. "Carry Over" ASP 2. Partial Quarter ASP Data 3. Determining the Payment Amount for Drugs and Biologicals Which Include

Intentional Overfill

4. WAMP/AMP

5. Price Substitutions

a. AMP threshold

b. AMP Price Substitution B. Ambulance Fee Schedule: Proposed Policy for Reporting Units when Billing for Ambulance Fractional Mileage 1. Policy for Reporting Units when Billing for Ambulance Fractional Mileage or

Other Services a. History of Medicare Ambulance Services (1) Statutory Covera ge of Ambulance Services (2) Medicare Regulati ons for Ambulance Services b. Mileage Reporting

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(1) Background and Current Process for Reporting Ambulance Mileage (2) Potential for Inaccuracies in Reporting Units and Associated Risks (3) Billing of Fractional Units for Mileage C. Clinical Laboratory Fee Sc hedule: Signature on Requisition D. Discussion of Chiroprac tic Services Demonstration E. Provisions Related to Payment for Re nal Dialysis Services Furnished by EndStage Renal Disease (ESRD) Facilities

1. CY 2005 Provisions

2. CY 2006 Provisions

3. CY 2007 Provisions

4. CY 2008 Provisions 5. CY 2009 Updates 6. CY 2010 Updates 7. Proposals for CY 2011

a. MIPPA Provisions

b. Affordable Care Act Provision 8. Proposed Update to the Drug A dd-on Adjustment to the Composite Rate a. Estimating Growth in Expenditures for Drugs and Biologicals for CY 2010 b. Estimating Growth in Expenditure s for Drugs and Biologicals in CY 2011 c. Estimating Per Patient Growth d. Applying the Proposed Growth U pdate to the Drug Add-On Adjustment e. Proposed Update to the Drug Add-on Adjustment f. Proposed Update to the Geogra phic Adjustments to the Composite Rate g. Proposed Updates to Core-Bas ed Statistical Area (CBSA) Definitions h. Proposed Updated Wage Index Values

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i. Reduction to the ESRD Wage Index Floor j. Proposed Wage index Values for Areas With No Hospital Data k. Budget Neutrality Adjustment l. ESRD Wage Index Tables F. Issues Related to the Medicare Impr ovements for Patients a nd Providers Act of 2008 (MIPPA) 1. Section 131: Physician Payment, Efficiency, and Quality Improvements - Physician Quality Reporting Initiative (PQRI) a. Program Background and Statutory Authority b. Incentive Payments for the 2011 PQRI c. Proposed 2011 Reporting Periods for Individual Eligib le Professionals d. Proposed 2011 PQRI Reporting Me chanisms for Individual Eligible

Professionals (1) Proposed Requirements for Indivi dual Eligible Professionals Who Choose the Claims-based Reporting Mechanism (2) Proposed Requirements for Indivi dual Eligible Professionals Who Choose the Registry-based Reporting Mechanism (3) Proposed Requirements for Indivi dual Eligible Professionals Who Choose the EHR-based Reporting Mechanism (4) Proposed Qualification Requirements for Registries (5) Proposed Qualification Re quirements for EHR Vendors and Their

Products e. Proposed Criteria for Satisf actory Reporting of Individual Quality

Measures for Individual E ligible Professionals f. Proposed Criteria for Satis factory Reporting Measures Groups for

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Individual Eligible Professionals g. Proposed Reporting Option for Satisfactory Reporting on Quality Measures by Group Practices (1) Group Practice Reporting Option – GPRO I (2) Process for Physician Group Prac tices to Participate as Group Practices and Criteria for Satisfactory Reporting h. Statutory Requirements and Other Considerations for 2011 PQRI Measures (1) Statutory Requirements for 2011 PQRI Measures (2) Other Considera tions for Measures Proposed for Inclusion in the 2011 PQRI i. Proposed 2011 PQRI Quality Measures for Individual Eligible

Professionals (1) Proposed 2011 Individual Quality Measures Selected From the 2010 PQRI Quality Measures Set Available for Claims based Reporting and Registry-based Reporting (2) Proposed 2011 Individual Quality Measures Selected From the 2010 PQRI Quality Measures Set Available fo r Registry based Reporting Only (3) New Individual Quality Meas ures Selected for Proposed for 2011 (4) Proposed 2011 Measures Ava ilable for EHR-based Reporting (5) Measures Proposed for Inclusion in 2011 Measures Groups j. Proposed 2011 PQRI Quality Meas ures for Physician Groups Selected to Participate in the Group Practice Reporting Option k. Public Reporting of PQRI Data l. Affordable Care Act Extension of Incentive for PQRI Program m. Affordable Care Act Timely Feedback Reports

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n. Affordable Care Act Informal Appeals Process o. Affordable Care Act Maintenance of Certification Program p. Affordable Care Act Physician Compare Web site q. Affordable Care Act Integra tion of PQRI EHR measures and HITECH measures in years after 2011

2. Section 132: Incentives for Electr onic Prescribing (eRx)– The Electronic Prescribing Incentive Program a. Program Background and Statutory Authority b. The 2011 Reporting Period for the eRx Incentive Program c. Proposed Criteria for Determinati on of Successful Electronic Prescriber for Eligible Professionals (1) Reporting the Electronic Prescribing Measure (2) The Reporting Denominator for the Electronic Prescribing Measure (3) Qualified Electronic Prescribing System – Required Functionalities and

Part D eRx Standards (4) The Reporting Numerator for the Electronic Prescribing Measure (5) Criteria for Successful Reporting of the Electronic Prescribing Measure d. Determination of the 2011 Incentive Payment Amount for Individual Eligible Professionals Who Are Successful Electronic Prescribers e. Proposed Reporting Option for Sa tisfactory Reporting of the Electronic Prescribing Measure by Group Practices (1) Definition of “Group Practice” (2) Process for Group Practices to Pa rticipate as Group Pr actices and Criteria for Successful Reporting of the Electronic Prescribing Measure by Group Practices

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f. Public Reporting of Names of Successful Electronic Prescribers G. DMEPOS Competitive Bidding Program Issues 1. Implementation of a National Mail Order Competitive Bidding Program for Diabetic Testing Supplies

a. Revision of the Definition of "Mail Order" (1) Legislative and Regulatory History of the Medicare Durable Medical Equipment, Prosthetics, Ort hotics, and Supplies (DMEPOS) Competitive Bidding Program (2) National Mail Order Competitive Bidding Program (3) The MIPPA and the Medicare DMEPOS Competitive Bidding Program (4) Competition for Mail Order Di abetic Supplies under Round 1 of the Medicare DMEPOS Competitive Bidding Program b. Overview of Proposed Rule c. Future Competitions for Diabetic Testing Supplies

d. Definition of Mail Order Item e. Special Rule in Case of National Mail Order Competition for Diabetic Testing Strips f. Anti-switching Rule in Case of National Mail Order Competition for Diabetic Test Strips 2. Off-the-Shelf (OTS) Orthotics Exemption 3. Changes to Payment for Oxygen and Oxygen Equipment a. Background b. Furnishing Oxygen Equipment after the 36-Month Rental Period (Cap) c. Furnishing Oxygen Equipment during the 36-Month Rental Period (Cap) 4. Grandfathering Rules Resulting in Extra Payments to Contract Suppliers

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Under the DMEPOS Competitive Bidding Program 5. Appeals Process a. Background b. Proposed Appeals Process (1) Purpose and Definitions: (§414.402) (2) Applicability (3) Contract Termination (4) Notice of Termination (5) Corrective Action Plan (6) Right to Request a Hearing by the CBIC Hearing Officer (7) Scheduling of the Hearing (8) Burden of Proof (9) Role of the Hearing Officer (10) CMS’s Fina l Determination (11) Effective Date of the Contract Termination (12) Effect of Contract Termination H. Provider and Supplier Enrollme nt Issue: Air Ambulance Provision

I. Technical Corrections

1. Physical Therapy, Occupational Therapy, and Speech-language Pathology 

### 2. Scope of Benefits

VII. Collection of In formation Requirements VIII. Response to Comments IX. Regulatory Impact Analysis A. RVU Impacts 1. Resource Based Work, PE, and Malpractice RVUs

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2. CY 2011 PFS Impact Discussion a. Changes in RVUs b. Combined Impact B. Geographic Practice Cost Indices (GPCIs) C. Rebasing and Revising of the MEI

D. The Affordable Care Act Provisions 1. Section 3103: Extension of Exceptions Process for Medicare Therapy Caps 2. Section 3104: Extension of Paymen t for Technical Component of Certain Physician Pathology Services

3. Sections 3105 and 10311: Extension of Ambulance Add-Ons 4. Section 3107: Extension of Physicia n Fee Schedule Mental Health Add-On 5. Section 3111: Payment for Bone Density Tests

6. Section 3122: Extension of Medicare Reasonable Costs Payments for Certain Clinical Diagnostic Laboratory Tests Furnished to Hospital Patients in Certain Rural

Areas 7. Section 3135: Modification of Equi pment Utilization Factor for Advanced Imaging Services 8. Section 3136: Revisions in Payments for Power Wheelchairs

9. Section 3401: Revisions of Certain Ma rket Basket Updates and Incorporation of Productivity Adjustments 10. Section 4103: Medicare Coverage of Annual Wellness Visit Providing a

Personalized Prevention Plan

11. Section 4104: Removal of Barriers to Preventive Services in Medicare 12. Section 5501: Expanding Access to Primary Care Serv ices and General Surgery Services

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13. Section 6003: Disclosure Require ments for In-office Ancillary Services Exception to the Prohibition of Physician Se lf-referral for Certain Imaging Services

14. Section 6404: Maximum Period fo r Submission of Medicare Claims

Reduced to not more than 12 Months E. Other Provisions of the Proposed Regulation 1. Part B Drug Payment: ASP Issues 2. Ambulance Fee Schedule: Proposed Policy for Reporting Units when Billing for Ambulance Fractional Mileage 3. Chiropractic Se rvices Demonstration 4. Renal Dialysis Services Furnished by ESRD Facilities 5. Section 131(b) of the MIPPA: Phys ician Payment, Efficiency, and Quality Improvements - Physician Quality Reporting Initiative (PQRI)

6. Section 132 of the MIPPA: Incentives for Electronic Prescribing (eRx)- The eRx Incentive Program 7 RHC/FQHC Issues 8. Durable Medical Equipment-Related Issues a. Off-the-Shelf (OTS) Orthotics Exemption b. Changes to Payment for Oxygen Equipment

F. Alternatives Considered G. Impact on Beneficiaries H. Accounting Statement Regulation Text Addendum A--Explanation and Use of Addendum B Addendum B--Proposed Relative Value Units and Related Information Used in Determining Medicare Payments for CY 2011

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Addendum C--[Reserved] Addendum D--Proposed CY 2011 Geogra phic Adjustment Factors (GAFs) Addendum E--Proposed CY 2011 Geographic Prac tice Cost Indices (GPCIs) by State and Medicare Locality Addendum F--Proposed CY 2011 Diagnostic Imag ing Services Subject to the Multiple Procedure Payment Reduction Addendum G--CPT/HCPCS Imaging Codes De fined By Section 5102(b) of the DRA Addendum H--Proposed CY 2011 “Always Therap y” Services* Subject to the Multiple Procedure Payment Reduction Addendum I--[Reserved] Addendum J--[Reserved] Addendum K--Proposed CY 2011 ESRD Wage Index for Urban Areas Based on CBSA

Labor Market Areas Addendum L--Proposed CY 2011 ESRD Wage Index for Rural Areas Based on CBSA

Labor Market Areas Acronyms In addition, because of the many organizations and terms to which we refer by acronym in this proposed rule, we are listing these acronyms and their corresponding terms in alphabetical order below: AA Anesthesiologist assistant AACVPR American Association of Cardiovascular and Pulmonary Rehabilitation

AANA American Association of Nurse Anesthetists ABMS American Board of Medical Specialties ABN Advanced Beneficiary Notice

ACA " Afforadable Care Act"

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ACC American College of Cardiology

ACGME Accreditation Council on Gr aduate Medical Education ACLS Advanced cardiac life support ACR American College of Radiology

AED Automated external defibrillator AFROC Association of Freestanding Radiation Oncology Centers

AHA American Heart Association AHFS-DI American Hospital Formulary Service-Drug Information AHRQ [HHS’] Agency for Healthcare Research and Quality

AMA American Medical Association

AMA-DE American Medical A ssociation Drug Evaluations AMP Average manufacturer price AO Accreditation organization AOA American Osteopathic Association APA American Psychological Association APTA American Physical Therapy Association ARRA American Recovery and Reinvestment Act (Pub. L. 111-5) ASC Ambulatory surgical center ASP Average sales price ASRT American Society of Radiologic Technologists ASTRO American Society for Therapeutic Radiology and Oncology

ATA American Telemedicine Association AWP Average wholesale price BBA Balanced Budget Act of 1997 (Pub. L. 105-33)

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BBRA [Medicare, Medicaid and State Child Health Insurance Program] Balanced Budget Refinement Act of 1999 (Pub. L. 106-113) BIPA Medicare, Medicaid, and SCHIP Be nefits Improvement Protection Act of 2000 (Pub. L. 106-554) BLS Basic Life support BN Budget neutrality BPM Benefit Policy Manual CABG Coronary artery bypass graft CAD Coronary artery disease CAH Critical access hospital

CAHEA Committee on Allied Health Education and Accreditation CAP Competitive acquisition program CBIC Competitive Bidding Implementation Contractor CBP Competitive Bidding Program

CBSA Core-Based Statistical Area

CF Conversion factor CfC Conditions for Coverage CFR Code of Federal Regulations CKD Chronic kidney disease CLFS Clinical laboratory fee schedule

CMA California Medical Association CMHC Community mental health center CMP Civil money penalty

CMS Centers for Medicare & Medicaid Services CNS Clinical nurse specialist

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CoP Condition of participation COPD Chronic obstructive pulmonary disease CORF Comprehensive Outpatient Rehabilitation Facility

COS Cost of service CPEP Clinical Practice Expert Panel

CPI Consumer Price Index CPI-U Consumer price index for urban customers CPR Cardiopulmonary resuscitation CPT [Physicians'] Current Proce dural Terminology (4th Edition, 2002, copyrighted by the American Medical Association)

CR Cardiac rehabilitation CRNA Certified registered nurse anesthetist CRP Canalith repositioning CRT Certified respiratory therapist

CSW Clinical social worker CY Calendar year DEA Drug Enforcement Agency DHS Designated health services DME Durable medical equipment DMEPOS Durable medical equipment, pr osthetics, ortho tics, and supplies DOQ Doctor’s Office Quality

DOS Date of service

DRA Deficit Reduction Ac t of 2005 (Pub. L. 109-171) DSMT Diabetes self-management training E/M Evaluation and management

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EDI Electronic data interchange EEG Electroencephalogram

EHR Electronic health record EKG Electrocardiogram EMG Electromyogram EMTALA Emergency Medical Treatment and Active Labor Act EOG Electro-oculogram EPO Erythopoeitin ESRD End-stage renal disease

FAX Facsimile FDA Food and Drug Administration (HHS)

FFS Fee-for-service

FR Federal Register GAF Geographic adjustment factor GAO General Accounting Office GEM Generating Medicare [Physician Quality Performance Measurement Results]

GFR Glomerular filtration rate GPO Group purchasing organization GPCI Geographic practice cost index HAC Hospital-acquired conditions

HBAI Health and behavior assessment and intervention HCPAC Health Care Professional Advisory Committee

HCPCS Healthcare Common Pr ocedure Coding System HCRIS Healthcare Cost Report Information System

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HDRT High dose radiation therapy HH PPS Home Health Prospective Payment System HHA Home health agency HHRG Home health resource group HHS [Department of] Health and Human Services HIPAA Health Insurance Portability and Accountability Act of 1996 (Pub. L. 104-191) HIT Health information technology HITECH Health Information Technology for Economic and Clinical Health Act (Title IV of Division B of the Recovery Act, together with Title XIII of Division A of the Recovery Act)

HITSP Healthcare Informati on Technology Standards Panel HIV Human immunodeficiency virus HOPD Hospital outpa tient department

HPSA Health Profe ssional Shortage Area

HRSA Health Resources Se rvices Administration (HHS) IACS Individuals Access to CMS Systems

ICD International Classification of Diseases

ICF Intermediate care facilities

ICR Intensive cardiac rehabilitation ICR Information collection requirement IDTF Independent diagnostic testing facility IFC Interim final rule with comment period IMRT Intensity-Modulated Radiation Therapy IPPE Initial preventive physical examination

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IPPS Inpatient prospective payment system

IRS Internal Revenue Service

ISO Insurance services office

IVD Ischemic Vascular Disease IVIG Intravenous immune globulin IWPUT Intra-service work per unit of time

JRCERT Joint Review Committee on Edu cation in Radiologic Technology KDE Kidney disease education LCD Local coverage determination MA Medicare Advantage MA-PD Medicare Advantage-Prescription Drug Plans MAV Measure Applicability Validation MCMP Medicare Care Management Performance

MDRD Modification of Diet in Renal Disease MedCAC Medicare Evidence Development and Coverage Advisory Committee (formerly the Medicare Covera ge Advisory Committee (MCAC)) MedPAC Medicare Payment Advisory Commission

MEI Medicare Economic Index MIEA-TRHCA Medicare Improvements and Extension Act of 2006 (that is, Division B

of the Tax Relief and Health Care Act of 2006 (TRHCA) (Pub. L. 109-432) MIPPA Medicare Improvements for Pa tients and Provide rs Act of 2008 (Pub. L. 110-275) MMA Medicare Prescription Drug, Improv ement, and Modernization Act of 2003 (Pub. L. 108-173)

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MMSEA Medicare, Medicaid, and SCHIP Extension Act of 2007 (Pub. L. 110-173) MNT Medical nutrition therapy

MOC Maintenance of certification MP Malpractice MPPR Multiple procedure payment reduction MQSA Mammography Quality Sta ndards Act of 1992 (Pub. L. 102-539) MRA Magnetic resonance angiography MRI Magnetic resonance imaging MSA Metropolitan statistical area NBRC National Board for Respiratory Care

NCD National Covera ge Determination NCQDIS National Coalition of Quality Diagnostic Imaging Services NDC National drug code NF Nursing facility

NISTA National Institute of Standards and Technology Act NP Nurse practitioner

NPI National Provider Identifier NPP Nonphysician practitioner NQF National Quality Forum NRC Nuclear Regulatory Commission OACT [CMS’] Office of the Actuary OBRA Omnibus Budget Reconciliation Act ODF Open door forum OGPE Oxygen generating portable equipment OIG Office of Inspector General

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OMB Office of Management and Budget ONC [HHS’] Office of the Nationa l Coordinator for Health IT OPPS Outpatient prospective payment system OSCAR Online Survey and Ce rtification and Reporting PA Physician assistant

PAT Performance assessment tool PC Professional component PCI Percutaneous coronary intervention PDP Prescription drug plan PE Practice expense PE/HR Practice expense per hour PEAC Practice Expense Advisory Committee PERC Practice Expense Review Committee PFS Physician Fee Schedule PGP [Medicare] Physician Group Practice

PHI Protected health information PHP Partial hospitalization program PIM [Medicare] Program Integrity Manual PLI Professional liability insurance

POA Present on admission

POC Plan of care PPI Producer price index PPIS Physician Practice Information Survey PPS Prospective payment system PPTA Plasma Protein Therapeutics Association

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PQRI Physician Quality Reporting Initiative PR Pulmonary rehabilitation PRA Paperwork Reduction Act PSA Physician scarcity areas PT Physical therapy PTCA Percutaneous transluminal coronary angioplasty PVBP Physician and Other Health Professional Value- Based Purchasing Workgroup RA Radiology assistant RBMA Radiology Business Management Association RFA Regulatory Flexibility Act

RHC Rural health clinic RIA Regulatory impact analysis RN Registered nurse

RNAC Reasonable ne t acquisition cost RPA Radiology practitioner assistant RRT Registered respiratory therapist RUC [AMA's Specialty Society] Relative (Value) Update Committee

RVU Relative value unit

SBA Small Business Administration SGR Sustainable growth rate SLP Speech-language pathology SMS [AMA’s] Socioeconomic Monitoring System SNF Skilled nursing facility SOR System of record

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SRS Stereotactic radiosurgery STARS Services Tracking and Reporting System TC Technical Component

TIN Tax identification number

TRHCA Tax Relief and Health Care Act of 2006 (Pub. L. 109-432) TTO Transtracheal oxygen UPMC University of Pittsburgh Medical Center USDE United States Depa rtment of Education USP-DI United States Pharmacopoeia-Drug Information VBP Value-based purchasing WAMP Widely available market price

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I. Background Since January 1, 1992, Medicare has paid for physicians' services under section 1848 of the Social Security Act (the Act), "P ayment for Physicians' Services." The Act requires that payments under the physician fee schedule (PFS) are based on national uniform relative value units (RVUs) based on th e relative resources used in furnishing a service. Section 1848(c) of the Act require s that national RVUs be established for physician work, practice expense (PE), a nd malpractice expense. Before the establishment of the resource-based relative value system, Medicare payment for physicians' services was based on reasonable charges. We note that throughout this proposed rule, unless otherwise noted, the term “practitioner” is used to describe both physicians and eligible nonph ysician practitioners (such as physician assistants, nurse practitioners, clinical nurse specialists, certified nurse midwives, psychologists, or social workers) that are permitted to furnish and bill Medicare under the PFS for the services

under discussion.

A. Development of the Relative Value System

1. Work RVUs The concepts and methodology underlying the PFS were enacted as part of the Omnibus Budget Reconciliation Act (OBR A) of 1989 (Pub. L. 101-239), and OBRA 1990, (Pub. L. 101-508). The final rule, published on November 25, 1991 (56 FR 59502), set forth the fee schedule for payment for physicians’ services beginning January 1, 1992. Initially, only the physician work RVUs were resource-based, and the PE and malpractice RVUs were based on average allowable charges. The physician work RVUs established fo r the implementation of the fee schedule in January 1992 were developed with extens ive input from the physician community. A

research team at the Harvard School of Pub lic Health developed th e original physician

### CMS-1503-P 37

work RVUs for most codes in a cooperative agreement with the De partment of Health and Human Services (DHHS). In constructing the code-specific vignettes for the original physician work RVUs, Harvard worked with pa nels of experts, both inside and outside the Federal government, and obtained input from numerous physician specialty groups. Section 1848(b)(2)(B) of the Act specifies that the RVUs for anesthesia services are based on RVUs from a uniform relative value guide, with appropriate adjustment of the conversion factor (CF), in a manner to a ssure that fee schedule amounts for anesthesia

services are consistent with t hose for other services of comparable value. We established a separate CF for anesthesia services, and we continue to utilize time units as a factor in determining payment for these services. As a result, there is a separate payment methodology for anesthesia services. We establish physician work RVUs for new and revised codes based on our review of recommendations received from the American Medical Association's (AMA) Specialty Society Relative Value Update Committee (RUC). 2. Practice Expense Relative Value Units (PE RVUs) Section 121 of the Social Security Act Amendments of 1994 (Pub. L. 103-432), enacted on October 31, 1994, amended section 1848(c)(2)(C)(ii) of the Act and required us to develop resource-based PE RVUs for each physician's service beginning in 1998. We were to consider general categories of expenses (such as office rent and wages of personnel, but excluding malprac tice expenses) comprising PEs. Section 4505(a) of the Balanced Budg et Act of 1997 (BBA) (Pub. L. 105-33), amended section 1848(c)(2)(C)(ii) of the Act to delay implementation of the resource-based PE RVU system until January 1, 1999. In addition, section 4505(b) of the BBA provided for a 4-year transition pe riod from charge-based PE RVUs to

resource-based RVUs.

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We established the resource-based PE R VUs for each physicians’ service in a final rule, published November 2, 1998 (63 FR 58 814), effective for services furnished in 1999. Based on the requirement to transition to a resource-based sy stem for PE over a 4-year period, resource-based PE RVUs did not become fully effective until 2002. This resource-based system was based on two significant sources of actual PE data: the Clinical Practice Expert Panel (CPEP) data; and the AMA's Socioeconomic Monitoring System (SMS) data. The CPEP data were collected from panels of physicians, practice administrators, and nonph ysicians (for example, registered nurses (RNs)) nominated by physician specialty soci eties and other groups. The CPEP panels identified the direct inputs re quired for each physician’s service in both the office setting and out-of-office setting. We have since refined and revised these inputs based on

recommendations from the RUC. The AMA’s SMS data provided aggregate specialty-specific information on hours worked and PEs. Separate PE RVUs are estab lished for procedures that can be performed in both a nonfacility setting, such as a physician's office, and a facility setting, such as a hospital outpatient department. The di fference between the facility and nonfacility RVUs reflects the fact that a facility typically receives separate payment from Medicare for its costs of providing the service, apart from payment und er the PFS. The nonfacility RVUs reflect

all of the direct and indirect PEs of providing a particular service. Section 212 of the Balanced Budget Refinement Act of 1999 (BBRA) (Pub. L. 106-113) directed the Secr etary of Health and Human Services (the Secretary) to establish a process under which we accept a nd use, to the maximum extent practicable

and consistent with sound data practices, data collected or developed by entities and organizations to supplement the data we normally collect in determining the PE component. On May 3, 2000, we published the in terim final rule ( 65 FR 25664) that set

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forth the criteria for the submission of these supplemental PE survey data. The criteria were modified in response to comme nts received, and published in the Federal Register (65 FR 65376) as part of a November 1, 2000 fi nal rule. The PFS final rules published in 2001 and 2003, respectively, (66 FR 55246 and 68 FR 63196) extended the period during which we would accept these suppl emental data through March 1, 2005. In the calendar year (CY) 2007 PFS final rule with comment period (71 FR 69624), we revised the methodology for calculating direct PE RVUs from the topdown to the bottom-up methodology beginning in CY 2007 and provided for a 4-year

transition for the new PE RVUs under this ne w methodology. This transition ended in

CY 2010 and direct PE RVUs are calculated in CY 2011 using this methodology, unless

otherwise noted.

In the CY 2010 PFS final rule with co mment period, we updated the PE/hour (HR) data that are used in the calculation of PE RVUs for most specialties (74 FR 61749). For this update, we used the Physic ian Practice Information Survey (PPIS) conducted by the AMA. The PPIS is a mu ltispecialty, nationally representative, PE survey of both physicians and nonphysic ian practitioners (NPPs) using a survey instrument and methods highly consistent with those of the SMS and the supplemental surveys used prior to CY 2010. We note that in CY 2010, for oncology, clinical laboratories, and independent diagnostic testing facilities (IDTFs), we continued to use the supplemental survey data to de termine PE/HR values (74 FR 61752). 3. Resource-Based Malp ractice (MP) RVUs Section 4505(f) of the BBA amended secti on 1848(c) of the Act requiring us to implement resource-based malpractice (MP) RVUs for services furnished on or after 2000. The resource-based MP RVUs were imp lemented in the PFS final rule published November 2, 1999 (64 FR 59380). The MP RVUs were based on malpractice insurance

### CMS-1503-P 40

premium data collected from commercial and physician-owned insurers from all the States, the District of Columbia, and Puerto Rico.

4. Refinements to the RVUs Section 1848(c)(2)(B)(i) of the Act requires that we review all RVUs no less often than every 5 years. The first Five-Year Review of the physician work RVUs was published on November 22, 1996 (61 FR 59489) and was effective in 1997. The second Five-Year Review was published in the CY 2002 PFS final rule with comment period (66 FR 55246) and was effective in 2002. The th ird Five-Year Review of physician work RVUs was published in the CY 2007 PFS fina l rule with comment period (71 FR 69624) and was effective on January 1, 2007. (Note : Additional codes relating to the third Five-Year Review of physician work RVUs were addressed in th e CY 2008 PFS final rule with comment period (72 FR 66360).) Th e fourth Five-Year Review of physician

work RVUs was initiated in the CY 2010 PFS final rule with comment period where we

solicited candidate codes from th e public for this review ( 74 FR 61941). Changes due to

the fourth Five-Year Review of physician work RVUs will be effective January 1, 2012. In 1999, the AMA’s RUC established th e Practice Expense Advisory Committee (PEAC) for the purpose of refining the direct PE inputs. Through March 2004, the PEAC provided recommendations to CMS for over 7,600 codes (all but a few hundred of the codes currently listed in the AMA's Current Procedural Terminology (CPT) codes). As part of the CY 2007 PFS final rule with comment period (71 FR 69624), we implemented a new bottom-up methodology for determining resource-based PE RVUs and transitioned the new methodology over a 4-year period. A comprehensive review of PE was undertaken prior to the 4-year transition period for the new PE methodology from the top-down to the bottom-up methodology, and th is transition was completed in CY 2010. In CY 2010, we also incorporated the new PP IS data to update the specialty-specific

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PE/HR data used to develop PE RVUs. Ther efore, the next Five-Year Review of PE

RVUs will be addre ssed in CY 2014.

In the CY 2005 PFS final rule with comment period (69 FR 66236), we implemented the first Five-Year Review of the MP RVUs (69 FR 66263). Minor modifications to the methodology were addr essed in the CY 2006 PF S final rule with comment period (70 FR 70153). The second Fi ve-Year Review and update of resourcebased malpractice RVUs was published in the CY 2010 PFS final rule with comment period (74 FR 61758) and was effective in CY 2010. 5. Adjustments to RVUs are Budget Neutral Section 1848(c)(2)(B)(ii)(II) of the Act provides that adjustments in RVUs for a year may not cause total PFS payments to di ffer by more than $20 million from what they would have been if the adjustments were not made. In accordance with section 1848(c)(2)(B)(ii)(II) of the Act, if revisions to the RVUs cause expenditures to change by more than $20 million, we make adjustments to ensure that expenditures do not increase or decrease by more than $20 million. As explained in the CY 2009 PFS fina l rule with comment period (73FR 69730), as required by section 133(b) of the Medi care Improvements for Patients and Providers Act of 2008 (MIPPA) (Pub. L. 110-275), the se parate budget neutrality (BN) adjustor resulting from the third Five-Year Review of physician work RVUs is being applied to the CF beginning in CY 2009 rather than to the work RVUs. For CY 2010, we adopted a number of new payment policies for which we estimated the potential for a redistributive effect under the PFS, including the use of the new PPIS data to develop the specialty -specific PE/HR used for the PE RVUs (74 FR 61749 through 61752) and the elimination of the reporting of all CPT consultation

codes in order to allow for correct and cons istent coding and appropriate payment for

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evaluation and management services under the PFS (74 FR 61767 through 61775). We recognize that clinical experience with these new PFS policies has been growing over the first 6 months of CY 2010 and, as we seek to improve future PFS payment accuracy for services, we are interested in public comme nts on the perspectives of physicians and nonphysician practitioners caring for Medica re beneficiaries under the current PFS coding and payment methodologies for physicians’ services.

B. Components of the Fee Schedule Payment Amounts To calculate the payment for every physic ians’ service, the components of the fee schedule (physician work, PE, and MP RVUs) are adjusted by a geographic practice cost index (GPCI). The GPCIs reflect the re lative costs of physician work, PE, and malpractice expense in an area compared to the national average costs for each

component.

RVUs are converted to dollar amounts thr ough the application of a CF, which is calculated by CMS’ Office of the Actuary (OACT). The formula for calculating the Medicar e fee schedule payment amount for a given service and fee schedule area can be expressed as: Payment = [(RVU work x GPCI work) + (RVU PE x GPCI PE) + (RVU malpractice x GPCI malpractice)] x CF.

C. Most Recent Changes to the Fee Schedule

The CY 2010 PFS final rule with comme nt period (74 FR 61738) implemented changes to the PFS and other Medicare Part B pa yment policies. It also finalized some of the CY 2009 interim RVUs and implemented interim RVUs for new and revised codes for CY 2010 to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of se rvices. The CY 2010 PFS final rule with

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comment period also addressed other policie s, as well as certain provisions of the

MIPPA. As required by the statute at the time of its issuance on October 30, 2009, the CY 2010 PFS final rule with comment period a nnounced the following for CY 2010: the PFS update of -21.2 percent; the initial estimate for the sustai nable growth rate of -8.8 percent; and the CF of $28.4061. On December 10, 2009, we published a correction notice (74 FR 65449) to correct several technical and typographical erro rs that occurred in the CY 2010 PFS final rule with comment period. This correc tion notice announced a revised CF for CY 2010 of $28.3895. On December 19, 2009, the Department of Defense Appropriations Act, 2010 (Pub. L. 111-118) was signed into law. Section 1011 of Pub. L. 111-118 provided a 2-month zero percent update to the CY 2010 PFS effective only for dates of service from January 1, 2010 through February 28, 2010. On March 2, 2010, the Temporary Extens ion Act of 2010 (Pub. L. 111-144) was signed into law. Section 2 of Pub. L. 111-144 extended the zero percent update to the PFS through March 31, 2010 that was in effect for claims with dates of service from January 1, 2010 through February 28, 2010. In addition, on April 15, 2010, the Continuing Extension Act of 2010 (Pub. L. 111-157) was signed into law. Se ction 4 of Pub. L. 111-157 extended through May 31, 2010 the zero percent update to the PFS th at was in effect for claims with dates of services from January 1, 2010 through Ma rch 31, 2010. The law is retroactive to April 1, 2010. In the May 11, 2010 Federal Register (75 FR 26350), we published a subsequent correction notice to correct several technical and typographical errors that occurred in the

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CY 2010 PFS final rule with co mment period and the December 10, 2009 correction notice. The May 11, 2010 correction notice announced a revised CF for CY 2010 of $28.3895. Finally, on March 23, 2010 the Patient Protection and Affordable Care Act (Pub. L. 111-148) was signed into law. Shortly thereafter, on March 30, 2010, the Health

Care and Education Reconcilia tion Act of 2010 (Pub. L. 111-152) was signed into law. These two laws are discussed in this proposed rule and are collectively referred to as the "Affordable Care Act" (ACA) th roughout this proposed rule. II. Provisions of the Proposed Ru le for the Physician Fee Schedule A. Resource-Based Practice Expense (PE) Relative Value Units (RVUs)

1. Overview Practice expense (PE) is the portion of the resources used in furnishing the service that reflects the general categories of physician and practitioner expenses, such as office rent and personnel wages but excluding malpractice expenses, as specified in section 1848(c)(1)(B) of the Ac t. Section 121 of the Social Security Amendments of 1994 (Pub. L. 103-432), enacted on October 31, 1994, required CMS to develop a methodology for a resource-based system for determining PE RVUs for each physician‘s service. We develop PE RVUs by looking at the direct and indirect physician practice re sources involved in furnishing each service. Direct expense categories incl ude clinical labor, medical supplies and medical equipment. Indirect expens es include administrative labor, office expense, and all other expenses. The se ctions that follow pr ovide more detailed information about the methodology for tr anslating the resources involved in furnishing each service into service-speci fic PE RVUs. In addition, we note that section 1848(c)(2)(B)(ii)(II) of the Act pr ovides that adjustments in RVUs for a

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year may not cause total PFS payments to differ by more than $20 million from what they would have been if the adju stments were not made. Therefore, if

revisions to the RVUs caus e expenditures to change by more than $20 million, we make adjustments to ensure that expenditu res do not increase or decrease by more than $20 million. We refer readers to the CY 2010 PFS final rule with comment period (74 FR 61743 through 61748) for a more detailed history of the PE methodology. 2. Practice Expense Methodology a. Direct Practice Expense We use a bottom-up approach to determine the direct PE by adding the costs of the resources (that is, the clinical staff, e quipment, and supplies) typically required to provide each service. The costs of the res ources are calculated using the refined direct PE inputs assigned to each CPT code in our PE database, which are based on our review

of recommendations received from the Am erican Medical Association’s (AMA's) Relative Value Update Committee (RUC). For a detailed explanation of the bottom-up direct PE methodology, including examples, we refer readers to the Five-Year Review of

Work Relative Value Units Under the PF S and Proposed Changes to the Practice Expense Methodology proposed notice (71 FR 37242) and the CY 2007 PFS final rule with comment period (71 FR 69629). b. Indirect Practice Expense per Hour Data We use survey data on indirect prac tice expenses incurred per hour worked (PE/HR) in developing the indirect portion of the PE RVUs. Prior to CY 2010, we primarily used the practice expense per hour (PE/HR) by specialty that was obtained from the AMA's Socioeconomic Monitoring Surveys (SMS). These surveys were conducted from 1995 through 1999. For severa l specialties that collected additional

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PE/HR data through supplemental surveys, we incorporated these data in developing the PE/HR values used annually. While the SMS was not specifically design ed for the purpose of establishing PE RVUs, we found these data to be the best available at the time. The SMS was a multispecialty survey effort conducted using a consistent survey instrument and method across specialties. The survey sample was randomly drawn from the AMA Physician Masterfile to ensure national representativen ess. The AMA discontinued the SMS survey in 1999. As required by the Balanced Budget Refinement Act of 1999 (BBRA) (Pub. L. 106-113), we also established a proc ess by which specialty groups could submit supplemental PE data. In the May 3, 2000 Federal Register  ̧ we issued the Medicare Program; Criteria for Submitting Supplemental Practice Expense Survey Data interim final rule (65 FR 25664) in wh ich we established criteria fo r acceptance of supplemental

data. The criteria were modified in th e CY 2001 and CY 2003 PFS final rules with comment period (65 FR 65380 and 67 FR 79971, resp ectively). In addition to the SMS, we previously used supplemental survey data for the following specialties: cardiology; dermatology; gastroenterology; radiology; ca rdiothoracic surgery; vascular surgery; physical and occupational therapy; inde pendent laboratories; allergy/immunology; independent diagnostic testing facilities (IDTFs); radiation oncology; medical oncology; and urology. Because the SMS data and the supplemental survey data were from different time periods, we historically inflated them by the Medicare Economic Index (MEI) to put them on as comparable a time basis as we could when calculating the PE RVUs. This MEI proxy was necessary in the past due to the lack of contemporaneous, consistently collected, and comprehensive multispecialty survey data. The AMA administered a new survey in CY 2007 and CY 2008, the Physician

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Practice Expense Information Survey (PPIS), which was expanded (relative to the SMS) to include nonphysician practitione rs (NPPs) paid under the PFS. The PPIS was designed to update the specialty-specific PE/HR data used to develop PE RVUs. The AMA and the CMS contractor, The Lewin Group (Lewin), analyzed the PPIS data and calculated the PE/HR for physician and nonphysician specialties, respectively. The AMA's summary worksheets and Lewin's final report are available on the CMS Web site at http://www.cms.gov/PhysicianFeeSched/PF SFRN/itemdetail.asp? filterType=none&filter ByDID=- 99&sortByDID=4&sortOrder=descendi ng&itemID=CMS1223902&intNumPerPage=10

. (See downloads labeled AMA PPIS Worksheet s 1-3 and Physician Practice Expense non MDDO Final Report) The PPIS is a multispecialty, nationally representative, PE survey of both physicians and NPPs using a c onsistent survey instrument a nd methods highly consistent with those used for the SMS and the supplemental surveys. The PPIS gathered information from 3,656 respondents across 51 physician specialty and healthcare professional groups.

We believe the PPIS is the most comprehensive source of PE survey information available to date. Therefore, we used the PPIS data to update the PE/HR data for almost all of the Medicare-recognized specialties that participated in the survey for the CY 2010 PFS. When we changed over to the PPIS data beginning in CY 2010, we did not change the PE RVU methodology itself or the manner in which the PE/HR data are used in that methodology. We only updated the PE/HR data based on the new survey. Furthermore, as we explained in the CY 2010 PFS final rule with comment period (74 FR 61751), because of the magnit ude of payment reductions for some specialties resulting from the use of the PPIS data, we finalized a 4-year transition (75/25

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for CY 2010, 50/50 for CY 2011, 25/75 for CY 2012, and 0/100 for CY 2013) from the previous PE RVUs to the PE RVUs developed using the new PPIS data.

Section 303 of the Medicare Pr escription Drug, Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108-173) added section 1848(c)(2)(H)(i) of the Act, which requires us to use the me dical oncology supplemental survey data submitted in 2003 for oncology drug administra tion services. Therefore, the PE/HR for medical oncology, hematology, and hematology/oncology reflects the continued use of these supplemental survey data. We do not use the PPIS data for repr oductive endocrinology, sleep medicine, and spine surgery since these specialties are not separately recognized by Medicare, and

we do not know how to blend these data with Medicare-recognized specialty data. Supplemental survey data on independent labs, from the College of American Pathologists, were implemented for paymen ts in CY 2005. Supplemental survey data from the National Coalition of Quality Diagnostic Imaging Services (NCQDIS), representing IDTFs, were blended with suppl ementary survey data from the American College of Radiology (ACR) and implemented for payments in CY 2007. Neither IDTFs nor independent labs participated in the PPIS . Therefore, we continue to use the PE/HR that was developed from their supplemental survey data. Finally, consistent with our past practice, the previ ous indirect PE/HR values from the supplemental surveys for medical oncology, independent laboratories, and IDTFs were updated to CY 2006 using the MEI to put them on a comparable basis with

the PPIS data. In the CY 2010 PFS final rule with comment period (74 FR 61753), we miscalculated the indirect PE/HR for IDTFs as pa rt of this update process. Therefore, for CY 2011, we are proposing to use a revised indirect PE/HR of $479.81 for IDTFs,

consistent with our final policy to update the indirect PE/HR values from prior

### CMS-1503-P 49

supplemental survey data that we are continui ng to use in order to put these data on a comparable basis with the PPIS data. This revision changes the IDTF indirect percentage from 51 percent to 50 percent. Previously, CMS has esta blished PE/HR values for various specialties without SMS or supplemental survey data by crossw alking them to other similar specialties to estimate a proxy PE/HR. For specialties that were part of the PPIS for which we previously used a crosswalked PE/HR, we instead use the PPIS-based PE/HR. We continue previous crosswalks for specialties that did not participate in the PPIS. However, beginning in CY 2010 we changed the PE/HR crosswalk for portable x-ray suppliers from radiology to IDTF, a more appropriate crosswalk because these specialties

are more similar to each other with respect to physician time.

In the CY 2010 PFS final rule with co mment period (74 FR 61752), we agreed that, under the current PE methodology, the PPIS data for registered dieticians should not

be used in the calculation of PE RVUs since th ese dieticians are paid 85 percent of what a physician would be paid for provi ding the service. To include their survey data in the PE calculation would influence the ratesetting by incorporating what the services would be paid if performed by registered dieticians and not strictly what the payment rates would be if provided by physicians. We further stated that we would utilize the "All Physicians" PE/HR, as derived from the PPIS , in the calculation of resource-based PE

RVUs in lieu of the PE/HR associated with re gistered dieticians. In the resource-based PE methodology for CY 2010, while we removed the specialty of registered dieticians from the ratesetting step we did not assign the "All Physicians" PE/HR to services furnished by registered dieticians. Instead, we allowed the PE/HR for those services to be generated by a weighted average of all the physician specialties that also furnished the

services. This method was consistent with our policy to not use the registered dietician

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PPIS PE/HR in calculating the PE RVUs for services furnished by registered dieticians but we did not actually crosswalk the special ty of registered dietician to the "All Physicians" PE/HR data as we had intended according to the final policy. Nevertheless, we are affirming for CY 2011 that the propos ed resource-based PE RVUs have been calculated in accordance with the final polic y adopted in the CY 2010 PFS final rule with comment period (74 FR 61752) for registered dietician services that crosswalks the specialty to the "All Physicians" PE/HR data. As provided in the CY 2010 PFS final rule with comment period (74 FR 61751), CY 2011 is the second year of the 4-year tran sition to the PE RVUs calculated using the PPIS data. Therefore, in general, th e CY 2011 PE RVUs are a 50/50 blend of the previous PE RVUs based on the SMS and s upplemental survey data and the new PE RVUS developed using the PPIS data as described above. Note that the reductions in the PE RVUs for expensive diagnostic imaging equi pment attributable to the change to an equipment utilization rate assumption of 75 percent (see 74 FR 61753 through 61755 and section II.A.3. of this proposed rule) are not subject to the transition.

c. Allocation of PE to Services To establish PE RVUs for specific services, it is necessary to establish the

direct and indirect PE associated with each service. (i) Direct costs. The relative relationship betw een the direct cost portions of the PE RVUs for any two services is determined by the relative relationship between the sum of the direct cost resources (that is, the clinical staff, equipment, and supplies) typically required to provi de the services. The costs of these

resources are calculated from the refined di rect PE inputs in our PE database. For example, if one service has a direct co st sum of $400 from our PE database and

another service has a direct cost sum of $200, the direct portion of the PE RVUs

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of the first service would be twice as mu ch as the direct portion of the PE RVUs

for the second service. (ii) Indirect costs. Section II.A.2.b. of this proposed rule describes the current data sources for specialty-speci fic indirect costs used in our PE

calculations. We allocate the indirect costs to the code level on the basis of the direct costs specifically associated with a code and the greater of either the clinical labor costs or the physician work RVUs. We also incorporate the survey

data described earlier in the PE/HR discussion. The general approach to developing the indirect portion of th e PE RVUs is described below.

• For a given service, we use the direct portion of the PE RVUs

calculated as described above and the av erage percentage that direct costs represent of total costs (based on survey data) across the specialties that perform the service to determine an initial indirect allocator. For example, if the direct portion of the PE RVUs for a given se rvice were 2.00 and direct costs, on average, represented 25 percent of total costs for the specialties that performed the service, the initial indirect allocator would be 6.00 since 2.00 is 25 percent of

8.00.

• We then add the greater of the work RVUs or clinical labor portion of the direct portion of the PE RVUs to th is initial indirect allocator. In our example, if this service had work RVUs of 4.00 and the clinical labor portion of the direct PE RVUs was 1.50, we woul d add 6.00 plus 4.00 (since the 4.00 work RVUs are greater than the 1.50 clinical labor portion) to get an indirect allocator of 10.00. In the absence of any further use of the survey data, the relative relationship between the indirect cost portions of the PE RVUs for any two services would be determined by the relative relationship between these indirect

### CMS-1503-P 52

cost allocators. For example, if one serv ice had an indirect cost allocator of 10.00

and another service had an indirect cost allocator of 5.00, the indirect portion of

the PE RVUs of the first service would be twice as great as the indirect portion of

the PE RVUs for the second service.

• We next incorporate the specialty-specific indirect PE/HR data into the calculation. As a relatively ex treme example for the sake of simplicity, assume in our example above that, based on the survey data, the average indirect cost of the specialties performing the first service with an allocator of 10.00 was half of the average indirect cost of the specialties performing th e second service with an indirect allocator of 5.00. In this case, the indirect portion of the PE RVUs of the first service would be equal to that of the second service.

d. Facility and Nonfacility Costs For procedures that can be furnished in a physician’s office, as well as in a hospital or facility setting, we establish two PE RVUs: facility and nonfacility. The methodology for calculating PE RVUs is the same for both the facility and nonfacility RVUs, but is applie d independently to yield two separate PE RVUs. Because Medicare makes a separate payment to the facility for its costs of furnishing a service, the facility PE RVUs are generally lower than the nonfacility

PE RVUs. e. Services with Technical Compone nts (TCs) and Prof essional Components (PCs) Diagnostic services are generally comprised of two components: a professional component (PC) and a technical component (TC), each of which may be performed independently or by differ ent providers, or they may be performed together as a "global" service. When services have PC and TC components that

### CMS-1503-P 53

can be billed separately, the payment for the global component equals the sum of the payment for the TC and PC. This is a result of using a weighted average of the ratio of indirect to direct costs across all the specialties that furnish the global components, TCs, and PCs; that is, we a pply the same weighted average indirect percentage factor to allocate indirect ex penses to the global components, PCs, and TCs for a service. (The direct PE R VUs for the TC and PC sum to the global under the bottom-up methodology.)

f. Alternative Data Sources and P ublic Comments on Final Rule for 2010.

In the CY 2010 PFS final rule with comment period (74 FR 61749 through 61750), we discussed the Medicare Paymen t Advisory Commission’s (MedPAC’s) comment that in the future, "CMS shoul d consider alternatives to collecting specialty-specific cost data or options to decrease the reliance on such data." We agreed

with MedPAC that it would be appropriate to consider the future of the PE RVUs moving forward. We sought comments from other stak eholders on the issues raised by MedPAC for the future. In particular, we reque sted public comments regarding MedPAC's suggestion that we consider alternatives fo r collecting specialty-specific cost data or options to decrease the reliance on such data . We noted MedPAC’s comment that, "CMS

should consider if Medicare or provider groups should spons or future data collection efforts, if participation should be voluntary (s uch as surveys) or mandatory (such as cost reports), and whether a nationally representative sample of practitioners would be sufficient for either a survey or cost reports ." MedPAC also stated that one option for decreasing the reliance on specialty-specific cost data would be the elimination of the use

of indirect PE/HR data in the last step of establishing the indirect cost portion of the PE RVUs as described previously.

### CMS-1503-P 54

Almost all of the commenters on the CY 2010 PFS final rule with comment period that addressed this issue expressed a general willingness to work with CMS on methodological improvements or future data co llection efforts. Although no commenters detailed a comprehensive ove rall alternative methodology, several commenters did provide suggestions regarding future data co llection efforts and sp ecific aspects of the current methodology.

The commenters that addressed the issue of surveys supported the use of surveys if they yielded accurate PE information. Th e few commenters that addressed the issue of cost reports were opposed to physician cost reports. The commenters varied with respect to their opinions regarding whether data co llection efforts should be led by organized medicine, individual specialty societies, or CMS. Several commenter s that addressed the issue of voluntary versus mandatory data collection efforts suppor ted voluntary data collection efforts and opposed mandato ry data collection efforts. Some commenters recommended no changes to the methodology or PE data in the

near future. Other commenters indicated th at the methodology and data changes needed to be made for CY 2011. Although most comme nters did not directly address the use of the indirect PE/HR data, those that did pr edominately opposed the elimination of the use

of these data. Many commenters addressed specifics of the PE methodology (as further

described in section II.A.2.c. of this proposed rule). Some were opposed to the scaling factor applied in the development of the direct PE portion of the PE RVUs so that in the aggregate the direct portion of the PE R VUs do not exceed the proportion indicated by the survey data (See Step 4 in g.(ii) below) . Several of these commenters advocated the

elimination of this direct sca ling factor, while others indicat ed that the issue should be examined more closely.

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A few commenters recommended that physician work not be used as an allocator in the development of the indirect portion of the PE RVUs as described earlier in this section. A few indicated that phys ician time, but not phys ician work, should be

used in the allocation. Other commenters su ggested that indirect costs should be allocated solely on the basis of direct costs. We note that many of the issues raised by commenters on the CY 2010 PFS final rule with comment period are similar to issues raised in the development of the original resource-b ased PE methodology and in subsequent revisions to the methodology, including the adoption of the bottom-up methodology. While we are not proposin g a broad methodological change or

broad data collection effo rt in this CY 2011 PFS proposed rule, we invite comments on our summary of the issues raised by the commenters on the CY 2010 PFS final rule with comment peri od, as presented above. The complete public comments on that final rule ar e available for public review at www.regulations.gov by entering "CMS-1413-FC" in the search box on the main

page. g. PE RVU Methodology For a more detailed description of the PE RVU methodology, we refer

readers to the CY 2010 PFS final ru le with comment period (74 FR 61745 through 61746). (i) Setup File First, we create a setup file for the PE methodology. The setup file

contains the direct cost inputs, the utilization for each procedure code at the specialty and facility/nonfacility place of service level, and the specialty-specific PE/HR data from the surveys.

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(ii) Calculate the Direct Cost PE RVUs Sum the costs of each direct input. Step 1 : Sum the direct costs of the inputs for each service. Apply a scaling adjustment to the direct inputs. Step 2 : Calculate the current aggregate pool of direct PE costs. This is the product of the current aggregate PE (aggre gate direct and indirect) RVUs, the CF, and the average direct PE percentage from the survey data. Step 3 : Calculate the aggregate pool of dir ect costs. This is the sum of the product of the direct costs fo r each service from Step 1 and the utilization data for

that service. Step 4: Using the results of Step 2 and St ep 3 calculate a direct PE scaling adjustment so that the aggregate direct cost pool does not exceed the current aggregate direct cost pool and apply it to the direct costs from Step 1 for each

service. Step 5 : Convert the results of Step 4 to an RVU scale for each service. To do this, divide the results of Step 4 by the CF. Note that the actual value of the

CF used in this calculation does not influe nce the final direct cost PE RVUs, as long as the same CF is used in Step 2 and Step 5. Different CFs will result in different direct PE scaling factors, but this has no effect on the final direct cost PE RVUs since changes in the CFs and changes in the associated direct scaling

factors offset one another. (iii) Create the Indirect Cost PE RVUs

Create indirect allocators. Step 6 : Based on the survey data, calculate direct and indirect PE percentages for each physician specialty.

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Step 7 : Calculate direct and indirect PE percentages at the service level by taking a weighted average of the results of Step 6 for the specialties that furnish

the service. Note that for services w ith TCs and PCs, the direct and indirect percentages for a given service do not vary by the PC, TC, and global

components. Step 8 : Calculate the service level allocators for the indirect PEs based on the percentages calculated in Step 7. The indirect PEs are allocated based on the three components: the direct PE RVUs , the clinical PE RVUs, and the work

RVUs.

For most services the indirect allocator is: indirect percentage * (direct PE RVUs/direct percentage) + work RVUs.

There are two situations where this formula is modified:

• If the service is a global service (that is, a service with global, professional, and technica l components), then the indirect allocator is: indirect percentage * (direct PE RVUs/direct percentage) + clinical PE

RVUs + work RVUs.

• If the clinical labor PE RVUs exceed the work RVUs (and the service is not a global service), then the indirect allo cator is: indirect percentage * (direct PE RVUs/direct percentage) + clinical PE RVUs. (Note : For global services, the indirect allocator is based on both the work

RVUs and the clinical labor PE RVUs. We do this to recognize that, for the PC service, indirect PEs will be allocated using the work RVUs, and for the TC service, indirect PEs will be allocated using the direct PE RVUs and the clinical

labor PE RVUs. This also allows the global component RVUs to equal the sum of the PC and TC RVUs.)

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For presentation purposes in the exam ples in the Table 2, the formulas were divided into two parts for each serv ice. The first part does not vary by service and is the: indirect percentage * (direct PE RVUs/direct percentage). The second part is either the work RVUs, clinical PE RVUs, or both depending on whether the service is a global service and whether the clinical PE RVUs exceed the work RVUs (as described earlier in this step). Apply a scaling adjustment to the indirect allocators. Step 9 : Calculate the current aggregat e pool of indirect PE RVUs by multiplying the current aggregate pool of PE RVUs by the average indirect PE percentage from the survey data. Step 10 : Calculate an aggregate pool of indirect PE RVUs for all PFS services by adding the product of the i ndirect PE allocators for a service from Step 8 and the utilization data for that service. Step 11 : Using the results of Step 9 and Step 10, calculate an indirect PE adjustment so that the aggregate indirect allocation does not exceed the available aggregate indirect PE RVUs and apply it to indirect allocators calculated in Step 8. Calculate the indirect practice cost index. Step 12 : Using the results of Step 11, calculate aggregate pools of specialty-specific adjusted indirect PE allocators for all PFS services for a specialty by adding the product of the ad justed indirect PE allocator for each

service and the utilization data for that service. Step 13 : Using the specialty-specific indirect PE/HR data, calculate specialty-specific aggregate pools of indirect PE for all PFS services for that specialty by adding the product of the indirect PE/HR for the specialty, the

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physician time for the service, and the specialty’s utilization for the service across all services performed by the specialty. Step 14 : Using the results of Step 12 and Step 13, calculate the specialty-specific indirect PE scaling factors. Step 15 : Using the results of Step 14, cal culate an indirect practice cost index at the specialty level by dividing each specialty-specific indirect scaling factor by the average indirect scaling factor for the entire PFS. Step 16 : Calculate the indirect practice cost index at the service level to ensure the capture of all indirect costs. Calculate a weighted average of the practice cost index values for the specialties that furnish the service. (Note : For services with TCs and PCs, we calculate the indirect practice cost index across the global components, PCs, and TCs. Under this method, the indirect practice cost index for a given service (for example, ech ocardiogram) does not vary by the PC, TC, and global component.) Step 17 : Apply the service level indirect practice cost index calculated in Step 16 to the service level adjusted indirect allocators calculated in Step 11 to get

the indirect PE RVUs. (iv) Calculate the Final PE RVUs Step 18 : Add the direct PE RVUs from St ep 6 to the indirect PE RVUs from Step 17 and apply the final PE budget neutrality (BN) adjustment, MEI rebasing adjustment, and multiple procedure payment reduction (MPPR) adjustment. The final PE BN adjustment is calculated by comparing the results of Step 18 (prior to the MEI rebasing and M PPR adjustments) to the current pool of PE RVUs. This final BN adjustment is required primarily because certain

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specialties are excluded from the PE RVU calculation for ratesetting purposes, but all specialties are included for purposes of calculating the final BN adjustment. (See "Specialties excluded from ratesetting calc ulation" below in this section.)

As discussed in section II.E.1. of th is proposed rule, we are proposing to

rebase and revise the Medicare Ec onomic Index (MEI) for CY 2011. As discussed in section II.C.4. of this propos ed rule, section 1848(c)(2)(K) of the Act (as added by section 3134 of the ACA) sp ecifies that the Secretary shall identify potentially misvalued codes by examining multiple codes that are frequently billed in conjunction with furnishing a single service. There is inherent duplication in the PE associated with those services which are frequently furnished together, so reducing PFS payment for the second and subsequent

services to account for th e efficiencies in multiple service sessions may be appropriate. Consis tent with this provision of the ACA, we are proposing a limited expansion of the current MPPR po licy for imaging services for CY 2011 and a new MPPR policy for therapy services. (v) Setup File Information

• Specialties excluded from ratesetting calculation: For the purposes of calculating the PE RVUs, we exclude certain specialties, such as certain nonphysician practitioners paid at a pe rcentage of the PFS and low volume specialties, from the calculation. These specialties are included for the purposes of calculating the BN adjustment. They are displayed in Table 1. TABLE 1: Specialties Excluded from Ratesetting Calculation Specialty Code Specialty Description 42 Certified nurse midwife 49 Ambulatory surgical center 50 Nurse practitioner 51 Medical supply company with certified orthotist

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52 Medical supply company with certified prosthetist 53 Medical supply company with certified prosthetist-orthotist 54 Medical supply company not included in 51, 52, or 53. 55 Individual certified orthotist 56 Individual certified prosthestist 57 Individual certified prosthetist-orthotist 58 Individuals not included in 55, 56, or 57 59 Ambulance service supplier, e.g., private ambulance companies, funeral homes, etc. 60 Public health or welfare agencies 61 Voluntary health or charitable agencies 73 Mass immunization roster biller 74 Radiation therapy centers 87 All other suppliers (e.g., drug and department stores) 88 Unknown supplier/provider specialty 89 Certified clinical nurse specialist 95 Competitive Acquisition Program (CAP) Vendor 96 Optician A0 Hospital A1 SNF A2 Intermediate care nursing facility A3 Nursing facility, other A4 HHA A5 Pharmacy A6 Medical supply company with respiratory therapist A7 Department store

1 Supplier of oxygen and/or oxygen related equipment 2 Pedorthic personnel 3 Medical supply company with pedorthic personnel



### • Crosswalk certain low volume phys ician specialties: Crosswalk the utilization of certain specialties with relatively low PFS utilization to the associated specialties.

• Physical therapy utilization: Crosswalk the utilization associated with all physical therapy services to the specialty of physical therapy.

• Identify professional and technical services not identified under the usual TC and 26 modifiers: Flag the serv ices that are PC and TC services, but do

not use TC and 26 modifier s (for example, electrocardiograms). This flag associates the PC and TC with the associated global code for use in creating the indirect PE RVUs. For example, th e professional servi ce, CPT code 93010 (Electrocardiogram, routine ECG with at least 12 leads; interpretation and report

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only), is associated with the global se rvice, CPT code 93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpreta tion and report).

• Payment modifiers: Payment m odifiers are accounted for in the creation of the file. For example, services billed with the assistant at surgery modifier are paid 16 percent of the PFS amount for that service; therefore, the utilization file is modified to only acc ount for 16 percent of any service that contains the assistant at surgery modifier.

● Work RVUs: The setup file contains the work RVUs from this proposed rule. (vi) Equipment cost per minute The equipment cost per minute is calculated as: (1/(minutes per year * usage)) * price * ((interest rate/(1-(1/((1 + interest rate) * life of equipment)))) + maintenance)

Where: minutes per year = maximum minutes per year if usage were continuous (that is, usage = 1); generally 150,000 minutes. usage = equipment utilization assu mption; 0.75 for certain expensive diagnostic imaging equipment (see 74 FR 61753 through 61755 and section II.A.3. of this proposed rule) and 0.5 for others. price = price of the particular piece of equipment.

interest rate = 0.11. life of equipment = useful life of th e particular piece of equipment. maintenance = factor for maintenance; 0.05.

Note : The use of any particular conversion fact or (CF) in Table 2 to illustrate the PE calculation has no effect on the resulting RVUs.CMS-1503-P63TABLE 2: Calculation of PE RVUs under Methodology for Selected CodesStep Source Formula99213Office visit, estNonfacility33533CABG,arterial, singleFacility71020Chest x-rayNonfacility71020-TCChest x-rayNonfacility71020-26Chest x-rayNonfacility93000ECG, completeNonfacility93005ECG, tracingNonfacility93010ECG, reportNonfacility(1)Labor cost(Lab)Step1AMA13.3277.525.745.740.006.126.120.00(2)Suppy cost(Sup)Step1 AMA2.987.343.393.390.001.191.190.00(3)Equipmentcost (Eqp)Step1AMA0.190.658.178.170.000.120.120.00(4)Direct cost(Dir)Step1 =(1)+(2)+(3)16.5085.5117.3117.310.007.437.430.00(5)Directadjustment(Dir Adj)Steps2-4Seefootnote*0.4840.4840.4840.4840.4840.4840.4840.484(6)AdjustedlaborSteps2-4=Lab*DirAdj =(1)*(5)6.4537.522.782.780.002.962.960.00(7)AdjustedsuppliesSteps2-4=Sup*DirAdj =(2)*(5)1.443.551.641.640.000.580.580.00(8)AdjustedequipmentSteps2-4=Eqp*DirAdj =(3)*(5)0.090.323.963.960.000.060.060.00(9)AdjusteddirectSteps2-4 =(6)+(7)+(8)7.9941.398.388.380.003.603.600.00(10)ConversionFactor (CF)Step5PFS36.079136.079136.079136.079136.079136.079136.079136.0791(11)Adj. laborcostconvertedStep5=(Lab*DirAdj)/CF=(6)/(10)0.181.040.080.080.000.080.080.00(12)Adj. supplycostconvertedStep5=(Sup*DirAdj)/CF=(7)/(10)0.040.100.050.050.000.020.020.00(13)Adj. equipcostconvertedStep5=(Eqp*DirAdj)/CF =(8)/(10)0.000.010.110.110.000.000.000.00(14)Adj. directcostconvertedStep5 =(11)+(12)+(13)0.221.150.230.230.000.100.100.00(15) Wrk RVUSetupFile PFS0.9733.750.220.000.220.170.000.17(16) Dir_pctSteps6, 7 Surveys25.5%18.0%28.9%28.9%28.9%29.0%29.0%29.0%CMS-1503-P64Step Source Formula99213Office visit, estNonfacility33533CABG,arterial, singleFacility71020Chest x-rayNonfacility71020-TCChest x-rayNonfacility71020-26Chest x-rayNonfacility93000ECG, completeNonfacility93005ECG, tracingNonfacility93010ECG, reportNonfacility(17) Ind_pctSteps6, 7Surveys74.5%82.0%71.2%71.2%71.2%71.1%71.1%71.1%(18)Ind. Alloc.formula(1st part)Step8See Step 8((14)/(16))*(17)((14)/(16))*(17)((14)/(16))*(17)((14)/(16))*(17)((14)/(16))*(17)((14)/(16))*(17)((14)/(16))*(17)((14)/(16))*(17)(19)Ind. Alloc.(1st part)Step8 See (18)0.655.230.570.570.000.240.240.00(20)Ind. Alloc.formulas(2nd part)Step8See Step 8(15)(15)(15)+(11)(11)(15)(15)+(11)(11)(15)(21)Ind. Alloc.(2nd part)Step8 See (20)0.9733.750.300.080.220.250.080.17(22)IndirectAllocator(1st+2nd)Step8 =(19)+(21)1.6238.980.870.650.220.500.330.17(23)IndirectAdjustment(Ind Adj)Steps9-11Seefootnote**0.3690.3690.3690.3690.3690.3690.3690.369(24)AdjustedIndirectAllocatorSteps9-11=Ind Alloc* Ind Adj0.6014.370.320.240.080.180.120.06(25)Ind.PracticeCost Index(PCI)Steps12-16See Steps12-161.1040.8310.8520.8520.8520.9260.9260.926(26)AdjustedIndirectStep17= Adj. IndAlloc*PCI =(24)*(25)0.6611.950.270.200.070.170.110.06(27)MEIRebasingAdjustmentStep18 PFS1.1681.1681.1681.1681.1681.1681.1681.168(28)MPPRAdjustmentStep18PFS1.0111.0111.0111.0111.0111.0111.0111.011(29) PE RVUStep18=(AdjDir+AdjInd) *budn *MEI Adj *MPPR Adj=((14)+(26))*budn *(27) *(28)1.0315.360.590.510.080.320.250.07Note: PE RVUs in Table 2, row 27, may not match Addendum B due to rounding.* The direct adj = [current pe rvus * CF * avg dir pct] / [sum direct inputs] = [Step 2] / [Step 3]** The indirect adj = [current pe rvus * avg ind pct] / [sum of ind allocators] = [Step 9] / [Step 10]

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3. Proposed PE Revisions for CY 2011 a. Equipment Utilization Rate As part of the PE methodology associated with the allocation of equipment costs for calculating PE RVUs, we currently use an equipment utilization rate assumption of 50 percent for most equipment, with the exception of expensive diagnostic imaging equipment (which is equipment priced at over $1 million, for ex ample, computed tomography (CT) and magnetic resonance imaging (MRI) scanners), for which we adopted a 90 percent utilizati on rate assumption and provide d for a 4-year transition beginning in CY 2010 (74 FR 61755). Therefore, CY 2010 is the first transitional payment year. Payment is made in CY 2010 fo r the diagnostic services listed in Table 3 (those that include expensive diagnostic imagi ng equipment in their PE inputs) based on 25 percent of the new PE RVUs and 75 percent of the prior PE RVUs for those services. Section 1848(b)(4)(C) of the Act (as a dded by section 3135(a) of the ACA) requires that with respect to fee schedules established for CY 2011 and subsequent years, in the methodology for determining PE RVUs for expensive diagnostic imaging equipment under the CY 2010 PFS final rule with comment period, the Secretary shall use a 75 percent assumption instead of the utilization rates otherwise established in that rule. The provision also requires that the reduc ed expenditures attributable to this change

in the utilization rate for CY 2011 and subse quent years shall not be taken into account when applying the budget neutrality limitation on annual adjustments de scribed in section 1848(c)(2)(B)(ii)(II) of the Act. As a result, the 75 percent equipment utilization rate assumption will be applied to expensive diagnostic imaging equipment in a nonbudget neutral manner for CY 2011, and the changes to PE RVUs will not be transitioned over a period of years. We will

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apply the 75 percent utilization rate assumption in CY 2011 to all of the services to which we currently apply the transitional 90 per cent utilization rate assumption in CY 2010.

These services are listed in a file on the CM S Web site that is posted under downloads for

the CY 2010 PFS final rule with comment period at: ( http://www.cms.gov/physicianfeesched/ downloads/CODES_SUBJECT_TO_90PCT_US AGE_RATE.zip ). These codes are also displayed in Table 3. TABLE 3: Current CPT Codes Subject to First Year (CY 2010) of 4-Year Transition to 90 Percent Equipment Utilizat ion Rate Assumption and that Will Be Subject to the 75 Percent Equipment Utilization Rate Assumption in CY 2011

CPT Code Short Descriptor 70336 Mri, temporomandi bular joint(s) 70450 Ct head/brain w/o dye 70460 Ct head/brain w/ dye 70470 Ct head/brain w/o & w/ dye 70480 Ct orbit/ear/fossa w/o dye 70481 Ct orbit/ear/fossa w/ dye 70482 Ct orbit/ear/fossa w/o & w/ dye 70486 Ct maxillofacial w/o dye 70487 Ct maxillofacial w/ dye 70488 Ct maxillofacial w/o & w/ dye 70490 Ct soft tissue neck w/o dye 70491 Ct soft tissue neck w/ dye 70492 Ct soft tissue neck w/o & w/ dye 70540 Mri orbit/face/neck w/o dye 70542 Mri orbit/face/neck w/ dye 70543 Mri orbit/face/neck w/o & w/dye 70551 Mri brain w/o dye 70552 Mri brain w/dye 70553 Mri brain w/o & w/dye 70554 Fmri brain by tech 71250 Ct thorax w/o dye 71260 Ct thorax w/ dye 71270 Ct thorax w/o & w/ dye 71550 Mri chest w/o dye 71551 Mri chest w/ dye 71552 Mri chest w/o & w/ dye 72125 CT neck spine w/o dye 72126 Ct neck spine w/dye

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CPT Code Short Descriptor 72127 Ct neck spine w/o & w/dye 72128 Ct chest spine w/o dye 72129 Ct chest spine w/dye 72130 Ct chest spine w/o & w/dye 72131 Ct lumbar spine w/o dye 72132 Ct lumbar spine w/dye 72133 Ct lumbar spine w/o & w/dye 72141 Mri neck spine w/o dye 72142 Mri neck spine w/dye 72146 Mri chest spine w/o dye 72147 Mri chest spine w/dye 72148 Mri lumbar spine w/o dye 72149 Mri lumbar spine w/dye 72156 Mri neck spine w/o & w/dye 72157 Mri chest spine w/o & w/dye 72158 Mri lumbar spine w/o & w/dye 72192 Ct pelvis w/o dye 72193 Ct pelvis w/ dye 72194 Ct pelvis w/o & w/ dye 72195 Mri pelvis w/o dye 72196 Mri pelvis w/ dye 72197 Mri pelvis w/o &w/ dye 73200 Ct upper extremity w/o dye 73201 Ct upper extremity w/dye 73202 Ct upper extremity w/o & w/dye 73218 Mri upper extr w/o dye 73219 Mri upper extr w/dye 73220 Mri upper extremity w/o & w/dye 73221 Mri joint upper extr w/o dye 73222 Mri joint upper extr w/dye 73223 Mri joint upper extr w/o & w/dye 73700 Ct lower extremity w/o dye 73701 Ct lower extremity w/dye 73702 Ct lower extremity w/o & w/dye 73718 Mri lower extremity w/o dye 73719 Mri lower extremity w/dye 73720 Mri lower ext w/ & w/o dye 73721 Mri joint of lwr extre w/o dye 73722 Mri joint of lwr extr w/dye 73723 Mri joint of lwr extr w/o & w/dye 74150 Ct abdomen w/o dye 74160 Ct abdomen w/ dye

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CPT Code Short Descriptor 74170 Ct abdomen w/o & w/ dye 74181 Mri abdomen w/o dye 74182 Mri abdomen w/ dye 74183 Mri abdomen w/o and w/ dye 74261 Ct colonography, w/o dye 74262 Ct colonography, w/ dye 75557 Cardiac mri for morph 75559 Cardiac mri w/stress img 75561 Cardiac mri for morph w/dye 75563 Cardiac mri w/stress img & dye 75571 Ct hrt w/o dye w/ca test 75572 Ct hrt w/3d image 75573 Ct hrt w/3d image, congen 77058 Mri, one breast 77059 Mri, broth breasts 77078 Ct bone density, axial 77084 Magnetic image, bone marrow

Additionally, for CY 2011, we are proposin g to expand the list of services to which the higher equipment utilization rate assumption applies to all other diagnostic imaging services that utilize similar expensive CT and MRI scanners. The additional 24 CPT codes (listed in Table 4) to which we are proposing to apply the 75 percent equipment utilization rate assumption also have expensive diagnostic imaging equipment (priced at over $1 million) included in their PE inputs. These services are predominantly diagnostic computed tomographic angiography (CTA) and magnetic resonance angiography (MRA) procedures that include similar expensive CT and MRI scanners in their direct PE inputs. We indicated in th e CY 2010 PFS final rule with comment period (74 FR 61754) that we were persuaded by PPIS data on angiography that the extrapolation of MRI and CT data (and their higher equipment utilization rate) may be inappropriate. However, this reference was limited to those procedures that include an angiography room in the direct PE inputs, such as CPT code 93510 (Left heart

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catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous). In contrast, CTA and MRA pr ocedures include a CT room or MRI room, respectively, in the direct PE inputs, and the PPIS data confirm th at a higher assumed utilization rate than 50 percent would be appr opriate. The PPIS angiography room data that reflected a 56 percent equipment utilization rate would not specifically apply to CTA and MRA procedures. Thus, on further review , we believe it is a ppropriate to include CTA and MRA procedures in the list of pro cedures for which we assume a 75 percent equipment utilization rate, and we are pr oposing to do so beginning in CY 2011. Consistent with section 1848(c)(2)(B)(v)( III) of the Act (as amended by section 3135 of the ACA), the reduced expenditures attrib utable to this change in the utilization rate assumption applicable to CY 2011 shall not be taken in to account when applying the budget neutrality limitation on annual ad justments descri bed in section 1848(c)(2)(B)(ii)(III) of the Act. As provided in the CY 2010 PFS final rule with comment period (74 FR 61751), CY 2011 is the second year of the 4-year tran sition to the PE RVUs calculated using the

PPIS data. The reductions in the PE RVUs for expensive diagnostic imaging equipment attributable to the change to an equipment utilization rate assumption of 75 percent for CY 2011 are not subject to the transition. TABLE 4: Proposed CPT Code Additions to the 75 Percent Equipment Utilization Rate Assumption CY 2011

CPT Code Short Descriptor 70496 Ct angiography, head 70498 Ct angiography, neck 70544 Mr angiography head w/o dye 70545 Mr angiography head w/dye 70546 Mr angiography head w/o & w/dye 70547 Mr angiography neck w/o dye 70548 Mr angiography neck w/dye

### CMS-1503-P 70

CPT Code Short Descriptor 70549 Mr angiography neck w/o & w/dye 71275 Ct angiography, chest 71555 Mri angio chest w/ or w/o dye 72159 Mr angio spone w/o&w/dye 72191 Ct angiography, pelv w/o & w/ dye 72198 Mri angio pelvis w/ or w/o dye 73206 Ct angio upper extr w/o & w/dye 73225 Mr angio upr extr w/o&w/dye 73706 Ct angio lower ext w/o & w/dye 73725 Mr angio lower ext w or w/o dye 74175 Ct angiography, abdom w/o & w/ dye 74185 Mri angio, abdom w/ or w/o dye 75565 Card mri vel flw map add-on 75574 Ct angio hrt w/3d image 75635 Ct angio abdominal arteries 76380 CAT scan follow up study 77079 Ct bone density, peripheral

b. HCPCS Code-Specific PE Proposals In this section, we discuss other speci fic CY 2011 proposals and changes related to direct PE inputs. The proposed changes that follow are included in the proposed CY 2011 direct PE database, whic h is available on the CMS Web site under the downloads for the CY 2011 PFS proposed rule at http://www.cms.gov/PhysicianFeeSched/

. (1) Biohazard Bags

We have identified 22 codes for which th e supply item "biohazard bag" (SM004) is currently considered a direct PE input. The item is already properly accounted for in

the indirect PE because it is not attributable to an individual patient service. Therefore, we are proposing to remove the biohazard ba g from the CY 2011 direct PE database and the changes in direct PE inputs for the associ ated services are reflected in the proposed

CY 2011 direct PE database.

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(2) PE Inputs for Professional Component (P C) Only and Technical Component (TC) Only Codes Summing to Global Only Codes In the case of selected diagnostic tests, di fferent but related CPT codes are used to describe global, profe ssional, and technical components of a service. These codes are unlike the majority of other diagnostic test CPT codes where modifiers may be used in billing a single CPT code in order to differen tiate professiona l and technical components.

When different but related CPT codes are used to report the components of these services, the different CPT codes are referre d to as "global only," "professional (PC) only," and "technical (TC) only" codes. Medicare payment systems are programmed to ensure that the PE RVUs for global only code s equal the sum of the PE RVUs for the PC and TC only codes. However, it has come to our attention that the direct PE inputs for certain global only codes do not reflect the appropriate summation of their related TC only and PC only component code PE inputs as they appear in the direct PE database. While the PFS payment calcul ations have been programmed to apply the correct PE RVUs for the global only code based on a summation of component code PE RVUs, the

direct PE database has reflected incorrect inputs that are overridden by the payment system. Therefore, we are proposing to corr ect the direct PE inputs for the global only codes so that the inputs reflect the appr opriate summing of the PE inputs for the associated PC only and TC only codes. The proposed CY 2011 direct PE database

includes PE corrections to the 14 CPT codes listed in Table 5. TABLE 5: Groups of Related CPT Codes with Proposed Changes to PE Inputs so that Inputs for Professional Component (PC) Only and Technical Component (TC) Only Codes Sum to Global Only Codes

CPT Code Long Descriptor

93224 Wearable electrocardiographic rhythm derive d monitoring for 24 hours by continuous original waveform recording and storage, with visual superimposition scanning; includes recording, scanning analysis with report, physician review and interpretation 93225 Wearable electrocardiographic rhythm derived monitoring for 24 hours by continuous

### CMS-1503-P 72

CPT Code Long Descriptor original waveform recording and storage, with visual superimposition scanning; recording (includes connection, recording, disconnection)

93226 Wearable electrocardiographic rhythm derive d monitoring for 24 hours by continuous original waveform recording and storage, with visual superimposition scanning; scanning analysis with report

93230 Wearable electrocardiographic rhythm derive d monitoring for 24 hours by continuous original waveform recording and storage without superimposition scanning utilizing a device capable of producing a full miniatur ized printout; including recording, microprocessor-based analysis with report, physician review and interpretation

93231 Wearable electrocardiographic rhythm derive d monitoring for 24 hours by continuous original waveform recording and storage without superimposition scanning utilizing a device capable of producing a full miniaturized printout; recording (includes connection, recording, and disconnection

93232 Wearable electrocardiographic rhythm derive d monitoring for 24 hours by continuous original waveform recording and storage without superimposition scanning utilizing a device capable of producing a full miniaturized printout; microprocessor-based analysis with report

93268 Wearable patient activated electrocardiograph ic rhythm derived event recording with presymptom memory loop, 24-hour attended monitoring, per 30 day period of time; includes transmission, physician review and interpretation

93270 Wearable patient activated electrocardiograph ic rhythm derived event recording with presymptom memory loop, 24-hour attended monitoring, per 30 day period of time; recording (includes connection, recording, and disconnection)

93271 Wearable patient activated electrocardiograph ic rhythm derived event recording with presymptom memory loop, 24-hour attended monitoring, per 30 day period of time; monitoring, receipt of transmissions, and analysis 93720 Plethysmography, total body; with interpretation and report 93721 Plethysmography, total body; tracing only, without interpretation and report

93784 Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; including recording, scanning analysis, interpretation and report 93786 Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; recording only 93788 Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; scanning analysis with report



### (3) Equipment Time Inputs for Certain Diagnostic Tests We have recently identified incorrect e quipment time inputs for four CPT codes associated with certain diagnostic tests (each is displayed in Table 5):

• CPT code 93225 is the TC only code th at includes the connection, recording, and disconnection of the holter monitor (CMS Equipment Code EQ127) used in 24 hour continuous electrocardiographic rhythm derive d monitoring. The current equipment time input for the holter monitor is 42 minutes, whic h parallels the intra-se rvice clinical labor input time for the CPT code. However, the equipment time should reflect the 24 hours of

### CMS-1503-P 73

continuous monitoring in which the device is used exclusively by the patient. Therefore, we are proposing to change the monitor equipment time for CPT code 93225 to 1440 minutes, the number of minutes in 24 hours.

• CPT code 93226 is the TC only code that includes the scanning analysis with report. The number of minutes the monitor (CMS Equipment Code EQ127) is used in this service should parallel th e intra-service clinic al labor input time of 52 minutes during which the monitor is in use, instead of the current equipment time of 1440 minutes, because this code does not represent 24 hours of device use. Therefore, we are proposing to change the monitor equipment time for CPT code 93226 to 52 minutes.

• CPT 93224 is the global only code that includes the connection, recording, and disconnection of the monitor (CMS Equipmen t Code EQ127) and the scanning analysis with report, as well as the physician review and interpretation. Under our proposal, its direct PE inputs have been appropriately summed to incl ude the 1492 total minutes of

time for the holter monitor that are included in CPT codes 93225 and 93226.

• CPT code 93788 is the TC only code that describes the scanning analysis with report for ambulatory blood pressure monitori ng. The equipment time input for the blood pressure monitor should paralle l the 10 minutes of clinical labor input for the CPT code since that is the time during which the monitor is in use. Currently, the equipment time input for the monitor is 1440 minutes, which is appropriate only for CPT code 93786, the

code that describes the 24 hours of ambulator y blood pressure monitoring recording. In this case, CPT code 93786’s direct PE inputs are correct. Therefore, we are proposing to correct the equipment time input for the ambulatory blood pre ssure monitor in CPT code

93788 to 10 minutes.

### CMS-1503-P 74

• CPT code 93784 is the global only code that includes the recording, the scanning analysis with report, and the phys ician interpretation a nd report for ambulatory blood pressure monitoring. Under our pr oposal, its direct PE inputs have been appropriately summed to incl ude the 1450 total minutes of time for the ambulatory blood pressure monitor that are incl uded in CPT codes 93786 and 93788. We have modified the proposed CY 2011 di rect PE database to reflect these changes. (4) Cobalt-57 Flood Source Stakeholders have requested that CMS reevaluate the useful life of the Cobalt-57 flood source (CMS Equipment Code ER001), given their es timate of appr oximately 271 days for the source’s half-life. The curre nt useful life input for the Colbalt-57 flood source is 5 years. Using publicly availabl e catalogs, we found that the Cobalt-57 flood source is marketed with a useful life of 2 ye ars. Therefore, we are proposing to change the useful life input from the current 5 years to 2 years. The Cobalt-57 flood source is included with the revised useful life input for 96 HCPCS codes in the proposed CY 2011

direct PE database. (5) Venom Immunotherapy One stakeholder provided updated price in formation for the venoms used for the five venom immunology CPT c odes, specifically 95145(Professional services for the supervision of preparation a nd provision of antigens for allergen immunotherapy (specify number of doses); single stinging insect venom); 95146 (Professional services for the supervision of preparation a nd provision of antigens for allergen immunotherapy (specify number of doses); 2 single stinging insect venoms); 95147 (Professional services for the supervision of preparation a nd provision of antigens for allergen immunotherapy (specify

### CMS-1503-P 75

number of doses); 3 single stinging insect venoms); 95148 (Professional services for the supervision of preparation a nd provision of antigens for allergen immunotherapy (specify number of doses); 4 single stinging insect venoms); 95149 (Professional services for the supervision of preparation a nd provision of antigens for allergen immunotherapy (specify number of doses); 5 single stinging insect venoms).

In the CY 2004 PFS final rule with comme nt period (68 FR 63206), we adopted a pricing methodology that utilizes the aver age price of a 1 millilite r dose of venom and adds that price per dose as direct PE inputs for CPT codes 95145 and 95146. When a patient requires three stinging insect venoms, as for CPT code 95147, the price input for a 3-vespid mix is used. This 3-vespid mix price is also used to value CPT codes 95148 (four venoms) and 96149 (five venoms), with the single venom price added once to CPT

code 97148 and twice to CPT code 97149. As requested by the stakeholder, we are updating the price inputs for the 1-milliliter dose of venom to $16.67 and for the 3-vespid mix to $30.22 in the proposed

CY 2011 direct PE database. (6) Equipment Redundancy Stakeholders have recently brought to our attention that the ECG, 3-channel (with SpO2, NIBP, temp, resp) (CMS Equipment Code EQ011) incorporates all of the functionality of the pulse oximeter with printer (CMS Equipment Code EQ211). Therefore, in HCPCS codes where CMS Equipment Code EQ011 is present, CMS Equipment Code EQ211 is redundant. On this basis, we are proposing to remove the pulse oximeter with printer (CMS Equipment Code EQ211) as an input for the 118 codes that also contain the ECG, 3-channel (with SpO2, NIBP, temp, resp) (CMS Equipment

### CMS-1503-P 76

Code EQ011). We have made these adjus tments in the proposed CY 2011 direct PE

database. (7) Equipment Duplication We recently identified a number of CPT c odes with duplicate equipment inputs in the PE database. We are proposing to rem ove the duplicate equipment items and have modified the proposed CY 2011 direct PE data base accordingly as detailed in Table 6. TABLE 6: CPT Codes with Proposed Removal of Duplicate Equipment Items in the Direct PE Database

CPT Code CMS Equipment

Code for Duplicate Equipment Description of Equipment

19302 P-mastectomy w/ln removal EF014 light, surgical ED005 camera, digital system, 12 megapixel (medical grade) EF031 table, power 19361 Breast reconstr w/lat flap EQ168 light, exam EF031 table, power 44157 Colectomy w/ileoanal anast EQ168 light, exam EF031 table, power 44158 Colectomy w/neo-rectum pouch EQ168 light, exam EF031 table, power 56440 Surgery for vulva lesion EQ170 light, fiberoptic headlight w-source EF031 table, power 57296 Revise vag graft, open abd EQ170 light, fiberoptic headlight w-source 58263 Vag hyst w/t/o & vag repair EF031 table, power 59610 Vbac delivery EF031 table, power EL005 lane, exam (oph) 67228 Treatment of retinal lesion EQ230 slit lamp (Haag-Streit), dedicated to laser use 76813 Ob us nuchal meas, 1 gest ED024 film processor, dry, laser 77371 Srs, multisource EQ211 pulse oximeter w-printer ED018 computer workstation, cardiac cath monitoring EL011 room, angiography EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) EQ032 IV infusion pump EQ088 contrast media warmer 93540

Injection, cardiac cath

EQ211 pulse oximeter w-printer ED018 computer workstation, cardiac cath monitoring EL011 room, angiography EQ011 ECG, 3-channel (with SpO2, NIBP, temp, resp) 93542 Injection for heart x-rays

EQ032 IV infusion pump

### CMS-1503-P 77

CPT Code CMS Equipment

Code for Duplicate Equipment Description of Equipment

EQ088 contrast media warmer EQ211 pulse oximeter w-printer



### (8) Establishing Overall Direct PE S upply Price Inputs Based on Unit Prices and Quantities

We have identified minor errors in tota l price inputs for a number of supply items due to mathematical mistakes in multiplying the item unit price and the quantity used in particular CPT codes for the a ssociated services. We are pr oposing to modify the direct PE database to appropriatel y include the overall supply price input for a supply item as the product of the unit price and the quantity of the supply item used in the CPT code. Most of the overall supply price input change s are small, and we have adjusted the proposed CY 2011 direct PE database accordin gly. The CPT and Level II HCPCS codes and associated supplies for nonfacility and f acility settings that are subject to these corrections are displayed in Tables 7 and 8, respectively. Table 7: Overall Supply Price Calculatio n Corrections for Nonfacility Settings

CPT/ HCPCS

Code Short Descriptor CMS Supply Code with Overall Price Corrections Description of Supply

11952 Therapy for contour defects SC029 needle, 18-27g 11954 Therapy for contour defects SC029 needle, 18-27g 15820 Revision of lower eyelid SA082 pack, ophthalmology visit (w-dilation) 15821 Revision of lower eyelid SA082 pack, ophthalmology visit (w-dilation) 15822 Revision of upper eyelid SA082 pack, ophthalmology visit (w-dilation) 17311 Mohs, 1 stage, h/n/hf/g SG078 tape, surgical occlusive 1in (Blenderm) 17312 Mohs addl stage SG078 tape, surgical occlusive 1in (Blenderm) 17313 Mohs, 1 stage, t/a/l SG078 tape, surgical occlusive 1in (Blenderm) 17314 Mohs, addl stage, t/a/l SG078 tape, surgical occlusive 1in (Blenderm) 21011 Exc face les sc < 2 cm SH046 lidocaine 1% w-epi inj (Xylocaine w-epi) 21013 Exc face tum deep < 2 cm SH046 lidocaine 1% w-epi inj (Xylocaine w-epi)

### CMS-1503-P 78

CPT/ HCPCS

Code Short Descriptor CMS Supply Code with Overall Price Corrections Description of Supply

21073 Mnpj of tmj w/anesth SG079 tape, surgical paper 1in (Micropore) 21076 Prepare face/oral prosthesis SL047 dental stone powder 21081 Prepare face/oral prosthesis SK024 film, dental 21310 Treatment of nose fracture SB034 mask, surgical, with face shield SG056 gauze, sterile 4in x 4in (10 pack uou) 23075 Exc shoulder les sc < 3 cm SH021 bupivacaine 0.25% inj (Marcaine) SG056 gauze, sterile 4in x 4in (10 pack uou) 24075 Exc arm/elbow les sc < 3 cm SH021 bupivacaine 0.25% inj (Marcaine) SG056 gauze, sterile 4in x 4in (10 pack uou) 25075 Exc forearm les sc < 3 cm SH021 bupivacaine 0.25% inj (Marcaine) SG056 gauze, sterile 4in x 4in (10 pack uou) 26115 Exc hand les sc < 1.5 cm SH021 bupivacaine 0.25% inj (Marcaine) 27327 Exc thigh/knee les sc < 3 cm SG056 gauze, sterile 4in x 4in (10 pack uou) 27618 Exc leg/ankle tum < 3 cm SG056 gauze, sterile 4in x 4in (10 pack uou) 28039 Exc foot/toe tum sc > 1.5 cm SG056 gauze, sterile 4in x 4in (10 pack uou) 28043 Exc foot/toe tum sc < 1.5 cm SG056 gauze, sterile 4in x 4in (10 pack uou) 28045 Exc foot/toe tum deep <1.5cm SG056 gauze, sterile 4in x 4in (10 pack uou) 28306 Incision of metatarsal SA048 pack, minimum multi-specialty visit 28307 Incision of metatarsal SA048 pack, minimum multi-specialty visit 28310 Revision of big toe SA048 pack, minimum multi-specialty visit 28312 Revision of toe SA048 pack, minimum multi-specialty visit 28313 Repair deformity of toe SA048 pack, minimum multi-specialty visit 28315 Removal of sesamoid bone SA048 pack, minimum multi-specialty visit 28340 Resect enlarged toe tissue SA048 pack, minimum multi-specialty visit 28344 Repair extra toe(s) SA048 pack, minimum multi-specialty visit 28345 Repair webbed toe(s) SA048 pack, minimum multi-specialty visit 28496 Treat big toe fracture SA048 pack, minimum multi-specialty visit 28755 Fusion of big toe joint SA048 pack, minimum multi-specialty visit 28820 Amputation of toe SA048 pack, minimum multi-specialty visit 28890 High energy eswt, plantar f SC051 syringe 10-12ml 29870 Knee arthroscopy, dx SG079 tape, surgical paper 1in (Micropore) 32553 Ins mark thor for rt perq SB034 mask, surgical, with face shield 36475 Endovenous rf, 1st vein SC074 iv pressure infusor bag 36592 Collect blood from picc SG050 gauze, non-sterile 2in x 2in 41530 To ngue base vol reduction SD 009 canister, suction 41805 Removal foreign body, gum SD134 tubing, suction, non-latex (6ft) with Yankauer tip (1) 41806 Removal foreign body,jawbone SD134 tubing, suction, non-latex (6ft) with Yankauer tip (1) 42107 Excision lesion, mouth roof SD009 canister, suction 46505 Chemodenervation anal musc SD009 canister, suction 49411 Ins mark abd/pel for rt perq SB 034 mask, surgical, with face shield

### CMS-1503-P 79

CPT/ HCPCS

Code Short Descriptor CMS Supply Code with Overall Price Corrections Description of Supply

49440 Place gastrostomy tube perc SK089 x-ray developer solution 49441 Place duod/jej tube perc SK089 x-ray developer solution 49442 Place cecostomy tube perc SK089 x-ray developer solution 49446 Change g-tube to g-j perc SK089 x-ray developer solution 49450 Replace g/c tube perc SK089 x-ray developer solution 49451 Replace duod/jej tube perc SK089 x-ray developer solution 49452 Replace g-j tube perc SK089 x-ray developer solution 49460 Fix g/colon tube w/device SK089 x-ray developer solution 49465 Fluoro exam of g/colon tube SK089 x-ray developer solution 50382 Change ureter stent, percut SB 034 mask, surgical, with face shield 50384 Remove ureter stent, percut SB 034 mask, surgical, with face shield 50385 Change stent via transureth SB034 mask, surgical, with face shield 50386 Remove stent via transureth SB034 mask, surgical, with face shield 50387 Change ext/int ureter stent SB034 mask, surgical, with face shield 50389 Remove renal tube w/fluoro SB 034 mask, surgical, with face shield 51100 Drain bladder by needle SH047 lidocaine 1%-2% inj (Xylocaine) 51101 Drain bladder by trocar/cath SH047 lidocaine 1%-2% inj (Xylocaine) 51727 Cystometrogram w/up SC051 syringe 10-12ml 51728 Cystometrogram w/vp SC051 syringe 10-12ml 51729 Cystometrogram w/vp&up SC051 syringe 10-12ml 52649 Prostate laser enucleation SA048 pack, minimum multi-specialty visit 53855 Insert prost urethral stent SB024 gloves, sterile 59300 Episiotomy or vaginal repair SG062 packing, gauze plain 0.25-0.50in (5 yd uou) 59812 Treatment of miscarriage SA052 pack, post-op incision care (staple) 64490 Inj paravert f jnt c/t 1 lev SK025 film, dry, radiographic, 8in x 10in SH021 bupivacaine 0.25% inj (Marcaine) 64493 Inj paravert f jnt l/s 1 lev SK025 film, dry, radiographic, 8in x 10in 65272 Repair of eye wound SA082 pack, ophthalmology visit (w-dilation) 65286 Repair of eye wound SA082 pack, ophthalmology visit (w-dilation) 66250 Follow-up surgery of eye SA082 pack, ophthalmology visit (w-dilation) 67031 Laser surgery, eye strands SA082 pack, ophthalmology visit (w-dilation) 67105 Repair detached retina SA082 pack, ophthalmology visit (w-dilation) 67110 Repair detached retina SA082 pack, ophthalmology visit (w-dilation) 67120 Remove eye implant material SA082 pack, ophthalmology visit (w-dilation) 67228 Treatment of retinal lesion SA082 pack, ophthalmology visit (w-dilation) 67901 Repair eyelid defect SA048 pack, minimum multi-specialty visit 75571 Ct hrt w/o dye w/ca test SJ019 electrode adhesive disk 75572 Ct hrt w/3d image SJ019 electrode adhesive disk 75573 Ct hrt w/3d image, congen SJ019 electrode adhesive disk 75574 Ct angio hrt w/3d image SJ019 electrode adhesive disk

### CMS-1503-P 80

CPT/ HCPCS

Code Short Descriptor CMS Supply Code with Overall Price Corrections Description of Supply

75960 Transcath iv stent rs&i SK034 film, x-ray 14in x 17in 76821 Middle cerebral artery echo SM013 disinf ectant, surface (Envirocide, Sanizide) 77371 Srs, multisource SG079 tape, surgical paper 1in (Micropore) 77372 Srs, linear based SG079 tape, surgical paper 1in (Micropore) 77373 Sbrt delivery SG079 tape, surgical paper 1in (Micropore) SC051 syringe 10-12ml 78452 Ht muscle image spect, mult SK092 x-ray fixer solution 78454 Ht musc image, planar, mult SK092 x-ray fixer solution 88125 Forensic cytopathology SL026 clearing agent (Histo-clear) SK073 skin marking ink (tattoo) SL061 embedding paraffin SL078 histology freezing spray (Freeze-It) 88355 Analysis, skeletal muscle SL201 stain, eosin SB023 gloves, non-sterile, nitrile SK073 skin marking ink (tattoo) SL061 embedding paraffin SL078 histology freezing spray (Freeze-It) SL108 pipette 88356 Analysis, nerve

SL201 stain, eosin SF004 blade, microtome SL179 1.0N NaOH SL183 slide, organosilane coated SL189 ethanol, 100% SL190 ethanol, 70% SL194 Hemo-De 88365 Insitu hybridization (fish)

SM016 eye shield, splash protection SC057 syringe 5-6ml SF004 blade, microtome SL030 cover slip, glass SL085 label for microscope slides SL178 0.2N HCL SL179 1.0N NaOH SL181 pipette tips, sterile SL183 slide, organosilane coated SL189 ethanol, 100% SL190 ethanol, 70% SL191 ethanol, 85% SL194 Hemo-De 88367 Insitu hybridization, auto

SM016 eye shield, splash protection 88368 Insitu hybridization, manual SF004 blade, microtome

### CMS-1503-P 81

CPT/ HCPCS

Code Short Descriptor CMS Supply Code with Overall Price Corrections Description of Supply

SL179 1.0N NaOH SL183 slide, organosilane coated SL189 ethanol, 100% SL190 ethanol, 70% SL194 Hemo-De SM016 eye shield, splash protection SL207 air, filtered, compressed SL218 DNA, Versagene, blood kit SL220 ethanol, 200% 88385 Eval molecul probes, 51-250 SL225 gas, nitogen, ultra-high purity (compressed), grade 5.0 SL207 air, filtered, compressed SL218 DNA, Versagene, blood kit SL220 ethanol, 200% 88386 Eval molecul probes, 251-500 SL225 gas, nitogen, ultra-high purity (compressed), grade 5.0 90470 Immune admin H1N1 im/nasal SB036 paper, exam table 91065 Breath hydrogen test (blank) Sivrite-4 91132 Electrogastrography SD062 electrode, surface 91133 Electrogastrography w /test SD062 electrode, surface 92550 Tympanometry & reflex thresh SK059 paper, recording (per sheet) 92597 Oral speech device eval SB022 gloves, non-sterile 92610 Evaluate swallowing function SB022 gloves, non-sterile 92626 Eval aud rehab status SK008 audiology scoring forms 92627 Eval aud status rehab add-on SK008 audiology scoring forms 92640 Aud brainstem implt programg SK068 razor 95004 Percut allergy skin tests SC023 multi-tine device SA048 pack, minimum multi-specialty visit 95024 Id allergy test, drug/bug SG050 gauze, non-sterile 2in x 2in SA048 pack, minimum multi-specialty visit 95027 Id allergy titrate-airborne SC052 syringe 1ml 95044 Allergy patch tests SK087 water, distilled 95052 Photo patch test SK087 water, distilled 95148 Antigen therapy services SH009 antigen, venom 95805 Multiple sleep latency test SK094 x-ray marking pencil 96040 Genetic counseling, 30 min SK062 patient education booklet 96102 Psycho testing by technician SK057 paper, laser printing (each sheet) SC018 iv infusion set SC051 syringe 10-12ml 96360 Hydration iv infusion, init SG050 gauze, non-sterile 2in x 2in SC018 iv infusion set 96365 Ther/proph/diag iv inf, init SC051 syringe 10-12ml

### CMS-1503-P 82

CPT/ HCPCS

Code Short Descriptor CMS Supply Code with Overall Price Corrections Description of Supply

SG050 gauze, non-sterile 2in x 2in 96366 Ther/proph/diag iv inf addon SB022 gloves, non-sterile 96367 Tx/proph/dg addl seq iv inf SB022 gloves, non-sterile 96369 Sc ther infusion, up to 1 hr SC013 infusion pump cassette-reservoir 96371 Sc ther infusion, reset pump SC013 infusion pump cassette-reservoir 96372 Ther/proph/diag inj, sc/im SB022 gloves, non-sterile SB022 gloves, non-sterile SC051 syringe 10-12ml 96374 Ther/proph/diag inj, iv push SG050 gauze, non-sterile 2in x 2in SB022 gloves, non-sterile 96375 Tx/pro/dx inj new drug addon SC051 syringe 10-12ml SC051 syringe 10-12ml 96401 Chemo, anti-neopl, sq/im SG050 gauze, non-sterile 2in x 2in SC051 syringe 10-12ml 96402 Chemo hormon antineopl sq/im SG050 gauze, non-sterile 2in x 2in SC018 iv infusion set 96409 Chemo, iv push, sngl drug SC051 syringe 10-12ml SC018 iv infusion set 96411 Chemo, iv push, addl drug SC051 syringe 10-12ml SC018 iv infusion set 96413 Chemo, iv infusion, 1 hr SC051 syringe 10-12ml 96417 Chemo iv infus each addl seq SC018 iv infusion set SC018 iv infusion set 96445 Chemotherapy, intracavitary SH069 sodium chloride 0.9% irrigation (500-1000ml uou) 96542 Chemotherapy injection SC018 iv infusion set 99366 Team conf w/pat by hc pro SK062 patient education booklet SK057 paper, laser printing (each sheet) G0270 MNT subs tx for change dx SK062 patient education booklet G0271 Group MNT 2 or more 30 mins SK057 paper, laser printing (each sheet) 

### Table 8: Overall Supply Price Calculatio n Corrections for Facility Settings

CPT/ HCPCS

Code Short Descriptor CMS Supply Code with Overall Price Corrections Description of Supply

15738 Muscle-skin graft, leg SG017 bandage, Kling, non-sterile 2in 15820 Revision of lower eyelid SA082 pack, ophthalmology visit (w-dilation) 15821 Revision of lower eyelid SA082 pack, ophthalmology visit (w-dilation) 15822 Revision of upper eyelid SA082 pack, ophthalmology visit (w-dilation) 19303 Mast, simple, complete SB006 drape, non-sterile, sheet 40in x 60in

### CMS-1503-P 83

CPT/ HCPCS

Code Short Descriptor CMS Supply Code with Overall Price Corrections Description of Supply

20900 Removal of bone for graft SA054 pack, post-op incision care (suture) 21011 Exc face les sc < 2 cm SA048 pack, minimum multi-specialty visit 21013 Exc face tum deep < 2 cm SA048 pack, minimum multi-specialty visit 21193 Reconst lwr jaw w/o graft SJ061 tongue depressor 21194 Reconst lwr jaw w/graft SJ061 tongue depressor 21240 Reconstruction of jaw joint SJ061 tongue depressor 21366 Treat cheek bone fracture SJ061 tongue depressor 21435 Treat craniofacial fracture SJ061 tongue depressor 21555 Exc neck les sc < 3 cm SA048 pack, minimum multi-specialty visit 21930 Exc back les sc < 3 cm SA048 pack, minimum multi-specialty visit 22902 Exc abd les sc < 3 cm SA048 pack, minimum multi-specialty visit 23075 Exc shoulder les sc < 3 cm SA048 pack, minimum multi-specialty visit 24075 Exc arm/elbow les sc < 3 cm SA048 pack, minimum multi-specialty visit 25075 Exc forearm les sc < 3 cm SA048 pack, minimum multi-specialty visit 26115 Exc hand les sc < 1.5 cm SA048 pack, minimum multi-specialty visit 27047 Exc hip/pelvis les sc < 3 cm SA048 pack, minimum multi-specialty visit 27327 Exc thigh/knee les sc < 3 cm SA048 pack, minimum multi-specialty visit 27618 Exc leg/ankle tum < 3 cm SA048 pack, minimum multi-specialty visit 28307 Incision of metatarsal SA048 pack, minimum multi-specialty visit 28340 Resect enlarged toe tissue SA048 pack, minimum multi-specialty visit 28345 Repair webbed toe(s) SA048 pack, minimum multi-specialty visit 28820 Amputation of toe SA048 pack, minimum multi-specialty visit 33516 Cabg, vein, six or more SA052 pack, post-op incision care (staple) 34510 Transposition of vein valve SA054 pack, post-op incision care (suture) 35013 Repair artery rupture, arm SA048 pack, minimum multi-specialty visit 41150 To ngue, mouth, jaw surgery SA 048 pack, minimum multi-specialty visit 41153 To ngue, mouth, neck surgery SA 048 pack, minimum multi-specialty visit 41155 To ngue, jaw, & neck surgery SA 048 pack, minimum multi-specialty visit 41805 Removal foreign body, gum SD134 tubing, suction, non-latex (6ft) with Yankauer tip (1) 41806 Removal foreign body,jawbone SD134 tubing, suction, non-latex (6ft) with Yankauer tip (1) 42160 Treatment mouth roof lesion SD122 suction tip, Yankauer 51925 Hysterectomy/bladder repair SB006 drape, non-sterile, sheet 40in x 60in 56620 Partial removal of vulva SA048 pack, minimum multi-specialty visit SA051 pack, pelvic exam 57284 Repair paravag defect, open SB006 drape, non-sterile, sheet 40in x 60in SA051 pack, pelvic exam 57285 Repair paravag defect, vag SB006 drape, non-sterile, sheet 40in x 60in SA051 pack, pelvic exam 57423 Repair paravag defect, lap SB006 drape, non-sterile, sheet 40in x 60in

### CMS-1503-P 84

CPT/ HCPCS

Code Short Descriptor CMS Supply Code with Overall Price Corrections Description of Supply

58660 Laparoscopy, lysis SB006 drape, non-sterile, sheet 40in x 60in 58662 Laparoscopy, excise lesions SJ046 silver nitrate applicator 58670 Laparoscopy, tubal cautery SJ046 silver nitrate applicator 58940 Removal of ovary(s) SA052 pack, post-op incision care (staple) 58952 Resect ovarian malignancy SB006 drape, non-sterile, sheet 40in x 60in 64632 N block inj, common digit SA048 pack, minimum multi-specialty visit 65112 Remove eye/revise socket SA050 pack, ophthalmology visit (no dilation) 65114 Remove eye/revise socket SA050 pack, ophthalmology visit (no dilation) 65235 Remove foreign body from eye SA082 pack, ophthalmology visit (w-dilation) 65265 Remove foreign body from eye SA082 pack, ophthalmology visit (w-dilation) 65272 Repair of eye wound SA082 pack, ophthalmology visit (w-dilation) 65273 Repair of eye wound SA082 pack, ophthalmology visit (w-dilation) 65280 Repair of eye wound SA082 pack, ophthalmology visit (w-dilation) 65285 Repair of eye wound SA082 pack, ophthalmology visit (w-dilation) 65286 Repair of eye wound SA082 pack, ophthalmology visit (w-dilation) 65290 Repair of eye socket wound SA082 pack, ophthalmology visit (w-dilation) 65770 Revise cornea with implant SA050 pack, ophthalmology visit (no dilation) 65850 Incision of eye SA082 pack, ophthalmology visit (w-dilation) 65865 Incise inner eye adhesions SA082 pack, ophthalmology visit (w-dilation) 65870 Incise inner eye adhesions SA082 pack, ophthalmology visit (w-dilation) 66180 Implant eye shunt SA082 pack, ophthalmology visit (w-dilation) 66185 Revise eye shunt SA082 pack, ophthalmology visit (w-dilation) 66220 Repair eye lesion SA082 pack, ophthalmology visit (w-dilation) 66250 Follow-up surgery of eye SA082 pack, ophthalmology visit (w-dilation) 66500 Incision of iris SA082 pack, ophthalmology visit (w-dilation) 66600 Remove iris and lesion SA082 pack, ophthalmology visit (w-dilation) 66605 Removal of iris SA082 pack, ophthalmology visit (w-dilation) 66625 Removal of iris SA082 pack, ophthalmology visit (w-dilation) 66630 Removal of iris SA082 pack, ophthalmology visit (w-dilation) 66635 Removal of iris SA082 pack, ophthalmology visit (w-dilation) 66682 Repair iris & ciliary body SA082 pack, ophthalmology visit (w-dilation) 66820 Incision, secondary cataract SA082 pack, ophthalmology visit (w-dilation) 66850 Removal of lens material SA082 pack, ophthalmology visit (w-dilation) 66852 Removal of lens material SA082 pack, ophthalmology visit (w-dilation) 66930 Extraction of lens SA082 pack, ophthalmology visit (w-dilation) 66940 Extraction of lens SA082 pack, ophthalmology visit (w-dilation) 66983 Cataract surg w/iol, 1 stage SA082 pack, ophthalmology visit (w-dilation) 67015 Release of eye fluid SA082 pack, ophthalmology visit (w-dilation) 67031 Laser surgery, eye strands SA082 pack, ophthalmology visit (w-dilation) 67036 Removal of inner eye fluid SA082 pack, ophthalmology visit (w-dilation)

### CMS-1503-P 85

CPT/ HCPCS

Code Short Descriptor CMS Supply Code with Overall Price Corrections Description of Supply

67040 Laser treatment of retina SA082 pack, ophthalmology visit (w-dilation) 67105 Repair detached retina SA082 pack, ophthalmology visit (w-dilation) 67107 Repair detached retina SA082 pack, ophthalmology visit (w-dilation) 67110 Repair detached retina SA082 pack, ophthalmology visit (w-dilation) 67115 Release encircling material SA082 pack, ophthalmology visit (w-dilation) 67120 Remove eye implant material SA082 pack, ophthalmology visit (w-dilation) 67228 Treatment of retinal lesion SA082 pack, ophthalmology visit (w-dilation) 67400 Explore/biopsy eye socket SA082 pack, ophthalmology visit (w-dilation) 67412 Explore/treat eye socket SA082 pack, ophthalmology visit (w-dilation) 67440 Explore/drain eye socket SA082 pack, ophthalmology visit (w-dilation) 67908 Repair eyelid defect SG008 applicator, cotton-tipped, non-sterile 6in 88356 Analysis, nerve SL108 pipette



### c. AMA RUC Recommendations in CY 2010 for Changes to Direct PE Inputs In a March 2010 letter, the AMA RUC made specific PE recommendations that

we consider below

. As stated earlier , the proposed changes that follow are included in the proposed CY 2011 direct PE database, wh ich is available on the CMS Web site under the downloads for the CY 2011 PFS proposed rule at http://www.cms.gov/PhysicianFeeSched/

. (1) Electrogastrography a nd Esophageal Function Test We are accepting the AMA RUC recommendations for the CY 2011 PE inputs for the following CPT codes: 91132 (Electroga strography, diagnostic, transcutaneous); 91133 (Electrogastrography, diagnostic, transc utaneous; with provocative testing); 91038 (Esophageal function test, gastroesophageal re flux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretation; prolonged (greater than 1 hour, up to 24 hours)). Fo r CPT code 91038, we have assumed a useful life of 5 years for the equipment item "ZEPHR impedance /pH reflux monitoring system with data recorder, software, monitor, work station and cart," based on its entry in the

### CMS-1503-P 86

AHA’s publication, "Estimated Usef ul Lives of Depreciable Ho spital Assets," which we use as a standard reference. The proposed CY 2011 direct PE database has been changed accordingly. (2) 64-Slice CT Scanner and Software The AMA RUC submitted an updated reco mmendation regarding the correct pricing of the 64-slice CT scanner and its accompanying software. Based on the documentation accompanying the recommendation, we are accepting this recommendation and updating the price input for the 64-slice scanner and software. This affects the following four CPT codes that use either the scanner, the software, or both: 75571 (computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium); 75572 (Comput ed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assessment of cardiac function, and evaluati on of venous structures, if performed)); 75573 (Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the se tting of congenital hear t disease (including 3D image postprocessing, asse ssment of LV cardiac function, RV structure and function and evaluation of venous structures, if performed)); and 75574 (Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac functi on, and evaluation of venous structure, if performed)). The proposed CY 2011 direct PE da tabase has been modified accordingly. (3) Cystometrogram The AMA RUC recently identified a rank order anomaly regarding CPT code 51726 (Complex cystometrogram (i e, calibrated electronic equipment)). Currently, this

### CMS-1503-P 87

procedure has higher PE RVUs, despite being less resource- intensive than the three CPT

codes for which it serves as the base: 51727 (Complex cystometrogram (ie, calibrated electronic equipment); with urethral pressure pr ofile studies (ie, uret hral closure pressure profile), any technique); 51728 (Complex cy stometrogram (ie, calibrated electronic equipment); with voiding pressure studies (ie, bladder voiding pressure), any technique); and 51729 (Complex cystometrogram (ie, calib rated electronic equipment); with voiding pressure studies (ie, bladder voiding pressure ) and urethral pressure profile studies (ie, urethral closure pressure pr ofile), any technique). Since usual AMA RUC policy is that CP T codes with a 0-day global period do not have pre-service time associated with the code, the AMA RUC recommended removing the nonfacility pre- service clinical staff time from the PE inputs for 51726. Additionally, the AMA RUC recommended that the nonfacility clinical intra-service staff

time for CPT code 51276 be reduced from the 118 minutes of intra-se rvice clinical staff time currently assigned to the code to 85 minutes of intra-service clinical staff time. These changes would resolve the rank order anomaly and bring the PE inputs for CPT code 51726 into alignment with the other three co des. Finally, and for the reasons stated above, the AMA RUC recommended that CMS remove the 23 minutes of pre-service nonfacility clinical staff time from CPT code 51725 (Simple cystometrogram (CMG) (eg, spinal manometer)). We are accepting th ese recommendations and, therefore, have changed the direct PE inputs for CPT c odes 51725 and 51726 in the nonfacility setting in the proposed CY 2011 direct PE database. (4) Breath Hydrogen Test The AMA RUC provide recommendations re garding the PE inputs for CPT code 91065 (breath hydrogen test (eg, for detection of lactase deficiency, fructose intolerance,

### CMS-1503-P 88

bacterial overgrowth, or oro-cecal gastrointestinal transit). We are accepting the recommendations with two modifications. We have folded the two pieces of equipment listed as "quinGas Table-Top Support Stand, 3 Tank" and "Drying Tu be, Patient Sample" into the "BreathTrackerDigital SC Inst rument" and summed their inputs into one equipment line-item, since these equipment items are used together specifically for the service in question. We have increased the us eful life input of the "BreathTrackerDigital SC Instrument" from 7 to 8 years based on our use of the American Hospital Association (AHA)’s publication entitled, "Estimated Useful Lives of Depreciab le Hospital Assets" as a standard reference. Additionally, be cause the AMA RUC did not include equipment times in their recommendations for this CPT code, we have used 53 minutes as the total time for all equipment items based on the total intra-service period for the clinical labor, consistent with our general policy for establishing equipment times. These modifications are reflected in the proposed CY 2011 direct PE database. (5) Radiographic Fluoroscopic Room

A recent AMA RUC review of services th at include the radi ographic fluoroscopic room (CMS Equipment Code EL014 ) as a direct PE revealed that the use of the item is no longer typical for certain services in which it is specified within the current direct cost inputs. The AMA RUC recommended to CMS that the radiographic fluoroscopic room

be deleted from CPT codes 64420 (Injection, anesthetic agen t; intercostal nerve, single); 64421 (Injection, anesthetic agent; intercosta l nerves, multiple, regional block); and 64620 (Destruction by neurolytic ag ent, intercostal nerve). We are accepting these recommendations and, therefore, these changes are included in the proposed CY 2011 direct PE database.

### CMS-1503-P 89

The AMA RUC also informed us that it has convened a workgroup to examine the inclusion of the fluoroscopic room across a broader range of codes. We will consider any future recommendations from the AMA RUC on this topic when they are submitted. d. Referral of Existing CP T Codes for AMA RUC Review As part of our review of high cost supp lies, we conducted a clinical review of the procedures associated with high cost supplie s to confirm that those supplies currently are used in the typical case described by the CPT codes. While we conf irmed that most high cost supplies could be used in the procedur es for which they are currently direct PE inputs, we noted that one of the high cost supplies, fiducial screws (CMS Supply Code SD073) with a current price of $558, is included as a direct PE input for two CPT codes, specifically 77301 (Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial to lerance specifications) and 77011 (Computed tomography guidance for stereotactic localization). The documentation used in the current pricing of the supply item desc ribes a kit that includes instructions, skull screws, a drill bit, and a collar for the TALON® System manufactured by Best nomos. Best nomos’ literature describes the insertion of the screws into the patient's skull to ensure accurate set-up. When CPT code s 77301 and 77011 were established in CY 2002 and CY 2003, respectively, we accepted th e AMA RUC recommendations to include

fiducial screws in the PE for these servi ces. Upon further review, while we understand why this supply may be considered a typical PE input for CPT code 77011, we do not now believe that fiducial screws, as described in the Best nomos literature, would typically be used in CPT code 77301, where th e most common clinical scenario would be treatment of prostate cancer.

### CMS-1503-P 90

Therefore, in order to ensure that CPT codes 77301 and 77011 are appropriately valued for CY 2011 through the inclusion or ex clusion of fiducial screws in their PE, we are asking the AMA RUC to review these CP T codes with respect to the inclusion of fiducial screws in their PE. We are requesting that the AMA RUC make recommendations to us regarding whether this supply should be included in the PE or

removed from the PE for CPT codes 77301 and 77011 in a timeframe that would allow us to adopt interim values for these codes for CY 2011, should the AMA RUC recommend a change. If the AMA RUC continues to recomme nd the inclusion of fiducial screws in the PE for CPT code 77301 and/or 77011 for CY 2011, we are requesting that the AMA RUC provide us with a detailed rationale for the inclusi on of this specialized supply in the PE for the typical case reported under the relevant CPT code. We would also request that the AMA RUC furnish updated pricing inform ation for the screws if they continue to recommend the screws as a PE input for one or both of these CPT codes in CY 2011. e. Updating Equipment and Supply Price Inputs for Existing Codes Historically, we have pe riodically received requests to change the PE price inputs for supplies and equipment in th e PE database. In the past , we have considered these requests on an ad hoc basis and updated the price inputs as part of quarterly or annual updates if we believed th em to be appropriate. In this proposed rule, we are proposing to establish a regular and more transparent process for considering public requests for changes to PE database price inputs for supplie s and equipment used in existing codes. We are proposing to act on public request s to update equipment and supply price inputs annually through rulemaking by followi ng a regular and consistent process as discussed in the following paragraphs. We are proposing to use the annual PFS proposed

### CMS-1503-P 91

rule released in the summer and the final rule released on or about November 1 each year as the vehicle for making these changes. We will accept requests for updating the price inputs for supplies and equipment on an ongoing basis; requests must be received no later than December 31 of each CY to be considered for inclusion in the next propos ed rule. In that next proposed rule, we would present our review of submitted re quests to update price inputs for specific equipment or supplies and our proposals for the subsequent calendar year. We would then finalize changes in the final rule for the upcoming calendar year. Our review of the

issues and consideration of public comments may result in the following outcomes that would be presented in the fina l rule with comment period:

● Updating the equipment or s upply price inputs, as requested.

● Updating the equipment or supply price inputs, with modifications.

● Rejecting the new price inputs.

● Declining to act on the request pending a recommendation from the AMA

RUC.

To facilitate our review a nd preparation of issues for the proposed rule, at a minimum, we would expect that requesters would provide the following information:

● Name and contact info rmation for the requestor.

● The name of the item exactly as it appears in the direct PE file under

downloads for the most recent PFS final rule with comment period, available on the CMS

Web site at http://www.cms.gov/PhysicianFee Sched/PFSFRN/list.asp#TopOfPage

. In order to best evaluate the requests in the context of our goal of utilizing accurate market prices for these items as direct PE inputs, we also would expect requestors to provide multiple invoices from different s uppliers/manufacture rs. In some

### CMS-1503-P 92

cases, multiple sources may not be available, whereupon a detailed explanation should be provided to support the request. When furnis hing invoices, requestors should take into consideration the following parameters: ++ May be either print or electr onic but should be on supplier and/or manufacturer stationery (for example, letterhead, billing statement, etc.) ++ Should be for the typical, common, a nd customary version of the supply or equipment that is used to furnish the services. ++ Price should be net of typical re bates and/or any discounts available, including information regarding the magnit ude and rationale for such rebates or

discounts. ++ If multiple items are presented on the same invoice, relevant item(s) should be clearly identified. We are soliciting public comments on this proposed process, including the information that requestors should furnish to f acilitate our full analysis in preparation for the next calendar year’s rulemaking cycle. B. Malpractice Relative Value Units (RVUs) 1. Background Section 1848(c) of the Act requires that each service paid under the PFS be comprised of three components: work, PE, and malpractice. From 1992 to 1999, malpractice RVUs were charge-based, usin g weighted specialty-specific malpractice expense percentages and 1991 average allowe d charges. Malpractice RVUs for new codes after 1991 were extrapolated from similar existing codes or as a percentage of the corresponding work RVU. Section 4505(f) of the BBA required us to implement

### CMS-1503-P 93

resource-based malpractice R VUs for services furnished beginning in 2000. Therefore, initial implementation of re source-based malpractice RVUs occurred in 2000. The statute also requires that we review , and if necessary adjust, RVUs no less often than every 5 years. The first review and update of resource-based malpractice

RVUs was addressed in the CY 2005 PF S final rule with comment period (69 FR 66263). Minor modifications to the methodology were addressed in the

CY 2006 PFS final rule with comment period (70 FR 70153). In the CY 2010 PFS final rule with comment perio d, we implemented the sec ond review and update of malpractice RVUs. For a discussion of the second review and update of malpractice RVUs see the CY 2010 PFS proposed rule ( 74 FR 33537) and final rule with comment period (74 FR 61758). 2. Malpractice RVUs for New and Revised Services Effectiv e Before the Next 5-Year

Review Currently, malpractice RVUs for new and re vised codes effective before the next 5-Year Review (for example, effective CY 2011 through CY 2014) are determined by a

direct crosswalk to a similar “source” code or a modified crosswalk to account for

differences in work RVUs between the new/ revised code and the source code. For the modified crosswalk approach, we adjust the malpractice RVUs for the new/revised code

to reflect the difference in work RVUs between the source code and the AMA RUC’s recommended work value (or the work value we are applying as an interim final value under the PFS) for the new code. For example, if the interim final work RVUs for the new/revised code are 10 percent higher than the work RVUs for the source code, the malpractice RVUs for the new/revised code would be increased by 10 percent over the source code RVUs. This approach presumes the same risk factor for the new/revised

### CMS-1503-P 94

code and source code but uses the work RVUs for the new/revised code to adjust for riskof-service. The assigned malpractice RVUs for new/revised codes effective between updates remain in place until th e next 5-Year Review. We will continue our current approach for determining malpractice RVUs for

new/revised codes that become effective before the next 5-Year Review and update. Under this approach we will crosswalk the new/revised code to the RVUs of a similar source code and adjust for differences in work (or, if greater, the clinical labor portion of the fully implemented PE RVUs), between th e source code and the new/revised code. Additionally, we will publish a list of new/revised codes and the analytic crosswalk(s) used for determining their malpractice RVUs in the final rule with comment period, which we have not previously done. The CY 2011 malpractice RVUs for new/revised codes will be imple mented as interim final values in the CY 2011 PFS final rule with comment period, where they will be subject to public comment. They will then be finalized in the CY 2012 PFS final rule with comment period. 3. Revised Malpractice RVUs for Sele cted Disc Arthroplasty Services As discussed in the CY 2010 PFS propos ed rule (74 FR 33539), we assign malpractice RVUs to each service based upon a we ighted average of the risk factors of all specialties that furnish the service. For the CY 2010 review of malpractice RVUs, we used CY 2008 Medicare payment data on allowed services to establish the frequency of a service by specialty. CPT code 22856 (Total di sc arthroplasty (artif icial disc), anterior approach, including discectomy with end plat e preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), single interspace, cervical)

had zero allowed services for CY 2008. Therefore, our contract or initially set the level of services to 1, and assigned a risk factor according to the average risk factor for all

### CMS-1503-P 95

services that do not explicitly have a separa te technical or professional component. We proposed to adopt our contractor’s initial malpractice RVUs for CPT code 22856 in the CY 2010 proposed rule. Application of the av erage physician risk factor would have resulted in a significant decrease in malpr actice RVUs for CPT code 22856 in CY 2010.

Several commenters on the CY 2010 PFS proposed rule expressed concern regarding the proposed malpractice RVUs for CPT code 22856, which represented a proposed reduction of more than 77 percent. The commenters stated that this service is predominantly furnished by neurosurgeons and orthopedic surgeons. Given the high risk factors associated with these specialty types and the changes in malpractice RVUs for comparable services, the commenters stated that a reduction in the malpractice RVUs of this magnitude for CPT code 22856 could not be correct.

After consideration of the public comments, for CY 2010, we set the risk factor for CPT code 22856 as the weighted average ri sk factor of six comparable procedures mentioned by the commenters: CPT code 22554 (Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); cervical below C2); CPT c ode 22558 (Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar); CPT code 22857 (Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), single interspace, lumbar); CPT code 22845 (Anterior instrumentation; 2 to 3 vertebral segments (list separately in addition to code for pr imary procedure)); CPT code 63075 (Discectomy, anterior, with deco mpression of spinal cord and/ or nerve root(s), including osteophytectomy; cerv ical, single interspace); and CPT code 20931 (Allograft for spine surgery only; structural (list separately in addition to code for

### CMS-1503-P 96

primary procedure)). The weighted average risk factor for these services is 8.4. Since publication of the CY 2010 PFS final rule with comment period, stakeholders have mentioned that we made significant changes to the malpractice RVUs

for CPT code 22856 in CY 2010. The commenter s also brought to our attention that other services are clinically similar to CP T code 22856 and have similar work RVUs, and therefore, some stakeholders believe these services shoul d all have simila r malpractice RVUs. Services mentioned by the stakeholders that are clinically similar to CPT code 22856 include CPT code 22857; CPT code 22861 (Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical); CPT code 22862 (Revision including replacement of total disc arthroplas ty (artificial disc) anterior approach, lumbar); CPT code 22864 (Removal of total disc arthroplasty (artificial disc), an terior approach, single inters pace; cervical); and CPT code 22865 (Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar). After further review of this issue, we ar e proposing to apply the same risk factor

used for CPT code 22856 to certain other serv ices within this family of services (CPT codes 22857 through 22865) for which there we re no allowed services in CY 2008. CPT

codes 22861 and 22864 had zero allo wed services in CY 2008 a nd our contractor initially set their malpractice RVUs in the same way as it did for CPT code 22856. Therefore, we will assign the weighted average risk fact or we use for CPT code 22856 (that is, the weighted average of the risk factors for CPT codes 20931, 22554, 22558, 22845, 22857, and 63075) to CPT codes 22861 and 22864. However, CPT codes 22857, 22862, and 22865 are low volume services (allowed servic es under 100). Our policy for low volume services is to apply the risk factor of the dominant specialty as indicated by our claims

### CMS-1503-P 97

data. We will conti nue to apply our policy for low volume services to CPT codes 22857, 22862, and 22865. C. Potentially Misvalued Services Under the Physician Fee Schedule 1. Valuing Services Under the PFS As discussed in section I. of this propos ed rule, in order to value services under the PFS, section 1848(c) of the Act requires the Secretary to determine relative values for physicians' services based on three component s: the work, practice expense (PE), and malpractice components. Section 1848(c)(1)(A ) of the Act defines the work component to include "the portion of the resources used in furnishing the service that reflects physician time and intensity in furnishing the service." Additionally, the statute provides that the work component shall include activities that occur before and after direct patient contact. Furthermore, the statute specifies that with respect to surgical procedures, the valuation of the work component for the code would reflect a "global" concept in which pre-operative and post-operative physicians' services related to the procedure would also

be included. In addition, section 1848(c)(2)(C)(i) of the Ac t specifies that "the Secretary shall determine a number of work relative value units (RVUs) for the service based on the relative resources incorporating physician time and intensity required in furnishing the

service." As discussed in de tail in sections I.A.2. and I.A.3 of this proposed rule, the statute also defines the PE and malpractice components and provides specific guidance in

the calculation of the RVUs for each of thes e components. Section 1848(c)(1)(B) of the Act defines the PE component as "the portion of the resources used in furnishing the service that reflects the general categories of expenses (such as office rent and wages of personnel, but excluding malpractice expens es) comprising practice expenses."

### CMS-1503-P 98

Section 1848(c)(2)(C)(ii) of the Act specifie s that the "Secretary shall determine a number of practice expense relative value units for the services for years beginning with 1999 based on the relative practice expense resour ces involved in furnishing the service." Furthermore, section 1848(c)(2)(B) of the Act directs the Secretary to conduct a periodic review, not less often than every 5 years, of the RVUs established under the PFS. Finally, on March 23, 2010, the Affordable Ca re Act was enacted, further requiring the Secretary to periodically review and iden tify potentially misvalued codes and make appropriate adjustments to the relative values of those services identified as being potentially misvalued. Secti on 3134(a) of the ACA added a new section 1848(c)(2)(K) of the Act which requires the Secretary to periodically identify potentially misvalued services using certain criteria, and to revi ew and make appropriate adjustments to the

relative values for those services. Section 3134(a) of the ACA also added a new section 1848(c)(2)(L) which requires the Secretary to develop a validation process to validate the RVUs of potentially misvalued codes under the PFS and make appropria te adjustments. As discussed in section I.A.1. of this pr oposed rule, we establish physician work

RVUs for new and revised c odes based on our review of recommendations received from the AMA RUC. The AMA RUC also provide s recommendations to CMS on the values for codes that have been identified as pot entially misvalued. To respond to concerns expressed by MedPAC, the Congress, and other stakeholders regarding accurate valuation of services under the PFS, the AMA RUC created the Five-Year Review Identification Workgroup. In addition to providing recommendations to CMS for work RVUs, the AMA RUC's Practice Expense S ubcommittee reviews direct PE (clinical labor, medical supplies, and me dical equipment) for individua l services and examines the many broad and methodological issues rela ting to the development of PE RVUs.

### CMS-1503-P 99

In accordance with section 1848(c) of the Act, we determine appropriate adjustments to the RVUs, taking into ac count the recommendations provided by the AMA RUC and MedPAC, and publish the explana tion for the basis of these adjustments in the PFS proposed and final rules. We note that section 1848(c)(2)(A)(ii) of the Act authorizes the use of extrapolation and ot her techniques to determine the RVUs for physicians' services for which specific data are not available, in addition to taking into

account the results of consultations with organizations representing physicians. 2. Identifying, Reviewing, and Validating the RVUs of Potentially Misvalued Services

under the PFS a. Background In its March 2006 Report to Congress, MedP AC noted that "misvalued services can distort the price signals for physicians' services as well as for other health care services that physicians order, such as hosp ital services." In that same report MedPAC postulated that physicians' services under th e PFS can become misvalued over time for a number of reasons: "For example, when a new service is added to the physician fee schedule, it may be assigned a relatively high value because of the time, technical skill, and psychological stress that are required to perform it. Over time, skill, and stress involved may decline as physicians become more familiar with the service and more efficient at providing it. The amount of ph ysician work needed to furnish an existing service may decrease when new technologies are incorporated. Services can also become overvalued when practice expenses decline. This can happen when the costs of equipment and supplies fall, or when equipment is used more frequently, reducing its cost per use. Likewise, services can become unde rvalued when physician work increases or practice expenses rise." In the ensuing years since MedPAC's 2006 report, additional

### CMS-1503-P 100

groups of potentially misvalued services ha ve been identified by Congress, CMS, MedPAC, the AMA RUC, and other stakeholders. In recent years CMS and the AMA RUC have taken increasingly significant steps to address potentially misvalue d codes. As MedPAC noted in its March 2009 Report to Congress, in the intervening years since MedPAC made the initial recommendations,

"CMS and the AMA RUC have ta ken several steps to improve the review process." Most recently, section 1848(c)(2)(K)(ii) of the Ac t (as added by section 3134 of the ACA) directed the Secretary to specifically examine potentially misvalued services in seven categories. (1) Codes and families of codes for which there has been the fastest growth. (2) Codes or families of codes that have experienced substantial changes in practice expenses. (3) Codes that are recently establis hed for new technologies or services. (4) Multiple codes that are frequently billed in conjunction with furnishing a single service. (5) Codes with low relative values, particularly those that are often billed multiple times for a single treatment. (6) Codes which have not been subject to review since the implementation of the RBRVS (the so-called 'H arvard-valued codes'). (7) Other codes determined to be appropriate by the Secretary. Section 1848(c)(2)(K)(iii) of the Act (as ad ded by section 3134 of the ACA) also specifies that the Secretary may use existing processes to receive recommendations on the review and appropriate adjustment of pot entially misvalued services. In addition, the Secretary may conduct surveys, other data co llection activities, studies, or other analyses

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as the Secretary determines to be appropriate to facilitate the review and appropriate adjustment of potentially misvalued services. This section authorizes the use of analytic contractors to identify and analyze potentia lly misvalued codes, conduct surveys or collect data, and make reco mmendations on the review and appropriate adjustment of potentially misvalued services. Finally, section 1848(c)(2)(K)(iii )(V) of the Act (as added by section 3134 of the ACA) specifies that the Secretary may make appropriate coding revisions (including using existing pro cesses for consideration of coding changes) which may include consolidation of individua l services into bundled codes for payment under the physician fee schedule. b. Progress in Identifying and Revi ewing Potentially Misvalued Codes Over the last several years, CMS, in conjunction with the AMA RUC, has identified and reviewed numerous potentially misvalued codes in all seven of the categories specified in section 1848(c)(2)(K)( ii) (as added by section 3134 of the ACA), and we plan to continue our work examinin g potentially misvalued codes in these areas over the upcoming years, consistent with the new legislative mandate on this issue. In the current process, the AMA RUC reviews potentially misvalued codes that are identified either by CMS or through its own processes and recommends revised work RVUs and/or direct PE inputs for those codes to CMS. CMS then assesses the

recommended revised work R VUs and/or direct PE inputs and, in accordance with section 1848(c) of the Act, we determine if the recommenda tions constitute appropriate adjustments to the RVUs under the PFS. Since CY 2009, CMS and the AMA RUC have identified over 700 potentiall y misvalued codes. For example, in regards to the first category (codes and families of codes for which there has been the fastest grow th), for CY 2009 CMS identified over 100

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potentially misvalued codes for which an analysis of the utilization data showed an annual growth in allowed se rvices of 10 percent (or more) for 3 consecutive years (73 FR 38586). Each of these codes had allowed charges of $1 million or more in CY 2007. We published this list in the CY 2009 proposed rule (73 FR 38586 through 38589) and requested that the AMA RUC immedi ately begin a review of the codes on this list. Meanwhile, in parallel with CMS' efforts, the AMA RUC also initiated processes to identify and revi ew potentially misvalued code s on an ongoing basis using certain screens, including screens for "CMS fastest growing procedures" and "high volume growth." Both of these AMA RUC screens are applicable to the first category of potentially misvalued codes specified in ACA. We plan to continue to analyze Medicare claims data over future years to identify additional services that exhibit rapid growth and high Medicare expenditures for referral to the AMA RUC for review as potentially

misvalued codes. Pertaining to the second category specified in section 1848(c)(2)(K)(ii) of the Act (as added by section 3134 of ACA) (codes or families of codes that have experienced substantial changes in practice expenses), in CY 2009 we requested that the AMA RUC continue its review of direct PE inputs, fo cusing particularly on high-volume codes where the PE payments are increasing significan tly under the transition to the new PE methodology (73 FR 38589). The AMA RUC has responded by sending CMS recommendations for revised direct PE inputs for codes identified for PE review on an ongoing basis. Additionally in CY 2009, we began an initia tive to review and update the prices for high-cost supplies in order to ensure the accuracy and completeness of the direct PE

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inputs. We discuss our most recent efforts in refining the process to update the prices of high-cost supplies in section II.C.5. of this proposed rule. For the third category of potentially misvalued codes identified in section 1848(c)(2)(K)(ii) (as added by section 3134 of the ACA) (codes that are recently established for new technologies or services), the AMA RUC routinely identifies such codes through a screen based on 3 years of Medicare claims data, and sends CMS

recommendations for revised work RVUs and/or direct PE inputs for these codes on an ongoing basis. The AMA RUC may determin e that a code for a new service requires reevaluation or does not require reevaluation, or it may conclude, on a case-by-case basis, that more than 3 years of claims data are ne cessary before the code can be reviewed. In that case, it would determine the appropriate future timeframe for review.

We also note that in its June 2008 Re port to Congress en titled "Reforming the Health Care System" and in the context of a discussion about primary care, MedPAC acknowledges, "...Efficiency can improve more ea sily for other types of services, such as procedures, with advances in technology, te chnique, and other factors. Ideally, when such efficiency gains are achieved, the fee schedule's relative value units (RVUs) for the

affected services should decline accordin gly, while budget neutrality would raise the RVUs for the fee schedule's primary care services." (page 27). Section III.C.5. of this proposed rule includes a discussion regarding periodic updates to the costs of high cost supplies. This discussion is highly relevant to new technology services, where growth in volume of a service as it diffuses into clinical practice may lead to a decrease in the cost of expensive supplies. We also expect that other efficiencies in physician work and PE may be achieved after an initial period of relative inefficiency that reflects the "learning curve." We plan to pay particular attention to the work values and direct PE inputs for

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these new services and the AMA RUC's periodic review process to ensure that any efficiencies are captured under the PFS over time, recognizing that the appropriate timing for revaluing these services needs to be considered on a case-by-case basis depending on the growth rate in service volume.

We have also addressed the fourth category (multiple codes that are frequently billed in conjunction with furnishing a single service) in rulemaking prior to the

enactment of the ACA. As discussed in the CY 2009 PFS proposed rule (73 FR 38586), we have a longstanding policy of reducing payment for multiple surgical procedures performed on the same patient, by the same physician, on the same day. Over the ensuing years, the multiple procedure payment reduction (MPPR) policy has been extended to a number of nuclear diagnostic and diagnostic imaging procedures. We continue our work to recognize efficiencies in this area with a proposal to expand the MPPR policy to additional combinations of ima ging services and to therapy services for

CY 2011 as described in section II .C.4. of this proposed rule. We note the AMA RUC has also established a screen to identify services performed by the same physician on the same date of service 95 percent of the time or more. Over the past 2 years, the CPT Edito rial Panel has establis hed new bundled codes to describe a comprehensive service for certain combinations of these existing services that are commonly furnished together, and the AMA RUC has recommended work values and direct PE inputs to CMS for these comp rehensive service codes that recognize the

associated efficiencies. CMS looks forward to working with the AMA RUC in this joint effort to examine codes commonly reported together and more appropriately value

common combinations services.

### CMS-1503-P 105

We address the fifth category of poten tially misvalued codes (codes with low relative values, particularly those that are often billed multiple times for a single treatment) in section II.C.3.b. of this proposed rule. That is, we are providing a list of services with low work RVUs that are commonly reported with multiple units in a single encounter and requesting that the AMA RUC re view these codes that we have identified as potentially misvalued. The sixth category (codes which have not been subject to review since the implementation of the RBRVS (the so-called 'Harvard-valued codes')) also continues to be addressed by CMS and the AMA RUC on an ongoing basis. As we noted in the CY 2009 PFS proposed rule (73 FR 38589), there were at that time approximately 2900 codes, representing $5 billion in annual spending, that were originally valued using

Harvard data and have no t subsequently been evaluated by the AMA RUC. Consequently, in CY 2009, we requested that the AMA RUC engage in an ongoing effort to review the remaining Harvard-valued code s, focusing first on the high-volume, low intensity codes (73 FR 38589). In res ponse to our request, the AMA RUC initially conducted an analysis of Harv ard-valued services with utilization above 10,000 services per year, which resulted in a list of 296 dis tinct services (73 FR 69883). The AMA RUC, in its public comment on the CY 2009 proposed rule, stated that it believes it would be effective to limit any review to these 296 servi ces and also noted that of the 296 services identified, 23 had already been identified by a nother screen and were in the process of being reviewed (73 FR 69883). To date, th e AMA RUC has reviewed and submitted to

CMS recommendations for revised work RVUs and/or direct PE inputs for a number of Harvard-valued codes, prioritizing those codes with utilization of over 1 million services.

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The AMA RUC and CMS intend to continue our ongoing assessment of Harvard-valued codes, next targeting codes with utilization of over 100,000 services. Finally, the seventh category of potentiall y misvalued codes me ntioned in section 1848(c)(2)(K)(ii) (as added by section 3134 of th e ACA) is all other codes determined to be appropriate by the Secretary. In this category, CMS has previously proposed policies and requested that the AMA RUC review codes for which there have been shifts in the site-of-service (site-of-service anomalies), as well as codes that qualify as "23-hour stay" outpatient services. The policies for valua tion of both the site-of-service anomaly codes and the "23-hour stay" codes are develope d further in sections II.C.3.d. and e., respectively, of this proposed rule. For CY 2011, we are also identifying codes with low work RVUs but are high volume based on claims data as another category of potentially misvalued codes and are referring these code s to the AMA RUC for review, as discussed in section II.C.3.b. of this proposed rule. In addition, for CY 2011 we are newly targeting key codes that the AMA RUC uses as reference services for valuing other services, termed "multispecialty points of comparison" services, and referring these to the AMA RUC for review as potentially misvalued codes as described in section II.C.3.a. of this proposed rule. Finally, we note the AMA RU C has also established screens to identify potentially misvalued codes in additional categ ories, including codes with a high intraservice work per unit of time (IWPUT) and codes representing services that had been surveyed by one specialty, but are now performed by a different specialty. We will

continue to review AMA RU C recommendations for revised work RVUs and/or direct PE inputs for codes that fall into these categories.

As a result of the combined efforts of CMS and the AMA RUC to address potentially misvalued codes, for CY 2009 the AMA RUC recommended revised work

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values and/or PE inputs for 204 misvalued services (73 FR 69883). For CY 2010, an

additional 113 codes were id entified as misvalued and the AMA RUC provided new

recommendations for revised work RVUs and/or PE inputs to CMS as discussed in the CY 2010 PFS final rule with comment peri od (74 FR 61778). Upon review of the AMA RUC-recommended work RVUs, CMS accepted the majority of the values as appropriate adjustments to the RVUs under the PFS, in accordance with section 1848(c) of the Act. However, for a number of codes, mainly the site-of-service anomaly codes, we indicated that although we would accept the AMA RU C valuations for these site-of-service anomaly codes on an interim ba sis through CY 2010, we had ongoing concerns about the methodology used by the AMA RUC to re view these services (73 FR 69883 and 74 FR 61776 through 61778, respectively). In the CY 2010 PFS final rule with comment period, we requested that the AMA RUC reex amine the site-of-service anomaly codes and use the building block methodology to revalue the services (74 FR 61777). In that same rule, we also stated that we would c ontinue to examine these codes and consider whether it would be appropriate to propose additional changes in future rulemaking. We discuss our CY 2011 proposal with respect to these codes in section II.C.3.d. of this proposed rule. c. Validating RVUs of Potentially Misvalued Codes In addition to identifying and reviewing potentially misvalued codes, section 1848(c)(2)(L) (as added by section 3134 of the ACA) specifies that the Secretary shall establish a formal process to validate relativ e value units under the PFS. The validation process may include validation of work elements (such as time, mental effort and professional judgment, te chnical skill and physical effort, and stress due to risk) involved with furnishing a service and may include va lidation of the pre, post, and intra-service

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components of work. The Secretary is direct ed to validate a sampling of the work RVUs of codes identified through any of the seve n categories of potentially misvalued codes specified by section 1848(c)(2)(K)(ii) (a s added by section 3134 of the ACA). Furthermore, the Secretary may conduct the validation using methods similar to those used to review potentially misvalued codes, including conducting surveys, other data collection activities, studies, or other analyses as the Secretary determines to be appropriate to facilitate the validation of R VUs of services. Currently, while CMS does

assess the AMA RUC- recommended work RVUs to determine if the recommendations constitute appropria te adjustments to the RVUs under th e PFS, we intend to establish a more extensive validation process of RVUs in the future in accordance with the requirements of section 1848(c)(2)(L) (a s added by section 3134 of the ACA). Therefore, we are soliciting public comme nts on this proposed rule on possible approaches and methodologies that we should co nsider for a validation process. We are especially interested in public comments regarding approaches, including the use of time and motion studies, to validate estimates of physician time and intensity that are factored into the work RVUs for services with rapid growth in Medicare expenditures, one of the categories that the statute specifically directs CMS to examine. We plan to discuss the validation process in a future PFS rule once we have considered the matter further in conjunction with any public comme nts and other input from stake holders that we receive.

3. CY 2011 Identification and Review of Potentially Misvalued Services In this section, we discuss codes that may be misvalued according to five different

criteria:

• Codes on the multi-specialty points of comparison list;

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• Codes with low work RVUs commonly billed in multiple units per single

encounter;

• Codes with high volume and low work RVUs;

• Codes with site-of-s ervice anomalies; and

• Codes that qualify as "23-hour stay" outpatient services. a. Codes on the Multispecialty Points of Comparison List The AMA RUC uses a scale referred to as the multispecialty points of comparison (MPC) to evaluate the reasonableness of a specialty society's recommended RVU value for a service. The MPC list contains reference codes of established comparison services

that are used in the valuation of new codes. The current MPC list consists of 316 codes which the AMA RUC may use to compare a nd contrast the relativity of codes under review to existing relative values. Since the AMA RUC may use the values on the MPC list as a basis for relativity when determining the values for new, revised, and newly reviewed codes (including potentially misvalued codes), it is essential that the services on the MPC list be appropriately valued since any codes misvalued on the MPC list could contribute to the misvaluing of other codes under review. While we believe that the

entire MPC list should be assessed to ensure that services are paid appropriately under the PFS, we have prioritized the review of the MPC list, ranking the codes by allowed service units and charges based on CY 2009 clai ms data. We are proposing to refer the

codes in Table 9 to the AMA RUC for review.

TABLE 9: Codes on the MPC List Referred for AMA RUC Review CPT Code Short Descriptor 66984 Cataract surg w/iol, 1 stage 97110 Therapeutic exercises 43239 Upper GI endoscopy, biopsy 20610 Drain/inject, joint/bursa

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CPT Code Short Descriptor 78815 Pet image w/ct, skull-thigh 45385 Lesion removal colonoscopy 45380 Colonoscopy and biopsy 11721 Debride nail, 6 or more 17000 Destruct premalg lesion 92980 Insert intracoronary stent 74160 Ct abdomen w/dye 71020 Chest x-ray 11100 Biopsy, skin lesion 66821 After cataract laser surgery 52000 Cystoscopy 92083 Visual field examination(s) 73721 Mri jnt of lwr extre w/o dye 93010 Electrocardiogram report 77334 Radiation treatment aid(s) 92250 Eye exam with photos 95810 Polysomnography, 4 or more 77003 Fluoroguide for spine inject 11056 Trim skin lesions, 2 to 4 76700 Us exam, abdom, complete 77290 Set radiation therapy field 77300 Radiation therapy dose plan 43235 Uppr gi endoscopy, diagnosis 71275 Ct angiography, chest 95900 Motor nerve conduction test 31231 Nasal endoscopy, dx 95165 Antigen therapy services 94060 Evaluation of wheezing 31575 Diagnostic laryngoscopy

b. Codes with Low Work RVUs Commonly Billed in Multiple Units Per Single

Encounter Consistent with section 1848(c)(2)(K)(ii) (as added by section 3134 of the ACA) which identifies categories of potentially mis valued codes for our review, we believe services with low work RVUs that are commonly billed with multiple units in a single encounter are an additional appropriate cat egory for identifying potentially misvalued codes. An example of a high multiple /low work RVU service is CPT code 95004

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(Percutaneous tests (scratch, puncture, prick) with allergen ic extracts, immediate type reaction, including test interpre tation and report by a physicia n, specify number of tests). For purposes of compiling a list of the high multiple/low work RVU services, we defined a high multiple service as one that is commonly performed in multiples of 5 or more per day. Then, we selected from high multiple services with work RVUs of less than or equal to 0.5 RVUs. We note that in selecting 5 per day as the minimum threshold for the number of common services performed in a multiple service encounter, we intended to establish a meaningful threshold which, in c onjunction with the threshold for work RVUs of 0.5 RVUs or less, would produce a reasonab le number of services for the RUC to review that have substantial total work RVUs for the comprehensive service furnished during a single treatment. That is, as a gene ral example, with a work RVU threshold of 0.5 RVUs and a multiple threshold of 5 per day, the total work RVUs for a typical treatment would equate to 2.5 RVUs, which is approximately comparable to a high level office visit, an interpretation of a comple x imaging procedure, or a minor surgical procedure. We are asking the AMA RUC to review the codes in Table 10.

TABLE 10: Codes with Low Work RVUs th at are Commonly Billed in Multiple Units Referred for AMA RUC Review CPT Code Short Descriptor 95904 Sense nerve conduction test 17003 Destruct premalg les, 2-14 95004 Percut allergy skin tests 11101 Biopsy, skin add-on 95024 Id allergy test, drug/bug 76000 Fluoroscope examination 95144 Antigen therapy services 95010 Percut allergy titrate test 88300 Surgical path, gross 95027 Id allergy titrate-airborne 95015 Id allergy titrate-drug/bug

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CPT Code Short Descriptor 95148 Antigen therapy services

c. Codes with High Volume and Low Work RVUs

We believe that codes that have low work RVUs but are high volume based on claims data are another category of potentia lly misvalued codes. Although these codes have low work RVUs (less than or equal to 0.25 RVUs), the high utilization of these codes represents significant expenditures under the PFS such that their appropriate valuation is especially important. Table 11 contains a list of such codes and we are requesting that the AMA RUC review these codes.

TABLE 11: Codes with Low Work RVUs that are High Volume Referred for AMA RUC Review CPT Code Short Descriptor 71010 Chest x-ray 73510 X-ray exam of hip 97035 Ultrasound therapy 88313 Special stains group 2 73630 X-ray exam of foot 72100 X-ray exam of lower spine 73030 X-ray exam of shoulder 73562 X-ray exam of knee, 3 73560 X-ray exam of knee, 1 or 2 94010 Breathing capacity test 77052 Comp screen mammogram add-on 88304 Tissue exam by pathologist 73564 X-ray exam, knee, 4 or more 72170 X-ray exam of pelvis 74000 X-ray exam of abdomen 73610 X-ray exam of ankle 11719 Trim nail(s) 73620 X-ray exam of foot 92567 Tympanometry 73110 X-ray exam of wrist 73130 X-ray exam of hand

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CPT Code Short Descriptor 93701 Bioimpedance, cv analysis 72040 X-ray exam of neck spine 92543 Caloric vestibular test

d. Codes with Site -of-Service-Anomalies In previous years, we requested that the AMA RUC review codes that, according to the Medicare claims database, have experienced a change in the typical site of service since the original valuation of the code. For example, we have found services that originally were provided in the inpatient setting but for which current claims data show the typical case has shifted to being furnished outside the inpatient setting. Since the procedures were typically performed in the inpatient setting when the codes were originally valued, the work RVUs for these c odes would have been valued to include the inpatient physician work provi ded, as well as to reflect the intensive care and follow-up normally associated with an inpatient procedure. If the typical case for the procedure has shifted from the inpatient setting to an outpatient or physician's office setting, it is reasonable to expect that there have been changes in medical practice, and that such changes would represent a decrease in physician time or intensity or both. The AMA

RUC reviewed and recommended to CMS revi sed work RVUs for 29 codes for CY 2009

and 11 codes for CY 2010 that were identifie d as having site-of-service anomalies. In the CY 2010 PFS proposed and final rules with comment period (74 FR 33556 and 74 FR 61777, respectively), we encouraged the AMA RUC to utilize the building block methodology when revaluing services w ith site-of-service anomalies. Specifically, where the AMA RUC has determined in its review that changes in the inclusion of inpatient hospital days, office visits, and hos pital discharge day ma nagement services (that is, the "building blocks" of the code) ar e warranted in the revaluation of the code,

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we asked the AMA RUC to adjust the site-o f-service anomaly code for the work RVUs associated with those changes. Additionally, we suggested that in cases where the AMA RUC has adjusted the pre-service, intra-service a nd post-service times of the c ode under review, the AMA RUC

should also make associated work RVU ad justments to account for those changes. However, we remain concerned that in the AMA RUC's recommendations of the work RVUs for the CYs 2009 and 2010 site-of-service anomaly codes, the AMA RUC may have determined that eliminating or reallocating pre-service and post-service times, hospital days, office visits, and hospital discharge day management services was appropriate to reflect the typical case that is now occurring in a different setting, but the work RVUs associated with those changes may not have been systematically extracted or

reallocated from the total work RVU value for the service.

In the CYs 2009 and 2010 PFS final rule s with comment period (73 FR 69883 and 74 FR 61776 through 61778, respectively), we indicated that although we would accept the AMA RUC valuations for these site-of-service anomaly codes on an interim basis through CY 2010, we had ongoing con cerns about the methodology used by theAMA RUC to review these services. We requested that the RUC reexamine the site-ofservice anomaly codes and use the building block methodology to revalue the services (74 FR 61777). We also stated that we w ould continue to examine these codes and

consider whether it would be appropriate to propose a dditional changes in future rulemaking. Accordingly, in preparation for CY 2011 rulemaking, we conducted a comprehensive analysis of the codes th at the AMA RUC reviewed for CYs 2009 and 2010 due to site-of-service anomaly concerns. We systematically applied the reverse

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building block methodology to the 29 co des from CY 2009 and 11 codes from CY 2010

as follows:

● First, we obtained the original work R VU value assigned to the code (this is the "starting value") and made a list of the building block services with RVUs that were originally associated with the code (that is , before the AMA RUC reviewed the code for site-of-service anomalies).

● Next, we examined the AMA RUC-recommended changes to the building

blocks of the code.

● We then deducted the RVUs associ ated with the AMA RUC's recommended eliminations from the code's starting RVU value. Generally, the AMA RUC eliminated inpatient hospital visit building blocks from

the value of the code since the site-of-service for the code has shifted from the inpatient setting to another setting. We note in some cases, the AMA RUC left an inpatient hospital visit in the valuation of the code. We believe this is inconsistent with the change in the site-of-service to non-inpatient settings. Accordingly, we adhered to the methodology and deducted the RVUs associated with all inpatient hospital visits from the starting value. In cases where the AMA RUC recommended adding or substituting outpatient visits, we also added or substituted the RVUs associated with those changes to the starting value. If the AMA RUC recommended changes to the pre, intra, or post-service times, we calculated the incremental change in RVUs associated with that time and either added or deducted that RVU amount from the starting value. We note that the RVU values associated with the incremental time change are calculated using the intensity associated with the pa rticular pre-, intra-, or post pe riod. For the intensity of the intra-service period, we utilized the original IWPUT associated with the code. The AMA

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RUC generally recommended allowing only half of a hospital discharge day management

service for the site-of-serv ice anomaly codes. That is, CPT code 99238 (Hospital discharge day management; 30 mi nutes or less) has a work RVU value of 1.28; therefore,

half the value associated with CPT code 99238 is 0.64. Accordingly, if a code had one CPT code 99238 listed as part of the origin al valuation, we deducted 0.64 RVUs from the starting value. We standardized the methodology so that each of the site-of-service anomaly codes has half of a hospital discharge day management service value accounted in the valuation. Finally, we note that while we eliminated the RVUs associated with all inpatient hospital visits built into the code's starting value, because the typical case no longer occurs in the inpatient setting, we allowed for the possibility that in some cases, some part of the work which had been performed in the inpatient setting may continue to be provided even in the outpatient setting. Therefore, to be conservative in our

deductions of work RVUs associated with the inpatient hospital codes from the starting values, we allowed the intra-time of any inpatient hospital visits included in the original valuation to migrate to the post-service pe riod of the code. Accordingly, while we deducted the full RVUs of an inpatient hospital visit from the starting value, we added the intra-service time of the inpatient hospital vi sit to the post-service time of the code and accounted for the incremental change in RVUs . The following description provides an example of our methodology. CPT code 21025 (Excision of bone (eg, for osteomyelitis or bone abscess); mandible) has a starting value of 11.07 RVUs. Table 12 shows the building blocks that are included in the original valuation of the code.

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TABLE 12:

PreService Time MedianIntraService Time Immediate Post -Service Time 99231 99232 99238 99211 99212 99213 Original IWPUT 75 min 120 min 43 min 1 visit (0.76 RVUs) 1 visit (1.39 RVUs) 1 visit (1.28 RVUs) 2 visits (0.36 RVUs) 2 visits (0.96 RVUs) 2 visits (1.94 RVUs) 0.0145



### The AMA RUC removed two inpatient hosp ital visits and reduced the outpatient

visits from 6 to 4 visits. Table 13 shows th e building blocks that were recommended for CY 2009 by the AMA RUC after its review of th e code for site-of- service anomalies.

TABLE 13:

PreService

Time MedianIntraService

Time ImmediatePostService

Time 99231 99232 99238 99211 99212 99213 Revised IWPUT

85min 90min 30min 2 visits 2 visits 0.0530



### Next we calculated the RVUs associated with the changes to the building blocks recommended by the AMA RUC. We note th at the immediate post-service value of 0.38 RVUs (Table 14) includes 30 minutes of intra-service time from inpatient hospital CPT code 99231 (Level 1 subsequent hospital care, per day). Also, the median intra-service value of 0.44 RVUs (Table 14) was deter mined using the starting IWPUT value of 0.0145. Additionally, our methodology accounted for a half of a hospital discharge day management service (CPT code 99238) for th e site-of-service anomaly code. Table 14 shows the RVU changes to the building bloc ks that were calculated based on the methodology discussed above.

TABLE 14:

Pre-Service Time MedianIntraService

Time ImmediatePostService

Time 99231 99232 99238 99211 99212 99213

0.22 RVUs -0.44 RVUs 0.38 RVUs -0.76 RVUs -1.39 RVUs -0.64 RVUs -0.36 RVUs

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In the final step, the RVUs associated with the changes to the building blocks recommended by the AMA RUC (Table 14) were deducted from or added to the starting value of 11.07 RVUs, which resulted in the CY 2011 reverse building block value of 8.08 RVUs (11.07+0.22-0.44+0.38-0.76- 1.39-0.64-0.36=8.08). The methodology discussed above was app lied to each of the site-of-service anomaly codes from CYs 2009 and 2010 and the results are summarized in Tables 15 and

16. TABLE 15: CY 2009 Site-of-Service Anomaly Codes 1

CPT Code Short Descriptor CY 2008 RVUs ("Starting Value") RUC Recommended Value for CY 2009 CY 2011 Reverse Building Block Value 21025 Excision of bone, lower jaw 11.07 9.87 8.09 23415 Release of shoulder ligament 10.09 9.07 10.63 25116 Remove wrist/forearm lesion 7.38 7.38 7.21 42440 Excise submaxillary gland 7.05 7.05 6.52 52341 Cysto w/ureter stricture tx 6.11 5.35 5.62 52342 Cysto w/up stricture tx 6.61 5.85 6.20 52343 Cysto w/renal stricture tx 7.31 6.55 5.90 52344 Cysto/uretero, stricture tx 7.81 7.05 5.58 52345 Cysto/uretero w/up stricture 8.31 7.55 5.76 52346 Cystouretero w/renal strict 9.34 8.58 6.05 52400 Cystouretero w/congen repr 10.06 8.66 7.00 52500 Revision of bladder neck 9.39 7.99 8.72 52640 Relieve bladder contracture 6.89 4.73 5.01 53445 Insert uro/ves nck sphincter 15.21 15.21 11.72 54410 Remove/replace penis prosth 16.48 15.00 14.00 54530 Removal of testis 9.31 8.35 8.88 57287 Revise/remove sling repair 11.49 10.97 10.20 62263 Epidural lysis mult sessions 6.41 6.41 6.99 62350 Implant spinal canal cath 8.04 6.00 0.41 62355 Remove spinal canal catheter 6.60 4.35 -0.43 62360 Insert spine infusion device 3.68 4.28 -3.14 62361 Implant spine infusion pump 6.59 5.60 -0.92 62362 Implant spine infusion pump 8.58 6.05 -0.51 62365 Remove spine infusion device 6.57 4.60 -0.35 63650 Implant neuroelectrodes 7.57 7.15 4.25 63685 Insrt/redo spine n generator 7.87 6.00 4.80 64708 Revise arm/leg nerve 6.22 6.22 6.17 64831 Repair of digit nerve 10.23 9.00 8.87

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CPT Code Short Descriptor CY 2008 RVUs ("Starting Value") RUC Recommended Value for CY 2009 CY 2011 Reverse Building Block Value 65285 Repair of eye wound 14.43 14.43 13.52 1 We note that in this table, we have not adjusted the RVUs for these codes for the RVU changes to the evaluation and management codes that resulted from the CY 2010 elimination of the consultation codes (74 FR 61775). However, we note that we may, if appropriate, adjust the RVUs for services with global periods to account for relevant changes in the RVUs for evaluation and management services as necessary.



### TABLE 16: CY 2010 Site-of-Service Anomaly Codes 2

CPT Code Short Descriptor CY 2009 RVUs ("Starting

Value") RUC Recommended Value for CY 2010 CY 2011 Reverse Building Block Value 28120 Part removal of ankle/heel 5.64 8.08 6.03 28122 Partial removal of foot bone 7.56 7.56 6.79 28725 Fusion of foot bones 11.97 11.97 12.41 28730 Fusion of foot bones 12.21 12.21 10.06 36825 Artery-vein autograft 10.00 15 13.12 42415 Excise parotid gland/lesion 17.99 17.99 15.17 42420 Excise parotid gland/lesion 20.87 20.87 17.80 49507 Prp i/hern init block >5 yr 9.97 9.97 9.37 49521 Rerepair ing hernia, blocked 12.36 12.36 11.59 49587 Rpr umbil hern, block > 5 yr 7.96 7.96 7.19 61885 Insrt/redo neurostim 1 array 7.37 7.57 3.22

2 We note that in this table, we have not adjusted the RVUs for these codes for the RVU changes to the evaluation and management codes that resulted from the CY 2010 elimination of the consultation codes (74 FR 61775). However, we note that we may, if appropriate, adjust the RVUs for services with global periods to account for relevant changes in the RVUs for evaluation and management services as necessary.



### For most codes in Tables 15 and 16, the CY 2011 reverse building blockmethodology produced a value that is somewhat lower than the AMA RUCrecommended value. While our re sults suggest that the majority of the codes with siteof-service anomalies continue to be ove rvalued under the AMA RUC's most recent recommendations, we also found that the me thodology may produce a result that is considerably reduced or, in several cases, a negative value. We understand that in previous years, stakeholders have expresse d confusion as to why the application of a building block methodology would produce negati ve values. We believe in some cases, the starting value, that is, the original work RVU, may have been misvalued using

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building block inputs that were not consistent with the service, although the overall work value of the code may have been consistent with the values for other similar services. Moreover, a number of these services are the Harvard-valued codes, for which the RVUs were established many years ago based on historical inputs that may no longer be appropriate for the code. An attempt to extract the RVUs associated with these inappropriate inputs through the revers e building block methodology could produce aberrant results. Furthermore, in some cases , we noticed that the original IWPUT of thecode was negative even before the code was reviewed by the AMA RUC for a site-ofservice anomaly. A negativ e value for the IWPUT is counterintuitive to the IWPUT concept, indicating that the code was originally misvalued at the building block level. At a minimum, we believe that in cases wh ere the reverse building block methodology produces aberrant results, and where clinical review indicates a need for further analysis,

the codes should be referred back to the AMA RUC for review and new valuation should be performed based on the building block methodology. We note the application of the reverse bu ilding block methodology is an objective way to account for changes in the res ources resulting from the change in the site-of-service in which the typical service is provided. However, because relative values under the PFS are "relative," that is, where work relative value units for a code are established relative to work relative value units for other codes, the recommended methodology of valuing services based on input building blocks is best applied within the

context of the AMA RUC discussion. For ex ample, we recognize that the AMA RUC

looks at families of codes a nd may assign RVUs based on a particular code ranking within the family. This method of valuing se rvices preserves relativity within the relative value scale for that code family. However, we have stated that we believe the relative

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value scale requires each service to be valued based on the resources used in furnishing the service as specified in section 1848(c)(1)(A) of the Act, which defines the physician work component to include "the portion of the resources used in furnishing the service that reflects physician time and intensity in furnishing the service." Furthermore, section 1848(c)(2)(C)(i) of the Act specifies that "the Secretary shall determine a number of work relative value units (RVUs) for the service based on the relative resources incorporating physician time and intensity required in furnishing the service." Read together, these two sections of the statute support our intention to rely on the building block methodology to determine appropriate work RVUs for codes. We note that we continue to rely on th e extensive expertise provided by the AMA RUC to recommend appropr iate input building blocks for codes. Additionally, the AMA RUC's unique infrastructure and broad perspective permits the valuation of a code within the context of relativity to the entire relative va lue system. Therefore, we believe that the recommended methodology of valuing services based on input building blocks is best applied within the context of the AMA RUC discussion. Accordingly, we are requesting that the AMA RUC review the CPT codes displayed in Tables 15 and 16. In addition, where the application of the CY 2011 reverse building block methodology produces an aberrant result that is clearly not a reflection of physician work for the service, we are re questing that the AMA RUC review the input building blocks and recommend an appropriate RVU value that is both consistent with the building blocks of the code and appropriate relative to th e values for other codes in the family. For other codes where the application of the CY 2011 reverse building block methodology produces a result that is consistent with the physician work for the service, we encourage the AMA RUC to confirm the values and recommend these work values

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for CY 2011. In this way, we would hope to receive new AMA RUC recommendations for all of the codes in Tables 15 and 16 for CY 2011. Furthermore, if the

recommendations that we receive from th e AMA RUC are not consistent with the building block methodology and not appropriate relative to the values of other services, and the application of the CY 2011 reverse building block methodology produces a result

that CMS medical advisors belie ve is consistent with the work for the service, we are proposing to adopt the CY 2011 reverse build ing block methodology values that are

listed in Tables 15 and 16 for CY 2011. In cases where the reverse building block methodology produces a negative work value, we are suggesting that the AMA RUC

review and revise the buildin g blocks of the code so th at a new valuation can be

determined based on the buildin g block methodology. For su ch codes, if the revised recommendations that we would hope to receive from the AMA RUC are still not consistent with the building block methodol ogy upon revision, because we cannot pay for these services based on negative work R VUs, we are proposing to modify the AMA

RUC-recommended values for these codes as CM S determines clinically appropriate and adopt the CMS-modified RVUs on a interim final basis for CY 2011. In their future work, we urge the AMA RUC to use the building block methodology when valuing services or provide CMS with extensive rationale for cases where the AMA RUC believes the building bl ock methodology is inappropriate for a specific code. Since section 1848(c)(2)(L) (as added by section 3134 of the ACA) specifies that the Secretary shall establish a process to validate work RVUs of potentially misvalued codes under the PFS, as we have discussed earlier in this section, we believe codes that are valued using the building bloc k methodology would be more likely to meet

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the standards of a systematic RVU valida tion process that coul d be developed in accordance with the requirements of the statute. e. Codes with "23-hour" Stays In the CY 2010 PFS proposed rule (74 FR 33557), we requested that the AMA RUC review services that are typically performed in the outpatient setting and require a hospital stay of less than 24 hours. We stated in the proposed rule that we believed these to be primarily outpatient serv ices and expressed concern that the value of evaluation and management (E/M) visits for inpatients was in appropriately included in the valuation of codes that qualify as "23-hour st ay" outpatient services.

We received a number of comments in re sponse to the discussion in the CY 2010 proposed rule. The AMA RUC stated that it already values stays of less than 23 hours appropriately by reducing the hospital discharge day management service (that is, CPT code 99238), from 1 day to a half day. The AMA RUC also explained that when the AMA RUC refers to 23-hour stay services in discussions at AMA RUC meetings, it is referring primarily to services that are reported in the Medicare claims database as typically outpatient services, but where the patient is kept overnight and, on occasion, even longer in the hospital. Because the AMA RUC believes the patient stays overnight in the hospital, it believes the inclusion of i npatient E/M visits to be appropriate in the valuation of this category of codes. We believe that the 23-hour stay issu e encompasses several scenarios. The typical patient is commonly in the hospital fo r less than 24 hours, which often means the patient may indeed stay overnight in the hospital. On occasion, the patient may stay longer than a single night in the hospital; how ever, in both cases, the patient is considered for Medicare purposes to be a hospital outpatient, not an i npatient, and our claims data

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support that the typical 23-hour stay servi ce is billed as an outpatient service. Accordingly, we believe that the valuation of the codes that fall into the 23-hour stay category should not reflect work that is typicall y associated with an inpatient service. For example, inpatient E/M visit codes such as CPT codes 99231 (Level 1 subsequent hospital care, per day); 99232 (Level 2 subsequent hospital care, per day); and 99233 (Level 3 subsequent hospital care, per day), s hould not be included at the full value in the valuation of 23-hour stay services. Currently, the valuation of 23-hour stay services is conducted in a nonuniform manner by the AMA RUC. The AMA RUC has indicated that it currently includes a half hospital discharge day management service and no hospital inpatient visits for outpatient services with expected hospital stays of 23 hour s or less. In contrast, for those outpatient

services where the AMA RUC believes that th e recovery period could be longer than 23 hours, the AMA RUC stated in its comment on the CY 2010 PFS proposed rule that it currently includes a full hospital discharge day management service and one or more inpatient E/M visits in the code's value. However, we note the typical 23-hour stay service is billed as an outpatient service and so long as the typical case continues to be billed as an outpatient service, we believe the code should not incorporate physician work values for services that are typically associ ated with an inpatient service. In the 2010 PFS proposed and final rule with co mment period (74 FR 33556 and 74 FR 61777, respectively), we stated that we believed the use of inpatient E/M visit codes for services rendered in the post-service period for outpatient 23-hour stay procedures would result in overpayment for pre- and post-service work that would not be provided. Accordingly, we proposed in the CY 2010 proposed rule (74 FR 33556 through 33557) not to allow any additional inpatient E/M service to be billed for care furnished during the

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post-procedure period when care is furnished fo r an outpatient service requiring less than a 24-hour hospital stay. However, we find it is plausible that while the patient receiving the 23-hour stay service remains a hospital outpatient, the patie nt would typically be cared for by the physician furnishing the procedure during th at post-procedure period. While we do not believe that post-procedure hos pital "visits" would be at the inpatient level since the typical case is an outpatient who would be r eady to be discharged from the hospital in 23 hours or less, we agree that the intra-servi ce time of the inpatient hospital visit may be included in the valuation for the 23-hour stay code. Accordingly, we are modifying our proposed CY 2010 approach and suggesting that in the future, when the AMA RUC reviews new and potentially misvalued codes that are identified as 23-hour stay services, the AMA RUC would apply the following methodology: (1) Begin with the starting RVU value of the 23-hour stay code under review and decrease the hospital discharge day management service from one day to a half day. (2) Deduct the RVUs of inpatient hospita l visits from the starting RVU value. (3) Reallocate the time associated with the intra-service portion of the inpatient hospital visits to the immediate post-service time of the 23-hour stay code under review. Example : A 23-hour stay code is currently valued at 15 RVUs and has 1 hospital discharge day management service and 1 level 3 subsequent hospital care visit incorporated in this value.

● Applying step (1): 15 - 0.64 * 

### = 14.36

● Applying step (2): 14.36 – 2 ** 

### = 12.36

● Applying step (3): 12.36 + (30 minutes x 0.0224) *** 

### = 13.032 RVUs

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* 

### Value associated with 1/2 hospita l discharge day management service. ** 

### Value associated with an inpa tient hospital visit, CPT code 99233. *** 

### Value associated with the reallocated intra-service time multiplied by the post-service intensity of the 23-hour stay code.

Finally, we note that since work rela tive value units are established by the Secretary in the context of relativity to other codes in the system, the recommended methodology for the evaluation of 23-hour stay co des is best applied w ithin the context of relativity. We appreciate that the AMA RU C has the ability to assess the 23-hour stay code after application of th e recommended methodology to ensure appropriate relativity

of this code and other codes within the system. We strongly encourage the AMA RUC to apply the recommended methodology to ensure the consistent and a ppropriate valuation of the physician work for these services. 4. Expanding the Multiple Procedure Paym ent Reduction (MPPR) Policy to Additional Nonsurgical Services a. Background Medicare has a longstanding policy to reduce payment by 50 percent for the second and subsequent surgical procedures fu rnished to the same patient by the same physician on the same day, largely based on th e presence of efficiencies in the PE and pre- and post-surgical physician work. Ef fective January 1, 1995, the multiple procedure payment reduction (MPPR) policy, with the sa me percentage reduction, was extended to nuclear medicine diagnostic pro cedures (CPT codes 78306, 78320, 78802, 78803, 78806, and 78807). In the CY 1995 PFS final rule with comment period (59 FR 63410), we indicated that we would consider applying the policy to other diagnostic tests in the

future.

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Consistent with recommendations of MedPAC in its March 2005 Report to Congress on Medicare Payment Policy, under the CY 2006 PFS, the MPPR policy was extended to the technical component (TC) of certain diagnostic imaging procedures performed on contiguous areas of the body in a single session (70 FR 70261). The reduction recognizes that, for the second a nd subsequent imaging procedures, there are some efficiencies in clinical labor, supplies, and equipment time. In particular, certain

clinical labor activitie s and supplies are not duplicated for subsequent procedures and, because equipment time and indirect costs are allocated based on clinical labor time, those would also be reduced accordingly. The imaging MPPR policy currently applies to computed tomography (CT) and computed tomographic angiography (CTA), magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA), a nd ultrasound services within 11 families of codes based on imaging moda lity and body region. When we adopted the policy in CY 2007, we stated that we believed effici encies were most likely to occur when contiguous body areas are the focus of the imaging because the patient and equipment have already been prepared for the sec ond and subsequent pr ocedures, potentially yielding resource savings in areas such as clerical time, tec hnical preparation, and supplies (70 FR 45850). Therefore, the MPPR policy currently applies only to procedures involving contiguous body areas w ithin a family of codes, not across families, and to those procedures that are provided in a single session. Additionally, while the MPPR policy applies to TC-only services a nd to the TC of global services, it does not apply to professional co mponent (PC) services. Under the current imaging MPPR policy, full payment is made for the TC of the highest-paid procedure, and payment is reduced by 25 percent of the TC for each

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additional procedure when an MPPR scenario applies. We had or iginally planned to phase in the MPPR policy over a 2-year peri od , with a 25 percent reduction in CY 2006 and a 50 percent reduction in CY 2007 (70 FR 70263). However, the Deficit Reduction Act of 2005 (Pub. L. 109–171) (DRA) capped th e PFS payment amount for most imaging procedures at the amount paid under the hosp ital Outpatient Prospective Payment System (OPPS). In view of the DRA, we determined that it would be prudent to retain the MPPR at 25 percent while we continued to ex amine the appropriate payment levels (71 FR 69659). The DRA also exempted reduced expenditures attributable to the MPPR policy from the PFS budget neutrality provision. Most recently, effective July 1, 2010, section 3135(b) of the ACA increased the MPPR on the TC of imaging services under the policy established in the CY 2006 PFS fina l rule with comment period from 25 to 50 percent and exempted the reduced expenditures attributable to this further change from the PFS budget neutrality provision. In the July 2009 GAO report entitled, "Medicare Physician Payments: Fees Could Better Reflect Efficiencies Achieved when Services are Provided Together," the GAO recommended that we take further steps to ensure that fees for services paid under

the PFS reflect efficiencies that occur when services are performed by the same physician on the same beneficiary on the same day. The GAO recommended the following: (1) expanding the existing MPPR policy to the PC to reflect efficiencies in physician work for certain imaging services; and (2) expanding the MPPR to reflect PE efficiencies that occur when certain nonsurgical, nonimaging services are provided together. The GAO also encouraged us to focus on service pa irs that have the most impact on Medicare spending.

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In the March 2010 report, MedPAC noted its concerns about mispricing of

services under the PFS. MedP AC indicated that it would ex plore whether expanding the unit of payment through packaging or bundling would improve payment accuracy and encourage more efficient use of services. In the CYs 2009 and 2010 PFS proposed rules (73 FR 38586 and 74 FR 33554, respectively), we stated that we planne d to analyze nonsurgical services commonly furnished together (for example, 60 to 75 percent of the time) to assess whether an expansion of the MPPR policy could be warran ted. MedPAC encouraged us to consider duplicative physician work, as well as PE, in any expansion of the MPPR policy. b. Proposed CY 2011 Expansion of the Imag ing Technical Component MPPR Policy to Additional Combinations of Imaging Services Over the past 2 years, the AMA RUC has examined several services billed 90 percent or more of the time together as part of the potentially misvalued service initiative and, in several cases, created one code to describe the complete service, with a value that reflects the expected efficiencies. Notwithstanding the bundling work of the RUC, there may be additional imaging and other diagnostic services that are furnished together less than 90 percent of the time where we could still expect efficiencies in the TC, and in some cases in the PC, resulting in potential overpayment for these services under current policy when furnished together. Section 1848(c)(2)(K) of the Act (as added by section 3134 of the ACA) specifies that the Secretary shall identify potentially misvalued codes by examining multiple codes that are frequently billed in conjunction with furnishing a single service, and review and make appropriate adjustments to their relative values. As a first step in applying this provision, we are proposing a limited expansion of the current imaging MPPR policy for

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CY 2011. We will continue to review other possible expansi ons of the MPPR policy to the TC and/or PC of imaging procedures or other diagnostic tests for the future. Any further changes would be addre ssed in future rulemaking. In a related policy for hospital outpatient payment of imaging services, in the CY 2009 OPPS/ASC final rule with comment period (73 FR 68559 through 68569), the OPPS adopted a policy to pay for two or more CT and CTA, MRI and MRA, or ultrasound procedures furnished in the sa me session through a single composite ambulatory payment classifica tion (APC) group. These composite APC payments were

based on the 11 families of codes subject to the MPPR under the PFS that were collapsed into 3 imaging families for the OPPS according to their modality – 1 for ultrasound, 1 for CT and CTA, and 1 for MRI and MRA services. At that time, we stated our belief that the contiguous body area concept that was incorporated in the PFS imaging families was not necessary for potential efficiencies to be achieved in an imaging session. We provide d examples to illustrate that we would not expect second and subsequent imaging se rvices of the same modality involving noncontiguous body areas to require duplicate fa cility resources (comparable to the TC under the PFS) for clinical labor activities such as gree ting the patient, providing education and obtaining cons ent, retrieving prior exams, setting up an intravenous infusion, and preparing and cleaning the room , any more than second and subsequent imaging procedures of the same modality involving cont iguous body areas. While we noted that multiple imaging claims under the OPPS are generally within the same imaging modality and involve contiguous body areas the vast majority of the time, we estimated that the collapsed 3 families, as opposed to the 11 PFS families, would add 12 percent additional claims to those eligible for a single composite APC payment under the

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OPPS based on the provision of 2 or more imaging services in a single session, allowing us to capture additional claims with efficiencies. Taking into consideration the OPPS policy that was adopted in the CY 2009 OPPS/ASC final rule with comment period, in this proposed rule, we are proposing to apply the MPPR regardless of family, that is, the policy would apply to multiple imaging services furnished within the same family of codes or across families. This proposal would simplify the current imaging MPPR polic y in a way that is consistent with the standard PFS MPPR policy for surgical proc edures that does not group procedures by body region. Therefore, the MPPR would apply to CT and CTA, MRI and MRA, and ultrasound procedures services furnished to the same patient in the same session, regardless of the imaging modality, a nd not limited to contiguous body areas. Because of the different pieces of equipment used for CT/CTA, MRI/MRA, and ultrasound procedures, it would be highly unlik ely that a single practitioner would furnish more than one imaging procedure involving 2 different modalities to one patient in a single session where the proposed MPPR polic y would apply. On the other hand, while most multiple procedures furnished with a single modality in one session would involve procedures currently assigned to one of the 11 imaging families, it would not be uncommon for more than one imaging procedur e of the same modality to be furnished across families and, like the scenario for hospita l outpatient imaging services, we would expect efficiencies to occur in these cases. Th erefore, we believe that an expansion of the current imaging MPPR policy to account for e fficiencies in such situations would allow us to pay more appropriately for these multiple imaging procedure sessions, consistent with our ongoing efforts to a ddress misvalued services.

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The proposed expansion of the imaging MPPR policy to include all of the current codes in a single family to which the st andard 50 percent re duction for second and subsequent procedures would apply would reduce payment for 20 percent more services than the current MPPR policy under the PFS. Thus, under the CY 2011 proposal, we would capture additional efficiencies and pay mo re appropriately in these cases. We note that, as indicated above, section 3135(b )(2) of the ACA specifies that reduced expenditures attributable to the increase in the imaging MPPR from 25 to 50 percent in CY 2011 are excluded from the PFS budget neutrality adjustment. However, the reduced payment for code combinations that would newly be subject to the imaging MPPR policy under this proposal would be made in a budge t neutral manner under the PFS, as these

new combinations are not included under section 1848(b)(4)(D) (added by section 3135(b) of the ACA), which a ddresses "single-session ima ging to consecutive body parts" under the established imaging MPPR policy. Finally, we are also proposing to add the codes displayed in Table 17 to the list of imaging services subject to the MPPR policy in CY 2011. These codes were newly

created for CY 2010 and are similar to codes currently in imaging family 2, titled CT and CTA (Chest/Thorax/Abdomen/Pelvis).

We further note that new CY 2010 CPT codes 74261 (Computed tomography (CT) colonography, diagnostic, including image postprocessing; without contrast material) and 74262 (Computed tomography (C T) colonography, diagnostic, including image postprocessing; with c ontrast material(s) including non-contrast images, if performed) were added to the CY 2010 MPPR policy through the July 2010 PFS quarterly update, with a retroactive effec tive date of January 1, 2010. These codes replaced CPT code 0067T (Computed tomogr aphic (CT) colonography (ie, virtual

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colonoscopy); diagnostic) in CY 2010, which was on the list of procedures subject to the imaging MPPR policy prior to CY 2010. As discussed earlier in this section, reduced expenditures attributable to the increase in the MPPR for multiple imaging procedures to consecutive body parts (that is, those previously designated in the same family of codes) are exempt from the budget neutrality provision of the PFS. However, th e reduced expenditures attributable to the MPPR for combinations of multiple imaging procedures that we are proposing for CY 2011 (the MPPR for multiple imaging proce dures not involving consecutive body parts) would be subject to budget neutrality adjus tment under the PFS. We note that this

formulation for whether redu ced expenditures are exempt from budget neutrality applies both to procedures currently subject to th e imaging MPPR and to new codes that are subject to the policy in CY 2011 and in future years. To the extent that imaging procedures described by the new codes ar e furnished in combination with other procedures that are subject to the imaging MPPR on consecutive body areas, the reduced expenditures attributable to the MPPR for th ese combinations would be exempt from the PFS budget neutrality adjustment. The complete list of codes subject to the proposed CY 2011 MPPR policy for diagnostic imaging services is included in Addendum F to this proposed rule. TABLE 17: Proposed CPT Code Additions to the Diagnostic Imaging MPPR Policy for CY 2011

CPT Code Short Descriptor 75571 Ct hrt w/o dye w/ca test 75572 Ct hrt w/3d image 75573 Ct hrt w/3d image, congen 75574 Ct angio hrt w/3d image c. Proposed CY 2011 Expansion of the MPPR Policy to Therapy Services

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In the July 2009 GAO report entitled, "Medicare Physician Payments: Fees Could Better Reflect Efficiencies Achieved when Services are Provided Together," the GAO found efficiencies when multiple physical therapy services were furnished in one

session and concluded that an MPPR policy could be appropria te for these services. In the report, the GAO noted that officials from the AMA RUC explained that time spent on pre-service and post-service therapy activities is spread across the number of services in a typical session in order to avoid duplication of the PE for the services. Nevertheless, the GAO found that there was duplication of certain activities in the intra-service period, and provided the example of time spent testing range of motion or muscle flexibility that was duplicated in commonly observed code pairs. In the typical clinical scenario for therapy services, we believe that therapy services are misvalued for PFS payment when multiple services are furnished to a patient in a single session because duplicate clinical la bor and supplies are included in the PE of

the services furnished. We believe this duplication should be accounted for under the PFS, as we currently account for efficiencies in multiple surgical and multiple diagnostic imaging procedures furnished in a single se ssion. Over the past 2 years, the AMA RUC has examined several services billed 90 percent or more of the time together as part of its potentially misvalued service initiative and, in se veral cases, created one code to describe the complete service, with a value that reflects the expected efficiencies. Notwithstanding the AMA RUC's analyses, in most cases it has not created one code to describe a complete therapy service, in part because many of the core therapy CPT codes

are timed codes based on increments of treatment time. Therefore, we are proposing a further step to implement section 1848(c)(2)(K) of the Act (as added by section 3134 of the ACA) that specifies that the Secretary shall

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identify potentially misvalued codes by examining multiple codes that are frequently billed in conjunction with furnishing a single service. For CY 2011 we are proposing an MPPR policy for the HCPCS codes listed in Ta ble 18, specifically the separately payable "always therapy" services that are only paid by Medicare when furnished under a therapy plan of care. These services are designated "always therapy" services regardless of who furnishes them and always require therapy m odifiers to be reported, specifically -GP (Services rendered under outpatient physical therapy plan of care); -GO (Services rendered under outpatient occupati onal therapy plan of care); or -GN (Services rendered under outpatient speech pathology plan of care). The therapy codes are available in a file on the CMS Web site at: http://www.cms.gov/TherapyServices/. We have excluded both contractor-priced and bundled codes from Table 18 because, under our proposal, an MPPR would not be applicable for "always th erapy" services furnished in combination

with these codes. In the case of bundled codes that are not separately paid, there are no explicit efficiencies in the direct PE to be reflected in payment for the second and subsequent therapy services furnished to th e patient on the same day. In the case of contractor-priced codes, there is no nationally established pric ing that could be uniformly adjusted to reflect the expected efficiencies when multiple therapy services are furnished. TABLE 18: Separately Payable "Always Therapy" Services Subject to the Proposed CY 2011 MPPR Policy*

CPT/HCPCS Code Short Descriptor 92506 Speech/hearing evaluation 92507 Speech/hearing therapy 92508 Speech/hearing therapy 92526 Oral function therapy 92597 Oral speech device eval 92607 Ex for speech device rx, 1hr 92608 Ex for speech device rx addl 92609 Use of speech device service

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CPT/HCPCS Code Short Descriptor 96125 Cognitive test by hc pro 97001 Pt evaluation 97002 Pt re-evaluation 97003 Ot evaluation 97004 Ot re-evaluation 97010 Hot or cold packs therapy 97012 Mechanical traction therapy 97016 Vasopneumatic device therapy 97018 Paraffin bath therapy 97022 Whirlpool therapy 97024 Diathermy eg, microwave 97026 Infrared therapy 97028 Ultraviolet therapy 97032 Electrical stimulation 97033 Electric current therapy 97034 Contrast bath therapy 97035 Ultrasound therapy 97036 Hydrotherapy 97110 Therapeutic exercises 97112 Neuromuscular reeducation 97113 Aquatic therapy/exercises 97116 Gait training therapy 97124 Massage therapy 97140 Manual therapy 97150 Group therapeutic procedures 97530 Therapeutic activities 97533 Sensory integration 97535 Self care mngment training 97537 Community/work reintegration 97542 Wheelchair mngment training 97750 Physical performance test 97755 Assistive technology assess 97760 Orthotic mgmt and training 97761 Prosthetic training 97762 C/o for orthotic/prosth use G0281 Elec stim unattend for press G0283 Elec stim other than wound G0329 Electromagntic tx for ulcers *Excludes contractor-priced and bundled codes.

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At this time, we are not proposing an MPPR policy for "sometimes therapy" services, specifically those services that may be furnished under a therapy plan of care or otherwise by physicians or NPPs as medical services. We believe that the care patterns are different for the latter gr oup of services that may some times be furnished as therapy services, and note that they are less commonly furnished with multiple services in a single session than the "always therapy" services. In the discussion that follows, our reference to therapy services means those HCPCS codes designated annually as "always therapy" services by CMS.

Based on CY 2009 PFS claims data, we identified over 500 therapy service code pairs billed for the same patient in a single session. We then reviewed a sample of the most common therapy code pairs, specifically those high volume code pairs with more than 250,000 combined services per year, to examine the potential for duplication in the PE. These codes pairs represented more than half of the occurrences of therapy services billed together. While we acknowledge that the PE inputs per service for some therapy

services were included in the direct PE data base based on one-half of the total PE inputs required for two services provided in a si ngle session, which would account for some duplication, this was not the case for all combin ations of therapy services. Of the high volume therapy services examined, approximate ly one-fourth of the code pairs were not valued based on two services. In addition, we note that the CY 2009 PFS claims data show that when multiple therapy services are billed on a claim for the same date of service, the median number is four services per day. Therefore, even for those clinical labor times that may reflect the allocation of total time across two units of therapy services, we believe that some elements of the current PE inputs are duplicated based on

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current patterns of therapy service delivery where most multiple service claims involve delivery of more than 2 services in a session. Duplicate labor activities currently included in the PE for the service period for these high volume pairs of therapy services are as follows: clean room/equipment;

education/instruction/counselin g/coordinating home care; gree t patient/provide gowning; obtain measurements, for example, ROM/st rength/edema; and post-treatment patient assistance. The most common duplicate supply item included in the PE was the multispecialty visit pack. Examples of duplicated and unduplicated labor activities and supplies for two sample therapy code pairs and our estimates of potential clinically appropriate time and quantity reductions for multiple service sessions are displayed in

Table 19. We note that CY 2009 PFS claims da ta for these sample code pairs include over 3.4 million pairs of CPT code s 97112 (Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of m ovement, balance, coor dination, kinesthetic sense, posture, and /or proprioception for sitting and/or standi ng activities) and 97110 (Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility) furnished by the same practitioner on the same day and over 500,000 pairs of CPT codes 97001 (Physical therapy evaluation) and 97140 (M anual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes).

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TABLE 19: Examples of Duplicate PE Inputs for Therapy Services that Should be Accounted for When Multiple Services are Furnished in One Session Example 1 : CPT code 97112 (Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and /or proprioception for sitting and/or standing activities) and CPT code 97110 (Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility)

Staff Description Labor Task Description Time Period Code A 97112 Labor Task Time Code B 97110 Labor Task Time Total Minute Reduction Physical Therapy Aide Clean room/equipment Service Period, PostService 1 1 1 Physical Therapy Assistant Education/instruction/ counseling/coord home care Service Period, PostService 2.5 2.5 2.5

Physical Therapy Aide Greet patient/provide gowning Service Period, PreService 1.5 1.5 1.5 Physical Therapy Assistant Obtain measurements, eg, ROM/strength/edema Service Period, PreService 1.5 1.5 1.5 Physical Therapy Assistant Obtain vital signs Service Period, PreService 1 1 1 Physical Therapy Assistant Phone calls between visits with patient, family Post-Service Period 1 1 1 Physical Therapy Aide Post treatment patient assistance Service Period, PostService 1 1 1 Physical Therapy Assistant Review/read documentation, plan of care, treatment goals Pre-Service Period 1.5 1.5 1.5

Physical Therapy Aide Verify/Coordinate availability of resources/equip Pre-Service Period 1.5 1.5 1.5

Supply Description Price Code A 97112 Quantity Code B 97110 Quantity Code B 97110 Quantity Reductionpack, minimum multispecialty visit $1.14 0.5 0.5 0 Thera-bands (6in width) $0.06 1.5 1.5 1.5

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Example 2: CPT code 97001 (Physical therapy evaluation) and CPT Code 97140 (Manual therapy techniques (eg, mobilization/manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes)

Staff Description Labor Task Description Time Period Code A 97001 Labor Task Time Code B 97140 Labor Task Time Total Minute Reduction Physical Therapy Aide Clean room/equipment Service Period, PostService 3 1 1 Physical Therapy Assistant Education/instruction/ counseling/coord home care Service Period, PostService 2 1 1

Physical Therapy Aide Greet patient/provide gowning Service Period, PreService 3 1.5 1.5 Physical Therapy Assistant Obtain measurements, eg, ROM/strength/edema Service Period, PreService 8 1.5 1.5 Physical Therapy Assistant Obtain vital signs Service Period, PreService 3 1 1 Physical Therapy Assistant Phone calls between visits with patient, family Post-Service Period 2 1 1 Physical Therapy Assistant Review/read documentation, plan of care, treatment goals Pre-Service Period 1 .5 .5

Physical Therapy Aide Verify/Coordinate availability of resources/equip Pre-Service Period 3 1.5 1.5

Physical Therapy Aide Prep and position patient Service Period, PreService 2 0 0 Physical Therapy Aide Prepare room, equipment, supplies Service Period, PreService 2 0 0 Physical Therapy Aide Post treatment assistance Service Period, PostService 0 1 0

Supply Description Price Code A 97001 Quantity Code B 97140 Quantity Code B 97140 Quantity Reduction pack, minimum multi-specialty visit $1.14 1 0.5 0.5 lotion, message, unscented $0.158 0 0.5 0



### We did not remove minutes for clinical la bor tasks that were not duplicated. For example, for CPT code pair 97001 and 97140 th e following tasks were not duplicated: post treatment patient assistan ce; prep and position patient; a nd prepare room, equipment, and supplies. In addition, we did not remove any supply items that would be required for only one of the separate services because these would not be duplicated in the PE

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applicable to the combination of services. We estimated no reduction for equipment time, even though efficiencies would be exp ected for equipment that is used in both services when they are furnished together. Finally, a corresponding reduction to the indirect expenses is appropriate since indirect costs are allo cated partially based on direct costs. For five high volume therapy code pairs that each occur over 2 million time in PFS claims for multiple therapy se rvices and account for almost half of such claims, we estimated that the resulting reduction in the PE for the lower paying code would range from 28 to 56 percent. In summary, given the duplicative clini cal labor activities a nd supplies as shown in the code combination examples, we belie ve it would be appropr iate to extend the 50 percent MPPR policy that is currently applied to surgical services and the TC of imaging services, to the PE component of certain ther apy services. Specifically, we are proposing to apply a 50 percent payment reduction to the PE component of the second and subsequent therapy services for multiple "always therapy" services furnished to a single patient in a single day. Because it would be difficult to determine the precise beginning and end of therapy sessions and we do not believe that benefi ciaries would typically have more than one therapy session in a single da y, we are proposing to apply the 50 percent MPPR policy to the PE component of subseque nt therapy services provided to the same patient on the same day, rather than in the same session. We note that many therapy services are time-based CPT codes, so multiple units of a single code may be billed for a single session that lasts for a longer period of time than one unit of the code. The proposed M PPR policy would apply to multiple units of the same therapy service, as well as to multiple different services, when furnished to the same patient on the same day. Full payment would be made for the service or unit with

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the highest PE and payment would be made at 50 percent of the PE component for the second and subsequent procedures or units of the service. The work and malpractice components of the therapy service payment w ould not be reduced. For therapy services furnished by a group practice or "incident to" a physician's service, the MPPR would apply to all "always therapy" services furnis hed to a patient on the same day, regardless of whether the services are provided in one therapy discipline or multiple disciplines, for example, physical therapy, occupational therapy, or speech-language pathology. The proposed CY 2011 MPPR policy would apply to both those services paid under the PFS that are furnished in the office setting and those services paid at the PFS rates that are furnished by outpatient hospitals, home h ealth agencies, comprehensive outpatient rehabilitation facilities (CORFs), and other entities that are paid by Medicare for outpatient therapy services. Table 20 provide s a sample calculation of the current and proposed CY 2011 payment for multiple therapy services furnished in on the same day. For those services paid under the PFS, the PFS budget neutrality provision would apply so that the estimated reduced expenditures for therapy services would be redistributed to increase payment for other PFS services.

TABLE 20: Sample Proposed Payment Calculation for Multiple Therapy Services Furnished to a Single Patient on the Same Day

Procedure 1 Unit 1 Procedure 1 Unit 2 Procedure 2 Current Total Payment Proposed CY 2011

Total Payment Proposed Payment Calculation Work $7.00 $7.00 $11.00 $25.00 $25.00 no reduction PE $10.00 $10.00 $8.00 $28.00 $19.00 $10 + (0.5 x $10) + (0.5 x $8) Malpractice $1.00 $1.00 $1.00 $3.00 $3.00 no reduction Total $18.00 $18.00 $20.00 $56.00 $47.00 $18 + $7 + (0.5 x $10) + $1 + $11 + (0.5 x $8) + $1



### We believe this proposed therapy MPPR policy would provide more appropriate payment for therapy services that are comm only furnished together by taking into

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account the duplicative clinical labor activitie s and supplies in the PE that are not furnished more than once in the single therap y session. This approach is consistent with the statutory requirement for the Secretary to identify, review, and adjust the relative values of potentially misvalued services under the PFS as specified by section 3134 of the ACA. We also believe this proposed polic y is responsive to Congressional concerns about significant growth in therap y spending and to MedPAC and GAO recommendations regarding the expansion of MPPR policies under the PFS to account for additional efficiencies. We note that payi ng more appropriately for therapy services based on PE relative values that are adjusted for the clinical scenario under which the

services are furnished would result in redu ced therapy expenditures, and beneficiaries would be able to receive more medically ne cessary outpatient therapy services before reaching the therapy cap. For a further discussion of potential alternatives to the therapy caps, we refer readers to section III.A.2. of this proposed rule. 5. High Cost Supplies a. Background MedPAC and the AMA RUC have long recommended that CMS establish a frequent price update process for high-cost supp lies that are direct PE inputs in the PE database for services paid unde r the PFS because of their speculation that prices for these items may decrease ove r time as competition increases and new technolog ies disseminate into medical practice. MedPAC in particular has pe rennially noted that it is important for CMS to update the prices of high-priced supplie s on a regular basis as inaccurate prices can distort PE RVUs over time, contributing to the misvaluing of established services

under the PFS. Most of the current prices for high-c ost supplies included in the direct PE

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database are from 2004 or earlier. There are currently 62 unique supplies with prices of $150 or more in the proposed CY 2011 PE da tabase, which is available on the CMS Web site under the supporting da ta files for the CY 2011 PFS proposed rule at http://www.cms.gov/PhysicianFeeSched/ . Finally, we note that we do not actually pay the supply prices included in the PE database but, instead, use them to develop the PE RVUs according to our standard PE methodology as described in section II.A.2. of this proposed rule. Payment for a procedure that uses a supply is based upon the PE RVUs that result from the PE methodology, and supplies are among the direct PE inputs for procedures. Therefore, it is the relativity of high-cost supply prices to prices for other PE items (equipment, low-cost supplies, a nd clinical labor) that is important. Accordingly, in the CY 2009 PFS proposed rule (73 FR 38582), we proposed a process to update the prices for high-cost supplies priced at $150 or more that are included in the PE inputs for procedures paid under the PFS PE methodology. The CY 2009 proposed rule described a publicly transparent process in which CMS would publish a list of the high-cost supplies in the PFS proposed rule (65 supplies were included in the CY 2009 PFS proposed rule), a nd specialty societies or other relevant organizations would provide acceptable doc umentation supporting the pricing for the supplies during the 60-day public comment period . Furthermore, in that same proposed rule (73 FR 38582), we provided guidan ce on what constitutes valid, reliable documentation that reflects the typical price of the high-cost item in the marketplace. We outlined examples of acceptabl e documentation, such as a deta iled description (including system components), sources, and current pric ing information, confir med by copies of catalog pages, invoices, and quotes from manuf acturers, vendors, or distributors. We

indicated that documentation that does not in clude specific pricing information such as

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phone numbers and addre sses of manufacturers, vendors, or distributors or Web site links without pricing information would not be accep table. We also noted that if acceptable

documentation was not received within th e proposed rule's 60-day public comment period, we would use prices from the Intern et, retail vendors, and supply catalogs to determine the appropriate cost, and that we w ould use the lowest price identified by these sources (73 FR 38582). Finally, we solicited public comments on alternatives that could be used to update pricing information in the absence of acceptable documentation provided by specialty societies or other interested organizations.

In the CY 2009 PFS final rule with comme nt period (73 FR 69882), we indicated that we received many comments on the pr oposed process and, wh ile some commenters expressed support, others be lieved the proposed process wa s flawed and burdensome. Moreover, although we received some data in response to our request for information on the 65 high-cost supplies with prices of $150 or more, much of what we received was not complete or did not represent typical market prices. In particular , we expressed concern that the submitted data often represented manu facturer list prices for the premier models of many supplies, while we believed there were less expensive alternatives. Therefore, we were unable to determine the most appr opriate, typical supply prices for our PFS payment methodology that prices the typical se rvice described by a HCPCS code. Rather than finalizing the proposed process for upda ting high-cost supplies and revising the prices for the 65 supplies based on inadequate pricing information, we stated in the

CY 2009 PFS final rule with comment period (73 FR 69882) that we would research the possibility of using an independe nt contractor to assist us in obtaining accurate pricing information. Furthermore, we informed the public that we planned to study the limitations of available pr icing data and deter mine how to revise our proposed process to

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elicit better data. In the CY 2010 PFS proposed rule a nd final rule with comment period (74 FR 33554 and 61776, respectively), we stated that we were continuing to examine ways to obtain accurate pricing information for high-cost supplies. We noted again in the CY 2010 PFS proposed rule that we would depend upon the cooperation of the medical community to obtain typical prices in the marketplace, and we provided stakeholders with another opportunity to submit public co mments on the process. In the CY 2010 PFS final rule with comment pe riod, we acknowledged commenters' general support for an initiative to ensure accurate pricing of high-c ost supplies. In general, the commenters strongly preferred a transparent and public pro cess, and we stated that we would consider this perspective as we explore the best wa y to ensure that accurate supply pricing information is used in the PFS payment methodology. b. Future Updates to the Prices of High-Cost Supplies In working towards refining a process to update the prices of high-cost supplies

and consistent with our inte ntion expressed in the CY 2009 PFS final rule with comment period (73 FR 69882), we contracted with an independent contractor during CY 2009 to help us study the availability of accurate pricing information. We requested that the independent contractor, L&M Policy Researc h, research pricing information for the 65 high-cost supplies listed in the CY 2009 pr oposed rule (73 FR 38583 through 38585) and determine what, if any, pricing information reflecting typical mark et prices could be obtained for these high-cost supplies. We first requested that the contractor ex plore publicly available sources to obtain typical market prices for these supplies. The contract or utilized supply vendor catalogs and web sites and directly contacted vendors, manufacturers, group purchasing

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organizations (GPOs), and any other suppliers that the contractor identified in their research in order to identify prices for each of the supplies. Where more than one version of a supply item appeared to ma tch a description of a high-cost supply and/or more than one possible vendor or manufacturer was iden tified, the contractor attempted to obtain prices from the multiple sources. Upon review of the high-cost supply list, the contractor refined the list to 62 unique high-cost items with prices of $150 or more for the study. The original list only

consisted of 64 items but incl uded one item inadvertently lis ted twice (CMS Supply Code SD207 (suture device for vessel closure(Perc lose A-T)) and one ite m (CMS Supply Code SH079 (collagen implant)) that was deleted fro m the PE database after CY 2007 because it was no longer used as an input for any code s. While the contractor was able to obtain prices for 37 of the 62 unique supplies, th e contractor was unable to obtain pricing information for the remaining 25 supplies. Do cumentation of these prices, a requirement we discussed in the CY 2009 PFS proposed rule (73 FR 38582), was only obtained for 25 of the 36 supplies with new pric ing information. For the remainder, while the contractor was given price quotes over the phone, th e sales agents or customer service representatives declined to provide any fo rm of written documentation, in some cases because company policies restricted providing pricing documentation to prospective customers without an account. Moreover, information on typical discounts was obtained for only seven products, and only one discount was documented. In the case of these products, companies disclosed the maximu m available discounts, ranging from 18 percent to 45 percent. Relative to prices currently included in the PE database, the contractor found higher prices for the majo rity of the medical supplies that were researched, specifically 23 supplies with high er prices, 8 with lower prices, and 3 with

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the same price. The high-cost supplies st udied by the contractor and their current database prices are displayed in Table 20.

TABLE 20: High-Cost Supplies with Prices of $150 or Greater in the PFS Direct PE Database that were Studied by the CMS Contractor

CMS Supply

Code Supply Description Current Database Unit Price Associated CPT Codes stent, ureteral, wguidewire, 3cm flexible tip $235 52332 probe, cryoablation, renal $1,175 50593 catheter, intradiscal (spineCATH) $1,380 22526, 22527 probe, cryoablation (Visica ICE 30 or 40) $1,589 19105 kit, capsule, ESO, endoscopy w-application supplies (ESO) $450 91111 catheter, balloon, lacrimal $306 68816 catheter, CVA, system, tunneled w-port, dual (LifeSite) $1,750 36566 stent, vascular, deployment system, Cordis SMART $1,645 37205, 37206 agent, embolic, 2 ml uou $258 37210

tube, jejunostomy $195 49441, 49446, 49451, 49452 SA005 kit, capsule endoscopy w-application supplies (M2A) $450 91110

SA010 kit, CVA catheter, tunneled, without portpump $308 36557, 36558, 36581

SA011 kit, CVA catheter, tunneled, with subcut port $495 36560, 36561, 36563, 36582, 36583

SA015 kit, for percutaneous thrombolytic device (Trerotola) $488 36870, 37184, 37186, 37187, 37188 SA020 kit, loop snare (Microvena) $275 36595, 37203 SA022 kit, percutaneous neuro test stimulation $305 63610, 64561 SA024 kit, photopheresis procedure $858 36522

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CMS Supply

Code Supply Description Current Database Unit Price Associated CPT Codes

SA025 kit, PICC with subcut port $586 36570, 36571, 36585 SA036 kit, transurethral mic rowave thermotherapy $1,149 53850 SA037 kit, transurethral needle ablation (TUNA) $1,050 53852 SA038 kit, transurethral waterinduced thermotherapy $650 53853 SA039 kit, vertebroplasty (LP2, CDO) $696 22520, 22521 SA074 kit, endovascular laser treatment $519 36478 SA075 kit, hysteroscopic tubal implant for sterilization $1,245 58565 SA077 kit, pleural catheter insertion $329 32550, 96440 SA087 tray, RTS applicator (Mammosite) $2,550 19296 SA091 tray, scoop, fast track system $750 31730 SA092 kit, gene, MLL fusion $1,395 88385 SA093 kit, priming, random $463 (6 pack) 88385, 88386 SC085 tubing set, plasma exchange $173 36514 SD018 catheter, balloon, thermal ablation (Thermachoice) $727 58353

SD019 catheter, balloon, ureteral-GI (strictures) $166 43456, 45303, 45340, 45386, 46604 SD020 catheter, CVA, tunneled, dual (Tesio) $355 36565

SD023 catheter, enteroclysis $183 74251, 74260, 89100, 89105, 89130, 89132, 89135, 89136, 89140, 89141 SD058 electrode, grid $475 95829 SD072 eyelid weight implant, gold $218 67912 SD073 fiducial screws (set of 4) $558 (set of 4) 77011, 77301 SD094 mammotome probe $200 19103

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CMS Supply

Code Supply Description Current Database Unit Price Associated CPT Codes

SD109 probe, radiofrequency, 3 array (StarBurstSDE) $1,995 20982, 32998, 41530, 50592 SD151 catheter, balloon, low profile PTA $432 35470, 35471, 35474

SD152 catheter, balloon, PTA $244 35472, 35473, 35475, 35476, G0392, G0393

SD154 catheter, microcatheter (selective 3rd order) $338 36217, 36247, 36481, 37183, 37210 SD155 catheter, RF endovenous occlusion $725 36475

SD175 guidewire, steerable (Transcend) $180 36217, 36247, 36481, 37183, 37205, 37206, 37210, 49440, 49441, 49442, 49446, 49450, 49451, 49452, 49460 SD177 hysteroscope, ablation device $1,146 58563 SD185 plasma antibody adsorption column (Prosorba) $1,150 36515

SD186 Plasma LDL adsorption column (Liposorber) $1,380 36516 SD189 plate, surgical, mini-compression, 4 hole $226 21208

SD191 plate, surgical, reconstruction, left, 5 x 16 hole $719 21125, 21127, 21215

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CMS Supply

Code Supply Description Current Database Unit Price Associated CPT Codes SD193 plate, surgical, rigi d comminuted fracture $389 21461, 21462 SD204 sensor, pH capsule (Bravo) $225 91035 SD205 sheath, endoscope ultrasound balloon $154 31620

SD207 suture device for vess el closure (Perclose A–T) $225 35470, 35471, 35472, 35473, 35474, 35475, 37184, 37187, 37188, 37205, G0392 SD215 probe, endometrial cryoablation (Her Option) $1,250 58356

SD216 catheter, balloon, esophageal or rectal (graded distention test) $165 91040, 91120 SD218 stent, ureteral, without guidewire $162 50382, 50384, 50385

SF028 laser tip (single use) $290 30117, 52214, 52224, 52317 SF029 laser tip, bare (single use) $150 46917, 46924 SF030 laser tip, diffuser fiber $850 52647, 52648 SL055 DNA stain kit (per test) $150 (10 pack) 88358 SL209 array kit, Genosensor $2,121 88386 SL225 gas, nitogen, ultra-high purity (compressed) grade 5.0 $190 88385, 88386

Next, we directed the contractor to access the United States General Services Administration (GSA) medical supply schedule to augment the results obtained through

review of vendor materials a nd direct contact with vendors, manufacturers, and GPOs. We note that the GSA establishes long-term government-wide contracts with commercial

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firms for many products, negotiating contract s and determining prices to be fair and reasonable prior to placing them on schedule. Included on the schedule are thousands of medical supplies at prices that, in most cas es, are established through competition. The GSA schedule is an open solic itation and a business of any size, if it is stable and financially sound, can request to be included on the schedule. GSA's vendors usually are

nationwide vendors with substa ntial non-government sales, and products on the schedule

must be manufactured in the U.S. or in a nation with a trade agreement with the United

States. Submissions for the schedule are received 365 days per year, vendor contracts can be of varying lengths, and vendors can a dd or delete products from the schedule. Depending on the aggregate cost estimate asso ciated with the vendor's supply items, the time to achieve inclusion on the schedule can vary from as short as several months to as long as 2 years. The GSA has delegated aut hority to the Department of Veterans Affairs (VA) to procure medical supplies under th e VA Federal Supply Schedules Program. Using the GSA general search engine unde r the category "Laboratory, Scientific,

& Medical" available at https://www.gsaadvantage.gov/advg sa/advantage/ma in/start_page.do the contractor obtained nine prices for items similar to the hi gh-cost supplies in the PE database and that are displayed in Table 20 from the publicly available information on the Internet, including pricing for one product for which its pr ior work did not yield an updated price.

We believe that add itional items that are similar to the high-cost supplies in the PE database and that may be used with the sa me procedures may be on the GSA schedule but we are still working through the crosswalk be tween our supplies and the way the supplies are presented on the GSA schedul e. Examples of high-cost supplies in the PE database

that the contractor located on the GSA sc hedule include: (1) kit, capsule, ESO,

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endoscopy w-application supplies (ESO), pr iced at $450 in the PE database and $444 on the GSA schedule; and (2) tube, jejunostomy, priced at $195 in the PE database and $60 to $83 on the GSA schedule, depending on the characteristics of the tube. Since the GSA medical supply schedule is a source for pricing information that is public and transparent and reflects the best government contract price for a product, we

believe it is a desirable resource for us to us e in a refined process for updating the prices of high-cost supplies. For historical cont ext, CMS has previously proposed to use VA prices that result from the competitive ma rketplace as comparison points to limit the Medicare prices for oxygen and certain items of durable medical equipment and prosthetic devices (62 FR 38100 thr ough 38107, and 64 FR 44227 through 44231) in 1997 and 1999, respectively. These prior proposal s were based on our determination that the Medicare payment amounts for these ite ms as durable medical equipment or prosthetics (not as physicians' services) we re not inherently reasonable. We note, however, that our current interest in the GS A schedule for pricing high-cost supplies for payment of physicians' services is not based on considera tions of inherent reasonableness, and we do not actually pay th e prices in the PE database for supplies

under the PFS. We further note that public commenter s on pricing high-cost supplies have consistently requested that CMS ensure that the pricing information used to update the prices is provided publicly. The commenters ha ve observed that this transparency would enable stakeholders to evaluate and provide feedback to the agency on pricing accuracy (74 FR 61776). We also acknowledge that our past attempts ove r several years to identify typical market prices for the high -cost supplies have been inhibited by the limited availability of public data that meet the documentation requirements we have

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previously established. Indi vidual vendors do not always publis h their product prices or provide typical discounts. Mo reover, discounts may vary de pending on suppliers and the volume of supplies purchased. Our understanding of the GSA medical supply schedule is that the publicly listed fair and reasonable pr ices on the schedule generally do not include volume and or certain other discounts that may be subsequently negotiated by the buyer. Consequently, we would consider the prices available on the GSA schedule to represent the "individual item ceiling" price for a single item purchase, which we believe would be appropriate to es timate the high-cost supply prices for physicians' office purchases. We are soliciting public comments regarding the high -cost supplies in the direct PE database for the CY 2011 PFS proposed rule, availabl e on the CMS Web site as noted earlier in this section, and the corresponding supplies or a lternative items that could be used for the same function that are currently on the GSA supply schedule. We encourage commenters to provide a detailed analysis of the current relationships between the items in the PE

database and those on th e GSA schedule. At this time, we would like to describe a refined pr ocess for regularly updating prices for high-cost supplies under the PF S and solicit comment s on how we could improve on this process. Th e process could occur every 2 years beginning as soon as CY 2013, although we note that we woul d propose the refined process through rulemaking before revising the prices fo r any high-cost supply item based on the GSA

schedule. We could also consider establis hing a different price update period depending on whether a high-cost supply was a new supply in the PE database or had been in use for some time, in which case we might expect that the price would have stabilized and, therefore, could be updated less frequently. In general, we would expect that the periodicity of updating prices for high-cost supplies that we eventually adopted would

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balance the associated administrative burden with the rate of price changes, to ensure that the associated procedures remain appropriately valued, rather than increasingly misvalued, over time. We envision that we would base high -cost supply price inputs on the publicly available price listed on the GSA medical suppl y schedule. Since the medical community would have several years to examine the GS A medical supply schedule before the refined process would be adopted, a nd we have found no apparent limitations on vendors placing products on the GSA schedule, beyond the schedu le's interest in competitive, best value procurements, stakeholders would have the opportunity to ensure that any high-cost direct PE input for a PFS service that ma y currently be missing from the GSA medical supply schedule would be included before CM S needs to access the publicly available price for the item. If a supply price were not publicly available on the GSA medical supply schedule by the time CMS needs to acce ss the price, we would propose to reduce the current price input for the supply by a percentage that would be based on the relationship between GSA prices at that time and the existing PE database prices for similar supplies (currently an average 23 percen t reduction). We believe that this refined process is desirable because it is consistent with commenters' repeated requests for the updating methodology to be tran sparent and predictable. Moreover, the VA (with responsibility delega ted by the GSA) determines whether prices are fair and reasonable by compar ing the prices and discounts that a company offers the government with the prices and discounts that the company offers to commercial customers. Therefore, using th e GSA medical supply schedule as a source for publicly available prices would also better account for product-specific market dynamics than the alternative of an across- the-board percentage reduction for supplies

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not on the GSA schedule based on general pric e trends for the high-cost supplies on the schedule. That is, if the market price of a particular supply were not to drop according to broad trends for other high-cost supplies, suppliers would ha ve the opportunity to provide their price to the public on the GSA schedul e in order to preclude any reduction in Medicare payment for procedures associated with that supply. Finally, we would like to reiterate that we are interested in receiving detailed public comments on the refined process discu ssed above, including all aspects of the price update methodology that we have pres ented. Moreover, we believe a similar approach could potentially be a ppropriate to update the prices for other supplies in the PE

database that would not fall under our definition of high-cos t supplies, and we welcome further public comments on that possible extens ion. We also invite further suggestions for alternative approaches to updating high-c ost supply prices, specifically those that would result in a predictable, public, and tran sparent methodology that would ensure that the prices in the PE database reflect typical market prices. These principles are particularly important in order to ensure that the services that utilize the high-cost supplies when provided in the physician's offi ce are appropriately valued under the PFS and continue to be appropriately valued over time. D. Geographic Practice Cost Indices (GPCIs) 1. Background Section 1848(e)(1)(A) of the Act requires us to develop separate Geographic Practice Cost Indices (GPCIs) to measure resource cost differences among localities compared to the national average for each of the three fee schedule components (that is, work, PE, and malpractice). While requiring that the PE and malpractice GPCIs reflect the full relative cost differences, section 1848( e)(1)(A)(iii) of the Act requires that the

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physician work GPCIs reflect only one-quarter of the relative cost differences compared to the national average. In addition, secti on 1848(e)(1)(G) of the Act sets a permanent

1.5 work GPCI floor in Alaska for services furnished beginning January 1, 2009. Section 1848(e)(1)(C) of the Act requires us to review an d, if necessary, adjust the GPCIs at least every 3 years. This section also specifies that if more than 1 year has elapsed since the last GPCI revision, we must phase in the ad justment over 2 years, applying only one-half of any adjustment in each year. As di scussed in the CY 2009 PFS final rule with comment period (73 FR 69740), the CY 2009 adjus tment to the GPCIs reflected the fully implemented fifth comprehensive GPCI update . CY 2010 would have typically included no adjustments to the GPCIs. However, s ection 3102(a) of the ACA amends section 1848(e)(1)(E) of the Act to extend the 1.0 work GPCI floor for services furnished through December 31, 2010. Additionally, section 3102(b) of the ACA adds a new subparagraph 1848(e)(1)(H) to the Act, wh ich specifies that for CY 2010 and CY 2011, the employee compensation and rent portions of the PE GPCI must reflect only one-half of the relative cost differences for each locality compared to the national average. The new subparagraph also includes a "hold harmless" provision for CY 2010 and CY 2011 for any PFS locality that would otherwise r eceive a reduction to its PE GPCI resulting from the limited recognition of cost differences. Additionally, section 1848(e)(1)(I) of the Act (as added by secti on 10324(c) of ACA) establishes a 1.0 PE GPCI floor for

services furnished in frontier States eff ective January 1, 2011. In May 2010, we provided our Medicare contractors with an updated CY 2010 payment file that included the 1.0

work GPCI floor and the PE GPCIs calculate d according to the methodology required by section 1848(e)(1)(H)of the Act (as added by section 3102(b) of ACA) for CY 2010, to be used for payment of services furnished on or after January 1, 2010.

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For the CY 2011 PFS proposed rule, we have completed the sixth review of the GPCIs and are proposing new GPCIs. We not e that section 1848(e)(1)(E) of the Act (as amended by section 3102(a) of ACA) exte nds the 1.0 work GPCI floor only through December 31, 2010. Under current statute, th e 1.0 work GPCI floor will expire on January 1, 2011. Therefore, the CY 2011 physician work GPCIs and summarized geographic adjustment factors (GAFs) do not reflect the 1.0 work floor. However, section 1848(e)(1)(G) of the Act (as amended by section 134(b) of the MIPPA) set a permanent 1.5 work GPCI floor in Alas ka for services furnished beginning January 1, 2009 and, as noted above , section 1848(e)(1)(I) of the Act (as added by section 10324(c) of ACA) provides for a permanent 1.0 PE GPCI floor for frontier States effective January 1, 2011. Therefore, as requi red by the statute, the 1.5 work GPCI floor

for Alaska and the 1.0 PE GPCI floor for frontie r States will be in effect for CY 2011. In addition to the limited recognition of certain cost differences for the PE GPCIs, section 1848(e)(1)(H) of the Act (as added by secti on 3102 (b) of ACA) also requires us to complete an analysis of the data sources used and cost share weights assigned to the PE GPCIs. Implementation of ACA provisions related to the CY 2011 PE GPCIs is

discussed in more detail in th e GPCI update section below. See Addenda D and E to this proposed rule for the proposed CY 2011 GPCIs and

summarized GAFs. 2. GPCI Update The proposed updated GPCI values were developed by Acumen, LLC (Acumen)

under contract to CMS. As mentioned above, there are three GPCI components (physician work, PE, and malpractice), and all GPCIs are developed through comparison to a national average for each component. A dditionally, each of the three GPCIs relies

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on its own data source(s) and methodology for ca lculating its value as described below. a. Physician Work GPCIs The physician work GPCIs are designed to capture the relative cost of physician labor by Medicare PFS locality. Previously , the physician work GPCIs were developed using the median hourly earnings from the 2000 Census of workers in seven professional specialty occupation categories which we us ed as a proxy for physicians’ wages and calculated to reflect one-quarter of the relative cost differences for each locality compared to the national average. Physicians’ wages are not included in the occupation categories because Medicare payments are a key determinant of physicians’ earnings. Including physicians’ wages in the physicia n work GPCIs would, in effect, have made the indices dependent upon Medicare payments. The physician work GPCIs were updated in CYs 2001, 2003, 2005, and 2008 using professional earnings data from the 2000 Census. However, wage and earnings data are no longer available from the Census long form and the 2000 data are outdated. Therefore, for the proposed sixth GPCI update, we used the 2006 through 2008 Bureau of Labor Statistics (BLS) Occupational Employment Statistics (OES) data as a replacement for the 2000 Census data. The use of BLS OES data as a replacement for the 2000

Census data is discussed in more detail in the update of th e PE GPCIs section. As noted above, the 1.0 work GPCI floor is se t to expire under current statute on December 31, 2010. Therefore, the CY 2011 proposed physician work GPCIs reflect the

removal of this floor. b. Practice Expense GPCIs (1) The Affordable Care Act Requirements for PE GPCIs General Methodology for the CY 2011 GPCIs

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ACA added a new subparagraph 1848(e)(1) (H) to the Act which revises the methodology for calculating the PE GPCIs for CY 2010 and CY 2011 so that the employee compensation and rent portions of the PE GPCIs reflect only one-half of the relative cost differences for each locality compar ed to the national average. Additionally, under section 1848(e)(1)(H)(iii) of the Act (a s added by section 3102(b) of the ACA), each PFS locality is held harmle ss so that the PE GPCI will not be reduced as a result of the change in methodology for PE GPCIs. In accordance with section 1848(e)(1)(H)(ii) of the Act (as added by sec tion 3102(b) of ACA), the empl oyee compensation and rent components of the proposed CY 2011 PE GPCIs we re calculated to reflect one-half of the cost differences for each PFS locality relative to the national average cost. Additionally, as required by the statute, physicians’ services furnished in each PFS locality would be adjusted by the higher of the locality’s PE GPCI calculated with the limited recognition of employee compensation and rent cost diff erences or the PE GPCI calculated without the limited recognition of cost differences. Phase-In of PE GPCIs Section 1848(e)(1)(C) of the Act requires us to phase in GPCI adjustments over 2 years if there was more than 1 year between GPCI adjustments. In accordance with the statute, we are proposing to phase in the updated PE GPCIs using one-half of the CY 2010 values and one-half of the fully implemented values (as described in this section). To apply the phase-in and hold harmless provisi ons of the Act, we calculated transitional

PE GPCIs based on two scenarios. Under th e first scenario, we calculated transitional CY 2011 PE GPCIs using the full recognition of employee compensation and rent cost differences for each locality as compared to the national average. The CY 2011

transitional PE GPCI values with full reco gnition of cost differences were calculated

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using one-half of the CY 2010 PE GPCI values with full recognition of cost differences and one-half of the updated PE GPCIs with full recognition of cost di fferences. The first scenario represents the transitional PE GPCI values prior to the limited recognition of cost differences. In other words, this scenar io does not include the effects of sections 1848(e)(1)(H)(i) and (ii) of the Act (a s added by section 3102(b) of ACA). For the second scenario, we calculated transitional CY 2011 PE GPCIs with the limited recognition of cost differences for the employee compensation and rent components (as required by sections 1848(e)(1 )(H)(i) and (ii) of the Act (as added by section 3102(b) of ACA)). The CY 2011 tran sitional PE GPCI values with the limited recognition of cost differences were calcula ted using one-half of the CY 2010 PE GPCIs

with the limited cost differences and one-ha lf of the updated PE GPCIs with the limited cost differences. The hold harmless provisi on under section 1848(e)(1)(H)(iii) of the Act (as added by section 3102(b) of ACA) was applied by selecting the greater of the CY

2011 transitional PE GPCI value calculate d with the limited recognition of cost

differences or the CY 2011 transitional PE GC PI value calculated with full recognition of

cost differences . The phase-in of the CY 2011 PE GPCIs and application of the hold harmless provision are illustr ated in Table 21 below.

Table 21. Phase-In of the CY 2011 PE GPCIs

CY 2010 Updated GPCIs CY 2011 (Transitional Year) Hold Harmless

File 1 PE GPCI Without 3102(b) of ACA Without ACA Without ACA (Updated Data) (1/2 of 2010)+ (1/2 Updated GPCI)

File 2 PE GPCI With 3102(b) of ACA With ACA With ACA (Updated Data) (1/2 of 2010 w/ ACA)+ (1/2 Updated GPCI w/ ACA) Greater of File 1 Transitional Value

or File 2 Transitional Value *ACA in this table means the Affordable Care Act. 

### Data Analysis

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Section 1848(e)(1)(H)(iv) of the Act (as ad ded by section 3102(b) of ACA) also requires the Secretary to "analyze current methods of establishing practice expense adjustments under subparagraph (A)(i) and ev aluate data that fairly and reliably

establishes distinctions in the cost of operating a medical practice in different fee schedule areas." This section also requires th e Secretary to make appropriate adjustments to the PE GPCIs no later than by Janua ry 1, 2012. To implement this statutory requirement, we are proposing to implement ch anges in PE data sources and cost share weights discussed herein e ffective beginning in CY 2011. In accordance with section 1848(e)(1)(H)(iv ) of the Act (as added by section 3102(b) of ACA), we have analyzed the curre nt methods and data sources used in the

establishment of the PE GPCIs. With re spect to the method used, we began with a review of the GAO’s March 2005 Report entitled, "MEDICARE PHYSICIAN FEES: Geographic Adjustment Indices Are Valid in Design, but Data and Methods Need Refinement" (GAO-05-119). While we have raised concerns in the past about some of the GAO’s GPCI recommendations, we note that with respect to the PE GPCIs, the GAO did not indicate any signifi cant issues with the methods underlying the PE GPCIs. Rather, the report focused on some of the data sources used in the method. For example, the GAO stated that the wage data used for the PE GPCIs are not current. Similarly, upon our reexamination of pub lic comments we have received on the PE GPCIs for previous updates, we note that the commenter s predominately focused on either the data

sources used in the method or raised issues such as incentivizing the provision of care in different geographic areas. However, the latte r issue (incentivizing the provision of care) is outside the scope of the statutory require ment that the PE GPCIs reflect the relative costs of the mix of goods and services compri sing practice expenses in the different fee

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schedule areas relative to the national average. One key component of the PE GPCI method that our analysis identified involved the office expense portion of the PE GPCIs a nd the cost share weight assigned to this component. Most significantly, we are pr oposing that the weight for the office rent component be revised from 12.209 percent to 8.41 0 percent to reflec t our more detailed breakout of the types of office expenses that are determined in local markets instead of national markets. For example, for previous GPCI updates, we used the office expenses cost category as the cost share weight fo r office rent and, therefore, all individual components previously included in the office expenses category were adjusted for local area cost differences by the GPCIs. As disc ussed in section II.E.1. of this proposed rule, we are proposing to disaggregate the broader office expenses component into 9 new cost categories as part of the proposed CY 2011 MEI rebasing. The disaggregation of the office expenses category indicates that the fixed capital cost category, for which the consumer price index (CPI) for owner’s equivale nt rent is the price proxy, is the office expense category applicable to the office rent component of the PE GPCI. Therefore, the fixed cost capital cost category is the only component of office expenses that we are proposing to adjust for local area cost di fferences beginning in CY 2011. We are proposing to assign other newly defined com ponents of the office expenses category (for example, utilities, chemicals, paper, rubber and plastics, telephone, postage, and moveable capital) to the medical equipment, supplies, and other miscellaneous expenses cost component of the PE GPCIs. As di scussed later in this section, the medical equipment, supplies, and othe r miscellaneous expenses component of the PE GPCIs is

assumed to have a national mark et and, therefore, this compone nt is not adjusted for local

area cost differences.

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The proposed expense categories for the PE GPCIs, along with their respective cost share weights, are primarily derive d from the 2006 American Medical Association (AMA) Physician Practice Information Survey (PPIS) for self-employed physicians and selected self-employed non-medical doctor specialties. The PPIS is the most comprehensive, multispecialty, contemporaneous, and consistently collected PE data source available. It was developed by medi cal organizations and captures the costs of operating a medical practice, including offi ce rents and nonphysician staff wages. Moreover, we also examined the feasibility of using the American Community Survey (ACS) and the Bureau of Labor a nd Statistics (BLS) Occupational Employment Statistics (OES) data for the employee comp ensation component of the PE GPCI. For previous updates, the employee comp ensation component was based on the 2000 Decennial Census long form data. Since th e Census data are significantly outdated and the 2010 Census no longer includes occupationa l wage data, we believed the ACS or BLS OES data might be viable alterna tives. While the ACS 3-year public use microsample (PUMS) is current ly available, it reflects only about 3 percent of households and the data exhibit significant variation due to the small sample. In particular, the ACS PUMS has fewer than 10 observations of pha rmacists in the Manhattan, Beaumont Texas, and Southern Maine localities. Therefore, we believe it would be premature to use the ACS data for determining GPCI values. The 2006, 2007, and 2008 panels from the BLS OES represent a larger sample than the AC S PUMS and more recent data than the 2000 Census. As such, we are proposing to use the BLS OES data for updating the GPCIs. We look forward to exploring the use of the full ACS data when they become available. Additionally, we explored other sources of rent data (includi ng commercial rental data and survey data) for use in calculatin g the PE GPCIs. We could not identify a

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reliable alternative rental data source available on a nationa l basis with coverage of nonmetropolitan areas.

We do not believe there is a national da ta source better than the Housing and Urban Development (HUD) data for determining the relative cost differences in office rents. Therefore, based on our review of the available data sources, we are proposing to use the 2010 apartment rental data produced by HUD at the 50th percentile as a proxy for the relative cost difference in physician office rents. We believe our analysis of the current methods of establishing PE GPCIs and our evaluation of data that fairly and reliably establish distincti ons in the cost of operating a medical practice in the different fee schedul e areas meet the statutory requirements of section 1848(e)(1)(H)(iv) of the Act (as adde d by section 3102(b) of ACA). A more detailed discussion of our analysis of curre nt methods of establishing PE GPCIs and

evaluation of data sources is included in Acum en’s draft report. Acumen’s draft report and associated analysis of the sixth GPCI update, including the PE GPCIs, will be posted on the CMS Web site after display of this CY 2011 PFS proposed rule. The draft report may be accessed from the PFS website at: http://www.cms.gov/PhysicianFeeSched/

under the "Downloads" section of the CY 2011 PFS proposed rule web page. Determining the Proposed PE GPCI Cost Share Weights To determine the cost share weights for the proposed CY 2011 GPCIs, we used the proposed 2006-based Medicare Economic Inde x (MEI) as discussed in section II.E.1. of this proposed rule. The proposed MEI was rebased and revised to reflect the weighted-average annual price change for va rious inputs needed to provide physicians’

services. As discussed in detail in that section, the proposed expense categories in the MEI, along with their respective weights, are primarily derived from data collected in the

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2006 AMA PPIS for self-employed physicians and selected self-employed non-medical doctor specialties. For the cost share weight for the PE GPCIs, we used the 2006-based MEI weight for the PE category of 51.734 percent minus th e professional liability insurance category weight of 4.295 percent. Therefore, the propos ed cost share weight for the PE GPCIs is 47.439 percent. For the employee compensati on portion of the PE GPCIs, we used the nonphysician employee compensation category weight of 19.153 percent. The fixed capital category weight of 8.410, for which the CPI for owner’s equivalent rent is the price proxy, was used for the office rent component. To determine the medical equipment, supplies, and other miscella neous expenses component, we removed professional liabilit y (4.295 percent), nonphysician employee compensation (19.153 percent), and fixed capital (8.410 percent) from the PE category weight (51.734 percent). Therefore, the proposed cost share weight fo r the medical equipment, supplies, and other miscellaneous expenses com ponent is 19.876 percent. Furthermore, the physician compensation cost category and its weight of 48.266 percent reflect the proposed work GPCI cost share weight and th e professional liability insurance weight of 4.295 percent was used fo r the malpractice GPCI cost share weight. We believe our analysis and evaluation of the weights assigned to each of the categories within the PE GPCIs meets the statutory re quirements of section 1848(e)(1)(H)(iv) of the Act (as added by section 3102(b) of ACA). The proposed cost share weights for th e CY 2011 GPCIs are displayed in Table

22 below. Table 22. Proposed Cost Share Weights for CY 2011 GPCI Update

Expense Category Current Cost Share Proposed Cost Share

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Weight Weight

Physician Work 52.466% 48.266% Practice Expense 43.669% 47.439% - Employee Compensation 18.654% 19.153% - Office Rent 12.209% 8.410% - Equipment, Supplies, Other 12.806% 19.876% Malpractice Insurance 3.865% 4.295% Total 100% 100%

PE GPCI Floor for Frontier States Section 10324(c) of ACA added a new s ubparagraph (I) under section 1848(e)(1)

of the Act to establish a 1.0 PE GPCI floor for physicians’ services furnished in frontier

States. In accordance with section section 1848(e)(1)(I) of the Act (as added by section 10324(c) of ACA), beginning in CY 2011, we will apply a 1.0 PE GPCI floor for physicians’ services furnished in States dete rmined to be frontier States. The statute requires us to define any State as a frontier State if at least 50 percent of the State’s counties are determined to be frontier counties, which the statute defines as counties that have a population density less than 6 pers ons per square mile. However, section 1848(e)(1)(I) of the Act (as added by section 10324(c) of ACA) also specifies that this provision shall not apply to States receiving a non-labor related share adjustment under section 1886(d)(5)(H) of the Act (which excl udes Alaska and Hawaii from qualifying as a frontier State). Consistent with the proposed FY 2011 hos pital npatient prospective payment system (IPPS) 1.0 wage index floor for frontier States (as required by section 10324(a) of the ACA) (75 FR 30920 through 30921) , we are proposing to identify frontier counties by analyzing population data and county defi nitions based upon the most recent annual population estimates published by the U.S. Cens us Bureau. We di vide each county’s

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population total by each county’s reported la nd area (according to the decennial census) in square miles to establish population density. We also are proposing to update this analysis from time to time, such as upon pub lication of a subseque nt decennial census, and if necessary, add or remove qualifying States from the list of frontier States based on the updated analysis. For a State that qualifies as a frontier State, in accordance with section 1848(e)(1)(I) of the Act (as added by sec tion 10324(c) of the ACA), we are proposing that physicians’ services furnished within that State would receive the higher of the applicable PE GPCI value calculated accord ing to the standard CY 2011 methodology or a minimum value of 1.00. Furthermore, in accordance with section 1848(e)(1)(I) of the Act (as added by section 10324(c) of the ACA) , the frontier State PE GPCI floor is not subject to budget neutrality and would only be extended to physicians’ services furnished

within a frontier State. For determining the proposed CY 2011 PFS PE GPCI values, the frontier States are the following: Montana; Wyoming; No rth Dakota; Nevada; and South Dakota (as reflected in Table 23).

Table 23. Frontier States Under Sectio n 1848(e)(1)(I) of the Act (as added by Section 10324(c) of the Affordable Care Act)

State Total Counties Frontier Counties Percent Frontier Counties Montana 56 45 80% Wyoming 23 17 74% North Dakota 53 36 68% Nevada 17 11 65% South Dakota 66 34 52%

(2) Summary of CY 2011 Proposed PE GPCIs The PE GPCIs include three componen ts: employee compensation, office rent,

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and medical equipment, supplies and misce llaneous expenses as discussed below: (i) Employee Compensation: We used the 2006 through 2008 BLS OES data to determine the proposed employee compensation component of the PE GPCIs. Employee compensation accounts for 40.4 percent of the total PE GPCIs. (ii) Office Rents: Consistent with the previous GPCI update, we used the most recent residential apartment rental data produced by HUD ( 2010) at the 50th percentile as a proxy for the relative cost differences in ph ysician office rents. Office rent accounts for 17.7 percent of the PE GPCIs. (iii) Medical Equipment, Supplies, and othe r Miscellaneous Expenses : We assumed that items such as medical equipment and supplie s have a national market and that input prices do not vary among geographic areas. As discussed in previous GPCI updates in the CY 2005 and CY 2008 PFS proposed rules, specifically the fourth GPCI update (69 FR 47503) and fifth GPCI update (72 FR 38138), respectively, some price differences may exist, but we believe these differences are more likely to be based on volume discounts rather than on geographic ma rket differences. Medical equipment, supplies, and miscellaneous expenses are fact ored into the PE GPCIs with a component index of 1.000. The medical equipment, s upplies, and other miscellaneous expense component are 41.9 percent of the PE GPCIs. c. Malpractice GPCIs The malpractice GPCIs are calculated based on insurer rate filings of premium data for $1 million to $3 million mature claims-made policies (policies for claims made rather than services furnished during the policy term). The proposed CY 2011 malpractice GPCI update refl ects 2006 and 2007 premium data. d. General GPCI Update Process

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The periodic review and adjustment of GPCIs is mandated by section 1848(e)(1)(C) of the Act. At each update, th e proposed GPCIs are published in the PFS proposed rule the year before they would take effect in order to provide an opportunity for public comment and further revisions in response to comments prior to implementation. As mentione d above, the proposed CY 2011 updated GPCIs for the first year of the 2-year transition and summarize d GAFs are displayed in Addenda D and E to this proposed rule. 3. Payment Localities The current PFS locality structure wa s developed and implemented in 1997. There are currently 89 localities; 34 localities are Statewide areas. There are 52 localities in the other 18 States, with 10 States having 2 localities, 2 States having 3 localities, 1 State having 4 localities, and 3 States having 5 or more localities. The District of Columbia, Maryland, and Virginia suburbs, Puerto Rico, and the Virgin Islands are additional localities that make up the remainder of the total of 89 localities. The development of the current locality structur e is described in detail in the CY 1997 PFS proposed rule (61 FR 34615) and the s ubsequent final rule with comment period(61 FR 59494). As we have previously noted in the CYs 2008 and 2009 proposed rules (72 FR 38139 and 73 FR 38513), any changes to th e locality configura tion must be made in a budget neutral manner within a State and can lead to significant redistributions in payments. For many years, we have not c onsidered making changes to localities without the support of a State medical association in order to demonstrate consensus for the change among the professionals whose pa yments would be affected (with some increasing and some decreasing). However, we have recognized that, over time, changes

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in demographics or loca l economic conditions may le ad us to conduct a more comprehensive examination of existing payment localities. For the past several years, we have been involved in discussions with physician groups and their representatives about rece nt shifts in relative demographics and economic conditions, most notably within the current California payment locality structure. We explained in the CY 2008 PFS final rule with comment period that we intended to conduct a thorough analysis of potential approaches to reconfiguring

localities and would addre ss this issue again in future rulemaking. For more information, we refer readers to the CY 2008 PFS proposed rule (72 FR 38139) and subsequent final rule with comment period (72 FR 66245). As a follow-up to the CY 2008 PFS fi nal rule with comment period, we

contracted with Acumen to conduct a preliminary study of se veral options for revising the payment localities on a nationwide basis. The contractor’s interim report was posted on the CMS Web site on August 21, 2008, and we requested comments from the public. The report entitled, "Review of Alternative GPCI Payment Locality Structures," remains accessible from the CMS PFS Web page under the heading "Interim Study of Alternative Payment Localities under the PFS." The report may also be accessed directly from the following link: http://www.cms.hhs.gov/PhysicianFeeSch ed/10_Interim_Study.asp#TopOfPage

. We accepted public comments on the interim report through November 3, 2008. The alternative locality configurations discu ssed in the report are de scribed briefly below

in this section. Option 1: CMS Core-Based Statistical Area (CBSA) Payment Locality Configuration

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This option uses the Office of Manage ment and Budget (OMB’s) Metropolitan Statistical Area (MSA) designations for the payment locality configuration. MSAs would be considered as urban CBSAs. Micropolitan Areas (as defined by OMB) and rural areas would be considered as non-urban (rest of State) CBSAs. This approach would be consistent with the IPPS pre-reclassification CBSA assignments and with the geographic payment adjustments used in other Medicar e payment systems. This option would

increase the number of PFS localities from 89 to 439. Option 2: Separate High-Cost Counties from Existing Localities (Separate Counties) Under this approach, higher cost countie s are removed from their existing locality structure and they would each be placed into their own locality. This option would

increase the number of PFS localities from 89 to 214, using a 5 percent GAF differential to separate high-cost counties. Option 3: Separate MSAs from Statewide Localities (Separate MSAs) This option begins with statewide localities and creates separate localities for higher cost MSAs (rather than removing higher cost counties from their existing locality as described in Option 2). This option would increase the number of PFS localities from 89 to 130, using a 5 percent GAF differential to separate high-cost MSAs. Option 4: Group Counties Within a State Into Locality Tiers Based on Costs (Statewide Tiers) This option creates tiers of counties (within each State) that may or may not be contiguous but share similar practice costs. This option would increase the number of PFS localities from 89 to 140, using a 5 percent GAF differential to group similar

counties into statewide tiers. As discussed in Acumen’s interim report, all four studied alternative locality

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configurations would increase the number of localities and separate higher cost areas

from rural "rest of state" areas. As a resu lt, payments to urban areas would increase, while rural areas would see a decrease in payment because they would no longer be grouped with higher cost "urbanized" areas. A number of public commenters on the draft report expressed support for Option 3 (separat e MSAs from Statewide localities) because the commenters believed this alternative would improve payment accuracy over the current locality configuration and could mitigate possible payment reductions to rural areas as compared to Option 1 (CMS CBSAs). Therefore, Acumen is conducting a more in-depth analysis of the dollar impacts that would result from the application of Option 3. For a detailed discussion of the public comments on the contractor’s interim locality study report, we refer readers to the CY 2010 PFS proposed rule (74 FR 33534) and subsequent final rule w ith comment period (74 FR 61757). E. PFS Update for CY 2010 1. Rebasing and Revising of th e Medicare Economic Index (MEI) a. Background The Medicare Economic Index (MEI) is required by section 1842(b)(3) of the Act, which states that prevailing charge levels beginning afte r June 30, 1973 may not exceed the level from the previous year except to the extent that the Secretary finds, on the basis of appropriate econo mic index data, that such higher level is justified by year-to-year economic changes. Beginning July 1, 1975, and continuing through today, the MEI has met this requirement by reflecting the weighted-average annual price change for various inputs needed to provide physicia ns' services. The MEI is a fixed-weight input price index, with an adjustment fo r the change in economy-wide, private nonfarm

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business multifactor productivity. This index is comprised of two broad categories: (1) physician's own time; and (2) physician's practice expense (PE).

The current form of the MEI wa s detailed in the November 25, 1992 Federal Register (57 FR 55896) and was based in pa rt on the recommendations of a Congressionally-mandated meeting of expert s held in March 1987. Since that time, the

structure of the MEI has remained essentiall y unchanged, with three exceptions. First, the MEI was rebased in 1998 (63 FR 58845), whic h moved the cost structure of the index from 1992 data to 1996 data. Second, the met hodology for the productivity adjustment

was revised in the CY 2003 PFS final rule (67 FR 80019) to reflect the percentage change in the 10-year moving average of econom y-wide private nonfarm business multifactor productivity. Third, the MEI was rebased in 2003 (68 FR 63239), which moved the cost

structure of the index from 1996 data to 2000 data. We are proposing to rebase and revise the MEI and incorporate it into the CY 2011 PFS update. The terms "rebasing" and "revising", while often used interchangeably, actually denote different activities. Rebasing refers to moving the base year for the structure of costs of an input pri ce index, while revising relates to other types of changes such as changing data sources, co st categories, or price proxies used in the input price index. As is always the case w ith a rebasing and revising exercise, we have attempted to use the most recently available, relevant, and appropriate information to develop the proposed MEI cost category weight s and price proxies. In the following sections of this proposed rule , we detail our proposals regarding the updated cost weights for the MEI expense categories, our rationale for selecting the price proxies in the MEI, and the results of the proposed reba sing and revising of the MEI.

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b. Use of More Current Data

The MEI was last rebased and revised in 2003 in the CY 2004 PFS final rule with comment period (68 FR 63239). The current ba se year for the MEI is 2000, which means that the cost weights in the index reflect physicians’ expenses in 2000. However, we believe it is desirable to peri odically rebase and revise th e index so that the expense shares and their associated price proxies refl ect more current conditions. For this reason, we propose to rebase the MEI to reflect a ppropriate physicians’ expenses in 2006. We are proposing several changes to the expe nses that are eligible to be included in the MEI. For instance, we are proposing to remove all costs rela ted to drug expenses as drugs are not paid for under the PFS nor are they included in the definition of "physicians' services" for purposes of the Sust ainable Growth Rate (S GR) system that is used to update the PFS. The details of the decision regarding the removal of physician-administered drugs from the SGR system can be found in the CY 2010 PFS proposed rule and finalized in the CY 2010 fi nal rule with comment period (74 FR 33651 and 74 FR 61961, respectively). Additionall y, we are proposing to remove costs associated with separately b illable supplies. The rationale for removing the separately billable supplies is discussed further below in section III.E.1.X of this proposed rule. We are proposing to revise the cost categories in the MEI by expanding the Office Expense category into nine detailed categories with additional price proxies associated with these categories. Additionally, we will continue to adjust the MEI for economywide multifactor productivity based on the 10-year moving average of total private

nonfarm business multi-fact or productivity.

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c. Rebasing and Revising Ex pense Categories in the MEI The MEI is used in conjunction with the SGR system to update the PFS and represents the price component of that upda te. The proposed expense categories in the index, along with their respective weights, ar e primarily derived from data collected in the 2006 AMA Physician Practice Informati on Survey (PPIS) for self-employed physicians and selected self-employed non-Me dical Doctor (non-MD) specialties. We included data from the following specialties in the MEI cost weight calculations (optometrists, oral surgeons , podiatrists, and chiropractors ) consistent with the definition of the term "physician" in section 1861(r) of the Act. In summary, the term "physician" when used in connection with the performance of functions or actions an individual is legally authorized to perform means the following: (1) a doctor of medicine or osteopathy; (2) a doctor of dental surgery or of dental medicine; (3 ) a doctor of podiatric medicine; (4) a doctor of optometry; or (5) a chiropractor. For a complete definition, please see section 1861(r) of the Act. We weighted the expense data from the abovereferenced specialties with the self-employed physician expense data using physician counts by specialty. The AMA data from the PPIS were used to determine expenditure weights for total expenses, physicians' earnings, physicia ns’ benefits, employed physician payroll, nonphysician compensation, office expenses, professional liability insurance (PLI), medical equipment, medical supplies, and a ll other expenses. To further disaggregate into subcategories reflecting more detailed expenses, we used data from the 2002 Bureau of Economic Analysis (BEA) Benchmark Input -Output table (I/O), the 2006 Bureau of the Census Current Population Survey (CPS) , the 2006 Bureau of Labor Statistics (BLS) Occupational Employment Survey (OES ) and Employment Cost for Employee

### CMS-1503-P 177

Compensation Survey (ECEC), and the 2006 Inte rnal Revenue Service (IRS) Statistics of Income (SOI) data. The development of each of the cost categories using these sources is

described in detail below. (1) Developing the Weights for Use in the MEI Developing a rebased and revised MEI requires selecting a base year and determining the appropriate ex pense categories. We are proposing to rebase the MEI to CY 2006. We choose CY 2006 as the base year for two primary reasons: (1) CY 2006 is the most recent year for which data were av ailable; and (2) we believe that the CY 2006 data provide a representative distribution of physicians’ compensation and PEs. Compared to the 2000-based MEI, we are proposing to include 9 new cost categories (along with their respective weig hts) that disaggregate the costs under the broader Office Expenses cost category. The 2000-based MEI did not break these expenses into individual categories. A more detailed discussion is pr ovided below in this section. In addition, we are proposing to ex clude the Pharmaceutical cost category as pharmaceuticals are neither paid for under the PFS nor are they included in the definition of "physicians' services" for purposes of calculating the physician update via the SGR system (for more details see the CY 2010 PFS final rule with comment period (74 FR 61961 through 61962)). Lastly, we are proposing to exclude the expenses associated with separately billable supplies since these items are not paid for under the

PFS. We determined the number and compositi on of expense categories based on the criteria used to develop the current MEI a nd other CMS input price index expenditure weights. These criteria are timeliness, reliability, relevance, and pub lic availability. Table 24 lists the set of mutually exclusive and exhaustive cost categories that make up

### CMS-1503-P 178

the proposed rebased and revised MEI. TABLE 24: Proposed 2006 MEI Cost Categories, Weights, and Price Proxies compared to the 2000 MEI Cost Categories and Weights

Cost Category Proposed 2006- Expense Weights (1, 2) 

### 2000 Expense Weights Proposed 2006 Price Proxies

Total 100.00 100.000 Physician’s Own Time (3) 

### 48.266 52.466 Wages and Salaries 43.880 42.730 AHE Total Nonfarm Private (5) 

### Benefits (3)(4) 

### 4.386 9.735 ECI-Benefits Total Nonfarm Private (6) 

### Physician’s Practice Expense 51.734 47.534 Nonphysician Employee Compensation 19.153 18.654 Nonphysician Employee Wages and Salaries 13.752 13.809 Prof/Tech Wages 6.006 5.887 ECI-Wages/Salaries: Private Professional &Technical Managerial Wages 1.446 3.333 ECI-Wages/Salaries: Private Managerial Clerical Wages 4.466 3.892 ECI-Wages/Salaries: Private Clerical Services Wages 1.834 0.696 ECI-Wages/Salaries: Private Service Nonphysician Employee Benefits (4) 

### 5.401 4.845 ECI-Ben: Private Blend Office Expenses 20.035 12.209 Utilities 1.139 - CPI Fuel & Utilities (7)

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Cost Category Proposed 2006- Expense Weights (1, 2) 

### 2000 Expense Weights Proposed 2006 Price Proxies

Chemicals 0.679 - PPI for Other Basic Organic Chemical Manufacturing PPI325190 (8) 

### Paper 0.616 - PPI for converted paper Rubber & Plastics 0.563 - PPI for rubber and plastics Telephone 1.415 - CPI for Telephone Services Postage 0.661 - CPI for Postage

All Other Labor-Related 4.718 - ECI Compensation Services Occupations (ECIPCSONS) Fixed Capital 8.410 - CPI for Owner’s Equivalent Rent Moveable Capital 1.834 - PPI for Machinery and Equipment PLI 4.295 3.865 CMS-Prof. Liab. Phys. Premiums Medical Equipment 1.978 2.055 PPI-Medical Instruments & Equip. Pharmaceuticals and Medical Materials and Supplies 1.760 4.320 Pharmaceuticals - 2.309 Medical Materials and Supplies 1.760 2.011 PPI Surg. Appliances and Supplies/CPI(U) Med Supplies Other Professional Expenses 4.513 6.433 CPI-U All Items Less Food and Energy (1) Due to rounding, weights may not sum to 100.000 percent. (2) Sources: 2006 Physician Practice Information Su rvey (PPIS), Center for Health Policy Research, American Medical Association; 2006 Employment Cost for Employee Compensation, U.S. Department of Labor, Bureau of Labor Statistics; 2006 Occupational Employment Statistics (OES), BLS; U.S. Department of Commerce, Bureau of Economic Analysis 2002 Benchmark Input Output Tables, and U.S. Department of Commerce, Bureau of the Census, 2006 Current Population Survey. (3) Includes employed physician payroll. (4) Includes paid leave. (5) Average Hourly Earnings (AHE) (6) Employment Cost Index (ECI) (7) Consumer Price Index (CPI) (8) Producer Price Index (PPI)



### The development of each of the cost categories in the proposed 2006 MEI is described, in detail, below. (2) Physician’s Own Time

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The component of the MEI that reflects th e physician's own time is represented by the net income portion of business receipts. The proposed 2006 cost weight associated with the physician’s own time (otherwise referred to as the Physician’s Compensation cost weight) is based on 2006 AMA PPIS data for mean physician net income (physician compensation) for self-employed physicia ns and for the selected self-employed specialties referenced previously in this rule. We are proposing to continue to add em ployed physician compensation to selfemployed physician compensation in order to calculate an aggregate Physician Compensation cost weight. By including th e compensation of employed physicians in the physician compensation expense category, these expenses will be adjusted by the appropriate price proxies for a physicia n’s own time. The proposed 2006 Physician Compensation cost weight is 48.266 percent as compared to a 52.466 percent share in the 2000-based MEI. We split the physician comp ensation component into subcategories: Wages & Salaries; and Benef its. For Physician Compensation, the ratio for Wages & Salaries and Benefits was calculated using da ta from the PPIS. Self-employed physician wages & salaries accounted for 92.3 percen t of physician earni ngs while physician benefits accounted for the remaining 7.8 percen t. For employed physician payroll, the distribution for wages & salaries and bene fits for 2006 was 85.8 percent and 14.2 percent, respectively. This ratio was determined by calculating a weighted average of available SOI data for partnerships, corporations, and S-corporations specific to physicians and outpatient care centers. Based on these pr oposed methods, the proposed 2006 Physician Wages & Salaries cost weight is 43.880 percent and the proposed 2006 Physician Benefits cost weight is 4.386 percent. (3) Physician’s Practice Expenses

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To determine the remaining individual Pr actice Expenses cost weights, we use mean expense data from the 2006 PPIS surv ey. The detailed explanations for the derivation of the individual weights unde r Practice Expenses are listed below. (A) Nonphysician Employee Compensation The cost weight for Nonphysician Empl oyee Compensation was developed using the 2006 AMA PPIS mean expenses for these cost s. We further divided this cost share into Wages & Salaries and Benefits using 2006 BLS Employer Costs for Employee Compensation (ECEC) data for th e Health Care and Social Assistance (private industry). Although this survey does not contain data speci fically for offices of physicians, data are available to help determine the shares associated with wages & salaries and benefits for private industry health care and social assi stance services (which include hospitals, nursing homes, offices of physicians, and offi ces of dentists). We believe these data provide a reasonable estimate of the split between wages and benefits for employees in physicians’ offices. Data for 2006 in the EC EC for Health Care and Social Assistance indicate that wages and benefits are 71.8 percent and 28.2 percent of compensation, respectively. The 2000-based MEI included a wage and benefit sp lit of 74.0 percent and 26.0 percent of compensation. As in the 2000-based MEI, we are pr oposing to use 2006 Current Population Survey (CPS) data and 2006 BLS Occupationa l Employment Statistics (OES) data to develop cost weights for wages for nonphys ician occupational gr oups. We determined total annual earnings for offices of physicia ns using employment data from the CPS and mean annual earnings from the OES. To a rrive at a distributi on for these separate categories, we determined annual earnings fo r each of the four categories (which are

Professional & Technical worker s, Managers, Clerical workers, and Service workers),

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using the Standard Occupationa l Classification (SOC) system. We then determined the overall share of the total for each. The propos ed distribution, as well as the distribution from the 2000-based MEI are presented in Table 25. TABLE 25: Percent Distribution of Nonphysician Payroll Expense by Occupational Group: 2006 and 2000

BLS Occupational Group 2006 Expenditure Shares 2000 Expenditure Shares Total 100.000 100.000 Professional & Technical Workers 43.671 42.635 Managers 10.517 24.138 Clerical Workers 32.477 28.187 Service Workers 13.336 5.040 Values may not sum to 100 due to rounding. 

### The decrease in the Management expenditu re share is directly related to a decrease in the total number of employees in Management occupa tions in physicians’ offices, in particular, "Medical and health service managers." The decrease in expenditure share may also be due, in part to the methods used in this rebasing. That is, for the 2006-based MEI, we are using data limited to "Offices of physicians." In the 2000-based version of the index, the only data that were available to inform these estimates were inclusive of physician offices and clinics ("Offices of physicians and clinics"). An examination of 2006 CPS and OES data comparing "Outpatient care centers" to "Offices of physicians" indicates th at there is a higher share of management occupations in the "Outpatient care centers " than in "Offices of physicians." The increase in the Service Workers expenditures share is attributable to a substantive increase in the number of employ ees in service occupations, particularly,

"Medical assistants and other health care support occupations". (B) Office Expenses The aggregate Office Expenses cost weight was derived using the 2006 AMA

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PPIS and is explained in more detail below in this section. This calculation resulted in a 20.035 percent share of total costs in 2006 compared to a 12.209 percent share in the

2000-based index. For the 2006-based MEI, we propose to further disaggregate the Office Expenses into more detailed cost categories using th e BEA 2002-Benchmark I/O data for Offices of physicians, dentists, and othe r health practitioners (NAICS 621A00). We used this data to develop the nine detailed 2002 costs weights as a percent of total office expenses, as measured by the BEA I/O data. The total Office Expenses cost category was calculated by matching the BEA I/O data as closely as possible to the AMA survey data, the latter of which defined office expenses as "office (non-medical) equipment and office (nonmedical) supplies, as well as rent, mortgage, interest, maintenance, refrigeration, storage, security, janitorial, depreciation on medical buildings used in your practice, utilities, or other office computer system s (including information ma nagement systems/electronic medical record systems) and telephone." We then aged the 2002 weights forward to 2006 to derive the 2006 detailed office expense cost weights as a percent of total O ffice Expenses. The methodology we used to age the data forward involved applying th e annual price changes from each respective price proxy to the appropriate cost categories. We repeated this practice for each year of the interval. We then applied the resu lting 2006 distributions to the aggregate 2006 AMA Office Expenses weight to yield th e detailed 2006 Office Expenses’ weights as a percent of total expenses. We are proposing to introduce these new, more detailed weights for the 2006-

based index based on our inte nt to derive an increase d level of precision while maintaining appropriate levels of aggregation in the market basket. The proposed proxies

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are described in section X. of this proposed ru le. The following is a description of what is included in each of the detailed cost categories.

● Utilities : The Utilities cost weight includes expenses classified in the fuel, oil and gas, water and sewage, a nd electricity industries. The proposed cost weight for utilities is 1.139 percent.

● Paper : The Paper cost weight includes expenses classified in the paper (including but not limited to pa per, paperboard, a nd sanitary paper pr oducts) and printing industries. The proposed cost weight for paper is 0.616 percent.

● Chemicals : The Chemicals cost weight includes expenses classified in the basic organic and inorganic chemical ma nufacturing industry (accounting for about 45 percent of the chemical expenses), as we ll as other chemical industries including but

not limited to industrial gas manufacturing and all other chemical pr oduct manufacturing. The proposed cost weight for chemicals is 0.679 percent.

● Rubber and Plastics : The Rubber and Plastics cost weight includes expenses

classified in the rubbe r and plastic industries, including but not limited to, urethane and other foam product manufacturing and other plastic and rubber manufacturing industries. The proposed cost weight for Rubbe r and Plastics is 0.563 percent.

● Telephone : The telephone cost weight incl udes expenses classified in the telecommunications (accounting for the majori ty of the telephone expenses) and cable industries. The proposed cost weight for Telephone services is 1.415 percent.

● Postage : The Postage cost weight incl udes postal service expenses. The proposed cost weight for Postage is 0.661 percent.

● All Other Services : The All Other Services cost weight includes other service expenses including, but not limited to, nonresid ential maintenance and repair, machinery

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repair, janitorial, and security services. This cost weight does not include expenses associated with professional services such as accounting, billing, legal and marketing which are included in the All Other Expenses cost weight derived using the AMA PPIS survey. The proposed cost weight fo r All Other Services is 4.718 percent.

● Fixed Capital : The Fixed Capital cost weight includes expenses for building leases and depreciation. The proposed cost weight for Fixed Capital is 8.410 percent.

● Moveable Capital : The Moveable Capital cost weight includes expenses for non-medical equipment including but not limite d to, computer equi pment and software, as well as the rental and leasing of automo tive and industrial machinery equipment. The proposed cost weight for Mov eable Capital is 1.834 percent. (C) Professional Liability Insurance (PLI) Expense The weight for PLI expense was derived from the 2006 AMA survey and was calculated as the mean PLI expense expressed as a percentage of total expenses. This calculation resulted in a 4.513 percent share of total costs in 2006 compared to a 3.865 percent share in the 2000-based index. The increase in the weight for PLI reflects the current prices of premiums, as well as an upda te to the level of co verage purchased by physicians in 2006 compared to 2000. (D) Medical Equipment Expenses The proposed weight for Medical Equipm ent was calculated using the 2006 AMA PPIS mean expense data. This calculation re sulted in a 1.978 percent share of total costs in 2006 compared to a 2.055 percent share in the 2000-based index. By definition, this category includes the expenses related to depreciation, maintenance contracts, leases/rental of medical equipment used in diagnosis or treatment of patients. The

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category would also include the tax-deduc tible portion of the purchase price or replacement value of medical e quipment, if not leased. (E) Medical Supplies Expenses The proposed weight for Medical Supp lies was calculated using the 2006 AMA PPIS mean expense data. This calculation re sulted in a 1.760 percent share of total costs in 2006 compared to a 2.011 percent share in the 2000-based index. By definition, this category includes the expenses related to medi cal supplies such as sterile gloves, needles, bandages, specimen containers, and catheters. Additionally, we are proposing to exclude the expenses related to separa tely billable supplies as these expenses are not paid for under the PFS. The Medical Supply cost cate gory does not include expenses related to drugs. (F) All Other Professional Expenses The proposed weight for All Other Profe ssional expenses was calculated using the 2006 AMA PPIS mean expense data. This calculation resulted in a 4.513 percent share of total costs in 2006 compared to a 6.433 percent share in the 2000-based index. By definition, this category includes the expenses related to tax-deductible expenses for any other expenses not reported in another catego ry from the PPIS. These expenses would include fees related to legal, marketing, ac counting, billing, office management services, professional association memberships, maintena nce of certification or licensure, journals and continuing education, professional car upkeep and depreciation, and any other professional expenses not re ported elsewhere on the PPIS.

d. Selection of Price Proxies for Use in the MEI After the proposed 2006 cost weights for the rebased and revised MEI were developed, we reviewed all of the price proxie s to evaluate their a ppropriateness. As was

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the case in the development of the 2000-based MEI (68 FR 63239) , most of the proxy

measures we considered are based on BLS data and are grouped into one of the following five categories:

● Producer Price Indices (PPIs) : PPIs measure price changes for goods sold in markets other than retail markets. These fixed-weight indexes are a measure of price change at the intermediate or final stage of production. They are the preferred proxies for physician purchases as these prices appropriately reflect the product’s first commercial

transaction.

● Consumer Price Indices (CPIs) : CPIs measure change in the prices of final goods and services bought by consumers. Like the PPIs, they are fixed-weight indexes. Since they may not represent the price changes faced by producers, CPIs are used if there are no appropriate PPIs or if the particular expenditure category is likely to contain purchases made at the final point of sale.

● Average Hourly Earnings (AHEs) : AHEs are available for production and nonsupervisory workers for specific industrie s, as well as for the nonfarm business economy. They are calculated by dividing gr oss payrolls for wages & salaries by total hours. The series reflects shifts in employme nt mix and, thus, is representative of actual changes in hourly earnings for industries or for the nonfarm business economy.

● ECIs for Wages & Salaries : These ECIs measure the rate of change in employee wage rates per hour worked. These fixed-weight indexes are not affected by employment shifts among industries or occ upations and thus, measure only the pure rate of change in wages.

● ECIs for Employee Benefits : These ECIs measure the rate of change in employer costs of employee benefits, such as the employer's share of Social Security

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taxes, pension and other retirement plans, insurance benefits (life, health, disability, and accident), and paid leave. Like ECIs for wages & salaries, the ECIs for employee benefits are not affected by employment shifts among industries or occupations. When choosing wage and price proxies for each expense category, we evaluate the strengths and weaknesses of each proxy vari able using the following four criteria.

● Relevance : The price proxy should appropriately represent price changes for specific goods or services within the expense category. Relevance may encompass judgments about relative efficiency of th e market generating the price and wage

increases.

● Reliability : If the potential proxy demonstrates a high sampling variability, or inexplicable erratic patterns over time, its viability as an appropriate price proxy is greatly diminished. Notably, low sampling variability can conflict with relevance -- since the more specifically a price variable is de fined (in terms of service, commodity, orgeographic area), the higher the possibility of high sampling variability. A wellestablished time series is also preferred.

● Timeliness of actual published data : For greater granularity and the need to be as timely as possible, we prefer monthly and quarterly data to annual data.

● Public availability : For transparency, we prefer to use data sources that are publicly available. The BLS price proxy categories previously described meet the criteria of relevance, reliability, timeline ss, and public availability. Below we discuss the proposed price-wage proxies for the rebased and revised MEI (as shown in Table 23). (1) Expense Categories in the MEI (A) Physician’s Own Time (Physician Compensation)

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In the proposed revised and rebased MEI, we are using the AHE for the private nonfarm economy as the proxy for the Physic ian Wages & Salaries component (BLS series code: CEU0500000008). As discussed extensively in the Novemb er 2, 1998 final rule (63 FR 58848), and again in the December 31, 2002 final rule (67 FR 80019), we believe that this price proxy represents the most appropriate proxy for use in the MEI. The AHE for the nonfarm business economy reflects the impacts of supply, demand, and economy-wide productivity for the average worker in the economy. As such, use of this proxy is consistent with the original legislative intent that the change in the physicians' earnings portion of the MEI follow the change in general earnings for the economy. Since earnings are expressed per hour, a constant qua ntity of labor input per unit of time is reflected. Finally, the use of the AHE data is also consistent with our using the BLS economy-wide private nonfarm business sect or multifactor productivity measures since economy-wide wage increases reflect economy-wide productivity increases. The current 2000-based MEI uses the ECI for Total Benefits (BLS series code: CIU2030000000000I) for total private industry as th e price proxy for Physician Benefits. We are proposing to use the same proxy for the 2006-based MEI. This means that both the wage and benefit proxies for physician earnings are derived from the private nonfarm business sector and are computed on a per-hour basis. (B) Nonphysician Employee Compensation For the 2006-based MEI, we are proposing to use Current Population Survey (CPS) data on employment by occupation and earnings from the BLS Occupational Employment Statistics for NAICS 6211, Office of Physicians, to develop labor cost shares for the nonphysician occupational gr oups shown in Table 23. The 2000-based

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MEI was based on CPS data for the Standa rd Industrial Classification 801 and 803, which included both office of physicians a nd outpatient care centers. Beginning in 2003, BLS began publishing CPS data on a NAICS basis which provided data for office of physicians (NAICS 6211)and outpatient care centers (NAICS 6214) separately. We believe using data for office of physicians is appropriate for the 2006-based MEI. The BLS maintains an ECI for each selected industry group. We propose to use these ECIs as price proxies for nonphysician employee wages in the same manner they are used in the

current MEI. As described in the CY 2008 PFS proposed rule (72 FR 38190), as a result of the

discontinuation of the White Co llar Benefit ECI for private workers, we are currently using a composite ECI benefit index. We are proposing to continue to use the composite ECI for nonphysician employees in the proposed rebased and revise d MEI; however, we are proposing to revise the weights within that blend in order to reflect the more recent

2006 data. Table 26 lists the four ECI series and corresponding weight s used to construct the 2006 composite benefit index. TABLE 26: CMS Composite Price Index for Nonphysician Employee Benefits

ECI series 2006 Weight Benefits, Private, Prof essional & Related 44% Benefits, Private, Manageme nt, Business, Financial 11% Benefits, Private, Office & Administrative Support 32% Benefits, Private, Se rvice Occupations 13%

(C) Utilities For the 2006-based MEI, we are proposing to use the CPI for Fuel and Utilities (BLS series code #CUUR0000SAH2 ) to measure the price growth of this cost category. This cost category was not broken -out separately in the 2000-based MEI.

### CMS-1503-P 191

(D) Chemicals For the 2006-based MEI, we are proposing to use the PPI for Other Basic Organic Chemical Manufacturing (BLS series code #PCU32519-32519) to measure the price changes of this cost category. We are proposing this industry-based PPI because BEA’s 2002 benchmark I/O data show that the majority of the office of physicians’ chemical expenses are attributable to Other Basic Organic Chemical Manufacturing (NAICS 32519). This cost category was not broken -out separately in the 2000-based MEI. (E) Paper For the 2006-based MEI, we are proposing to use the PPI for Converted Paper and Paperboard (BLS series code #WPU0915) to measure the price growth of this cost category. This cost category was not broken-out separately in the 2000-based MEI. (F) Rubber and Plastics For the 2006-based MEI, we are proposing to use the PPI for Rubber and Plastic Products (BLS series code #WPU07) to measure the price growth of this cost category. This cost category was not broken-out separately in the 2000-based MEI. (G) Telephone For the 2006-based MEI, we are proposing to use the CPI for Telephone Services (BLS series code #CUUR0000SEED ) to measure the price growth of this cost category. This cost category was not broken-out separately in the 2000-based MEI. (H) Postage For the 2006-based MEI, we are proposing to use CPI for Postage (BLS series code #CUUR0000SEEC01) to measure the price growth of this cost category. This cost category was not broken-out separa tely in the 2000-based MEI. (I) All Other Services

### CMS-1503-P 192

For the 2006-based MEI, we are proposing to use the ECI for Compensation for Service Occupations (private industry) (BLS series code #CIU2010000300000I) to measure the price growth of this cost categ ory. This cost category was not broken-out separately in the 2000-based MEI. (J) Fixed Capital For the 2006-based MEI, we are proposing to use the CPI for Owner’s Equivalent Rent (BLS series code #CUUS0000SEHC) to measure the price growth of this cost category. This price index represents about 50 percent of the CPI for Housing which was used to in the 2000-based MEI to proxy total office expenses. (K) Moveable Capital For the 2006-based MEI, we are proposing to use the PPI for Machinery and Equipment (series code #WPU11) to measure the price growth of this cost category. This cost category was not broken-out separately in the 2000-based MEI. (L) Professional Liability Insurance In order to accurately reflect the price changes associated with PLI, each year, we solicit PLI premium data for physicians from a sample of commercial carriers. This information is not collected through a survey fo rm, but instead is requested directly from, and provided by (on a voluntary basis), seve ral national commercial carriers. As we require for our other price proxies, the prof essional liability price proxy is intended to reflect the pure price change associated with this particular cost category. Thus, it does not include changes in the mix or level of liability coverage. To accomplish this result, we obtain premium information from a sample of commercial carriers for a fixed level of coverage, currently $1 million per occu rrence and a $3 million annual limit. This information is collected for every State by physician specialty and risk class. Finally, the

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State-level, physician-special ty data are aggregated by effective premium date to compute a national total, using counts of physic ians by State and specialty as provided in the AMA publication, Physician Character istics and Distribution in the U.S

. The resulting data provide a quarterly time series, indexed to a base year consistent with the MEI, and reflect the national trend in the average professional liability premium for a given level of coverage, generally $1 million/$3 million of claims-made mature policies. From this series, quarterly and annual percent changes in PLI are

estimated for inclusion in the MEI. The most comprehensive data on professional liability costs are held by the State insurance commissioners, but these data are available only with a substantial time lag and hence, the data currently incorporated into the MEI are much timelier. We believe that, given the limited data available on professional liability premiums, the information and methodology described above adequately reflect the PLI price trends facing physicians. (M) Medical Equipment The Medical Equipment cost category in cludes depreciation, leases, and rent on medical equipment. We are proposing to use the PPI for Medical Instruments and Equipment (BLS series code: WPU1562) as the price proxy for this category, consistent with the price proxy used in the 2000-base d MEI and other CMS input price indexes. (N) Medical Materials and Supplies As is used in the 2000-based MEI, we are proposing to use a blended index comprised of 50/50 blend of the PPI Surgical Appliances (BLS series code: WPU156301) and the CPI-U for Medical Equipment and Supplies (BLS series code: CUUR0000SEMG). We believe physicians purchase the ty pes of supplies contained within these proxies, including such items as bandages, dressings, catheters, I.V.

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equipment, syringes, and other general di sposable medical supp lies, via wholesale purchase, as well as at the retail level. Consequently, we are proposing to combine the

two aforementioned indexes to re flect those modes of purchase. (O) Other Professional Expenses 

### This category includes the residual subcat egory of other professional expenses such as accounting services, legal services , office management services, continuing education, professional associa tion memberships, journals, pr ofessional car expenses, and other professional expenses. Given this heterogeneous mix of goods and services, we are proposing to use the CPI-U for All Items Less Food and Energy, consistent with the price proxy used in the 1996 and 2000-based MEI. (2) Productivity Adjustment to the MEI The MEI has been adjusted for changes in productivity since its inception. In the CY 2003 PFS final rule (67 FR 80019), we implemented a change in the way the MEI was adjusted to account for those changes in productivity The MEI used for the 2003 physician payment update incorporated changes in the 10-year moving average of private nonfarm business (economy-wide) multifactor productivity that were applied to the entire index. Previously, the index incorporated changes in productivity by adjusting the labor portions of the index by the 10-year movi ng average of economy-wide private nonfarm business labor productivity. We are proposing to continue to use the current method for adjusting the full MEI for multifactor productivity in the rebased and revised MEI.

As described in the CY 2003 PFS final rule, we believe this adjustment is appropriate because it explicitly reflects the productivity gains associated with all inputs (both labor and non-labor). We believe that using the 10-year moving average percent

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change in economy-wide multifactor productivit y is appropriate for deriving a stable measure that helps alleviate the influence that the peak (or a trough) of a business cycle may have on the measure. The adjustment will be based on the latest available historical economy-wide nonfarm business multifactor productivity data as measured and published by BLS. e. Results of Rebasing Table 27 illustrates the results of updating the MEI from the following changes to the weights for the Physician Compensation, Pr actice Expenses (excluding PLI), and PLI. TABLE 27: Percent Distribution of Selected Physician Expenses used to Calibrate RVUs: CYs 2006 and 2000 CY 2006 Weight CY 2000 Weight Physician Compensation (Own Time) 48.266% 52.466% Practice Expenses (less PLI) 47.439% 43.669%

PLI 4.295% 3.865%

The rebased and revised ME I has several differences as compared to the 2000- based MEI; these changes have been discussed in detail in prior sections of this rule. Table 28 shows the average calendar year percent change from CY 2004 to CY 2011 for both the 2000- and 2006-based MEIs. The 2006-based MEI annual percent changes differ from the 2000-based MEI annual percent changes by 0.0 to 0.8 percentage point. In the 5 most recent years (CYs 2007-2011), the annual percent change in the rebased and revised MEI was within 0.3 percentage point of the percent change in the 2000-based MEI. In the earlier years, there were bi gger differences between the annual percent change in the rebased and revised MEI and th e 2000-based MEI. The majority of these

differences can be attributed to the lower benefit cost weight, as measured by the 2006

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AMA data, and the exclusion of the drug co st weight. The remaining differences are attributable to the higher cost weight fo r PLI, as measured by the 2006 AMA data.

TABLE 28: Annual Percent Change in the Current and Proposed Revised and Rebased MEI Update Year (A) 

### Proposed 2006-based MEI Current 2000-based MEI CY 2004 2.4 2.7 CY 2005 2.1 2.9 CY 2006 2.0 2.5 CY 2007 1.7 2.0 CY 2008 1.9 1.8 CY 2009 1.7 1.7 CY 2010 1.4 1.2 CY 2011 (B) 

### 0.3 0.3 Avg. Change for CYs 2004- 2011 1.7 1.9 (A) Update year based on historical data through the second quarter of the prior calendar year. For example, the 2010 update is based on historical data through the second quarter 2009. (B) based on the 1 st quarter 2010 forecast by HIS Global Insight. With historical data through the 4 th quarter 2009.



### As shown in Table 29, the projection of the proposed rebased and revised MEI for the CY 2011 PFS proposed rule is an increase of 0.3 percent, identical to the projected increase using the 2000-based MEI. In the CY 2011 PFS final rule, we will incorporate historical data through th e second quarter of 2010; ther efore, the current estimated increase of 0.3 percent for 2011 may differ in the final rule.

TABLE 29: Forecasted Annual Percent Change in the Cu rrent and Proposed Revised and Rebased MEI for CY 2011 Proposed 2006-Based MEI 2000-Based MEI CY 2011 0.3 0.3

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TABLE 30: Forecasted Annual Percent Change in the Proposed Revised and Rebased MEI CY 2011, All Categories 1



### Cost Categories 2006 Weight 2 

### Projected CY 2011 Percent Changes MEI Total, productivity adjusted 100.000% 0.3 Productivity: 10-year moving average of MFP N/A 1.3 MEI Total, without productivity adjustment 100.000% 1.6

Physician Compensation (Own Time) 3 

### 48.266% 2.4 Wages and Salaries 43.880% 2.5 Benefits 4.386% 1.5 Practice Expenses 51.734% 0.9 Nonphysician Compensation 19.153% 1.5 Nonphysician Wages 13.752% 1.5 P&T 6.006% 1.2 Management 1.446% 1.0 Clerical 4.466% 1.8 Services 1.834% 2.0 Nonphysician Benefits 5.401% 1.4 Other Practice Expenses 26.308% 0.4 Office Expenses 20.035% 0.8 Utilities 1.139% -3.0 Chemicals 0.679% -1.1 Paper 0.616% -1.0 Rubber & Plastics 0.563% -0.7 Telephone 1.415% 1.1 Postage 0.661% 5.5 All Other Services 4.718% 2.0 Fixed Capital 8.410% 0.9 Moveable Capital 1.834% -0.1 PLI 4 

### 4.295% -2.2 Medical Equipment 1.978% 0.8 Medical supplies 1.760% 0.5 All Other Expenses 4.513% 1.4

1 The forecasts are based upon the latest available Bureau of Labor Statistics data as of December 2009. 2 The weights shown for the MEI components are the 2006 base-year weights, which may not sum to subtotals or totals because of rounding. Th e MEI is a fixed-weight, Laspeyres-type input price index whose category weights indicate the distribution of expenditures among the inputs to physicians' services for CY 2006. To determine the MEI level for a given year, the price proxy level for each component is multiplied by its 2006 weight. The sum of these products (weights multiplied by the price

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index levels) overall cost categories yields the composite MEI level for a given year. The annual percent change in the MEI levels is an estimate of price change over time for a fixed market basket of inputs to physicians' services. 3 The measures of productivity, average hourly earnings, Employment Cost Indexes, as well as the various Producer and Consumer Price Indexes can be found on the Bureau of Labor Statistics Web site at http://stats.bls.gov

. 4 Derived from a CMS survey of several major commercial insurers N/A Productivity is factored into the MEI categories as an adjustment to the price variables; therefore, no explicit weight exists for productivity in the MEI.



### In addition to the proposed revisions to the MEI mentioned earlier in this section, we are also proposing to convene a technical a dvisory panel later this year to review all aspects of the MEI, including the inputs, i nput weights, price-measurement proxies, and productivity adjustment. We will ask the pane l to assess the relevance and accuracy of these inputs to current physician practices. The panel’s analysis and recommendations will be considered in future rule making to ensure that the MEI accurately and appropriately meets its inte nded statutory purpose. We are requesting comments from the physician community and other intere sted members of the public on any other specific issues that should be cons idered by the technical panel. f. Adjustments to the RVU Shares to Match the Proposed Rebased MEI Weights As described in the previous section, we are proposing to rebase the MEI for

CY 2011 based on the most curre nt data and establish new weights for physician work, PE, and malpractice under the MEI. As stat ed in the previous section, the MEI was rebased to a CY 1996 base year beginning with the CY 1999 MEI (63 FR 58845), and to a CY 2000 base year beginning with the CY 2004 MEI (68 FR 63239). For both the CY 1999 and CY 2004 rebasing, we made adjust ments to ensure that our estimates of aggregate PFS payments for work, PE, and ma lpractice were in proportion to the weights for these categories in the rebased MEI (63 FR 58829 and 69 FR 1095). Consistent with our past practice wh en the MEI has been rebased, we are proposing to make adjustments to ensure that estimates of aggregate CY 2011 PFS

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payments for work, PE, and malpractice are in proportion to the weights for these categories in the rebased CY 2011 MEI. Our proposal would necessitate increas ing the proportion of aggregate CY 2011 PFS payments for PE and malpractice and decreasing the proportion for work. This could be accomplished by applying adjustment s directly to the work, PE, and malpractice RVUs. However, we are cognizant of the public comments made during prior rulemaking on issues related to scaling the work RVUs. Many commenters have indicated a preference for the work RVUs to remain stable over time and for any necessary adjustments that would otherwise be made broadly to the work RVUs to be accomplished in an alternative manner. For example, in past 5-Year Reviews of the work RVUs, many commenters have cited stability in the work RVUs, among other reasons, in their requests that any required budget neutralit y adjustments not be made directly to the work RVUs. Given these prior comments, we are proposing to make the necessary MEI rebasing adjustments without adjusting the work RVUs. Instead, we are proposing to increase the PE RVUs by an adjustment fact or of 1.168 and the malpractice RVUs by an adjustment factor of 1.413. The RVUs in A ddendum B to this proposed rule reflect the application of these adjustment factors. We note that an application of the 1.413 adjustment factor to the malpractice RVUs for services with malpractice RVUs of 0.01 will, due to rounding, result in malpractice RVUs of 0.01. Section 1848(c)(2)(B)(ii)(II) of the Ac t requires that changes to RVUs cannot cause the amount of expenditures for a year to differ by more than $20 million from what expenditures would have been in the absence of the changes. Therefore, as required by section 1848(c)(2)(B)(ii) of the Act, we are proposing to make an adjustment of 0.921 to

the CY 2011 conversion factor to ensure that the 1.168 adjustment to the PE RVUs and

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the 1.413 adjustment to the malpractice RVUs do not cause an increase in CY 2011 PFS expenditures. The current law estimate of the CY 2011 CF is $26.6574. III. Code-Specific Issues for the PFS A. Therapy Services 1. Outpatient Therapy Caps for CY 2011 Section 1833(g) of the Act applies an a nnual, per beneficiary combined cap on expenses incurred for outpatient physical therapy and speech-language pathology

services under Medicare Part B. A simila r separate cap for out patient occupational therapy services under Medicare Part B also a pplies. The caps do not apply to expenses incurred for therapy services furnished in an outpatient hospital setting. The caps were in effect during 1999, from September 1, 2003 through December 7, 2003, and beginning January 1, 2006. The caps are a permanent provision, that is, there is no end date specified in the statute fo r therapy caps. Beginning January 1, 2006, the Deficit Reduction Act (Pub. L. 109–171) (DRA) provided for exceptions to the therapy caps until December 31, 2006. The exceptions process for therapy caps has been extended through December 31, 2009 pursuant to three subsequent amendments (in MEIA-TRHCA, MMSEA, and MIPPA). Section 1833(g)(5) of the Act (as amende d by section 3103 of the ACA) extended the exceptions process for therapy caps through December 31, 2010. We will announce the amount of the therapy cap for CY 2011 in the CY 2011 PFS final rule with comment period. The annual change in the therapy cap is computed by multiplying the cap amount for CY 2010, which is $1860, by the MEI for CY 2011, and rounding to the nearest $10. This amount is added to the CY 2010 cap to obtain the CY 2011 cap. The agency’s authority to provide for exceptions to therap y caps (independent of the outpatient hospital

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exception) will expire on December 31, 2010, unless the Congress acts to extend it. If the current exceptions process expires, the caps will be applicable in accordance with the statute, except for services furnished and billed by outpatient hospitals. 2. Alternatives to Therapy Caps a. Background In section 4541 of the Balanced Budget Act of 1997 (Pub.L. 105-33) (BBA), the Congress enacted the financial limitations on out patient therapy services (the "therapy caps" discussed above for physical therapy, occupational therapy, and speech-language pathology). At the same time, the Congress requested that the Secretary submit a Report to Congress that included recommendations on the establishment of a revised coverage policy for outpatient physical therapy serv ices and outpatient occupational therapy

services under the statute. The Bala nced Budget Refinement Act of 1999 (Pub. L. 106-113) (BBRA) placed the first of a series of moratoria on implementation of the limits. In addition, it required focused me dical review of claims and revised the report requirements in secti on 4541(d)(2) of the BBA to request a report that included recommendations on the following: (A) the establishment of a mechanism for assuring appropriate utilization of outpatient physical therapy services, outpatient occupational therapy services, and speech-language pathology services; and (B) the establishment of an alternative payment policy for such servi ces based on classification of individuals by diagnostic category, functional status, prio r use of services (in both inpatient and outpatient settings), and such other criteria as the Secretary determines appropriate, in place of the limits. In 1999, therapy services were not defi ned, but services documented as therapy were billed and reported when furnished by a variety of individuals in many different

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settings. These services were not identified in a way that would allow analysis of utilization or development of alternative payment policies. We have studied therapy services with the assistance of a number of contractors over the past 11 years. Reports of these pr ojects are available on the CMS Web site at www.cms.gov/TherapyServices/ . On November 9, 2004, we delivered the Report to Congress, Number 137953, "Medicare Financ ial Limitations on Outpatient Therapy Services" that referenced two utilization analyses. We periodically updated the utilization analyses and posted other contracted reports in or der to further respond to the requirements of the BBRA. S ubsequent reports highlighted the expected effects of limiting services in various ways and presen ted plans to collect data about patient condition using available tools. The general belief was that if patie nt condition could be reliably determined, an objective payment po licy could be developed that would ensure appropriate payment for appropriately utilized services. Over the past decade, significant progress has been made in identifying the outpatient therapy services that are billed to Medicare, the demographics of the beneficiaries who utilize those services, the types of services, the HCPCS codes used to bill the services, the allowed and paid am ounts of the services, and the settings, geographic locations, and provider types where services are furnished. Some of the information that is necessary to ensure appropriate utilization and develop objective and equitable payment alternatives to th erapy caps based on patient condition has proven difficult to develop. The influence of prio r use of inpatient services on outpatient use of therapy services was not accessible due to systems issues and differences in the policies, billing, and reporting practices for inpatient and outpatient therapy services. The weakness of the ICD- 9-CM diagnostic codes in describing the

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condition of the rehabilitation patient obscured analyses of claims to assess the need for therapy services. The primary diagnosis on the claim is a poor predictor for the type and duration of therapy services required, which complicates assignment of patient cohorts for analysis. Although changes to the guidance in the Medicare Benefit Policy Manual (Pub. 100-02) on documentation of therapy serv ices in 2005 improved the consistency of records and facilitated chart review, it becam e increasingly obvious that neither claims analysis nor chart review could serve as a reliable and valid method to determine a patient’s need for services or to form the ba sis for equitable payment. We concluded that in order to develop alterna tive payment approaches to the therapy caps, we needed a method to identify patients with similar risk -adjusted conditions (cohorts) and then we would identify the therapy services that are necessary for the patients to attain the best

outcomes with the most efficient use of resources. While we studied therapy utilization, a number of proprietary tools were developed by researchers in the professi onal community to assess the outcomes of therapy. Some tool sponsors collected su fficient information to predict with good reliability the amount or length of treatment that would result in the best expected outcomes. We encouraged the use of these proprietary tools in ma nual instructions, but proprietary tools do not serve CMS’ purposes because modifi cation of proprietary tools may only be done by the tool sponsor. There now are some versions of the tools in the public domain and they are being utilized wide ly to identify patient conditions and, by some insurers, to pay for efficient and eff ective treatment. Examples of such tools including the National Outcomes Measurement System (NOMS) by the American Speech-Language Hearing Association and Patient Inquiry by Focus On Therapeutic Outcomes, Inc. (FOTO).

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In 2006, Focus on Therapeutic Outcomes, In c. delivered to CMS a report titled, "Pay for Performance for Physical Therapy and Occupational Therapy," which is also

available on the CMS Web site at www.cms.gov/TherapyServices . The purpose of this project was to simulate a pay-for-perfor mance implementation, designed to align

financial incentives with the achievement of better clinical outcomes from services that were delivered efficiently. The project , funded by HHS/CMS Grant #18-P-93066/9-01, demonstrated the predictive validity of the risk-adjusted pay-for- performance model and the feasibility of reducing payments without a ffecting services to be neficiaries who need

them.

b. Current Activities

The Tax Relief and Health Care Act of 2006 (TRHCA) extended the therapy cap exceptions process through December 31, 2007 and provided funds used for two CMS projects related to developing alternative payment approaches for therapy services that are based on beneficiary needs. A 5-year project titled "Development of Outpatient Therapy Alternatives" (DOTPA), awarded to RTI International, was initiated in order to develop a comprehensive and uniform therapy- related data collection instrument, assess its feasibility, and determine the subset of the measures that we could routinely and reliably collect in support of payment a lternatives. While DOTPA will identify measurement items relevant to payment, the project will not deliver a standardized measurement tool. We may either develop a tool or allow other tools to be used for payment purposes when they include those items that identify the following: (a) beneficiary need; and (b) outcomes (that is eff ectiveness of therapy services). In addition to therapy caps, the DOTPA project addresses our interest in value- based purchasing by

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identifying components of value, including beneficiary need and the effectiveness of therapy services. The DOTPA project reports are availabl e on the contractor’s Web site at http://optherapy.rti.org/ . The data collection design a nd instrument development have been completed, and a Paperwork Reduction Act (PRA) package was submitted for approval of the data collection forms by the Office of Management and Budget (OMB).

The Federal Register notice for the second round of public comment on this package was published on April 23, 2010 (75 FR 21296). Once the PRA package is approved, the contractor will begin data c ollection. While approval is pending, the contractor is recruiting potential participants in the data collection, devel oping training materials for participants, and updating the project web site. We are not seeking public comments on the DOTPA project in this proposed rule. The TRCHA also funded the 2-year proj ect contracted to Computer Sciences Corporation (CSC) titled "Short Term Alterna tives for Therapy Services" (STATS). STATS will provide recommendations regarding alternative payment approaches to therapy caps that could be considered be fore completion of the DOTPA project. The STATS project draws upon the analytical a nd clinical expertise of contractors and stakeholders to consider polic ies, measurement tools, and claims data that are currently available to provide further information about patient condition and the outcomes of therapy services. The final report, due in the fall of CY 2010, w ill include recommended

actions we could take within 2 or 3 cale ndar years to replace the current cap limits on therapy services with a policy that pays appropriately for necessary therapy services.

c. Potential Short-Term A pproaches to Therapy Caps

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On June 30, 2009, we received a draf t of the CSC report titled "STATS Outpatient Therapy Practice Guidelines," a summary of expert workgroup discussions, and several short-term paymen t alternatives for consideration. CSC discussed options based on the assumption that s hort-term policy changes shoul d facilitate the development of adequate function and/or outcomes reporting tools. In the long-term, CSC recommended that payment be based on f unction or quality measurements that adequately perform risk adjustment for episode-based payment purposes. Based on the draft report, additional stakeholder input, and subsequent communications with the contractor, in this proposed rule we are discussing several potential alternatives to the therapy caps that could lead to more appropriate payment for medically necessary and effective therapy services that are furnished efficiently. We are soliciting public comments on this proposed rule regarding all aspects of these alternatives, including the potential associated benefits or problems, clinical concerns, practitioner administrative burden, consistency with other Medicare and private payer payment policies, and claims processing c onsiderations. We are not proposing either short-term or long-term payment alternatives to the therapy caps at this time. However, we refer readers to section II.C.4.(c) of th is proposed rule for our CY 2011 proposal to expand the MPPR policy to "always therapy" services furnished in a single session in order to pay more appropriately for therap y services, taking into consideration the expected efficienci es when services are furnished together. While we are not proposing the adoption of an MPPR policy for therapy serv ices specifically as an alternative to the therapy caps, we acknowledge that by paying more appropriately for combinations of therapy services that are commonly furnishe d in a single session, practitioners would be able to furnish more medically necessary therapy services to a given beneficiary before

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surpassing the caps. This proposed policy would have the potential to reduce the number of beneficiaries impacted by the therapy caps in a given year. The three specific short-term options that we are discussing in this proposed rule would not require statutory changes. Some would require moderate reporting changes that would yield more detailed information a bout patient function a nd progress to inform future payment approaches and facilitate the medical review of services above the therapy caps at the present time. Others require new coding and bundled per-session payment that would be a first step toward episode-based payment. They are not necessarily independent of each other. Under each of these alternatives, administrative simplification with respect to current policies, such as HCPCS code edits and

"ICD-9-CM to HCPCS code" crosswalk edits th at serve to limit utilization without regard to the patient’s clinical presentation, could be pursued in the context of these options. The first option would modify the current therapy caps exceptions process to capture additional clinical information regarding therapy patient severity and complexity in order to facilitate medical review. This approach would complement the DOTPA project, which is identifying items to m easure patient condition and outcomes. We believe the first option may have the greatest potential for rapid implementation that could yield useful information in the short-term . We are especially interested in detailed public comments on this option that could info rm a potential proposal to adopt such an alternative through future rulemaking. The second option would involve introducing additional claims edits regarding medical ne cessity, in order to reduce overutilization. The third option would be to adopt a per-se ssion bundled payment that would vary based on patient characteristics and the complexity of evaluation and treatment services furnished in the session. Each option would require significant provider and contractor

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education, and all would nece ssitate major claims processing systems changes. Moreover, some of the options may affect be neficiaries by changing the type or amount of services covered by Medicare or the be neficiary’s cost sharing obligations. Option (1): Revise therapy caps exceptions process by requiring the reporting of new patient function- related Level II HCPCS code s and severity modifiers

. This option would require that clinicians submit beneficiary function-related nonpayable HCPCS codes to replace the -KX mo difier (Specific required documentation on file). Codes would not be submitted on every claim, but at episode onset and at periodic intervals (for example, progress re port intervals of 12 sessions or 30 days – whichever is less). Codes would be submitted for all patients in order for the claims to be paid and not only those claims approaching or surpassing the therapy caps. The current - KX modifier is not useful to identify claims exceeding therapy caps, because it is used for services both before and after the caps are exceeded, and it must be used on the entire claim for facilities. New codes also would not identify claims above the cap, but they would perform the same function as the current –KX modifier to signal that documentation in the medical record supported medical necessity that should lead to an exception to the therapy caps. The codes would also provide more information for

medical review. Six Level II HCPCS G-codes representing functions addressed in the plan of care and 5 (or 7) modifiers representing severi ty/complexity would be utilized to report

information on the claim. Examples of six new func tion-related G-codes:

● GXXXU – Impairments to body functions and/or structures – current.

● GXXXV – Impairments to body functi ons and/or structures – goal.

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● GXXXW – Activity limitations and/or pa rticipation restrictions – current.

● GXXXX – Activity limitations and/or pa rticipation restrictions – goal.

● GXXXY – Environmental barriers – current.

● GXXXZ – Environmental barriers – goal. Two potential severity/complexity scales ha ve been suggested that would require the adoption of 5 or 7 new severity modifi ers, respectively. Under one scenario,

modifiers based on the Interna tional Classification of Functi on could identify severity as

follows:

● None (0 to 4 percent);

● MILD (5 to 24 percent);

● MODERATE (25 to 49 percent);

● SEVERE (50 to 95 percent); or

● COMPLETE (96 to 100 percent). Alternatively, a proportiona l severity/complexity scale would use 7 modifiers to describe impairments, limitations, or barriers:

● 0 percent;

● 1 to 19 percent;

● 20 to 39 percent;

● 40 to 59 percent;

● 50 to 79 percent;

● 80 to 99 percent; or

● 100 percent. Implementation of this general approach would require 6 months to 2 years to modify claims processing for the current therapy caps and exceptions processing of

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claims, and to develop, pilot test, and refine coding befo re applying the approach nationally. While therapists initially would need to learn the new codes and update their billing systems, ultimately their reporting burden would be reduced because the –KX modifier would not be required on each claim line for patients with expenditures approaching or exceeding the therapy caps. This option could potentially result in a small reduction in outpa tient therapy expenditures due to increased Medicare contractor scrutiny of episodes where functional severity scores did not change over time, or to other atypical reporting patterns associated with the new codes. In the long-term, these codes and modi fiers could be mapped to reliable and validated measurement tools (either currentl y available tools in the public domain or newly developed tools from items on the DOTPA instrument or the Continuity

Assessment Record and Evaluati on (CARE) tool). When st atistically robust patient

condition information has been collected from claims data, it may be possible to develop Medicare payment approaches for outpatie nt therapy services that would pay appropriately and similarly for efficient and effective services furnished to beneficiaries

with similar conditions who have good potential to benefit from the services furnished. At a minimum, the new codes would allow contractors to more easily identify and limit the claims for beneficiaries that show no improvement over reasonable periods of time. Option (2): Enhance existing therapy caps exceptions process by applying medical necessity edits when per-beneficiary expenditures reach a predetermined value. The existing automatic process for exceptions, and the revised exceptions process described in Option 1 above, pay practitioners indefinitely for services if they attest on the claim by appending a specific modifier to therapy HCPCS codes that the services being furnished are medically necessary and that supporting documentation is included in

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the medical record. Unless the contractor us es claims edits or does post payment review, these processes do not identify or limit unusually high annual per-beneficiary utilization. High utilization is not limited to beneficiaries with multiple or complex conditions. We could use existing therapy utilization data to develop annual per- beneficiary medical necessity payment edits, such as limits to the number of services per session, per episode, or per diagnostic grouping, for exceptions to the therapy caps which could be set at benchmark payment levels that only a small pe rcentage of beneficiaries would surpass in a single year. Once these levels were reach ed, additional claims would be denied and practitioners would need to appeal those denials if they wished to challenge Medicare’s

nonpayment. This alternative would require 1 to 2 ye ars to implement as an expansion of existing policy, and its effects could be anticipated by analysis of the current utilization of therapy services. Additional practitione r burden would be incurred in the small number of cases exceeding the per-beneficiary expenditure edits when the practitioner chooses to appeal the medical necessity denial. Option (3): Introduce per-session "Eva luation/Assessment and Intervention" (E&I) codes to bundle payment for groups of current therapy HCPCS codes into a single per-session payment. As discussed in section II.C.4.(c) of th is proposed rule, multiple therapy services are often furnished in a single session, and we are proposing to expand the MPPR policy to "always therapy" services in CY 2011 in order to take into consideration the efficiencies that occur when multiple services (the typical therapy scenario) are furnished in one session to a beneficiary. Furthermor e, we note that section 1848(c)(2)(K) of the Act (as added by section 3134 of the ACA) regarding potentially misvalued codes under

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the PFS specifies that the Secretary may make appropriate coding changes, which may

include consolidation of i ndividual services into bundled codes for payment under the PFS, as part of her review and adjustment of the relative values for services identified as potentially misvalued. This option would require that practitioners submit a single new Level II HCPCS code to represent all the therapy services currently reported and paid separately for an outpatient therapy session. Payment for th e HCPCS code would be based on patient characteristics (as identified through prior CMS contractor analyses) and the complexity

of the evaluation/assessment and intervention services furnished during the session. The new coding requirements would not disrupt th e current exceptions process or the revised exceptions process described in Option (1) above. Approximately 12 E&I codes would be needed, taking into consideration the basic algorithm shown in Table 31.

TABLE 31: Evaluation/Assessment & Intervention Level II HCPCS Codes Evaluation/Assessment Complexity Minimal Moderate Significant None E&I Code #1 E&I Code #2 E&I Code #3 Minimal E&I Code #4 E&I Code #5 E&I Code #6 Moderate E&I Code #7 E& I Code #8 E&I Code #9 Intervention Level Significant E&I Code #10 E&I Code #11 E&I Code #12

We would need to develop and test operational definitions for each E&I code so that practitioners would be able to properly report services and appropriate relative values could be established for each per-session code. We believe that a pilot study might reveal that the different practice patterns for the three therapy professions (physical therapy, occupational therapy, and speech-language pathology) could necessitate separate relative value determinations for each E&I code by type of therapy service furnished. As a result, up to 36 total new Level II HCPCS codes c ould be needed (12 per discipline).

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We anticipate that the definitions of E&I codes 1 through 3 and 7 through 12 would describe services that may only be furn ished by a "clinician" (therapist, physician, or nonphysician practitioner). E& I codes 1 through 3 would be reported for sessions that consisted only of evaluations. In addition, the definitions of E&I codes 4 through 6

would describe services that could be furn ished by or under the permissible supervision of all qualified out patient therapy professi onals. Based upon historical therapy utilization patterns, the vast majority of E&I codes submitted would likely fall in the 4 through 9 code range. We would expect the RVUs unde r the PFS for all E&I codes to take into consideration the efficiencies when multiple services (those that would be currently reported under multiple CPT codes) are furnished. This option would require 2 to 4 years to add new codes and co nduct a short-term pilot study to refine coding and value the 12 new HCPCS codes (or 36 if they are specific to each therapy discipline). There would be significant initial pr actitioner administrative burden to learn new codes and update billin g systems. However, ultimately, with elimination of the practitioner’s reporting of 76 different codes and many of the associated claims processing edits, the administrative burden of reporting therapy

services to Medicare woul d be minimized. This bundled approach to reporting and payment could result in more appropriate valuation of ther apy services that reflects

efficiencies when indi vidually reported services are furn ished in the same session. As a result, it could lead to reduced therapy expe nditures, as well as a reduction in the number of beneficiaries affected by the therapy caps in a given year. In conclusion, we emphasize that we c ontinue to be committed to developing alternatives to the therapy caps that woul d provide appropriate payment for medically necessary and effective therapy services fu rnished to Medicare beneficiaries based on

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patient needs, rather than the current therapy caps which establish financial limitations on Medicare payment for therapy services in some settings regardless of medical necessity. The Congress has repeatedly intervened to a llow exceptions to these caps for certain time periods, and the current exceptions are automatically processed based on a practitioner’s

attestation that medical necessi ty is documented in the chart for an individual patient. We believe that, ultima tely, payment for therapy servi ces should incentivize the most effective and efficient care, consistent with Medicare’s focus on value in its purchasing. Therefore, we are soliciting public comme nts on potential alternatives to the therapy caps, including those discussed in this section of this proposed rule. The STATS contractor has worked closely with a broa d variety of clinicians, administrators, scientists, researchers, and other contractors to develop the 3 alternatives presented this

discussion. We welcome a ll public comments on this propose rule from interested stakeholders, including individual therapists from both facility and nonfacility settings treating Part B (outpatient) bene ficiaries. Among the topics of interest to us are the following:

● Recommendations for alternative payment policies (options discussed in this proposed rule or others) that address pa tient needs, while minimizing payment for inefficient services or those of limited patient benefit;

● Assessment of the practitioner burde n associated with the recommended policies;

● Likelihood that recommended chan ges would minimize fraud, abuse, and

waste;

● Whether the recommendations could a ssist CMS in obtaining meaningful information on patient function and how that information could be utilized;

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● Whether measurement tools relevant to assessing the need for therapy services exist in the public domain and how they might be utilized;

● What function information should be co llected and how it could be utilized to ensure necessary care, while minimizing paym ent for inefficient services or those of limited patient benefit; and

● How therapist behavior, plans of care, or patient scheduling would be affected by the recommended alternatives. We are committed to finding alternatives to the current therapy cap limitations on expenditures for outpatient therapy services that will ensure that beneficiaries continue to receive those medically necessary therapy services that maximize their health outcomes.

We continue to dedicate our resources to id entifying alternatives that would encourage the most efficient and cost-effective treatments. We believe motivated therapists, with attention to the most cost-effective practices, can incorporate practice efficiencies that benefit patients by achievin g the best possible results at the lowest cost. Our STATS and DOTPA projects, which ar e currently engaged in data collection and analysis to inform short-term and long-term alternatives to the therapy caps, respectively, lay the foundation for future payment alternatives for outpatient therapy services. We are optimistic that the STATS project will identify s hort-term, feasible alternatives that may be tested in the future. The DOTPA project will create a tool and test its use to collect patient condition information that can then be applied to identify patient need for therapy services. Together , these projects may provide the basis for a long-term plan to reshape Medicare’s paymen t policy for outpatient therapy services to align with the value-based purchasing principl es that are now guiding principles of the

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Medicare program. We encourage the public to provide comments so that we may consider all perspectives as we conti nue our work in this important area. B. Diabetes Self-Management Training (DSMT) Services (HCPCS Codes G0108 and G0109) 1. Background Section 4105(a) of BBA pr ovided coverage for DSMT in outpatient settings without limiting this coverage to hospital outpa tient departments. DS MT services consist of educational and training serv ices furnished to an individua l with diabetes by a certified provider in an outpatient setting. Section 4105(a) of the BBA stipulated th at training would be furnished by a “certified provider” which is a physician or other individual or entity that also provides other items or services for which payment may be made under Medicare. This program is intended to educate beneficiaries in the successful self-management of diabetes. The program includes instructions in self-monitori ng of blood glucose; education about diet and exercise; an insulin treatment plan de veloped specifically for the patient who is insulin-dependent; and motivation for patients to use the skills for self-management. DSMT services are reported under HCPCS codes G0108 (Diabete s outpatient selfmanagement training services, indivi dual, per 30 minutes) and G0109 (Diabetes outpatient self-management traini ng services, group session (2 or more), per 30 minutes). 2. Proposed Payment for DSMT Services In accordance with section 4105(a) of the BBA, Medicare payment for outpatient

DSMT services is made under the PFS as specified in §414.1 through §414.48. When we created HCPCS codes G0108 and G0109, the only direct costs included in the PE were registered nurse labor. Section 410.144(a)(4)(a) states that the DSMT team includes at

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least a registered dietitian and a certified diabetes educator. We did not establish work RVUs for DSMT services because we believed training would typically be performed by individuals other than a physician, such as a registered nurse (65 FR 83130). However, since that time, we have received requests from a number of stakeholders, including the

American Association of Clin ical Endocrinologists (AACE) , the American Association of Diabetes Educators (AADE), and the J uvenile Diabetes Research Foundation, to include physician work in valuing DSMT services that is similar to the physician work

that has been included in medical nutriti on therapy (MNT) services since CY 2007 and kidney disease education (KDE) services sinc e CY 2010. The stakeholders argued that because physicians coordinate DSMT pr ograms, provide patie nt instruction, and communicate with referring physicians, physic ian work should be included in the RVUs

for DSMT services. The stakeholders also re quested that we reconsider the direct PE inputs for DMST services and include clinical labor for diabetes educators at a higher hourly rate instead of registered nurse labor. In addition, they stated that the supplies and equipment in the PE for DSMT services shoul d be the same as for KDE services, with additional direct PE inputs for a diabetic educator curriculum, data tracking software, and DSMT program accreditation. For CY 2011, we are proposing to assign physician work RVUs to DSMT services that are comparable, as adjusted for the service times of the HCPCS codes, to the work RVUs for MNT services. We are pr oposing that HCPCS G0108 for 30 minutes of

individual DSMT services w ould be crosswalked to CPT code 97803 (Medical nutrition therapy; re-assessment and intervention, indivi dual, face-to-face with the patient, each 15 minutes) for purposes of assigning work RVUs , with the physician work RVUs for CPT code 97803 multiplied by two to account for the greater time associated with HCPCS

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code G0108 (that is, 30 minutes). We ar e also proposing that HCPCS G0109 for 30 minutes of group DSMT services would be crosswalked to CPT code 97804 (Medical nutrition therapy; group (2 or more indivi duals(s)), each 30 minutes) for purposes of assigning work RVUs. The rationale fo r the proposed work RVUs for the DSMT HCPCS G-codes is based on the similarity of DSMT services to MNT services in the individual (CPT code 97803) and group (CPT code 97804) setting. For CY 2011, we are also proposing to modi fy the PE inputs for DSMT services to reflect the current equipment and supplies for the KDE HCPCS G-codes implemented

in the CY 2010 PFS final rule with comme nt period (74 FR 61901) (that is, HCPCS codes G0420 (Face-to-face educational services related to the care of chronic kidney disease; individual, per session, per one hour) and G0421 (Face-to-face educational

services related to the care of chronic ki dney disease; group, per session, per one hour)), based on the similarity in the equipment and supplies necessary for DSMT and KDE services. We have made adjustments to some of the equipment times for the 30 minute DSMT individual and group services as co mpared to the 1 hour individual and group KDE services. We are also including a diabetic educator curriculum and data tracking software in the PE inputs for DSMT services, but it is our general practice not to include program accreditation costs in those PE inputs. With respect to clinical labor, rather than changing the current labor type for DSMT se rvices, we are proposing to utilize the same approach as we adopted for MNT services when we provided physician work RVUs for those services in CY 2007 (71 FR 69645). Specifically, we are removing all of the clinical labor from the group DSMT code a nd most of the clinical labor from the individual DSMT code, given that we are proposing work RVUs for both DSMT codes

for CY 2011.

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We believe these proposals would value DS MT services more consistently with other similar services that are paid under th e PFS. As a result of our proposed CY 2011 changes, the proposed work RVUs for HCPCS codes G0108 and G0109 are 0.90 and 0.25, respectively. As described above, we ar e also proposing to modify the direct PE inputs for these codes for CY 2011. C. End-Stage Renal Disease Related Serv ices for Home Dialysis (CPT codes 90963, 90964, 90965, and 90966) 1. End-Stage Renal Disease Home Dialysis Monthly Capitation Payment Services (CPT codes 90963, 90964, 90965, and 90966)

In the CY 2004 PFS final rule with comment period (68 FR 63216), we

established new Level II HC PCS G-codes for end-stage re nal disease (ESRD) monthly capitation payment (MCP) services. For center -based patients, payment for the G-codes varied based on the age of the beneficiary a nd the number of face-to-face visits furnished each month (for example, 1 visit, 2-3 visits and 4 or more visits). Under the MCP methodology, the lowest payment applied when a physician provided one visit per month; a higher payment was provided for two to three visits per month. To receive the highest payment, a physician would have to pr ovide at least four ESRD-related visits per month. However, payment for home dialysis MCP services only varied by the age of beneficiary. Although we did not initially specify a frequency of required visits for home dialysis MCP services, we stated that we “expect physicians to provide clinically appropriate care to manage the hom e dialysis patient” (68 FR 63219). Effective January 1, 2009, the CPT Edito rial Panel created new CPT codes to replace the G-codes for monthly ESRD-related services, and we accepted the new codes

for use under the PFS in CY 2009. The CPT c odes for monthly ESRD-related services

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for home dialysis patients include the following, as displayed in Table 32: 90963, 90964, 90965, and 90966. In addition, the clinical vignet tes used for the valuation of CPT codes 90963, 90964, 90965, and 90966 include scheduled (a nd unscheduled) examinations of the ESRD patient. Given that we pay for a physician (or practitioner) to evaluate the ESRD patient

over the course of an entire month under th e MCP, we believe that it is clinically appropriate for the physician (o r practitioner) to have at least one in-person, face-to-face encounter with the patient per month. Ther efore, we are proposing to require the MCP physician (or practitioner) to furnish at least one in-person patient visit per month for home dialysis MCP services (as describe d by CPT codes 90963 through 90966). This requirement would be effective for home di alysis MCP services beginning January 1, 2011. We believe this requirement reflects a ppropriate, high quality medical care for ESRD patients being dialyzed at home and gene rally would be consistent with the current standards of medical practice. 2. Daily and Monthly ESRD-Related Services (CPT Codes 90951 through 90970) In CY 2008, the AMA RUC submitted reco mmendations for valuing the new CY 2009 CPT codes displayed in Table 32 that replaced the MCP HCPCS G-codes for monthly ESRD-related services. We accept ed these codes for use under the PFS. TABLE 32: MCP Codes Recognized Under the PFS

MCP Code Long Descriptor

90951 End-stage renal disease (ESRD) related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of pa rents; with 4 or more face-to-face physician visits per month

90952 End-stage renal disease (ESRD) related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2-3 face-to-face physician visits per month

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MCP Code Long Descriptor

90953 End-stage renal disease (ESRD) related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 1 face-to-face physician visit per month

90954 End-stage renal disease (ESRD) related services monthly, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-toface physician visits per month

90955 End-stage renal disease (ESRD) related services monthly, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counselin g of parents; with 2-3 face-to-face physician visits per month

90956 End-stage renal disease (ESRD) related services monthly, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counselin g of parents; with 1 face-to-face physician visit per month

90957 End-stage renal disease (ESRD) relate d services monthly, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-toface physician visits per month

90958 End-stage renal disease (ESRD) relate d services monthly, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counselin g of parents; with 2-3 face-to-face physician visits per month

90959 End-stage renal disease (ESRD) relate d services monthly, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counselin g of parents; with 1 face-to-face physician visit per month 90960 End-stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 4 or more fa ce-to-face physician visits per month 90961 End-stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 2-3 face-to-face physician visits per month 90962 End-stage renal disease (ESRD) related services monthly, for patients 20 years of age and older; with 1 face-to-face physician visit per month

90963 End-stage renal disease (ESRD) relate d services for home dialysis per full month, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of gr owth and development, and counseling of parents

90964 End-stage renal disease (ESRD) relate d services for home dialysis per full month, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents

90965 End-stage renal disease (ESRD) relate d services for home dialysis per full month, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents 90966 End-stage renal disease (ESRD) relate d services for home dialysis per full month, for patients 20 years of age and older

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There are four additional CPT codes for ESRD-related services that are reported on a per-day basis. These daily CPT codes are: 90967 (End-stage renal disease (ESRD) related services for dialysis less than a full m onth of service, per day; for patients younger than 2 years of age); 90968 (End-stage renal dis ease (ESRD) related services for dialysis less than a full month of service, per day; for patients 2-11 years of age); 90969 (Endstage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 12-19 years of age); and 90970 (End-stage renal disease (ESRD) related services for dialysis less than a fu ll month of service, per day; for patients 20 years of age and older). For the MCP codes displayed in Tabl e 32, the AMA RUC initially recommended 36 minutes of clinical labor time for the pr e-service period. They also recommended an additional 6 minutes in the post-pe riod for CPT codes 90960, 90961, 90962, and 90966. For the four codes describing daily serv ices (CPT codes 90967 through 90970), the AMA RUC recommended including 1.2 minutes of clini cal labor per day, which is the prorated amount of pre-service clinical labor included in the monthly codes. The AMA RUC also

recommended that CPT codes 90952 and 90953 be contractor-priced.

In the CY 2009 PFS final rule with co mment period (73 FR 69898), we asked the

AMA RUC to reconsider their recommended PE inputs in the interest of making certain that they accurately reflected the typical direct PE resources required for these services. In addition, we asked the AMA RUC to re view the physician times for CPT codes 90960

and 90961 that are used in the calculation of th e PE RVUs. We accepted the work values for the new CPT codes for ESRD-related services that were recommended by the AMA

RUC. Since CY 2009, we have continued to calcu late the PE RVUs for the entire series

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of MCP codes displayed in Table 32 by usin g the direct PE inputs from the predecessor HCPCS G-codes, except for CPT codes 90952 and 90953 which are contractor-priced. We have also continued to use the physician time associated with the predecessor

HCPCS G-codes for CPT c odes 90960 and 90961 for purposes of calculating the PE

RVUs. In CY 2009, the AMA RUC submitted new recommendations for CPT codes 90951 and 90954 through 90970. For each of th e MCP codes (CPT code 90951 and CPT codes 90954 through 90966), the AMA RUC recommended an increased pre-service clinical staff time of 60 minutes. For each of the daily dialysis service codes (CPT codes 90967 through 90970), the AMA RUC recommended an increased clinical labor time of two minutes, which is the prorated amount of clinical labor included in the monthly codes. The AMA RUC also recommended an additional 38 minutes of physician time for

CPT codes 90960 and 90961. This resulted in a total physician time of 128 minutes and 113 minutes, respectively, for these codes. The AMA RUC continued to recommend that CPT codes 90952 and 90953 be contractor-priced. For CY 2011, we are proposing to accept these AMA RUC recommendations as more accurate reflections of the typical dire ct PE resources require d for these services. Therefore, we are proposing to develop the PE RVUs for CPT code 90951 and CPT codes 90954 through 90970 using the direct PE inputs as recommended by the AMA RUC and reflected in the proposed CY 2011 PE database, which is available on the CMS Web site under the supporting data files for the CY 2011 PFS proposed rule at: http://www.cms.gov/PhysicianFeeSched/ . We are also proposing to use the AMA RUCrecommended physician times for CPT code s 90960 and 90961. Consistent with the AMA RUC’s recommendations, we are proposin g to continue to contractor-price CPT

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codes 90952 and 90953. D. Portable X-Ray Se t-Up (HCPCS code Q0092) When a portable x-ray is furnished to a sing le patient, as many as four component HCPCS codes may be billed and paid for the service, including the portable x-ray transportation (HCPCS code R0070 (Transportation of por table x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen)); the portable x-ray set-up (HCPCS code Q0092 (Set- up of portable x-ray equipment)); and the professional and technical com ponents of the x-ray service itself (CPT 70000 series). Currently, the direct PE databa se contains x-ray equipment in both the radiology codes in the 70000 series of CPT and HCPCS code Q0092, the code for the set-up of a portable xray. In the technical component of the x-ray service is the direct PE input of a radiology room which contains x-ray equipment for th e various radiology codes in the 70000 series of CPT. In addition, portable x-ray equipm ent is included as a direct PE input for HCPCS code Q0092. Thus, x-ray equipment curren tly is recognized within the direct PE

values for two of the HCPCS codes that woul d be reported for the portable x-ray service, resulting in an overvaluation of the comprehensive portable x-ray service. Therefore, for CY 2011 we are proposing to remove portable x-ray equipment as a direct PE input for HCPCS code Q0092, in order to pay more appropriately for the x-ray equipment used to furnish a portable x-ray service. We believe the resulting payment for the comprehensive portable x-ray service would more appropriately reflect the resources used to furnish portable x-ray services by providing payment for the x-ray equipment solely through payment for the tec hnical component of the x-ray service that

is furnished. E. Pulmonary Rehabilitation Services (HCPCS Code G0424)

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In the CY 2010 PFS proposed rule (74 FR 33614), we proposed to create new HCPCS G-code G0424 (Pulmonary rehabilitation, including ae robic exercise (includes monitoring), per session, per day) to describe the services of a pulmonary rehabilitation (PR) program as specified in section 144(a) of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). Us ing CPT code 93797 (Cardiac rehab without telemetry) as a reference code, we pr oposed to assign 0.18 work RVUs and 0.01 malpractice RVUs to G0424. To establish PE RVUs, we reviewed the PE inputs of similar services, particularly those of the respiratory therapy HCPCS codes G0237 (Therapeutic procedures to increase strength or endurance or respiratory muscles, face to face, one on one, each 15 minutes (include s monitoring)) and G0238 (Therapeutic procedures to improve respiratory function, other than described by G0237, one on one, face to face, per 15 minutes (includes monitoring)), as well as the cardiac rehabilitation codes, CPT codes 93797 and 93798 (Physician services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session)). In the CY 2010 PFS final rule with comment period (74 FR 61886), we fi nalized our proposal with modifications to the code descriptor and PE inputs, as recommended by some commenters.

Based on commenters’ recommendations fro m the CY 2010 PFS final rule with comment period and further information furnis hed by stakeholders, we are proposing to

increase the work RVUs for HCPCS code G0424 to 0.28 for CY 2011 to be comparable

to the work RVUs for cardiac rehabilitation w ith monitoring (CPT code 93798) in view of the monitoring required for HCPCS code G0424. In addition, we are also proposing to in crease the clinical labor time for the respiratory therapist from 15 minutes to 30 mi nutes and to crosswalk the PE equipment inputs for HCPCS code G0424 to those for resp iratory treatment services (HCPCS code

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G0238), which include a 1-channel ECG and a pulse oximeter. We would retain the treadmill currently assigned to HCPCS code G0424 and adjust the equipment time to 45 minutes. While several pub lic commenters recommended this equipment, these commenters also requested a full 60 minutes of respiratory therapist time be included in the PE for HCPCS code G0424, comparable to the 15 minutes of respiratory therapist time included in the one on one codes for 15 minutes of respiratory treatment services (HCPCS codes G0237 and G0238). However, because PR services reported under

HCPCS code G0424 can be furnis hed either individually or in groups, we believe that 30 minutes of respiratory therapist time would be more appropriate for valuing the typical

PR service. F. Application of Tissue-Cultured Skin S ubstitutes to Lower Extremities (HCPCS Codes GXXX1 and GXXX2) There are currently two biological products, Apligraf and Dermagraft, which are FDA-approved for the treatment of diabetic foot ulcers. While commonly used by podiatrists for this purpose, th ese products are also used by other specialists in the

treatment of other clinical conditions, such as burns. Many Medicare contractors have estab lished local coverage determinations specifying the circumstances under which thes e services are covered. In the case of diabetic foot ulcers, clinical studies of Apligraf weekly application were based on up to 5 treatments over a 12-week period. In contrast, Dermagraft was applied weekly, up to 8 treatments over a 12-week period. The skin substitute CPT codes were reviewed and new codes were last created by

the CPT Editorial Panel for CY 2006. There ar e currently 2 skin repair CPT codes that describe Apligraf appli cation, one primary code, CP T code 15340 (Tissue cultured

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allogeneic skin substitute; first 25 sq cm or less) and one add- on code, CPT code 15341 (Tissue cultured allogeneic skin substitute; each additional 25 sq cm, or part thereof (List separately in addition to c ode for primary procedure)) and 4 codes that describe Dermagraft application, two initial codes based on body area, CPT codes 15360 (Tissue cultured allogeneic dermal subs titute, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children) and 15365 (Tissue cultured allogeneic dermal substitute, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infa nts and children) and two add-on codes, CPT codes 15361 (Tissue cu ltured allogeneic de rmal substitute, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for pr imary procedure)) and 15366 (Tissue cultured allogeneic dermal subs titute, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and ch ildren, or part thereo f (List separately in addition to code for primary procedure)).

Several stakeholders have expressed concern about the appropriateness and equity of the coding and payment for these services, given their similar uses and the office resources required when the products are app lied repeatedly over a number of weeks for treatment of lower extremity ulcers. They are concerned that current coding, with the associated payment policies and relative values , does not provide for appropriate payment for the services based on how they are furnis hed. In addition, some stakeholders believe that the current coding and payment provides a financial incentive for the selection of one tissue-cultured product over anot her, rather than facilitatin g clinical decision-making based solely on the most clinically appropr iate product for the patient’s case. For

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example, the Dermagraft and Apligraf appli cation codes have 90-d ay and 10-day global periods, respectively, and their current valu es include several follow-up office visits. When patients are treated periodically with re peated applications of the products over several weeks, the patients may be seen in follow-up by the physician. However, those

encounters would not be evaluation and ma nagement visits but, instead, would be procedural encounters that would typically be valued differently under the PFS than the follow-up office visits currently included in the values for the Dermagraft and Apligraf application codes. Furthermore, while di fferent stakeholders have indicated that debridement and site preparation are variably performed when these products are applied, the CPT codes for Dermagraft application a llow separate reporting of these preparation services when they are performed, while th e Apligraf application codes bundle these services. Since CY 2006, the PFS has accep ted the RUC work and PE recommendations for the Dermagraft and Apligraf application codes and has paid accordingly. With respect to Medicare payment policy, some Medicare contractors allow the use of modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) to be reported with the skin substitute application codes and provide full payment for the service each time it is performed, even if the subsequent application(s) is within the global period of the service. Other contractors do not allow the use of modifier -58, and therefore, pr ovide a single payment for a series of applications over 90 days or 10 days, as applic able to the particular code reported for the product’s initial a pplication. Because of the current inconsistencies in valuing similar skin substitute application services and the common clinical scenarios for their use for Medicare beneficiaries, we believe th at it would be appropriate to temporarily create Level II

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HCPCS G-codes to report application of tissue-cultured skin substitutes applied to the lower extremities in order to provide appropri ate and consistent payment for the services as they are commonly furnished. Therefore, we are proposing to create two new HCPCS G-codes for CY 2011, GXXX1 (Application of ti ssue cultured allogeneic skin substitute or dermal substitute; for use on lower limb, includes the site preparation and debridement if performed; first 25 sq cm or less) a nd GXXX2 (Application of tissue cultured allogeneic skin or dermal substitute; for use on lower limb, includes the site preparation and debridement if performed; each additional 25 sq cm), that would be recognized for payment under the PFS for the application of Ap ligraf or Dermagraft to the lower limb. These codes would not allow separate repor ting of CPT codes for site preparation or debridement. We emphasize that we would expect that the use of these HCPCS G-codes for payment under Medicare would be temporar y, while stakeholders work through the

usual channels to establish a ppropriate coding for these services that reflects the current common clinical scenarios in which the skin substitutes are applied. Furthermore, we would expect to receive recommendations from the AMA RUC for appropriate work values and direct practice expense inputs for the applicable codes, according to the usual process for new or revised codes. Under the PFS, as a temporary measure, the HCPCS G-codes would be assigned a 0-day global period so payment would be made each a time a covered service was furnished. We are proposing to base paymen t on the physician work relative values and the direct PE inputs for the existing CPT code s for Apligraf application, with adjustments for the global period differences because the HCPCS G-codes and the Apligraf application CPT codes. Thes e CPT codes resemble the new HCPCS G-codes in terms of wound size description and the inclusion of site preparation and debridement in their

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current values so we believe they appropriate ly represent the physician work involved in the proposed HPCPCS G-codes. However, we would adjust the work RVUs of the Apligraf application codes to derive the HC PCS G-code proposed CY 2011 work values by extracting the values for any office vis its and discharge day management services because the HCPCS G-codes have a 0-day gl obal period. In addition, we would adjust the direct PE inputs of the Apligraf appli cation codes to develop the proposed CY 2011 direct PE inputs of the HPCPS G-code s that have a 0-day global period. Our crosswalks and adjustments result in proposed CY 2011 work RVUs of 2.22

for HPCPCS code GXXX1 and 0.50 for HC PCPS GXXX2. The proposed direct PE inputs for HCPCS codes GXXX1 and GXXX2 are in cluded in the direct PE database for the CY 2011 proposed rule that is posted on the CMS Web site at http://www.cms.gov/Physicia nFeeSched/PFSFRN/list.asp

. We note that many Medicare contractors currently have local coverage policies that specify the circumstances under which Medicare covers the application of skin substitutes. The local coverage policies may include diagnostic or prior treatment requirements, as well as frequency limitations on the number and periodicity of treatments. We expect that these policie s would be updated in the context of the temporary new HCPCS G-codes that we are proposing for use in CY 2011 to report the application of tissue cultured a llogeneic skin or dermal subs titutes. We are proposing to establish the HCPCS G-codes for temporary use in CY 2011 in order to improve the consistency and resource-based nature of PFS payments for skin substitute application services that require similar resources. Ho wever, we note our continued interest in ensuring that skin substitutes are properly utilized for Medicare beneficiaries who will

benefit from that treatment. We will continue to monitor the utilization of these services

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and plan to identify any concerning trends in utilization that contractors may want to examine further through medical re view or other approaches. G. Canalith Repositioning (CPT code 95992) For CY 2009, CPT created a new code for canalith repositioning, specifically CPT code 95992 (Cana lith repositioning procedure(s) (eg, Epley maneuver, Semont maneuver), per day). This service may be furnished by both physicians and therapists. Although we accepted the RUC-recommended work RVUs and PE inputs, we initially bundled this procedure on an interim basis in the CY 2009 PFS final rule with comment period (73 FR 69896), indicating that we believed it would be paid through the E/M service that it would accompany. Subsequently, in view of concerns from therapists who cannot furnish E/M services, we clarified that therap ists could report one of the generally defined therapy CPT codes when canalith repositioning was furnished. In the CY 2010 PFS final rule with comment period (74 FR 61766), we changed the code’s status under the PFS to “not recognized for payment under Medicare,” consistent with our expectation that another payable code would be reported when the service was furnished.

Based on further information from stakeholde rs regarding the distinct and separate nature of this procedure from an E/M service and their request that we recognize this CPT code for payment, similar to our separate payment for most other procedures commonly

furnished in association with an E/M servi ce, we are proposing to recognize CPT code 95992 for payment under the CY 2011 PFS, consistent with our typical treatment of most other codes for minor procedures. In doing so, we are proposing to change the code’s

status to “A” and utilize the CY 2009 RUC re commendations for work RVUs (0.75) and PE inputs for establishing its payment in CY 2011. (That is, status “A” means Active code. These codes are separately payable under the PFS if covered.) Because canalith

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repositioning (CPT code 95992) can be furnished by physicians or therapists as therapy services under a therapy plan of care or by physicians as physicians’ services outside of a therapy plan of care, we would add CPT code 95992 to the “sometimes therapy” list on the therapy code abstract file.

H. Intranasal/Oral Immunization Codes (CPT codes 90467, 90468, 90473, and 90474)

To ensure that the PE RVUs are consistent between the intranasal/oral and injectable immunization administration CPT codes that describe services that utilize similar PE resources, we are proposing to cr osswalk the PE values for CPT code 90471 (Immunization administration (includes percut aneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid)) to CPT codes 90467 (Immunization administration younger than age 8 years (includes intranasal or oral routes of administration) when th e physician counsels the patient/family; first administration (single or combination vacci ne/toxoid), per day) and 90473 (Immunization administration by intranasal or oral r oute; one vaccine (single or combination vaccine/toxoid)) . Similarly, we are also proposing to cro sswalk the PE values for CPT code 90472 (Immunization administration (includes percut aneous, intradermal, subcutaneous, or intramuscular injections); each additional va ccine (single or combination vaccine/toxoid) (List separately in additi on to code for primary pro cedure)) to CPT codes 90468 (Immunization administration younger than age 8 years (includes intranasal or oral routes of administration) when the physician c ounsels the patient/famil y; each additional administration (single or combination vaccine/toxoid), per day (List separately in addition to code for primary procedure)) and 90474 (Immunization administration by

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intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)).

I. Refinement Panel Process As discussed in the November 25, 1992 PF S final rule (57 FR 55938), we adopted a refinement panel process to assist us in reviewing the public comments on interim physician work RVUs for CPT codes with that status in each year and developing final work values for the subsequent year. Our decision to convene multispecialty panels of physicians was based on our n eed to balance the interests of those who commented on the work RVUs against the budgetary and redist ributive effects that could occur if we accepted extensive increases in work RVUs across a broad range of services. The refinement panel reviews and discusses the work involved in each procedure and then each member individually rates the work of the procedure. Since 1992, the refinement panels' recommendation to change a work value or to retain the interim value has hinged solely on the outcome of a statistical test on the ratings (an F-test). Depending on the number and range of co des that public commenters, typically specialty societies, request be subject to refi nement, we establish re finement panels with representatives from 4 groups of physicians: clinicians representing the specialty most identified with the procedures in question; phys icians with practices in related specialties; primary care physicians; a nd contractor medical direct ors (CMDs). Typically the refinement panels meet in the summer prio r to the promulgation of the final rule finalizing the RVUs for the codes. Typica l panels have include d 8 to 10 physicians across the 4 groups. Over time, the statistical test used to evaluate the RVU ratings of individual panel members have become less reliable as the physicians in each group have tended to select a previously discussed value, rather than independently evaluating the

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work. In addition, the resulting RVUs have occasionally exhibited rank order anomalies (that is, a more complex procedure is assigned lower RVUs than a less complex procedure). Most recently, section 1848(c)(2)(K) of the Act (as added by section 3134 of the ACA) authorizes the Secretary to revi ew potentially misvalued codes and make appropriate adjustment s to the relative values. In addition, MedPAC has encouraged CMS to critically review the values assigned to the services under the PFS. MedPAC has stated its belief that CMS has historically relied too heavily on specialty societies to identify services that are misvalued by acce pting so many recommendations of the RUC. We believe the refinement pa nel process continues to pr ovide stakeholders with a meaningful opportunity for review and disc ussion of the interim work RVUs with a clinically diverse group of experts that then provides informed recommendations to CMS. Therefore, we would like to continue the re finement process, including the established composition that includes representatives fro m the 4 groups of physicians, but with

administrative modification a nd clarification. Specifical ly, for refinement panels beginning in CY 2011 (that is, for those code s with CY 2011 interim values that would be subject to refinement during CY 2011), we are proposing to eliminate the use of the Ftest and instead base revised RVUs on the median work value of the panel members’ ratings. We believe this approach will simplify the refinement process administratively, while resulting in a final panel recommendation that reflects the summary opinion of the panel members based on a commonly used m easure of central tendency that is not significantly affected by outlier values. In addition, we are clarifying that we have the final authority to set the RVUs, and therefore, may make adjustments to the work RVUs resulting from refinement if policy co ncerns warrant their modification.

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J. Remote Cardiac Monitoring Services (CPT codes 93012, 93229, 93268, and 93271)

In the CY 2010 PFS final rule with co mment period (74 FR 61755), we indicated

that we continued to have c oncerns about the issue of deve loping PE RVUs for services that are utilized 24 hours a day, 7 days a week (24/7), such as those that require certain monitoring system equipment. The PE equipment methodology was developed for equipment that is in use during standard physician’s office business hours and not this type of 24/7 equipment. We stated that we would conduct further analysis of this issue. Services that were contractor-priced in CY 2009 remained contractor-priced in CY 2010. We also indicated that any proposed chan ges will be communicated through future rulemaking. Since publication of the CY 2010 PFS fi nal rule with comme nt period, we have focused our additional analysis on four of the CPT codes that co mmenters have brought to our attention because they involve conc urrent, remote, 24/7 a ttended monitoring of multiple patients from a central location: CPT code 93012 (Telephonic transmission of post-symptom electrocardiogram rhythm stri p(s); 24-hour attended monitoring, per 30 day period of time; tracing onl y); CPT code 93229 (Wearable mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of acce ssible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; tec hnical support for connection and patient instructions for use, attended surveillance, analysis and physician prescribed transmission of daily and emergent data reports); CP T code 93268 (Wearable patient activated electrocardiographic rhythm derived event recording with presymptom memory loop, 24- hour attended monitoring, per 30 day period of time; includes tran smission, physician

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review and interpretation); and CPT 93271 code (Wearable patient activated electrocardiographic rhythm derived event recording with presymptom memory loop, 24-hour attended monitoring, per 30 day period of time; monitoring, receipt of transmissions, and analysis). Of these four codes, CPT code 93229 is currently contractor-priced in CY 2010, meaning that the local Medicare contractors determine payment rates for the service within the PFS geographic areas in their jurisd iction. The three services that are currently nationally-priced on the PFS are in the first year of a 4-year transition to lower payment

rates based on the use of th e PPIS data adopted in the CY 2010 PFS final rule with comment period. We refer readers to sec tion II.A.2. of this proposed rule for a description of the general PFS PE methodol ogy that is the basis for the following discussion of approaches to establishing PE RVUs for these four CPT codes.

We examined several alternative met hods for developing PE RVUS upon which PFS payment rates for these four CPT codes could be based. Each of these services

involves transmission of information fro m multiple patients who wear individual monitoring devices that transmit patient-specific information to centralized equipment that is simultaneously in use for multiple patients. We believe it would be most consistent with the principles underlying the PFS PE methodology to classify the centralized monitoring equipment as an indirect cost since it is servicing multiple patients at the same time. After classifying this equipment as an indirect cost, we used our standard methodology to calculate an indir ect practice cost inde x value for each code based on the PE/HR survey data of the hist orical mix of specialties providing these services. Establishing payment rates for th ese codes based on this approach would result in decreases in the payment rates for these services, including the typical contractor’s

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price for CPT code 93229. For the three se rvices that are nationally priced, these decreases would be relative to the lower paym ent rates based on the use of the PPIS data after the 4-year transition.

We also received PE/HR data from the Remote Cardiac Services Provider Group (RCSPG), a group of IDTF suppliers of these types of services. For sensitivity analysis purposes, we substituted these data for the PE /HR data of the spec ialties performing these services, while continuing to treat the centra lized monitoring equipment as an indirect cost. We found that establishing payment ra tes for these codes based on the approach of using the submitted RCSPG PE/HR data would again result in decreases in the payment rates for these services, including the typica l contractor’s price for CPT code 93229. As in the prior alternative, the decreases for the nationally priced codes would be relative to the payment rates reflecting the 4-year transition to the PPIS data. Although we believe that it would be most consistent with the principles underlying the PE methodology to classify th e centralized monitoring equipment as an indirect cost, we also performed a sensitivity analysis of the payment rates if the centralized monitoring equipment were classified as a direct cost. In this simulation, we assumed that the centralized monitoring equipment was in year-round use, 7 days per week for 24 hours per day. We found that establishing payment rates for these codes based on the approach of classifying the centralized monitoring equipment as a direct cost would again result in decreases in th e payment rates for the nationally priced services relative to their payment rates after the 4-year transition to the use of the PPIS data, as well as to the typical curren t contractor’s price for CPT code 93229. Finally, we considered proposing contracto r-pricing for all four of these services for CY 2011. However, we are cognizant of pa st public comments on this issue that have

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requested that all of these services be pr iced nationally on the PFS, including the one service (CPT code 93229) that is currently contractor- priced. We also considered that the services currently priced nationally on the PFS are scheduled to receive lower payment rates under the 4-year transition to the PPIS data and that the contractor’s price for CPT 93229 wa s recently reduced in the area where the majority of the billings for this service currently occur. After taking all these factors into c onsideration, we are not proposing CY 2011 methodological or direct cost input changes for CPT codes 93012, 93268, or 93271 - the services that are currently nationally priced under the PFS. We are also proposing to continue contractor-pricing for CPT 93229 for CY 2011. We continue to be interested in public comments on this issue, including re sponses to our analysis of alternative approaches to establishing PE RVUs for 24/7 services, and further discussion of the

issues we have identified in our alternative pricing methodolog ies. In addition, while we have focused the 24/7 services analysis to date on developing the PE RVUS for remote cardiac monitoring services, there may be 24/7 services in other areas of medicine, either currently paid under the PFS or in developmen t for the future. Therefore, we are also interested in public comments on these curr ent or emerging 24/7 services, including descriptions of the similarities or differences between these other services and remote cardiac monitoring services, particularly with respect to the issues we have identified in our analysis of alternative approaches to establishing PE RVUs for remote cardiac monitoring services under the PFS. IV. Medicare Telehealth Services For The Physician Fee Schedule A. Billing and Payment for Telehealth Services 1. History

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Prior to January 1, 1999, Medicare coverage for services delivered via a telecommunications system was limited to serv ices that did not require a face-to-face

encounter under the traditional model of medical care. Ex amples of these services included interpretation of an x-ray or electr ocardiogram or electroencephalogram tracing, and cardiac pacemaker analysis. Section 4206 of the BBA provided for covera ge of, and payment for, consultation services delivered via a telecommunications sy stem to Medicare beneficiaries residing in rural health professiona l shortage areas (HPSAs) as define d by the Public Health Service Act. Additionally, the BBA required that a Medicare practitioner (telepresenter) be with the patient at the time of a te leconsultation. Further, the BB A specified that payment for a teleconsultation had to be shared between the consulting practitioner and the referring practitioner and could not exceed the fee sche dule payment which would have been made to the consultant for the service provided. The BBA prohibited payment for any telephone line charges or fac ility fees associated with the teleconsultation. We implemented this provision in the CY 1999 PFS final rule with comment period (63 FR 58814). Effective October 1, 2001, section 223 of the Medicare, Medicaid and SCHIP Benefits Improvement Prot ection Act of 2000 (Pub. L. 106-554) (BIPA) added a new section 1834(m) to the Act which significantl y expanded Medicare telehealth services. Section 1834(m)(4)(F)(i) of the Act defines Medicare telehealth services to include consultations, office visits, office psychiat ry services, and any additional service specified by the Secretary, when delivered via a telecommunications system. We first implemented this provision in the CY 2002 PFS final rule with comment period (66 FR 55246). Section 1834(m)(4)(F)(ii) requi red the Secretary to establish a process

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that provides for annual updates to the lis t of Medicare telehealth services. We established this process in the CY 2003 PFS final rule with comment period (67 FR 79988). As specified in regulations at §410.78(b), we generally require that a telehealth

service be furnished via an interactive te lecommunications system. Under §410.78(a)(3), an interactive telecommunications system is defined as multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and the practitioner at the distant site. Telephones, facsimile machines, and electronic ma il systems do not meet the definition of an interactive telecommunications system. An interactive telecommunications system is generally re quired as a condition of payment; however, section 1834(m)(1)of the statute does allow th e use of asynchronous "store-and-forward" technology in delivering these services when th e originating site is a Federal telemedicine demonstration program in Alaska or Hawa ii. As specified in regulations at §410.78(a)(1), store and forward means the asynchronous transmission of medical information from an originating site to be reviewed at a later time by the practitioner at

the distant site. Medicare telehealth services may be provide d to an eligible telehealth individual notwithstanding the fact that the individual practitioner providing the telehealth service is not at the same location as the beneficiary. An eligible telehealth individual means an

individual enrolled under Part B who receives a telehealth service furnished at an originating site. As spec ified in BIPA, originating sites are limited under section 1834(m)(3)(C) of the statute to specified medical facilities located in specific geographic areas. The initial list of telehealth originatin g sites included the office of a practitioner, a

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critical access hospital (CAH), a rural health clinic (RHC), a federally qualified health center (FQHC) and a hospital. More recent ly, section 149 of the Medicare Improvements

for Patients and Providers Ac t of 2008 (Pub. L. 110-275) (MIPPA) expanded the list of telehealth originating sites to include hospital-based renal dialysis centers, skilled nursing facilities (SNFs), and community mental health centers (CMHCs). In order to serve as a telehealth originating site, these sites must be located in an area designated as a rural health professional shortage area (HPSA), in a county that is not in a metropolitan statistical area (MSA), or must be an entity that participate in a Federal telemedicine demonstration project that has been approved by (or receives funding from) the Secretary

of Health and Human Services as of Decembe r 31, 2000. Finally, section 1834(m) of the statute does not require the eligible telehealth individual to be presented by a practitioner at the originating site. 2. Current Telehealth Billing and Payment Policies As noted above, Medicare telehealth services can only be furnished to an eligible telehealth beneficiary in an originating site. An originating site is defined as one of the specified sites where an eligible telehealth individual is located at the time the service is being furnished via a telecommunications system. In general, originating sites must be located in a rural HPSA or in a county outside of an MSA. The originating sites authorized by the statute are as follows:

● Offices of a physician or practitioner

● Hospitals

● CAHs

● RHCs

● FQHCs

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● Hospital-Based Or Critical Access Hospital-Based Renal Dialysis Centers (including Satellites)

● SNFs

● CMHCs Currently approved Medicare telehealth services include the following:

● Initial inpatient consultations

● Follow-up inpatient consultations

● Office or other outpatient visits

● Individual psychotherapy

● Pharmacologic management

● Psychiatric diagnostic interview examination

● End Stage Renal Disease (ESRD) related services

● Individual medical nutrition therapy (MNT)

● Neurobehavioral status exam

● Individual health a nd behavior assessment a nd intervention (HBAI). In general, the practitioner at the distant site may be any of the following, provided that the practitioner is licensed unde r State law to furnish the service being furnished via a telecommunications system:

● Physician

● Physician assistant (PA)

● Nurse practitioner (NP)

● Clinical nurse specialist (CNS)

● Nurse midwife

● Clinical psychologist

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● Clinical social worker

● Registered dietitian or nutrition professional. Practitioners furnishing Medicare telehealth services are located at a distant site, and they submit claims for telehealth services to the Medicare contractors that process

claims for the service area where their dist ant site is located. Section 1834(m)(2)(A) of the Act requires that a practitioner who furnishes a telehealth service to an eligible telehealth individual be paid an amount e qual to the amount that the practitioner would have been paid if the service had been furn ished without the use of a telecommunications system. Distant site practitioners must sub mit the appropriate HCPCS procedure code for a covered professional te lehealth service, appended with the -GT (Via interactive audio and video telecommunications system) or –GQ (Via asynchronous telecommunications system) modifier. By reporting the –GT or –GQ modifier with a covered telehealth procedure code, the distant site practitioner cer tifies that the beneficiary was present at a telehealth originating site when the telehealth service was furnished. The usual Medicare deductible and coinsurance policies apply to the telehealth services reported by distant site practitioners. Section 1834(m)(2)(B) of the Act provides for payment of a facility fee to the originating site. To be paid the originating site facility fee, the provider or supplier where the eligible telehealth indi vidual is located must submit a claim with HCPCS code Q3014 (Telehealth originating site f acility fee), and the provider or supplier is paid according to the applicable payment methodology for that facility or location. The usual Medicare

deductible and coinsurance policies apply to HCPCS code Q3014. By submitting HCPCS code Q3014, the originating site authenticates that it is located in either a rural HPSA or non-MSA county or is an entity that participates in a Federal telemedicine

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demonstration project that has been approved by (or receives funding from) the Secretary

of Health and Human Services as of December 31, 2000 as specified in section 1834(m)(4)(C)(i)(III) of the Act. As described above, certain professional services that are commonly furnished remotely using telecommunications technology, but that do not require the patient to be present in-person with the practitioner when they are furnished, are covered and paid in the same way as services delivered without the use of telecommunications technology when the practitioner is in-person at the medical facility furnishing care to the patient. Such services typically involve circumstance s where a practitioner is able to visualize some aspect of the patient's condition without the patient being present and without the interposition of a third person's judgment. Visualization by the practitioner can be possible by means of x-rays, electrocardiogram or electroencephalogram tracings, tissue samples, etc. For example, the interpretation by a physician of an actual electrocardiogram or electroencephalogram tracing that has been transmitted via telephone (that is, electronically, rather than by means of a verbal description) is a covered physician's service. These remote se rvices are not Medicare telehealth services

as defined under section 1834(m). Rather, these remote services that utilize telecommunications technology ar e considered physicians' services in the same way as services that are furnished in-person without the use of telecommunications technology; they are paid under the same conditions as in-person physicians' services (with no requirements regarding permissi ble originating sites), and s hould be reported in the same way (that is, without the –GT or –GQ modifier appended). B. Requests for Adding Services to th e List of Medicare Telehealth Services

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As noted above, in the December 31, 2002 Federal Register (67 FR 79988), we established a process for adding services to or deleting services from the list of Medicare

telehealth services. This process provides the public with an ongoing opportunity to submit requests for adding services. We assign any request to make additions to the list of Medicare telehealth services to one of the following categories:

● Category 1: Services that are similar to professional consultations, office visits, and office psychiatry services. In re viewing these requests, we look for similarities between the requested and existing telehealth services for the roles of, and interactions among, the beneficiary, the physician (or ot her practitioner) at the distant site and, if necessary, the telepresenter. We also l ook for similarities in the telecommunications system used to deliver the proposed service, for example, the use of interactive audio and video equipment.

● Category 2: Services that are not similar to the current list of telehealth services. Our review of these requests includes an assessment of whether the use of a telecommunications system to deliver the service produces similar diagnostic findings or therapeutic interventions as compared with the in-person delivery of the same service. Requestors should submit evidence showing that the use of a telecommunications system does not affect the diagnosis or treatment plan as compared to in-person delivery of the requested service. Since establishing the process to add or remove services from the list of approved telehealth services, we have added the following to the list of Medicare telehealth services: individual HBAI services; psychiat ric diagnostic interview examination; ESRD services with 2 to 3 visits per month and 4 or more visits per month (although we require at least 1 visit a month to be furnished in-per son by a physician, CNS, NP, or PA in order

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to examine the vascular access site); indivi dual MNT; neurobehavior al status exam; and initial and follow-up inpatient telehealth consultations for beneficiaries in hospitals and skilled nursing facilities (SNFs). Requests to add services to the list of Medicare telehealth services must be

submitted and received no later than December 31 of each calendar year to be considered for the next rulemaking cycle. For example, requests submitted before the end of CY 2010 are considered for the CY 2012 propos ed rule. Each request for adding a

service to the list of Medicare telehealth services must include any supporting documentation the requester wishes us to consid er as we review the request. Because we use the annual PFS rulemaking process as a vehicle for making changes to the list of Medicare telehealth services, requestors should be advised that any information submitted is subject to public disclosure for this purpose. For more information on submitting a request for an addition to the list of Medicare telehealth services, including where to mail these requests, we refer readers to the CMS Web site at www.cms.gov/telehealth/

. C. Submitted Requests for Addition to the List of Telehealth Services for CY 2011 We received requests in CY 2009 to add the following services as Medicare

telehealth services effective for CY 2011: (1) individual kidney disease education (KDE) services; (2) individual diabet es self-management training (DSMT) services; (3) group KDE, DSMT, MNT, and HBAI services; (4) initial, subsequent, and discharge day management hospital care services; (5) initial, subsequent, discharge day management, and other nursing facility care services; (6) neuropsychological testing services; (7) speech-language pathology services; and (8) home wound care services. The following

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presents a discussion of these requests, incl uding our proposals for additions to the CY

2011 telehealth list.

1. Individual KDE Services The American Society of Nephrology, Di alysis Patient Citizens, AMGEN, and Kidney Care Partners submitted requests to add individual KDE services, reported by HCPCS code G0420 (Face-to-face educational se rvices related to the care of chronic kidney disease; individual, per session, per one hour), to the list of approved telehealth services for CY 2011 on a category 1 basis. Individual KDE services, covered under the new Medicare KDE benefit effective for services furnished beginning in CY 2010, are defined as face-to-face educational services provided to a patient with stage IV chronic kidney disease (CKD). We believe

the interaction between a practitioner and a beneficiar y receiving individual KDE

services is similar to the e ducation, assessment, and counse ling elements of individual MNT services, reported by HCPCS code G0270 (Medical nutrition therapy; reassessment and subsequent intervention(s) following sec ond referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face with the patient, each 15 minutes); CPT code 97802 (Medical nutrition therapy; initial assessm ent and intervention, individual, face-toface with the patient, each 15 minutes); a nd CPT code 97803 (Medical nutrition therapy;

re-assessment and interventi on, individual, face-to-face with the patient, each 15 minutes), all services that are currently on the telehealth list. Therefore, we are proposing to add HCPC S code G0420 to the list of telehealth services for CY 2011 on a category 1 basis. C onsistent with this proposal, we are also

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proposing to revise our regulations at §410.78(b) and §414.65(a)(1) to include individual

KDE as a Medicare telehealth service.

2. Individual DSMT Services The Tahoe Forest Health System and the Marshfield Clinic submitted requests to add individual DSMT services, reported by HCPCS code G0108 (Diabetes outpatient self-management training servi ces, individual, per 30 minutes), to the list of telehealth services for CY 2011 on a category 1 basis. In the CY 2009 PFS final rule with comment period (73 FR 69743), we stated that we be lieve individual DSMT services are not analogous to individual MNT services because of the element of skill-based training that is encompassed within individual DSMT services that is not an aspect of individual MNT services (or any other services currently approved for telehealth). Due to the statutory requirement that DSMT servi ces include teaching beneficiaries the skills necessary for the self-administration of injectable drugs, we have stated our belief that DSMT, whether provided to an individual or a group, must be evaluated as a category 2 service as specified in the CY 2009 PFS proposed rule (73 FR 38516). We have considered several previous requests to add DSMT to the list of Medicare telehealth services. We have not

added individual DSMT to the list of telehealth services because we believe that skill-based training, such as teaching patients how to inject insulin, would be difficult to accomplish effectively without the physical pr esence of the teaching practitioner (70 FR 45787 and 70157, and 73 FR 38516 and 69743). In considering the new request to add individual DSMT services to the list of

telehealth services in CY 2011, we have taken into account requestors' argument that individual DSMT services are highly similar to individual MNT services and that injection training constitutes just a small proportion of DSMT services. Except for the

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component of individual DSMT se rvices that involves instruction in self-administration of injectable drugs for eligible beneficiaries, we agree with the requestors that individual DSMT services are similar to individual MNT services, which are currently on the list of

Medicare telehealth services. We note that Medicare coverage of DSMT services was initially authorized in the Balanced Budget Act of 1997. After more than a decade of Medicare coverage, the most recent information shows that DSMT continues to be significantly underutilized in the context of the eligible population of Medicare

beneficiaries. While we ar e uncertain to what extent geographic barriers to care contribute to this underutilization, given the morbidity associated with poorly managed diabetes and the growing evidence-base regarding effective DSMT services, we believe it is very important to facilitate Medicare beneficiary access to these underutilized services. While we have previously been concerne d about treating the components of DSMT services differently in the context of considering DSMT services for the telehealth list,

we believe that our concern regarding the skill-based in jection training component of DSMT services can be addressed by impos ing a requirement that a minimum portion of the training be furnished in-person. We note that for beneficiaries who meet the coverage criteria, Medicare covers 10 hours of DSMT se rvices in the year following the initial training, as described in the Medicare Benefit Policy Manual (Pub. 100-02, Chapter 15, Section 300.3). Taking into consideration the initial year coverage of DSMT services, we are proposing that a minimum of 1 hour of in struction in injection training must be furnished in-person during the year following the initial DSMT service. Imposing this condition would allow us to expand access to DSMT services by adding individual DSMT services to the list of telehealth services, while ensuring effective injection training for beneficiaries.

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Therefore, we are proposing to add HCPC S code G0108 to the list of telehealth services beginning in CY 2011. We are also proposing that, as a condition of payment for individual DSMT services furnished as telehealth services to an eligible telehealth individual, a minimum of 1 hour of in-person instruction in the se lf-administration of injectable drugs must be furnished to the individual during the year following the initial DSMT service. The injection training may be furnished through either individual or group DSMT services. By reporting the –G T or –GQ modifier with HCPCS code G0108 as a telehealth service, the distant site practitioner would certify that the beneficiary has received or will receive 1 hour of in-person DSMT services for purposes of injection training during the year following the initial DSMT service. Consistent with this proposal, we are proposing to revise our regulations at §410.78(b) and §414.65(a)(1) to

include individual DSMT services as a Medicare telehealth service, with the exception of 1 hour of in-person instruction in self-adminis tration of injectable drugs which must be furnished to the eligible telehealth indi vidual as individual or group DSMT services during the year following the initial DSMT service. We note that, as specified in §410.141(e) , individual DSMT services may be furnished by a physician, individual, or en tity that furnishes other services for which direct Medicare payment may be made and that submits necessary documentation to, and is accredited by, an accreditation organization approved by CMS. However, consistent with the statutory requirements of section 1834(m)(1) of the Act and as provided in §410.78(b)(1) and (b)(2) of our regulations, Me dicare telehealth services, including

individual DSMT furnished as a telehealth se rvice, could only be furnished by a licensed PA, NP, CNS, certified nur se-midwife, clinical psychologist, clinical social worker, or registered dietitian or nutrition professional.

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3. Group KDE, MNT, DSMT, and HBAI Services The American Society of Nephrology, Dial ysis Patient Citizens, AMGEN, Tahoe Forest Health Systems, Kidney Care Partne rs, the American Tele medicine Association,

and the Marshfield Clinic s ubmitted requests to add one or more of the following group

services to the telehealth list for CY 2011:

● Group KDE services, reported by HCPCS code G0421 (Face-to-face

educational services related to the care of chronic kidney disease; group, per session, per one hour);

● Group MNT services, reported by CPT code 97804 (Medical nutrition therapy; group (2 or more individu al(s)), each 30 minutes);

● Group DSMT services, reported by HCPCS code G0109 (D iabetes outpatient self-management training services, group sessi on (2 or more), per 30 minutes); and/or

● Group HBAI services, reported by CPT code 96153 (Hea lth and behavior intervention, each 15 minutes, face-to-face; group (2 or more patients)) and 96154 (Health and behavior intervention, each 15 minut es, face-to-face; family (with the patient present)). When furnished as individual services, HBAI and MNT services are currently on

the list of Medicare telehealth services. Fu rthermore, we are proposing to add individual

KDE and DSMT services to the list of Me dicare telehealth services beginning in

CY 2011 as described above.

In the CY 2007 and CY 2010 PFS rule making cycles (70 FR 45787 and 70157, and 74 FR 33543 and 61764), we stated that we did not believe that group services could be appropriately delivered thr ough telehealth. We have observed that currently there are no group services approved as Medicare telehea lth services and that there is a different

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interactive dynamic between the practitioner and his or her patients in group services as compared to individual services. We previous ly have considered requests to add various group services to the list of Medicare telehea lth services on a category 2 basis because we have believed that, especially given the interactive dynamic between practitioners and their patients, group services are not similar to other services on the list of Medicare telehealth services. Therefore, we have maintained that it is necessary to evaluate the addition of group services by comparing diag nostic findings or therapeutic interventions

when services are furnished via telehealth ve rsus when services are furnished in-person.

We continue to be lieve that the group dynamic ma y be a critical and defining element for certain services, and that this characteristic precludes many group services from being considered on a category 1 basis for addition to the list of Medicare telehealth services. For example, we believe that due to the therapeutic nature of the group dynamic that is integral to group psychothe rapy, group psychotherapy is fundamentally

different from other Medicare telehealth servi ces and, therefore, could not be considered on a category 1 basis for addition to the telehea lth services list. For the same reason, in the absence of evidence to the contrary, we do not believe group psychotherapy services could be appropriately deliver ed through telehealth. However, upon further consideration, w ith regard to the particular group education and training services for whic h we received requests for addition to the

Medicare telehealth services lis t, we believe the group dynamic is not central to the core education and training components of thes e particular services, specifically DSMT, MNT, KDE, and HBAI services. We believe that these group services are sufficiently similar to the individual, related services that are already on the telehealth services list or are proposed for addition beginning in CY 2011. Specifically, we believe that for these

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group services, which consist principally of an information exchange for the purpose of education and training, the roles of, and interactions between, the patients and the practitioner are sufficiently similar to the related individual education and training

services that the services can be furnished appropriately as a telehealth service. Therefore, we are proposing to add HCPCS code G0421 for group KDE services, CPT code 97804 for group MNT services, HCPCS code G0109 for group DSMT services, and CPT codes 96153 and 96154 for group HBAI services to the Medicare telehealth services list on a category 1 basis. Furthermore, because the concerns we raised above regarding adequate injection training with the addition of individual DSMT are also present for group DS MT, we are proposing to require the same minimum of 1 hour of in-person instruction for injection training within the year following the initial DSMT service for any beneficiary that receives DSMT services via telehealth. By reporting the –GT or –GQ m odifier with HCPCS code G0109, the distant site practitioner would certify that the benefici ary has received or will receive 1 hour of in-person DSMT services for purposes of inje ction training during the year following the

initial DSMT service. Consistent with th is proposal to add these group education and training services, we are also proposing to revise our regulations at §410.78(b) and §414.65(a)(1) to include group KDE, MNT, DS MT, and HBAI services as Medicare telehealth services, with the exception of 1 hour of in-person instruction of individual or group DSMT services in the year follo wing the initial DSMT service.

As described above for individual DSMT services, we note that group DSMT services may be furnished by a physician, individual, or entity that furnishes other services for which direct Medicare payment may be made and that submits necessary documentation to, and is accredited by, an accreditation organization approved by CMS,

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as specified in §410.141(e) for DS MT services. However, consistent with the statutory requirements of section 1834(m)(1) of th e Act and as provided in §410.78(b)(1) and (b)(2) of our regulations, Medicare telehealth services, including group DSMT furnished as a telehealth service, could only be fu rnished by a licensed PA, NP, CNS, certified nurse-midwife, clinical psychologist, clinical social worker, or registered dietitian or nutrition professional. 4. Initial, Subsequent, and Discharge Day Management Hospital Care Services The University of Louisville School of Medicine, the Americ an Telemedicine Association, and Mille Lacs Health System submitted various re quests to add initial hospital care services (reporte d by CPT codes 99221 (Level 1 initial hospital care), 99222 (Level 2 initial hospital care), and 99223 (Lev el 3 initial hospital care)); subsequent hospital care services (reported by CPT code s 99231 (Level 1 subsequent hospital care), 99232 (Level 2 subsequent hospital care), and 99233 (Level 3 subsequent hospital care)); and/or hospital discharge day manageme nt services (reported by CPT codes 99238 (Hospital discharge day mana gement; 30 minutes or less) and 99239 (Hospital discharge day management; more than 30 minutes) to the Medicare telehealth services list beginning in CY 2011, generally on a category 1 basis. Some of the requestors also recommended that we limit the delivery of these services through telehealth to the provision of services to patients with a psyc hiatric diagnosis or to those treated in a psychiatric hospital or licensed psychiatric bed. We appreciate the recommendations of the requestors to substantially expand the list of Medicare telehealth services. The requestors submitted a number of studies regarding the outcomes of telehealth services in caring for patients with psychiatric diagnoses. However, we note that the CPT c odes for hospital care services are used to

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report care for hospitalized pa tients with a variety of diag noses, including psychiatric diagnoses. We do not believe it would be appropr iate to add services to the telehealth list only for certain diagnoses because the service described by a HCPCS code is essentially the same service, regardless of the patient's diagnosis. When evaluating the addition of services for telehealth on a category 1 basis, our focus is on the roles of, and interactions among, the beneficiary, the physician or practitioner, and the telepresenter (if applicable), which generally are similar across diagnoses for services that may be reported with the same HCPCS codes. Even in the unique case of certain ESRD services, we limited

additions to the list of Medicare telehealth services based on the appropriateness of certain specific codes, taking into consideration the full service descriptions (69 FR 47511). Therefore, we continue to believe that it is most appr opriate to consider additions to the list of telehealth services based on the overall suitability of the services described by the relevant HCPCS codes to delivery through telehealth. In the CY 2005, CY 2008, and CY 2009 PFS rulemakings (69 FR 47510 and 66276, 72 FR 38144 and 66250, and 73 FR 38517 and 69745, respectively), we did not add initial, subsequent, or discharge day mana gement hospital care services to the list of approved telehealth services be cause of our concern regarding the use of telehealth for the ongoing evaluation and management (E/M) for the generally high acuity of hospital inpatients. While we continue to have some concern in this area, we also share the requestors' interest in improving access fo r hospitalized patients to care furnished by treating practitioners. Therefore, we have reevaluated these services in the context of the CY 2011 requests, including considering the possibility that these services could be added on a category 1 basis based on their re semblance to services currently on the telehealth list, such as initial and follow-up inpatient telehealth consultations. The

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following presents a discussion of our revi ew of the subcategories of hospital care services included in these requests. Currently, one of the three codes for an initial hospital care service (specifically CPT codes 99221, 99222, or 99223) is reported for th e first hospital inpatient E/M visit tothe patient by the admitting or a consulting practitioner when that visit is furnished inperson. In addition, we note that curren tly there are several HCPCS G-codes on the Medicare telehealth services list that may be reported for initial and follow-up inpatient consultations through telehealth, specifical ly HCPCS codes G0406 (Follow-up inpatient

telehealth consulta tion, limited, physicians typically spend 15 minutes communicating with the patient via telehealth); G0407 (Fo llow-up inpatient tele health consultation, intermediate, physicians typi cally spend 25 minutes communicating with the patient via telehealth); G0408 (Follow-up inpatient telehealth consultation, complex, physicians typically spend 35 minutes or more communi cating with the patient via telehealth); G0425 (Initial inpatient telehealth consultation, typically 30 minutes communicating with the patient via telehealth); G0426 (Initial inpatient telehealth consu ltation, typically 50 minutes communicating with the patient via telehealth); and G 0427 (Initial inpatient telehealth consultation, typica lly 70 minutes or more communicating with the patient via telehealth). While initial inpatient consultation services are currently on the list of approved telehealth services, there are no services on the current list of telehealth services that resemble initial hospital care for an acutely ill patient by the admitting practitioner who has ongoing responsibility for the patient's treatment during the hospital course. Therefore, we are unable to consider initial hospital care services on a category 1 basis

for the telehealth list.

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We have reviewed the do cumentation submitted in s upport of adding the initial hospital care codes to the Medicare telehealth services list as category 2 requests. Most of the studies provided by the requestors were specific to the treatment of patients with particular diagnoses. Additionally, the studies were not specific to initial hospital care visits by admitting practitioners. Finally, most of the studies concluded that more research was required in order to establish medical equivalence be tween telehealth and in-person services. Therefore, we receive d no information that provides robust support for the addition of initial hospital care services to the approved telehealth list on a category 2 basis. The initial hospital care codes describe the first visit to the hospitalized patient by the admitting practitioner who may or may not have seen the patient in the decision-making phase regardin g hospitalization. We believe it is critical that the initial hospital visit by the admitting practitioner be conducted in-person to ensure that the practitioner with ongoing trea tment responsibility comprehens ively assesses the patient's condition upon admission to the hospital th rough a thorough in-person examination. Therefore, we are not proposing to add initial hospital care services to the Medicare

telehealth services list for CY 2011. We have again considered adding subs equent hospital care services reported by CPT codes 99231 through 99233 to th e telehealth list for CY 2011 on a category 1 basis. In the CY 2005 and CY 2008 PFS proposed rules (69 FR 47511 and 72 FR 38155), we stated that the potential acuity of patients in the hospital setting precludes consideration of subsequent hospital visits as similar to existing telehealth services. However, as stated earlier, we also note that HCPCS codes for initial and follow-up inpatient consultation services are on the list of telehealth services. These E/M services are furnished to high acuity hospitalized patients, although not by the admitting practitioner himself or herself.

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However, in light of the increasingly prevalent care model that entails multidisciplinary team care for patients with complex medical illnesses that involve multiple body systems, consulting practitioners may often play a key, intensive, and ongoing role in caring for hospitalized patients. Therefor e, we believe that subseque nt hospital care visits by a patient's admitting practitioner may sufficiently resemble follow-up inpatient consultation services to consider these subsequent hosp ital care services on a category 1 basis for the telehealth list. While we still believe the potential acuity of hospital inpatients is greater than those patients likely to receive currently approved Medicare telehealth services, we also believe that it would be appropriate to permit some subsequent hospital care services to be furnished through telehealth in orde r to ensure that hosp italized patients have frequent encounters with thei r admitting practitioner. However, we also continue to believe that the majority of these vis its should be in-person to facilitate the comprehensive, coordinated, and personal care that medically volatile, acutely ill patients require on an ongoing basis. Therefore, we are proposing that subse quent hospital care services, specifically CPT codes 99231, 99232, and 99233, be added to th e list of telehealth services on a category 1 basis for CY 2011, but with some limitations on the frequency that these services may be furnished through telehealt h. Because of our concerns regarding the potential acuity of hospital inpatients, we are proposing to limit the provision of subsequent hospital care services through te lehealth to once every 3 days. We are confident that admitting practitioners will continue to make appropriate in-person visits to all patients who need such care during th eir hospitalization. Consulting practitioners

should continue to use the i npatient telehealth consultation HCPCS G-codes, specifically

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G0406, G0407, G0408, G0425, G0426, or G0427 when reporting consultations furnished to inpatients via telehealth. Consistent with this proposal, we are proposing to revise §410.78(b) and §414.65(a)(1) to include subsequent hospital care services as Medicare telehealth services, with the limitation of one telehealth subsequent hospital care service every 3 days. We also considered adding hospital disc harge day management services to the list

of telehealth services. These services , reported by CPT codes 99238 and 99239, include

the final examination of the patient, discussion of the hospital stay, instructions for continuing care to all relevant caregiver s, and preparation of discharge records, prescriptions, and referral forms. These serv ices are furnished when a practitioner deems it medically reasonable and necessary to assess a patient's readiness for discharge and to prepare a patient for discharge from an acute care environment to a less intensive setting.

There are no services on the current list of telehealth services that resemble such preparation of a patient for discharge. We believe it is especially important that, if apractitioner furnishes a discharge day management service, the service be furnished inperson in order to allow the practitioner to comprehensively assess the patient's status in preparation for discharge so that the patient will have a higher likelihood of making a successful transition to the less intensive setting. Therefore, we are not considering hospital discharge day management services for addition to the Medicare telehealth services list on a category 1 basis.

We have reviewed the documentation submitted by requestors in support of adding these codes to the Medi care telehealth services list on a category 2 basis. Most of the submitted studies were specific to the treatment of patients with specific diagnoses

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and were not specific to discharge services. Additionally, most of the studies concluded that more research was required in order to establish medical equivalence between telehealth and in-person services. The submitted documentation did not provide the necessary evidence to alter our previous conclusion that hospital discharge day management services should be provided in-p erson in light of the acuity of hospitalized patients, their typically complex post-hospita lization care needs, and the importance of patient education by the admitting practitioner who had ongoing responsibility for the patient's treatment during the hospital stay. Therefore, we are not proposing to add hospital discharge day management services to the list of telehealth services for CY 2011. 5. Initial, Subsequent, Discharge Day Management, and Other Nursing Facility Care

Services

The American Telemedicine Association and the Marshfield Clinic submitted requests to add nursing facility care codes, covering the spectrum of initial (reported by CPT codes 99304 (Level 1 initial nursing fac ility care), 99305 (Level 2 initial nursing facility care) and 99306 (Level 3 initial nursing facility care)); subse quent (reported by CPT codes 99307 (Level 1 subsequent nursing facility care), 99308 (Level 2 subsequent nursing facility care), 99309 (Level 3 subsequent nursing facility care), and 99310 (Level 4 subsequent nursing facility care)); discharge day management (reported by CPT codes 99315 (Nursing facility discharge day ma nagement; 30 minutes or less) and 99316 (Nursing facility discharge day management; more than 30 minutes)); and other (reported by CPT code 99318 (Evaluation and manageme nt of a patient involving an annual nursing facility assessment)) services, to the Medicare telehealth services list beginning in CY 2011. The requests for the addition of th ese services expresse d concerns regarding

limited access to care if we do not allow these se rvices to be furnished through telehealth,

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and requested that CMS acknowledge the re cent Congressional inclusion of nursing facilities as telehealth originating sites by adding these codes to the list of Medicare

telehealth services. In the CY 2010 PFS proposed and fina l rules (74 FR 33544 and 74 FR 61762), we discussed concerns about poten tial disparities in patient acu ity between nursing facility

services and the current list of Medicare telehealth services. We have also declined to add HCPCS codes to the Medicare telehealth services list that are used exclusively to describe Federally-mandated nursing facility visits. As discussed in the CY 2010 PFS proposed rule (74 FR 33543), the long-term care regulations at §483.40(c) require that residents of SNFs receive initial and periodic personal visits. These regulations ensure that at least a minimal degree of personal contact between a practitioner and a SNF resident is maintained, both at the point of admission to the facility and periodically during the course of the resident's stay. We continue to believe that these Federallymandated visits should be conduc ted in-person, and not as Medi care telehealth services. Therefore, in the CY 2010 PFS final rule with comment period, we revised §410.78 to preclude physicians and other practitioners from furnishing the physician visits required under §483.40(c) through telehealth. We reviewed the use of telehealth for each of the subcategories of nursing facility services included in the requests for CY 2011. We identified the E/M services that fulfill Federal requirements for personal visits under §483.40(c), and we are not proposing for CY 2011 to add any HCPCS codes to the Medicar e telehealth services list that are used exclusively to describe these Federally-ma ndated visits. These codes include the CPT codes for initial nursing facilit y care (CPT codes 99304 thr ough 99306) that are used to report the initial E/M visit that fulfills Fe derally-mandated requi rements under §483.40(c)

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and other nursing facility service (CPT code 99318) that is only payable by Medicare if

the visit is substituted for a Fede rally-mandated visit under §483.40(c). The nursing facility discharge day management services reported under CPT code 99315 and 99316 are E/M visits that prepare a nurs ing facility resident for discharge from the facility. There are no Medicare requirements that such a service be furnished. If a practitioner chooses to furnish this service, we continue to believe that an in-person visit is most appropriate in order to ensure the resident is prepared for discharge from the nursing facility. These services are furnished when a practitioner deems it medically reasonable and necessary to asse ss a patient's readiness for and to prepare a patient being discharged from the monitored nursing facility environment to another typically less intensive setting. There are no services on the current list of telehealth services that resemble such preparation of a patient for discharge. As in the case of hospital discharge day management services, we believe it is especially important that, if a practitioner furnishes a nursing facility discharge day mana gement service, the service be furnished in-person. The practitioner must be able to co mprehensively assess the patient's status in preparation for discharge so that the patient will have a higher likelihood of making a successful transition from the nursing facility to another setting. Therefore, we are not considering nursing facility discharge day management services for addition to the Medicare telehealth services list on a category 1 basis. When we considered the addition of these services under category 2, we had no evidence that nursing facility discharge services furnished through telehealth are e quivalent to in-person discharge services. Therefore, we are not proposing to add nursing facility discharge day management

services to the CY 2011 telehealth list.

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Subsequent nursing facility serv ices, reported by CPT codes 99307 through 99310, may be used to report either a Fede rally-mandated periodic visit under §483.40(c) or another E/M visit, prior to or after the initia l nursing facility care visit, as long as the subsequent nursing facility care visit is medically reasonable and necessary for the

resident's care. While we continue to be lieve that many SNF residents have complex medical care needs, we believe that it is a ppropriate to consider the addition of these codes to the telehealth list on a category 1 basis. As we state above in the context of ourdiscussion of subsequent hospital care services, the HCPCS codes for initial and followup inpatient consultation services for nursing facility patients are on the list of Medicare telehealth services, and subsequent nursing fa cility services are similar to those services. These E/M services are furnished to high ac uity, complex SNF patients, although not by the admitting practitioner himself or herself. Therefore, we believe that subsequent nursing facility visits by a patient's admittin g practitioner sufficiently resemble follow-up inpatient consultation services to consider them on a category 1 basis for the telehealth list. We have concluded that it would be appropriate to permit some subsequent nursing facility care services to be furnished through telehealth to ensure that complex nursing facility patients have freque nt encounters with their ad mitting practitioner, although we

continue to believe that the Federally-mandated visits should be in-person to facilitate the comprehensive, coordinated, and personal car e that these complex patients require on an ongoing basis. Therefore, we are proposing that subs equent nursing facility care services, specifically CPT codes 99307, 99308, 99309 and 99310, be added to the list of Medicare

telehealth services on a cate gory 1 basis beginning in CY 2011, with some limitations on furnishing these services through telehealt h. Because of our concerns regarding the

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potential acuity and complexity of SNF inpa tients, we are proposing to limit the provision of subsequent nursing facility care services furnished through telehealth to once every 30 days. We are especially interested in public comments, including any evidence regarding patterns of high qualit y care and clinical outcomes, re garding this proposal to limit the provision of subsequent nursing facility care services furnished through telehealth to once every 30 days. We remain committed to ensuring that SNF inpatients receive appropriate in-person visits and that Medicare pays only fo r medically reasonable and necessary care. Currently and continuing in CY 2011, an unlimited number of initial and follow-up consultation services may be furnished through telehealth to these patients so we believe that only a limited number of subsequent nursing facility care services by the admitting practitioner would be appropriate for SNF inpatients. Finally, we are specifying that subsequent nursing facility care services re ported for a Federally-mandated periodic visit under §483.40(c) may not be furnished through tele health. In light of this proposal for CY 2011, we remain confident that admittin g practitioners will c ontinue to make appropriate in-person visits to all patients who need such care during their SNF stay. Consistent with this proposal, we are proposing to revise §410.78(b) and §414.65(a)(1) to include subsequent nursing facility care servi ces as Medicare telehealth services, with the limitation of one telehealth subsequent nursing facility care service every 30 days. Federally-mandated periodic visits may not be furnished through telehealth, as specified currently in §410.78(e)(2). 6. Neuropsychological Testing The American Telemedicine Association submitted a request to add neuropsychological testing services, descri bed by CPT codes 96119 (Neuropsychological testing (eg, Halstead-Reitan Neuropsychologi cal Battery, Wechsler Memory Scales and

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Wisconsin Card Sorting Test), per hour of the psychologist's or physician's time, both face-to-face time administering tests to the pa tient and time interpretin g these test results and preparing the report); and 96119 (Neurops ychological testing (eg, Halstead-Reitan Neuropsychological Battery, Wechsler Memory scales and Wisconsin Card Sorting Test), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face-to-f ace), to the list of te lehealth services for CY 2011 based on their similarity to other telehealth services.

In the CY 2008 PFS final rule with comment period (72 FR 66251), we stated that we have received conflicting comments a nd data regarding the appropriateness of furnishing neuropsychological testing via te lehealth. While we appreciate the recent request for addition of these same services to the Medicare telehealth services list, we do not believe that these services are similar to services currently on the Medicare telehealth services list and, therefore, we conclude that they would not be appropriate for consideration or addition under category 1. In this year's request for the addition of the these services, we received no information to indicate that the diagnostic findings of neuropsychological testing through telehea lth are similar to those based upon in-person testing, and therefore, that testing through telehealth does not affect the patient's diagnosis. Therefore, we are not proposing to add neuropsychological testing services to the list of approved Medicare te lehealth services for CY 2011. 7. Speech-Language Pathology Services The Marshfield Clinic submitted a request to add various speech-language pathology services to the list of approve d telehealth services for CY 2011. Speechlanguage pathologists ar e not permitted under section 1842(b)(18)(C) of the Act to furnish and receive payment for Medicare tele health services. Therefore, we are not

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proposing to add any speech-language pat hology services to the list of Medicare

telehealth services for CY 2011. For further di scussion of these services in the context of telehealth, we refer readers to the CY 2005 and CY 2007 PFS proposed and final rules with comment period (69 FR 47512 and 66276, and 71 FR 48995 and 69657).

8. Home Wound Care Services Wound Care Associates, LLC, submitted a request to add wound care in the home setting to the list of Medicare telehealth services. A patie nt's home is not permitted under current statute to serve as an originating site for Medicare telehealth services. Therefore, we are not proposing to add home wound care serv ices to the list of Medicare telehealth

services for CY 2011. D. Summary of CY 201 1 Telehealth Proposals In summary, we are proposing to add the following requested services to the list

of Medicare telehealth services for CY 2011:

● Individual and group KDE servic es (HCPCS codes G0420 and G0421, respectively);

● Individual and group DSMT services, with a minimum of 1 hour of in-person instruction to be furnished in the year following the initial DSMT service to ensure effective injection training (HCPCS codes G0108 and G0109, respectively);

● Group MNT and HBAI services (CPT codes 97804, and 96153 and 96154, respectively);

● Subsequent hospital care services, with the limitation for the patient's admitting practitioner of one telehea lth visit every 3 days (CPT codes 99231, 99232, and 99233);

and

● Subsequent nursing facility care serv ices, with the limitation for the patient's

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admitting practitioner of one te lehealth visit every 30 days (CPT codes 99307, 99308, 99309, and 99310). Furthermore, we are proposing to revise §410.78(b) and §414.65(a)(1) accordingly. Specifically, we are proposing to add individual and group KDE services, individual and group DSMT services, group MNT services, group HBAI services, and subsequent hospital care and nursing facility care services to the list of telehealth services for which payment will be made at the appli cable PFS payment amount for the service of the practitioner. In addition, we have reordered the listing of services in these two sections and removed "initial and follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals and SNFs" in §410.78(b) because these are described by the more general term "professional consultations" that is in the same section. Finally, we are continuing to specify that the physic ian visits required under §483.40(c) may not be

furnished as telehealth services.

V. Provisions of the Patient Protection and Affordable Care Act of 2010 The following section addresses certain provisions of the Pa tient Protection and Affordable Care Act (Pub. L. 111-148), en acted on March 23, 2010, as amended by the

Health Care and Educati on Reconciliation Act of 2010 (Pub. L. 111-152) enacted on March 30, 2010 (collectively known as the Affordable Care Act (ACA)). A. Section 3002: Improvements to the Physician Quality Reporting System

Section 3002 of ACA makes a number of changes to the Physician Quality Reporting Initiative (PQRI), including author izing incentive payments through 2014, and requiring a penalty beginning in 2015, for elig ible professionals w ho do not satisfactorily submit quality data. For a more detailed discussion of the provisions of section 3002 of the ACA, please refer to secti on VI.G.1. of this proposed rule.

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B. Section 3003: Improvements to the Ph ysician Feedback Program and Section 3007: Value-based Payment Modifier U nder The Physician Fee Schedule 1. Background As required under section 1848 (n) of the Act, as added by section 131(c) of MIPPA, we established and implemented by January 1, 2009, the Physician Resource Use Measurement & Reporting (RUR) Progra m for purposes of providing confidential reports to physicians that measure the resour ces involved in furnishing care to Medicare beneficiaries. Section 1848(n) of the Act al so authorizes CMS to include information on the quality of care furnished to Medicare be neficiaries by a physician or group of physicians. We are continuing a phased implement ation of the program. Phase I was discussed in the CY 2010 proposed and final rules (74 FR 33589, and 74 FR 61844, respectively), and has been completed. Phase I consisted of several activities including extensive data analysis to inform decisions a bout topics such as measures, attribution, and risk adjustment and formative testing of report design with practicing physicians. We concluded Phase I by sending to individual practicing physicians in 12 geographic areas 1 

### several hundred reports that contained per cap ita and episode-based cost information. Phase I of the Program focused on provi ding confidential feedback on resource use measures. Section 1848 (n)(1)(A)(iii) of th e Act states that th e Secretary may also include information on the quality of care furnished to Medicare beneficiaries by physicians (or groups of physicians) in the fe edback reports. We believe that providing physicians with feedback on both quality and cost is consistent with the direction of other CMS value based purchasing (VBP) initiatives. As a result, we decided to include

1 The 12 geographic areas are: Boston, MA, Syracuse, NY, Northern New Jersey, Greenville, SC, Miami, FL, Little Rock, AR, Indianapolis, IN, Cleveland, OH, Lansing, MI, Phoenix, AZ, Seattle, WA, and Orange County, CA.

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quality measures in Phase II of the program and, in particular, we considered measures used in PQRI and claims-based measures such as GEM measures (74 FR 61846). Section 1848 (n)(1)(A)(ii) also states that the S ecretary may provide reports at the physician group level. Accordingly, as part of Phase II of the program, we will also include reporting to group practices, define d as more than one physician practicing medicine together (74 FR 61846). In addition, we noted that the definition applies to the following types of physician groups: (1) form ally established single or multi-specialty group practices; (2) physicians practicing in defined geographic regions; and (3) physicians practicing within facilities or larger systems of care (74 FR 61846). As we continue with Phase II, we plan to repor t to both physician group practices and their affiliated practitioners, recognizing that many physicians practice in arrangements other than solo practices. We believe that us ing both group and indivi dual level re porting will also allow us to gain experience with the sample size issues that arise when individual physicians have too few Medicare beneficiar ies with specific conditions to generate reliable information. (See the CY 2010 fina l rule with comment period (74 FR 61844) for a detailed discussion of plans for Phase II.) 2. Effect of the ACA of 2010 on the Program The ACA contains two provisions releva nt to the RUR program. Section 3003

continues the confidential fee dback program and requires the Secretary, beginning in 2012, to provide reports that compare patterns of resource use of individual physicians to other physicians. In addition, section 3007 of the ACA requires the Secretary to apply a separate, budget-neutral paymen t modifier to the Fee-For-Service physician fee schedule payment formula. The payment modifier, which will be phased in beginning January 1, 2015 through January 1, 2017, will provide fo r differential payment under the fee

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schedule to a physician or gr oups of physicians, and later, possibly to other eligible professionals, based upon th e relative quality and cost of care of their Medicare beneficiaries. Accordingly, our goal is to have Medicare physicians receive a confidential feedback report prior to impleme ntation of the payment modifier. We view these two provisions as complementary, as we expect the work done for the confidential feedback program under section 3003 of the AC A will inform our implementation of the payment modifier under section 3007 of the ACA. The approach used in the confidential feedback reports will serve as the founda tion for implementing the payment modifier. Specifically, throughout future phases of reports under the RUR program, we will

continue to enhance our measures and met hods and improve the content of the reports

based on both our research and the feedback of stakeholders before the payment modifier begins to affect physician payments in 2015. We plan to engage in a large-scale effort to garner widespread stakeholder involvement with regard to how we continue to build and expand the confidential feedback program and transition to impleme ntation of the payment modifier. We recognize that such a payment modifier may have an impact on the delivery of care to Medicare beneficiaries. Reports that will be produced in the future based on changes as a

result of section 3003 of the ACA will contai n both cost and quality data, and work done to improve these reports with regard to fair and actionable measures in each of these domains will aid our decision making in how to apply the payment modifier. We intend to seek stakeholder input on va rious aspects of program design, including cost and quality measures, methodologies for compositing measures, and feedback report content and delivery. Such feedback may be gathered through rulemaking, open door forums, or

other mechanisms.

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3. Phase II Proposed Changes We anticipate that reports in Phase II of the RUR Program will be distributed in the fall of 2010. We are proposing, however, se veral changes to the program parameters for Phase II that were finalized in prior rules. First, we plan to discontinue our use of commercially-available proprieta ry episode grouping software. In particular, section 3003 of the ACA requires that the Secretary de velop a Medicare-specific episode grouper by January 1, 2012, the details of which must be made public. This grouper will address the limitations found in the propr ietary software. We recognize that episode-specific cost information is meaningful and actionable for physicians, and we plan to provide such information in feedback reports after the public grouper software is de veloped. Prior to that, we may consider other potential interim options for grouping to provide such information. We believe that our use of proprietary episode grouping software in pr evious phases of the program had limitations. These software products were not intended fo r use with Medicare claims data, and we discovered several problems w ith the data outputs. Specifically, the groupers do not work well to create episodes for beneficiaries with multiple chronic conditions, which is a significant portion of Medicare beneficiaries. For example, when a beneficiary with a chronic disease is hospitalized for an acute condition, that beneficiary most likely also receives treatments unrelated to the condition for which he or she is hospitalized, but related to the chronic disease. The groupers, which are proprietary and often re ferred to as “black boxes,” do not enable users to understand the coding to determine ho w to accomodate these issues. Therefore,

CMS had to make several decisi ons about how to pre-process th e claims data so that the groupers could recognize and attempt to deal with these issues in the clinical grouping

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logic. After report production in Phase I, we discovered several problems with the preprocessing, which resulted in inaccurate episode cost information being disseminated. Until a Medicare-specific episode grouping software is developed, we plan to produce reports for Phase II that contain per capita cost information. More specifically, instead of episode-specific co st information, we plan to provide overall per capita cost information, as well as per capita cost info rmation for those beneficiaries with five common chronic diseases: (1) diabetes, (2) co ngestive heart failure, (3) coronary artery disease, (4) chronic obstructive pulmonary disease, and (5) prostate cancer. This information will not be specific to the cost of treating the disease itself, but will provide total Part A/B per capita cost information, as well as service category breakdowns, for treating the subset of attributed be neficiaries with that disease. Second, while commenters have been ge nerally supportive of including PQRI measures in the reports, we propose not incl uding data from PQRI in the reports. The current support contractor for this program has only 2007 PQRI data. This was the first year of PQRI, and participation was still qu ite low. Because of the low number of physicians reporting under PQRI , and because providers have the flexibility to choose which measures to report under PQRI, we believe it would be difficult to make meaningful peer comparisons for purposes of these reports. Instead, for Phase II, we propose using the claims-based measures deve loped by CMS in the Generating Medicare Physician Quality Performance Measurement Results (GEM) project. 2 

### This is a core set of 12 process quality measures that can be calculated using only administrative claims data. However, in future phases of the program, we intend to explore the possibility of linking this program to the HITECH incentiv e program for meaningful use of electronic health records, and the group practice reporting option in PQRI. Both of these programs

2 http://www.cms.gov/GEM

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offer measures and measure sets, as well as methods of reporting data which may be more conducive to meaningful peer comparisons among physicians. Third, we propose to distribute reports elect ronically in Phase II, by leveraging the infrastructure used to distribute PQRI feedback reports. This infrastructure will enable groups to utilize an el ectronic portal to download their Phase II reports. Individual practitioners will be able to contact their MACs/fiscal intermediaries to receive an e-mailed copy of their reports. We have received feedback from physicians that the reports distributed in Phase I were too long and cumbersome to manage in hard copy. Our intent is a condensed report w ith electronic dissemination that allows for easier navigation. We are seeking pub lic comment on the above proposals. 4. Implementation of Sections 3003 and 3007 of the ACA The Affordable Care Act provisions th at we mention above contain several important implementation dates. In additi on to developing an episode grouper by January 1, 2012, we are required to publish the cost and quality measures we intend to use in determining the payment modifier to be effective on January 1, 2012. We are also required to begin implementing the program parameters through rulemaking in 2013. The payment modifier is effective on Janua ry 1, 2015, with a phased implementation so that all physicians paid under the physician fee schedule will be subject to the modifier by January 1, 2017. On or after January 1, 2017, we have the authority to also apply the payment modifier to other eligible professionals. In anticipation of impleme nting sections 3003 and 3007 of the ACA, we intend to perform extensive data analysis and researc h, and to seek stakeholder input on issues related to cost and quality me asures so that we can be prepared to publish, by January 1, 2012, those measures we intend to use for the payment modifier. We intend for the work

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done in determining measures for use in the payment modifier to inform the continued

dissemination of confidential feedback reports to both individual physicians and physician groups. Specifically, the measures c hosen for use in the payment modifier will be candidates for inclusion in future pha ses of the confidential feedback reports. As mentioned above, Phase I included repor ts to several hundre d physicians. In Phase II we anticipate disseminating reports to about 40 large physician groups and the approximately 2,000 physic ians affiliated with those groups . We anticipate future phases of the reports to include additional dissemination to increasing numbers of practitioners and groups such that virtually every applic able Medicare practitioner receives a report prior to implementation of the payment modifier. 5. Comments Sought on Specific Statistical Issues Related to the ACA Sections 3003

and 3007 We recognize that there are many im portant decisions to be made when implementing a program that compares physicia ns to their peers, especially when such information can lead to differential payment. Since the inception of the RUR program, all data have been price standardized which includes accounting for geographic adjustments. We have identifie d important statistical issues in previous rules, and as we have done in previous rules, CMS seeks input on several of these topics as they relate to future phases of reports. These include, but are not limited to: risk adjustment; attribution; benchmarking; pe er groups; minimum case sizes; cost and quality measures; and compositing methods. To date, the public comments we have re ceived have not led us to a single methodology to propose for deali ng with any of these issues. Therefore, we do not make formal proposals in this propos ed rule. Specific parameters of the RUR program are based on the most current inform ation we have available to us. These

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parameters will continue to evolve and we will continue to evaluate them as the state of the art in these areas continues to improve. Therefore, we seek public comment on these

issues. a. Risk Adjustment The cost data used in Phase I will be risk adjusted. For the per capita costs, we used the Hierarchical Condition Categories (HCC) model developed for risk adjustment in Medicare Advantage plans. This model takes into account beneficiary characteristics such as age, sex, and Medicaid status, and th en predicts costs for beneficiaries based on their unique mix of health cond itions. Several other socioec onomic factors, such as the median income per capita in the county where the physician practices, were used. For the episode costs, we used the risk adjustment/severity levels in the proprietary grouper

software. The cost data in Phase II are risk adjusted using the HCC model, but excluding

the additional socioeconomic factors such as the median income per capita in the county where the physician practices, as mentioned a bove. Regression analyses indicated that

these additional socioeconomic factors did little to improve the fit of the model, so we will not include them. And since there are no episode-based costs in Phase II – only annual per capita costs - the H CC model will be the only met hod used. Other methods of risk adjustment exist that we have not used, such as the CC (complications and comorbidities) and MCC (major complications and comorbidities) indicators implemented in the 2008 MS-DRG system. The quality data included in Phase II will not be risk adjusted because the GEM measures are all clinical process measures, and it is generally accepted that such measures need not be risk adjusted. Benefi ciaries should receive the indicated preventive

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services (for example, breast cancer screening) regardless of their demographic characteristics or presence or absence of health conditions. We seek comment on the appropriate method for risk adjusting cost data, as well as our reasoning for not risk adjustin g clinical process quality measures.

b. Attribution Deciding which physician(s) is/are responsible for the care of which beneficiaries is an important aspect of measurement. CMS must strike a balance between only attributing cost information to physicians for the services they personally delivered, and attributing costs to physicians based on a more encompassing view of the services provided to each beneficiary so as to encourage better care coordination and accountability for patient outcomes. There are several methods that are genera lly used for attributing beneficiaries’ costs to physicians for the purposes of measuring and comparing performance. In Phase I, we used two different attribution met hodologies. Half of the reports used the “multiple-proportional” attribution, in which a benefici ary’s costs were summed, and then divided among the physicians who treated that beneficiary in the same proportion as their share of evaluation and management (E &M) services provided. The other half of the reports used the “plurality-minimum” me thod, in which a beneficiary’s entire cost (either for the episode or for the year) was attributed to the physician who performed the plurality of the E&M services, subject to a minimum percentage (in that case, 10 percent). In Phase II reports, we plan to use the “plurality-minimum” method with a minimum percentage threshold of E&M services of 20 percent for individual physicians and a minimum percentage threshold of E&M se rvices of 30 percent of the E&M services

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for physician group level reports. These min imum threshold determin ations were based on our analysis of the claims data. We reco gnize that other attribution methods exist, which may be either more or less appropriate given the aspect of care one is measuring. For example, it may be desirable to attribute the entire cost of a surgical episode to the performing surgeon. Another me thod for attributing costs is referred to as “multipleeven,” in which the entire beneficiary’s cost is attributed to multiple physicians who treated the beneficiary. We seek comment on the topic of attri bution methodologies, including both of those we have already used in the program, as well as others that may or may not be

mentioned here. c. Benchmarking and Peer Groups Determining the relevant comparisons to make among physicians is also an important policy aspect of the program. CMS’ research conducted in Phase I of the program indicated that physicians prefer to be compared only to those physicians most like them (that is, the narrowest peer group) . We recognize the importance of fair comparison, but are also faced with the challeng e that very narrow peer groups are most often not large enough to make sta tistically significant comparisons. The individual-level reports in both phases of the program have contained, or will contain, two peer group comparisons: (1) physic ians in the same specialty in the same geographic area; and (2) physicians in the sa me specialty across all 12 geographic areas. In each of these peer groups, a physician is shown where he or she falls on a distribution that specifically identified the 10 th 

### , 50 th 

### , and 90 th 

### percentiles. These benchmarks were

finalized on an interim basis in th e CY 2010 proposed rule (74 FR 33589).

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In determining applicability for episode meas ures in Phase I, we used a statistical reliability test. For per capita measures in Phase I, a physician had to have 20 or more beneficiaries to be measured and compar ed. There was no minimum peer group size requirement. The original MIPPA mandate require s CMS to make comparisons among physicians on cost, and gives the Secretar y the authority to include comparisons on quality. The use of quality measures in th e program was finalized in the CY 2010 final rule (74 FR 61846). In Phase II, comparisons with appropriate peer groups will be made for both cost and quality. Phase II reports will be provided only to those physicians that have 30 or more patients for each of the co st measures. For the quality measures, we plan to use the measure specifications in the GEM project to define minimum case sizes,

which are at least 11 beneficiaries. We also plan to impose a minimum peer group size of 30 in Phase II for both the cost and quality measures. A minimum sample size of 30 is generally accepted in the research community as the minimum sample size to represent a group and make comparisons. We seek comment on the most appropr iate and relevant peer groups for comparison, including the appropriate minimum case sizes and minimum peer group sizes. We are also interested in methodolog ies that can account for small case sizes. d. Cost and Quality Measur es and Compositing Methods As mentioned above, and in previous rule s, section 1848(n)(1)(A)(ii) of the Act gives the Secretary the authority to include both cost and quality information in the feedback reports. In Phase I, we chose to use only cost information, and used both per capita and episode cost measurements. As me ntioned above, we previously finalized the use of quality measures in Phase II (74 FR 61846), but propose to discontinue our use of

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episode cost measurements. We have yet to include any composite measures of cost or quality in the feedback reports. Section 3007 of the ACA requires CMS to pay physicians differentially based on a modifier derived with composites of both qua lity and cost measures. Accordingly, we will need to devise a methodology in the future for compositing cost measures and quality measures, including considering, am ong other things, possible methodologies to develop a single score. In the future, epis ode-based cost measures developed using the public Medicare-specific episode grouper software also may be considered in developing a composite score. Other domai ns of measures that may be considered include patientlevel utilization statistics (for example, emergency department visits per 1,000 patients)

and structural measures such as whether a provider has adopted an electronic health record. We recognize that measure compos ites are methodologically and operationally complex and, therefore, we are seeking comment on this topic. We plan to continue a phased approach in the future. Although we will continue to move from phase-to-phase, any substantive changes to the RUR program will be implemented through rulemaking. We also an ticipate continuing to gather feedback from stakeholders about the importa nt data-driven policy topics that affect the feedback

reports.

C. Section 3102: Extension of the Work Ge ographic Index Floor and Revisions to the Practice Expense Geographic Adjustment unde r the Medicare Physician Fee Schedule,

and Protections for Frontier Stat es as amended by Section 10324 Section 1848(e)(1)(E) of the Act (as ame nded by section 3102(a) of the ACA) extends application of the 1.0 work GPCI fl oor for services furnished through December 31, 2010. In addition, section 1848(e)(1) of th e Act (as amended by section 3102(b) of

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the ACA) specifies that for CY 2010 and CY 2011, the employee wage and rent portions of the PE GPCI must reflect only one-half of the relative cost differences for each locality compared to the national average and includ es a “hold harmless” provision for any PFS locality that would receive a reduction to its PE GPCI resulting from the limited recognition of cost differences. Section 1848( e)(1) of the Act (as amended by section 3102(b) of the ACA) also requires an analysis of the current methods and data sources

used to determine the relative cost differe nces in office rent and employee wages compared to the national average and the cost share weights assigned to each PE GPCI component: employee wages, office rent, and supplies. Finally, section 1848(e)(1) of the Act (as amended by section 3102(b) of the ACA) requires the Secretary to make appropriate adjustment s to the PE GPCI by no later than January 1, 2012. In addition, section 1848(e)(1) of the Act (as amended by section 10324(c) of the ACA) establishes a

1.0 PE GPCI floor for services furnished in frontier states effective January 1, 2011. The provisions of the ACA related to the GPCIs are discussed in detail in section II.D. of this proposed rule. D. Section 3103: Extension of Excepti ons Process for Medicare Therapy Caps Section 1833(g)(5) of the Act (as amende d by section 3103 of the ACA) extends the exceptions process for therapy caps th rough December 31, 2010. Therapy caps are

discussed in detail in section II I.A. of this proposed rule. E. Section 3104: Extension of Payment fo r Technical Component of Certain Physician Pathology Services Section 542(c) of the Medicare, Medicai d, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) (Pub. L. 106- 554), as amended by section 732 of the Medicare Prescription Drug, Improvement, and Modernization Ac t of 2003 (MMA) (Pub.

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L. 108-173), section 104 of division B of th e Tax Relief and Hea lth Care Act of 2006 (MIEA-TRHCA) (Pub.L. 109-432), section 104 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) (Pub. L. 110- 173), and section 136 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) (Pub. L. 110-275) is amended by section 3104 of the ACA to con tinue payment to inde pendent laboratories for the TC of physician pathology services for fee-for-service Medicare beneficiaries who are inpatients or outpatients of a covered hospital through CY 2010. The technical component (TC) of physician pa thology services refers to the preparation of the slide involving tissue or cells that a pathologist interprets. The profe ssional component (PC) of physician pathology services refers to the pathologist’s interpretation of the slide. When the hospital pathologist furnishes the PC service for a hospital patient, the PC service is separately billable by the pathologist. When an independent laboratory’s pathologist furnishes the PC service, the PC service is usually billed with the TC service

as a combined service. Historically, any independent laboratory could bill the Medicare contractor under the PFS for the TC of physician pathology se rvices for hospital patients even though the payment for the costs of furnishing the pathol ogy service (but not its interpretation) was already included in the bundled inpatient stay payment to the hospital. In the CY 2000 PFS final rule with comment period (64 FR 59408 through 59409), we stated that this policy has contributed to the Medicare program paying twice for the TC service: (1) to the hospital, through the inpatient prospec tive payment rate, when the patient is an inpatient; and (2) to the independent laboratory that bills the Medicare contractor, instead of the hospital, for the TC service. While the policy also permits the independent laboratory to bill for the TC of physician pathology services for hospital outpatients, in

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this case, there generally would not be dup licate payment because we would expect the hospital to not also bill for the pathology service, which would be paid separately to the hospital only if the hospital were to specifically bill for it. We further indicated that we would implement a policy to pay only the hos pital for the TC of physician pathology services furnished to its inpatients. Therefore, in the CY 2000 PFS final rule with comment period, we revised §415.130(c) to state that for physician pathology services furnished on or after January 1, 2001 by an independent laboratory, payment is made only to the hospital for the TC furnished to a hospital inpatient . Ordinarily, the provisions in the PFS final rule with comment period are implemented in the following year. However, the change to §415.130 was delayed 1 year (until January 1, 2001) , at the request of the industry, to allow independent laboratories and hospitals sufficient time to negotiate arrangements. Full implementation of §415.130 was further delayed by section 542 of the BIPA and section 732 of the MMA, which directed us to continue payment to independent laboratories for the TC of physician patholog y services for hospital patients for a 2-year period beginning on January 1, 2001 and for CYs 2005 and 2006, respectively.

In the CY 2007 MPFS final rule with comment period (71 FR 69624 and 69788), we amended § 415.130 to provide that, for services furnished after December 31, 2006, an independent laboratory may not bill the carrier for the TC of physician pathology services furnished to a hospital inpatient or outpatient. However, section 104 of the MIEA-TRHCA continued payment to independe nt laboratories for the TC of physician pathology services for hospital patient s through CY 2007, and section 104 of the MMSEA further extended such payment thro ugh the first six months of CY 2008.

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Section 136 of the MIPPA extended the payment through CY 2009. Most recently, section 3104 of the ACA amended th e prior legislation to extend the payment through CY 2010. Consistent with this legislative change, we are proposing to revise §415.130(d) to: (1) amend the effective date of our payment po licy to reflect that for services furnished after December 31, 2010, an inde pendent laboratory may not b ill the Medicare contractor for the TC of physician pathology services fu rnished to a hospital i npatient or outpatient; and (2) reformat this subsection into subparagraphs.

F. Sections 3105 and 10311: Extension of Ambulance Add-Ons

1. Amendment to Secti on 1834(l)(13) of the Act Section 146(a) of the MIPPA amended s ection 1834(l)(13)(A) of the Act to specify that, effective for ground ambulance se rvices furnished on or after July 1, 2008 and before January 1, 2010, the ambulance fee schedule amounts for ground ambulance

services shall be increased as follows:

• For covered ground ambulance transports which originate in a rural area or in a

rural census tract of a metr opolitan statistical area, the fee schedule amounts shall be increased by 3 percent.

• For covered ground ambulance transports which do not originate in a rural area

or in a rural census tract of a metropolitan statistical area , the fee schedule amounts shall be increased by 2 percent. Sections 3105(a) and 10311(a) of the AC A further amend section 1834(l)(13)(A) of the Act to extend the payment add-ons de scribed above for an additional year, such that these add-ons also apply to covere d ground ambulance transports furnished on or after January 1, 2010 and before January 1, 2011. We are revising § 414.610(c)(1)(i) to

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conform the regulations to this statutory requi rement. This statutory requirement is selfimplementing. A plain reading of the statute requires only a ministerial application of the mandated rate increase, and doe s not require any substantive exercise of discretion on the part of the Secretary. For further informa tion regarding the extension of these payment add-ons, please see Transmittal 706 (C hange Request 6972) dated May 21, 2010. 2. Amendment to Section 146(b)(1) of MIPPA Section 146(b)(1) of the MIPPA amended the designation of rural areas for payment of air ambulance services. The statute specified that any area that was designated as a rural area for purposes of making paym ents under the ambulance fee schedule for air ambulance services furnished on December 31, 2006, sh all continue to be treated as a rural area for purposes of making payments under the ambulance fee sche dule for air ambulance services furnished during the period July 1, 2008 through December 31, 2009. Sections 3105(b) and 10311(b) of the ACA am end section 146(b)(1) of MIPPA to extend this provision for an additional year, through December 31, 2010. Accordingly, for areas that were designated as rural on December 31, 2006, and we re subsequently re-designated as urban,

we have re-established the “rural” indicat or on the ZIP Code file for air ambulance services, effective January 1, 2010 through December 31, 2010. We are revising §414.610(h) to conform the regulations to this statutory requirement. This statutory requirement is self-implementing. A plai n reading of the statute requires only a ministerial application of a rural indicator, and does not require any substantive exercise of discretion on the part of the Secretary. For further information regarding the extension of this MIPPA provision, please see Trans mittal 706 (Change Reque st 6972) dated May 21, 2010.

3. Amendment to Secti on 1834(l)(12) of the Act

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Section 414 of the MMA added paragraph (12) to section 1834(l) of the Act, which specified that in the case of ground ambul ance services furnished on or after July 1, 2004, and before January 1, 2010, for which tr ansportation originates in a qualified rural area (as described in the statute), the Secretary shall provide for a percent increase

in the base rate of the fee schedule for such transports. The statute requires this percent increase to be based on the Secretary’s estimate of the average cost per trip for such services (not taking into account mileage) in the lowest quartile of all rural county populations as compared to the average cost pe r trip for such services (not taking into account mileage) in the highest quartile of rural county populations. Using the methodology specified in the July 1, 2004 interim final rule (69 FR 40288), we determined that this percent increase was equal to 22.6 percent. As required by the MMA, this payment increase was applied to ground ambulance transports that originated in a “qualified rural area”; that is, to transpor ts that originated in a rural area included in those areas comprising the lowest 25 th 

### percentile of all rura l populations arrayed by population density. For this purpose, rural areas included Goldsmith areas (a type of rural census tract). Sections 3105(c) and 10311(c) of the ACA amend section 1834(l)(12)(A) of the Act to extend this ru ral bonus for an additional year through December 31, 2010. Therefore, as directed by the ACA, we are continuing to apply the rural bonus described above (in the same ma nner as in previous years), to ground

ambulance services with dates of servi ce on or after January 1, 2010 and before January 1, 2011 where transportation orig inates in a qualified rural area. We are revising § 414.610(c)(5)(ii) to conf orm the regulations to this statutory requirement. This statutory requirement is se lf-implementing. The statute requires a one year extension of the rural bonus (which was previously established by the Secretary),

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and does not require any substantive exercise of discretion on the part of the Secretary. For further information regarding the extens ion of this rural bonus, please see Transmittal 706 (Change Request 69 72) dated May 21, 2010. G. Section 3107: Extension of Physic ian Fee Schedule Mental Health Add-On Section 3107 of the ACA amends section 138( a)(1) of the MIPPA to continue the 5 percent increase in Medicare payment for specified mental health services through December 31, 2010. This payment increase was originally authorized under section 138 of the MIPPA from July 1, 2008 until December 31, 2009. Accordingly, payment for the 24 psychiatry CPT codes in Table 33, repr esenting “specified services,” remains increased by 5 percent until December 31, 2010. TABLE 33: Specified Mental Health Services Subject to the Five Percent Increase in Medicare Payment through December 31, 2010 Office or Other Outpatient Facility Insight Oriented, Beha vior Modifying and/or Supportive Psychotherapy 90804 (Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient;) 90805 (Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services) 90806 (Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient;) 90807 (Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services) 90808 (Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient;) 90809 (Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services) 

### Interactive Psychotherapy 90810 (Individual psychotherapy, interactive, usin g play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient;) 90811 (Individual psychotherapy, interactive, usin g play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services) 90812 (Individual psychotherapy, interactive, usin g play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient;)

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90813 (Individual psychotherapy, interactive, usin g play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services) 90814 (Individual psychotherapy, interactive, usin g play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient;) 90815 (Individual psychotherapy, interactive, usin g play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services) 

### Inpatient Hospital, Partial Hospital or Residential Care Facility Insight Oriented, Behavi or Modifying and/or Supportive Psychotherapy

90816 (Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in aninpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-toface with the patient;) 90817 (Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in aninpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-toface with the patient; with medical evaluation and management services) 90818 (Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in aninpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-toface with the patient;) 90819 (Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in aninpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-toface with the patient; with medical evaluation and management services) 90821 (Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in aninpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-toface with the patient;) 90822 (Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in aninpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-toface with the patient; with medical evaluation and management services) 

### Interactive Psychotherapy

90823 (Individual psychotherapy, interactive, usin g play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient;) 90824 (Individual psychotherapy, interactive, usin g play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face with the patient; with medical evaluation and management services) 90826 (Individual psychotherapy, interactive, usin g play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient;) 90827 (Individual psychotherapy, interactive, usin g play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 45 to 50 minutes face-to-face with the patient; with medical evaluation and management services) 90828 (Individual psychotherapy, interactive, usin g play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient;) 90829 (Individual psychotherapy, interactive, usin g play equipment, physical devices, language interpreter, or other mechanisms of non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services)

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H. Section 3108: Permitting Ph ysician Assistants to Order Post-Hospital Extended Care

Services The ACA included a self-implementing pr ovision relating to SNFs. Section 3108 adds physician assistants (PAs) to the list of practitioners (that is, physicians, nurse practitioners (NPs), and clinical nurse speci alists) that can perform the required initial certification and periodic rece rtifications under section 1814( a)(2)(B) of the Act with respect to the SNF level of care. Accordin gly, we are proposing to make appropriate revisions to include PAs in §424.20(e)(2), in which we refer to NPs, clinical nurse specialists, and PAs collectively as “physician extenders.” I. Section 3111: Payment for Bone Density Tests Section 1848(b) of the Act (as amended by section 3111 of the ACA) changes the payment calculation for dual-energy x-ray ab sorptiometry (DXA) services described by two specified DXA CPT codes for CYs 2010 and 2011. This provision requires payment for these services at 70 percent of th e product of the CY 2006 RVUs for these DXA codes, the CY 2006 conversion factor (CF) , and the geographic adjustment for the relevant payment year. Effective January 1, 2007, the CPT codes for DXA services were revised. The former DXA CPT codes 76075 (Dual energy X- ray absorptiometry (DXA), bone density study, one or more sites; axial skeleton (e g, hips, pelvis, spine)); 76076 (Dual energy Xray absorptiometry (DXA), bone density study, one or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel)); and 76077 (Dual energy X-ray absorptiometry (DXA), bone density study, one or more sites; vertebral fracture asse ssment) were deleted and replaced with new CPT codes 77080, 77081, and 77082 that have the same respective code descriptors as the predece ssor codes. Section 1848(b) of the Act (as

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amended by section 3111 of the ACA) specifie s that the revised payment applies to two of the predecessor codes (CPT codes 76075 and 76077) and "any succeeding codes," which are, in this case, CPT codes 77080 and 77082. Section 1848(b) (as amended by section 3111 of the ACA) revises the payment for CPT codes 77080 and 77082 during CY 2010 and CY 2011. We have provided payment in CY 2010 under the PFS for CPT codes 77080 and 77082 at the specified rates. We

note that the RVUs included in Addendum B to this proposed rule reflect the RVUs that result from application of this statutory provision and the proposed CY 2011 conversion

factor. Because the statute specifies a payment amount for these services as described previously, we imputed RVUs for CY 2011 to include in Addendum B that would provide the specified payment amount for th ese services when multiplied by the CY 2011 CF. Specifically, we divided the payment am ount based on the statutory requirements by the CY 2011 CF for this proposed rule, and di stributed the imputed total RVUs across the work, PE, and malpractice components propor tionately to their CY 2006 distribution. Therefore, these imputed RVUs for CP T codes 77080 and 77082 are displayed in Addendum B to this proposed rule. J. Section 3114: Improved Access for Certified Nurse-Midwife Services Section 1833(a)(1)(K) of the Act (as am ended by section 3114 of the ACA) increases the amount of Medicare paymen t made under the PFS for certified nursemidwife (CNM) services. Currently, section 1833(a)(1)(K) of the Act specifies that the payment amount for CNM services is 80 percent of the lesser of the actual charge or 65 percent of the PFS amount. Under secti on 1833(a)(1)(K) of the Act (as amended by section 3114 of the ACA), effective for serv ices furnished on or after January 1, 2011, Medicare payment for CNM services is increased to 100 percent of the PFS amount(or 80

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percent of the actual charge if that is less). We are proposing to revise our regulations at §414.54 (Payment for certified nurse-midwives’ services) accordingly to reflect the increased payment for CNM services effective for services furnished on or after January 1, 2011. Although CNMs are currently paid under Me dicare Part B for their professional services, there is no mention of CNMs under the regulatory provision that lists the providers and suppliers of services to whom payment is made under the Medicare Part B program. Accordingly, we are proposing to make a technical revision to §410.150 (To whom payment is made) to specify that Me dicare Part B pays CNMs for professional services in all settings, as well as services and supplies furnished incident to those

services. CNMs are authorized under the statute to be paid directly for services that they are legally authorized to furnish under State law and that are of the type that would otherwise be covered if furnished by a physic ian or incident to a physician’s services. Additionally, there is no requirement under the CNM benefit for physician oversight or supervision. Accordingly, CNMs are authoriz ed to personally furnish diagnostic tests that fall under their State scope of practice w ithout regard to the levels of physician supervision required under the diagnostic test s benefit. Therefore, we are amending §410.32(b)(2) (Exceptions to the levels of ph ysician supervision required for diagnostic tests) to include CNMs who furnish diagnostic tests that fall within their State scope of practice.

K. Section 3122: Extension of Medicar e Reasonable Costs Payments for Certain Clinical Diagnostic Laboratory Tests Furnished to Hospital Patients in Certain Rural

Areas

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Section 416 of the MMA established a re asonable cost payment for outpatient clinical diagnostic laboratory tests furnished by hospitals with fewer than 50 beds that are located in qualified rural areas for cost re porting periods beginning during the 2-year period beginning on July 1, 2004.

Section 105 of the Tax Relief and Hea lth Care Act of 2006 (Pub. L. 109-432) (TRHCA) extended the 2-year period in sec tion 416(b) of the MMA for an additional cost-reporting year. Section 107 of the Medicare, Medi caid, and SCHIP Extension Act of 2007 (Pub. L. 110-173) (MMSEA) extended the time period for cost reporting periods beginning on July 1, 2004 and ending on June 30, 2008. For some hospitals with cost reports that began as late as June 30, 2008, this extension affected se rvices performed as late as June 29, 2009, because this was the da te those cost reports would have closed.

Section 3122 of the ACA reinstitutes r easonable cost payment for clinical diagnostic laboratory tests performed by hos pitals with fewer than 50 beds that are located in qualified rural areas as part of their outpatient services for cost reporting periods beginning on or after July 1, 2010 through June 30, 2011. For some hospitals with cost reports that begin as late as J une 30, 2011, this reinstitution of reasonable cost payment could affect services performed as la te as June 29, 2012, because this is the date those cost reports will close.

L. Section 3134: Misvalued Code s Under the Physician Fee Schedule Section 1848(c)(2)(K) of the Act (as adde d by section 3134 of the ACA) requires the Secretary to periodically review and id entify potentially misvalued codes and make appropriate adjustments to the relative values of those services identified as being potentially misvalued. Section 1848(c)(2)(K) of the Act (as added by section 3134 of the

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ACA) further specifies that the Secretary may use existing processes to receive recommendations on the review and appropri ate adjustment of potentially misvalued services, as well as conduct surveys or implement other data collection activities, studies, or other analyses as the Secretary determines to be appropriate to facilitate the review and appropriate adjustment of the relative values of potentially misvalued codes. Finally, section 1848(c)(2)(L) of the Act (as added by section 3134 of the ACA) provides that the Secretary shall establish a process to valid ate relative value units under the PFS. We note that over the past several years, we have been working with the AMA RUC to identify approaches to addressing th e issue of potentially misvalued services. Our proposed CY 2011 approaches to categor ies of potentially misvalued codes are

discussed in section II.C . of this proposed rule.

M. Section 3135: Modificati on of Equipment Utilization Factor for Advanced Imaging

Services 1. Adjustment in Practice Expense to Reflect Higher Presumed Utilization Section 1848(b)(4)(C) of the Act (as a dded by section 3135(a) of the ACA) adjusts the utilization rate for expensive diagnostic imaging equipment to 75 percent in the methodology for establishing the PE of the associated procedures. As discussed further in section II.A.3.a. of this propos ed rule, effective January 1, 2011 we are proposing to assign a 75 percent equipment utilization rate assumption to expensive diagnostic imaging equipment used in servi ces described by the HCPCS codes displayed

in Table 4.

In the CY 2010 PFS final rule with comme nt period (74 FR 61755), we finalized a policy to increase the utilization rate to 90 percent for expensive diagnostic equipment priced at more than $1 million (CT and MRI scanners), providing for a 4-year transition

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to the 90 percent utilization rate from the CY 2009 utilization rate of 50 percent. Therefore, in CY 2010 we were transitioning to a 90 percent equi pment utilization rate assumption, applying a 25/75 blend of the ne w and old PE RVUs, respectively, for the associated procedures. Sec tion 1848(b)(4)(C) of the Act (as added by section 3135(a) of the ACA) does not provide for any further tran sition and, therefore, we are assigning a 75 percent equipment utilization rate assumption to CT and MRI scanners, effective January 1, 2011. Under section 1848(b)(4) of the Act (as amended by section 3135(a) of the ACA), this change in the equipment utiliz ation rate assumption from CY 2010 to CY 2011 is not budget neutral under the PFS. The equipment utilization rate assumption remains at 50 percent for all other equipm ent included in the PFS PE methodology. 2. Adjustment in Technical Component “Discount” on Single-Session Imaging to Consecutive Body Parts Section 1848(b)(4)(D) of the Act (as a dded by section 3135(a) of the ACA) increases the established PFS multiple procedure payment reduction (MPPR) for the technical component (TC) of certain single-session imaging services to consecutive body areas from 25 to 50 percent, effective July 1, 2010, and section 1848(c)(2)(B)(v)(VI) of the Act (as added by section 3135(b) of the ACA) exempts this change from the PFS budget neutrality provision. This policy is disc ussed in detail in section II.C.4 of this proposed rule. Effective January 1, 2006, we adopted an MPPR of 25 percent for the technical component (TC) of certain diagnostic imagi ng procedures, applie d to the second and subsequent services when more than one se rvice in one of 11 imaging families, defined by imaging modality and contiguous body area, is furnished in a single session (70 FR 70261 through 70263). The established imaging MPPR applies to TC-only services and

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to the TC of global services. It does not a pply to professional com ponent (PC) services. Under this policy, full payment was made for the TC of the highest priced procedure, while payment was made at 75 percent of the TC for each additional procedure. As of July 1, 2010 and continuing in CY 2011, paymen t is made at 50 percent of the TC for each additional procedure, consiste nt with the statutory provision.

N. Section 3136: Revision for Pa yment for Power-Driven Wheelchairs 1. Payment Rules for Power Wheelchairs Durable medical equipment (DME) is defi ned at section 1861(n) of the Act and includes wheelchairs necessary for use in th e patient’s home. Section 1861(n) provides that wheelchairs included in the definition of DME “may include a power-operated vehicle that may be appropriately used as a wheelchair, but only where the use of such a

vehicle is determined to be necessary on the basis of the individual’s medical and physical condition.” The general Medicare payment rules for DME are set forth in section 1834(a) of the Act and 42 CFR part 414, subpart D of our regulations. Section 1834(a)(1) of the Act and §414.210(a) of our regulations establish that the Medicare payment for a DME item is generally equal to 80 percent of either the lower of the actual charge or the fee schedule amount for the item. The beneficiary coinsurance is generally equal to 20 percent of either the lower of the actual charge or the fee schedule amount for

the item once the deductible is met. For Medicare payment purposes, power wh eelchairs or power-driven wheelchairs

are classified under various codes in the Healthcare Common Procedure Coding System (HCPCS) based on the level of performance and functional characteristics of each power wheelchair that accommodate the specific needs of patients. Power wheelchairs classified under performance Groups 1 through 3 are covered under Medicare for use in

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the patient’s home. Power wheelchair groups were established in 2006 with the release of the Power Mobility Device Coding Guid elines published by the Durable Medical Equipment Regional Carriers (DMERCs) currently called the Durable Medical Equipment Medicare Administrative Contract ors (DME MACs). The DMEPOS quality standards define certain power wheelchairs falling as “complex, rehabilitative” power wheelchairs, and these “complex, rehabilitative” power wheelchairs are treated as a separate product category for the purpose of implementing the DMEPOS Competitive Bidding Program (CBP) mandated by section 1847(a) of the Act. In both the quality standards and the DMEPOS competitive bidding program, complex, rehabilitative power wheelchairs are defined or identified as pow er wheelchairs classi fied as Group 2 power wheelchairs with power options that can accommodate rehabilitative features (for example, tilt in space) or Group 3 power wheelchairs. With the exception of power wheelchairs furnished during calendar year 1990, power wheelchairs have been paid under th e capped rental category of DME since January 1, 1989. The payment rules for capped rental DME are provided at section 1834(a)(7) of the Act and §414.229 of our regulations. Payment for these items is generally on a monthly rental basis, with re ntal payments capped at 13 months. After a 13-month period of continuous use during whic h rental payments are made, the statute and regulations require that the supplier transfer title to the wheelchair to the beneficiary. In addition, effective for power wheelchairs furnished on or after January 1, 1991, section 1834(a)(7) of the Act, as amended by sec tion 4152(c)(2) (D) of the Omnibus Budget Reconciliation Act of 1990 (Pub. L. 101-508), mandates that the supplier of the power wheelchair offer the patient the option to purch ase rather than rent the item. Since 1991,

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over 95 percent of Medicare beneficiaries ha ve exercised this lump-sum purchase option for power wheelchairs. Consistent with payment for ot her DMEPOS items, §414.210(f)(1) permits payment for replacement of capped rental DME if the item has been in continuous use for the equipment’s reasonable useful lifetime or is lost, stolen, or irreparably damaged. Section 414.210(f)(1) states the r easonable useful lifetime fo r equipment is determined through program instructions. In the absenc e of CMS program instructions, the carrier may determine the reasonable useful lifetime for equipment, but in no case can it be less than 5 years. Computation is based on when the equipment is delivered to the beneficiary, not the age of the equipment. If the beneficiary elects to obtain a new capped rental item after the reasonable useful lifetime, a new 13-month rental payment period would begin for the new equipment in accordance with the requirements of §414.229. Section 1834(a)(7)(A) of the Act, § 414.229(b) and (c) set forth the current fee schedule amounts for capped rental items. Purs uant to section 1834(a)(7)(A)(i)(II) of the Act and § 414.229(b), the current rental fee sche dule amounts for months 1 thru 3 of the 13-month capped rental period are calculated to pay 10 percent of the average of allowed purchase price for the item. Th e rental fee schedule amounts for months 4 thru 13 of the 13-month capped rental period are calculated to pay 7.5 percent of the average of allowed purchase price for the item. The purchase price is determined consistent with section 1834(a)(8) of the Act and § 414.229(c) and §414.220(e) and (f) and is updated by the covered item update, as requi red by section 1834(a)(14) of the Act and § 414.229(d). The current purchase price amount for po wer wheelchairs acquired on a lump sum

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purchase basis is 100 percent of the purchase pr ice calculated for the item when rented, as

discussed above. 2. Revision of Payment Am ounts for Power Wheelchairs Section 3136(a) of the ACA made severa l changes to section 1834(a)(7)(A) of the Act. Section 3136(a)(1) of the ACA amends section 1834(a)(7)(A) of the Act by adding a new subclause (III) to section 1834(a)(7)(A)(i ) of the Act. Subclause (III) revises the capped rental fee schedule amounts for all power wheelchairs, modifying the current payment structure of 10 percent of the purchas e price for months 1 thru 3 and 7.5 percent of that purchase price for months 4 through 13 that was discussed above. The rental fee

schedule amount for months 1 thru 3 of th e 13-month capped rental period for power wheelchairs is revised to 15 percent of the purchase price for the item. The rental fee

schedule amounts for months 4 thru 13 of th e 13-month capped rental period for power wheelchairs is revised to 6 percent of the purchase price for the item. The statutory provision does not change the methodologies us ed to calculate and subsequently update of the purchase price of power wheelchairs. Therefore, the methodology described above for determining the purchase price amounts will continue to apply. Pursuant to section 3136(c) of the ACA, the changes made by section 3136(a) of the ACA apply to power-driven wheelchairs furnished on or after January 1, 2011. Furthermore, as discussed above, secti on 3136(c)(2) of the ACA states that the changes made by section 3136(a), including the new payment structure for power wheelchairs, do not apply to payment made for items and services furnished pursuant to

contracts entered into under section 1847 of the Act for the DMEPOS CBP prior to January 1, 2011 which applies to the implement ation of the first round of the DMEPOS CBP. As a result, contract suppliers furnishing power wheelchairs in competitive bidding

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areas (CBA) pursuant to contracts entered in to prior to January 1, 2011 as part of Round 1 of the DMEPOS CBP will continue to be pa id based under the current regulations using 10 percent of the purchase price for months 1 through 3 and 7.5 percent for each of the remaining months. As a result, we are proposing to make changes to §§ 414.202, 414.229 and 414.408 to reflect these statutory requirements. 3. Elimination of Lump Sum Payment for Standard Power Wheelchairs Section 3136(a)(2) of the ACA further amends section 1834(a)(7)(A)(iii) by inserting the term “complex rehabilitative” befo re the term “power-driven wheelchairs.” As a result, section 1834(a)(7)(A)(iii) of the Act now extends the lump sum purchase option only to complex rehabilitative power wheelchairs. As discussed above, “complex rehabilitative power whee lchairs are power wheelchairs that are classified as: (1) Group 2 power wheelchairs with power options that can accommodate rehabilitative features (for example, tilt in space), or (2) Group 3 power wh eelchairs. We cons ider all other power

wheelchairs to be standard power wheelchairs. Therefore, we propose to interpret the language “complex rehabilitative” in section 1834(a)(7)(A) of th e Act consistent with this longstanding classification. As a result, the changes made by section 3136 to section 1834(a)(7)(A)(iii) eliminate the lump sum purchase option for standard power

wheelchairs. Pursuant to section 3136(c) of the ACA, the changes made to section 1834(a)(7)(A)(iii) of the Act apply to power-d riven wheelchairs fu rnished on or after January 1, 2011. The lump sum purchase payment option will no longer extend to standard power driven wheelchairs fu rnished on or after January 1, 2011. Furthermore, section 3136(c)(2) of the AC A states that the changes made by section 3136(a), including the limitation of the lump sum purchase payment option to

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complex, rehabilitative power wheelchairs, do not apply to payment made for items and services furnished pursuant to contracts ente red into under section 1847 of the Act for the DMEPOS CBP prior to January 1, 2011 pursuant to the implementation of the first round of the DMEPOS CBP. As a result, contract suppliers furnishing power wheelchairs in CBAs pursuant to contracts entered into pr ior to January 1, 2011 as part of Round 1 of the DMEPOS CBP must continue to offer beneficiaries the lump sum purchase option for all power wheelchairs. We are proposing changes to §§414.229 and 414.408 to reflect our interpretation of these statutory requirements. O. Section 3139: Payment for Biosimilar Biological Products

Section 3139 of the ACA amends secti on 1847A of the Act to provide for Medicare payment of biosimilar biological pr oducts using the average sale price (ASP) methodology. Section 1847A of the Act, as amende d by the ACA, defines a biosimilar biological product as a biolog ical product approved under an abbreviated application for a license of a biological product that relies in part on data or information in an application for another biological product licensed under section 351 of the Public Health Service Act (PHSA). The reference biological product for a bios imilar biological product is defined by the statute as th e biological product licensed under such section 351 of the PHSA that is referred to in the application of the biosimilar biological product.

The ACAct also amends section 1847A of the Act to specify that the payment amount for a biosimilar biological product will be the sum of the following two amounts: the ASP of all NDCs assigned to the biosimila r biological drug product determined using the methodology in section 1847A(b)(6) of the Act, and 6 percent of the payment amount

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determined using the methodology in section 1847A(b)(4) of the Act for the corresponding reference biological product . Sections 7001 to 7003 of the ACA also established a licensing path way for biosimilar biological products, and in accordance with the statute, the effective date for Me dicare ASP statutory provisions is July 1, 2010. We are proposing conforming regulation text changes at §414.902 and §414.904 and we welcome comments on these conforming changes. We anticipate that as biosimilar biologi cal drug products are approved, we will

receive ASP sales data thr ough the ASP data submission process and publish national payment amounts in a manner that is consistent with our current approach to other drugs and biologicals that are paid under section 1847A of the Act and set forth in 42 CFR Part 414 subpart J. Until we have collected sufficient sales data, as reported by manufacturers, payment limits w ill be determined in accordance with the provisions in section 1847A(c)(4) of the Act. If no manufac turer data is collected, prices will be determined by local contractors using an y available pricing information, including provider invoices. More information about the ASP payment methodology and the data submission process may be found on the CMS Web site at http://www.cms.gov/McrPartBDrug AvgSalesPrice/01_overview.asp and in this rule, in the section VI.A.1. of this proposed rule, “Carry Over” ASP.

P. Section 3401: Revision of Certain Mark et Basket Updates a nd Incorporation of Productivity Improvements into Market Ba sket Updates That Do Not Already Incorporate Such Improvements.

1. ESRD Market Basket Discussion Section 3401(h) of the ACA amended se ction 1881(b)(14)(F) of the Act and directs the Secretary to annually increase payment amounts established under the ESRD

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market basket. Please see section VI.E. of th is proposed rule for a detailed description of these provisions. 2. Productivity Adjustment regarding Ambulator y Surgical Center, Ambulance, Clinical Laboratory and DMEPOS Fee Schedules Section 3401 of the ACA requires that th e update factor under certain payment systems be annually adjusted by changes in economy-wide productivity. The year that the productivity adjustment is effective varies by payment system. Specifically, section 3401 of the ACA requires that in CY 2011 (and in subsequent years) update factors under the ambulatory surgical center (ASC) payment system, the ambulance fee schedule (AFS), and the clinical laboratory fee schedule (CLFS) be adjusted by changes in economy-wide productivity. Section 3401(a) am ends section 1886(b)(3)(B) of the Act to add clause (xi)(II) which sets forth the de finition of this productivity adjustment. The statute defines the productivity adjustment to be equal to the 10-year moving average of changes in annual economy-wide privat e nonfarm business multifactor productivity (MFP) (as projected by the Secretary for the 10-year period ending with the applicable fiscal year, year, cost reporting period, or ot her annual period) (the “MFP adjustment”).

Please see http://www.bls.gov/mfp for more information on MFP. This is the link to the Bureau of Labor Statistics (BLS) histori cal published data on the measure of MFP. The projection of MFP will be produced by an economic forecasting firm, currently HIS Global Insight (IGI). In order to generate a forecast of MFP, IGI would replicate the MFP measure calculated by the BLS using a series of proxy variables

derived from the IGI US Macro-economic mode ls. These models take into account a very broad range of factors that influen ce the total US economy. IGI forecasts the underlying proxy components such as Gross Domestic Product (GDP), capital, and labor

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inputs required to estimate MF P, and will combine those projections according to the BLS methodology. For more information on the BLS measure of MFP, including technical notes, visit: http://www.bls.gov/mfp/ . Table 34 lists the MFP component series employed by the BLS and the corresponding concepts estimated by IGI.

Table 34: Multifactor Productivity Comp onent Series Employed by the Bureau of Labor Statistics and HIS Global Insight

BLS Series IGI Series Real value-added output, constant 2000 dollars Real gross non-farm value added output, chained 2005 dollar billions Private non-farm business sector labor input; 2000=100.00 Hours of all persons -private nonfarm business sector; 1992=1.0 Aggregate capital inputs; 2000=100.00 Real effective capital stock used for full employment GDP, chained 2005 dollar billions To identify the appropriate proxy variable s, IGI compared the historical growth

rates of the BLS and IGI com ponents listed above a nd found they were consistent across all series and therefore suitable proxies for calculating MFP. IGI would use the growth rates of the forecasted IGI concepts to proj ect BLS’ components of MFP, and derive the MFP adjustment that would be used under s ection 3401 to adjust the updates for the ASC payment system, the AFS, and the CLFS. As discussed below, for each of these pa yment systems, the update factor is the percentage increase (or percentage decrease for the CLFS) in the consumer price index for all urban consumers (CPI-U) (referred to as the “CPI-U update factor”). The statute for all three payment systems generally states that the Secretary shallreduce the CPI-U adjustment by the MFP adjustment. In order to calculate the MFPadjusted updates to these payment systems, the MFP percentage adjustment would be subtracted from the CPI-U update factor (f or the most recent 12-month period beginning with July 1 of the previous year and ending with June 30 of the current year). For

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example, if the update factor (CPI-U) is 4.0 percent, and the projected MFP is 1.3 percent, the MFP-Adjusted update factor (or MFP-Adjusted CPI-U for these payment systems) would be a 2.7 percent increase. The period on which the CPI-U is calculated is for the most recent 12-month period beginning with July 1 of the previous year and ending with June 30 of the current year, and we propose that the end of the 10-year moving average of changes in the MFP

should coincide with the end of this CPI-U time frame. Since the CPI-U update factor is reduced by the MFP adjustment to dete rmine the annual update for these payment systems, we believe it is appropriate for th e numbers associated with both parts of the calculation to be projected as of the same end date (in this case, the end date of the time

frame for both estimates would be June 30 th 

### of the year preceding the update year itself). In this way, changes in market conditions are aligned. We will round the final annual adjustment to the one-tenth of one percen tage point level up or down as applicable according to conventional rounding rules (tha t is, if the number we are rounding is followed by 5, 6, 7, 8, or 9, we will round the number up; if the number we are rounding is followed by 0, 1, 2, 3, or 4, we will round the number down). Below, we provide more information on the statutory requirements and proposals for each of the three payment systems. The statutory requirements for the ASC payment system will also be addressed in the CY 2011 OPPS/ASC proposed rule. We note that, in this proposed rule, we are describing the legislative provision and outlining the methodology we propose to use to calculate a nd apply the MFP adjustment to determine the annual updates for ASCs, the AFS, and th e CLFS for CY 2011 and each subsequent year. We will set forth the final MFP adju stment for CY 2011 in the CY 2011 PFS final rule.] Once we finalize the methodology for determining and applying the MFP

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adjustment to the CPI-U update factors fo r these payment systems, for subsequent calendar years, as we have done in the past, we intend to notify the general public of the annual update to the AFS and CLFS via CM S instruction and on the CMS website.

These notifications would set forth both the CP I-U percentage increase or decrease and the MFP adjustment for the applicable year. For ASCs, for subsequent calendar years, as we have done in the past, we would continue to notify th e general public of the annual update to the ASC payment amount via OPPS/ASC rulemaking. We welcome comments on these proposals. a. Ambulatory Surgical Centers (ASCs) Section 1833(i)(2)(C) of the Act requires that , if the Secretary has not updated the ASC payment amounts in a calendar year, the payment amounts shall be increased by the percentage increase in the CPI-U as estimated by the Secretary for the 12-month period ending with the midpoint of the year invol ved. Because the Secretary does update the ASC payment amounts annually, we adopted a policy, which we codified at §416.171(a)(2)(ii), to update th e ASC conversion factor using the CPI-U for CY 2010 and subsequent calendar years. Therefore, the annual update to the ASC payment system is the CPI-U (referred to as the CPI-U upda te factor). Section 3401(k) of the ACA amends section 1833(i)(2)(D) of the Act by a dding a new clause (v) which requires that “any annual update under [the ASC payment] syst em for the year . . . shall be reduced by the productivity adjustment descri bed in section 1886(b)(3)(B)(xi)(II)” (which we refer to as the MFP adjustment) effective with the calendar year beginning January 1, 2011. Section 3401(k) of the ACA states that app lication of the MFP adjustment to the ASC payment system may result in the update to the ASC payment system being less than zero

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for a year and may result in payment rates under the ASC payment system for a year being less than such payment rates for the preceding year. In accordance with section 1833(i)(2)(C)(i) of the Act, before applying the MFP adjustment, the Secretary first determines th e “percentage increase” in the CPI-U, which we interpret cannot be a nega tive number. Thus, in the instance where the percentage change in the CPI-U for a year is negative, we propose to hold the CPI-U update factor for the ASC payment system to zero. Secti on 1833(i)(2)(D)(v) of the Act, as added by section 3401(k) of the ACA, then requires that the Secretary reduce the CPI-U update factor (which would be held to zero if the CPI-U percentage change is negative) by the MFP adjustment, and states that application of the MFP adjustment may reduce this percentage change below zero. If the app lication of the MFP adjustment to the CPI-U percentage increase would result in a MFP-adjusted CPI-U update factor that is less than zero, then the annual update to the ASC paym ent rates would be negative and payments would decrease relative to the prior year. Table 35 provides illustrative examples of how the MFP would be applied to the ASC payment system. These examples show the implication of a positive CPI-U update factor with a smaller MFP, a positive CPI-U upda te factor with a large MFP, and a CPI-U update factor of 0. We discuss the application of the MFP to the CPI-U update factor for the ASC payment system under the OPPS/ASC CY 2001 proposed rule (1504-P), which will be published around the same time as this proposed rule. Comments on the specific

mathematical calculation of the MFP shoul d be made to this PFS proposed rule. Comments on the application of the MFP to the CPI-U update factor under the ASC payment system should be made to the OPPS/ASC CY 2011 proposed rule (1504-P). TABLE 35: Multifactor Productivity Adjusted Payment Update: Illustrative Example

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CPI-U (Percent) MFP (Percent) MFP-Adjusted CPI-U Update Factor (Percent) 4.0 1.3 2.7 4.0 4.7 -0.7 0.0 0.2 -0.2

b. Ambulance Fee Schedule (AFS) In accordance with section 1834(l)(3)(B) of the Act, the AFS is required to be increased each year by the percentage increase in the CPI-U (U.S. city average) for the 12-month period ending with June of the previ ous year. We refer to this update as the Ambulance Inflation Factor (AIF). Sec tion 3401(j) of the ACA amends section 1834(l)(3) of the Act to add a new subparagra ph (C) which states that, for CY 2011 and each subsequent year, after determining the percentage increase under section 1834(l)(3)(B) (that is, the CPI-U percentage in crease, or AIF), the Secretary shall reduce such percentage increase by the MF P adjustment described in section 1886(b)(3)(B)(xi)(II) (as discussed above). Section 3401(j) further amends section 1834(l)(3) to state that the application of s ubparagraph (C) (that is, the reduction of the CPI-U percentage increase by the MFP adjus tment) may result in that percentage increase being less than zero for a year, and may result in payment rates for a year being less than such payment rates for the preceding year. In accordance with section 1834(l)(3) of th e Act as amended by section 3401(j) of the ACA, before applying the MFP adjustment, the Secretary first determines the “percentage increase” in the CPI-U, which we interpret cannot be a negative number. Thus, in the instance where the percentage change in the CPI-U for a year is negative, we propose to hold the AIF to zero. The statute then requires that the Secretary reduce the CPI-U percentage increase (which would be held to zero if the CPI-U percentage change

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is negative) by the MFP adjustment, and states that application of the MFP adjustment may reduce this percentage increase belo w zero. If the application of the MFP adjustment to the CPI-U percentage increase would result in an MFP-adjusted AIF that is less than zero, then the annual update to th e AFS would be negative and payments would decrease relative to the prior year. Table 36 provides illustrative examples of how the MFP would be applied to the AFS. Finally, we propose to revise §414.610(f) to require that the AIF be reduced by the MFP adjustment as required by the statut e in determining the annual update under the ambulance fee schedule for CY 2011 and each subsequent year, and to revise § 414.620 to state that changes in payment rates resu lting from the incorporation of the AIF and the MFP adjustment will be announced by CMS by instruction and on the CMS website, as

we discuss above. TABLE 36: Examples of the Application of the Multifactor Productivity Adjustment to the Ambulance Fee Schedule

A B C D CPI-U AIF MFP Final Update Rounded 2.0% 2.0% 1.3% 0.7% 0.0% 0.0% 1.3% -1.3% -2.0% 0.0% 1.3% -1.3% 1.0% 1.0% 1.3% -0.3%

c. Clinical Labor atory Fee Schedule Section 1833(h)(2)(A)(i) of the Act, as amended by section 3401(l) of the ACA, requires the Secretary to annually adjust the CLFS “by a percentage increase or decrease equal to the percentage increase or decrease in the Consumer Price Index for All Urban Consumers (United States city average minus, for each of the years 2009 through 2010,

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0.5 percentage points.” Therefore, the adjus tment to the fee schedule can be an increase

or a decrease. Section 3401(l) of the ACA also adds new clause (iv) that applies in CY 2011 and each subsequent year. This clause requires the Secretary to reduce the adjustment in clause (i): (1) by the MFP adjustment de scribed in section 1886(b)(3)(B)(xi)(II) for 2011 and each subsequent year and (2) by 1.75 percentage points for each of 2011 through 2015 (the “percentage adjustment”). However, section 3401(l) of the ACA states that the MFP adjustment will not apply in a year where the adjustment to the fee schedule determined under clause (i) is zero or a per centage decrease for a year. Further, the application of the MFP adjustment may not result in an adjustment to the fee schedule under clause (i) of less than zero for a year. Therefore, we are proposing to apply the MFP adjustment as follows:

● If the CPI-U update factor is positive, it would be reduced by the MFP. However, if application of the MFP would re sult in a negative update, the update would

be held to zero.

● If the CPI-U update factor is zero or negative, the MFP adjustment would not be applied. Section 3401(l) of the ACA also states th at the application of the percentage adjustment may result in an adjustment to the fee schedule under clause (i) being less than zero for a year and may result in payment rates for a year being less than such payment rates for the preceding year. Therefore, we are proposing to apply the percentage reduction of 1.75 percentage point s to any adjustment to the fee schedule under the CLFS as directed by Section 3401(l) of the ACA.

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Table 37 provides illustrative examples of how these adjustments would be applied to fees under the CLFS. TABLE 37: Examples of the Application of the Multifactor Productivity Adjustment to the Clinical Lab Fee Schedule

A B C D E CPI-U MFP Productivity Adjusted Update (-1.75%) Percentage Point Reduction Resultant Change to

CLFS

Greater of 0.0% or (Col.A) - (Col.B) Col.C – Col.D 2.0% 1.3% 0.7% -1.75% -1.05% 0.0% N/A 0.0% -1.75% -1.75% -2.0% N/A 0.0% -1.75% -1.75% 

### d. DMEPOS Fee Schedule Sections 1834(a)(14), 1834(h)(4), and 1842(s)(1) of the Act mandate annual updates to the fee schedule amounts established in accordance with these respective

sections for covered items of durable medi cal equipment defined in section 1834(a)(13) of the Act, prosthetic devices , orthotics, and pros thetics defined in section 1834(h)(4)(B) and (C) of the Act, and parenteral and enteral nutrients, equipment, and supplies described in section 1842(s)(2)(D) of the Act. The annual updates for 2011 for these sections are based on the percentage incr ease in the CPI-U for the 12-month period ending with June 2010. The annual updates for years subsequent to 2011 are based on the percentage increase in the CPI-U for the 12-month period ending with June of the previous year (that is, June 2011 for 2012, June 2011 for 2013, etc.). Since 1990 for durable medical equipment, pr osthetic devices, orthotics, and prosthetics and 2003 for parenteral and enteral nutrients, equipmen t, and supplies, these annual fee schedule updates have been implemented on an annual basis thr ough program instructions. Section 3401(m) of the ACA amends secti on 1834(a)(14) of the Act to add a new subparagraph (L) which provides that, for CY 2011 and each subsequent year, the fee

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schedule update factor based on the CPI-U for the 12-month period ending with June of the previous year is to be reduced by the MFP adjustment described in section 1886(b)(3)(B)(xi)(II) of the Act (as discu ssed above). Section 3401(m) of the ACA further amends section 1834(a)(14) of th e Act to state that the application of subparagraph (L) (that is, the reduction of th e CPI-U percentage increase by the MFP adjustment) may result in that percentage increase being less than zero for a year, and may result in payment rates for a year being less than such payment rates for the preceding year. Section 3401(n) of ACA amends section 1834(h)(4)(A) of the Act to add a new clause (xi) which provides that, for CY 2011 and each subsequent year, the fee schedule update factor based on the CPI-U for the 12 -month period ending with June of the previous year is to be reduced by th e MFP adjustment described in section 1886(b)(3)(B)(xi)(II) of the Act (as discu ssed above). Section 3401(n) of the ACA further amends section 1834(h)(4) of the Act to state that the application of subparagraph (A)(xi) (that is, the reduction of the CPI-U percentage increase by the MFP adjustment) may result in that percentage increase being less than zero for a year, and may result in payment rates for a year being less than such payment rates for the preceding year. Section 3401(o) of ACA amends secti on 1842(s)(1) of the Act to add a new subparagraph (B) and clause (ii) which pr ovides that, for CY 2011 and each subsequent year, the fee schedule update factor based on the CPI-U for the 12-month period ending with June of the previous year is to be reduced by the MFP adjustment described in section 1886(b)(3)(B)(xi)(II) (as discussed above). Section 3401(o) further amends section 1842(s)(1) to state that the application of subpara graph (B)(ii) (that is, the reduction of the CPI-U percentage increase by the MFP adjustment) may result in that

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percentage increase being less than zero for a year, and may result in payment rates for a year being less than such payment rates for the preceding year. The MFP adjustments to the CPI-U percentage increases used in calculating the fee schedule adjustment factors for these DMEPOS items and services as mandated by sections 3401(m), (n), and (o) of ACA are simple mathematical calculations and are ministerial in nature. Therefore, we plan to implement these adjustments for 2011 and subsequent years as part of the annual progra m instructions related to the DMEPOS fees schedule updates. Q. Section 4103: Medicare Coverage of A nnual Wellness Visit Providing a Personalized

Prevention Plan 1. Background a. Medicare Coverage of Preventive Ph ysical Examinations and Routine Checkups Section 1862(a)(7) of the Act explicitly prohibits Medicare payment for routine physical checkups with certain exceptions. One exception is for the Initial Preventive Physical Exam (also referred to as the “Welcome to Medicare” exam) established for new

beneficiaries effective for services furnis hed on or after January 1, 2005. Section 4103 of the ACA has provided another exception to section 1862(a)(7). Congress has expanded Medicare coverage under part B to incl ude an Annual Wellness Visit Providing Personalized Prevention Plan Services (hereinafter referred to as the annual wellness visit) in sections 1861(s)(2)(FF) and 1861(hhh)of the Act. This ex panded benefit will be effective on January 1, 2011. Preventive care has become an increasing focus of the Medicare program. For instance, section 101 of the MIPPA expanded Medicare’s authority to establish coverage for preventive services that meet specified criteria. Among other things, the annual wellness

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visit will encourage beneficiaries to obtain the preventive services already covered by Medicare, and that are appropriate fo r each individual beneficiary. b. Requirements for Coverage of an Annual Wellness Visit Section 4103 of the ACA provides for covera ge of an annual wellness visit, which

includes and/or takes into account a health risk assessment (HRA), and creates a personalized prevention plan for beneficiaries, subject to certain eligibility and other limitations. Section 4103 of the ACA also requi res the identification of elements that must be provided to a beneficiary as part of the first visit for personalized prevention plan services and requires the establishment of a yearly schedule for appropriate provision of

such elements thereafter. The Affordable Care Act specifies elements that may be included in a personalized prevention plan, including estab lishment of, or update to, the individual’s medical and family history, a list of the indi vidual’s current provide rs and suppliers and medications prescribed for the individual; measurement of height, weight, body-mass index (BMI) or waist circumference, and blood pressure; detection of any cognitive impairment; establishment or update of an a ppropriate screening schedule for the next 5 to 10 years; establishment or update of a list of risk factors and conditions (including any mental health conditions) for which interv entions are recommended or underway; and furnishing of personalized health advice and re ferral, as appropriate, to health education or preventive counseling services or programs. The Affordable Care Act also permits the Secretary to add other elements to the annual we llness visit determined to be appropriate. 2. Proposed Revisions a. Proposed Revisions to §411.15, Particul ar Services Excluded from Coverage To conform the regulations to the stat utory requirements of the ACA, we are

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proposing to revise §411.15 by specifying an exception to the routine physical checkups exclusion from coverage in §411.15(a)(1) a nd modifying §411.15(k)(15). We would add a provision to permit coverage of annual wellness visits that meet the eligibility limitation and the conditions for coverage we are specifying in §410.15 (Annual Wellness Visit Providing Personalized Prevention Plan Services). Coverage of the annual wellne ss visit is furnished under Medicare Part B only. As provided in the statute, this new coverage a llows payment for an annual wellness visit if provided after January 1, 2011 for an individual who is no longer within 12 months after

the effective date of his or her first Me dicare Part B coverage period, and has not

received either an IPPE or an annual welln ess visit within the past 12 months. b. Proposed revisions to Part 410, Subpart B – Medical and Other Health Services We propose to add §410.15(a), Condition for Coverage of Annual Wellness Visits Providing Personalized Prevention Pl an Services, and §410.15(b), Limitation on Coverage of Annual Wellness Vi sits Providing Personalized Prevention Plan Services, to codify the coverage of the annual wellness visit providing personalized prevention plan

services. We are proposing to define several term s in §410.15. These include the following terms: (1) Detection of any cognitive impairment; (2) Review of the individual’s functional ability and level of safety; (3) Health professional; (4) Establishment of, or update to the individual’s medical and family history; (5) Eligible beneficiary; (6) First annual wellness visit providing personalized prevention plan services; and (7) Subsequent annual wellness visit provid ing personalized prevention plan services. Further, the ACA allows the addition of any other element dete rmined appropriate by the Secretary for inclusion in an annual wellness visit. We reviewed the relevant

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medical literature, current clinical practice guidelines, and the recommendations of the

United States Preventive Services Task Force (USPSTF). Pursuant to that review, we propose to add depression scr eening and functional status screening as elements of the first annual wellness visit only. In their December 2009 Recommendation Statement, the U.S. Preventive Services Task Force (USPSTF) recommends screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment and follow-up (Grade: B recommendation). That is, the USPSTF recommends the service; and there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. The USPSTF is currently updating its 1996 recommendation regarding screening for hearing impairment in older adults as well as its recommendation on falls in the elderly. Until those recommendations can be published, functional status screening (including assessment of hearing impairment, ability to successfully perform activities of daily living, fall risk and hom e safety) appears supportable by evidence only for the first

annual wellness visit. We also are proposing that the definition of the term “Establishment of, or an update to the individual’s medical and family history” include more than a list of all of an individual’s prescribed medicati ons as provided in the statute, but also supplements such

as vitamins and calcium that an individual ma y use or be exposed to. Supplements such as these are commonly used by many benefi ciaries and the medical literature supports that their use be closely monitored by health professionals because they can interact with prescribed medications and may result in unintended medical problems in individual cases. The statute expressly permits the Secretary to add other elements such as this to

the annual wellness visits.

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(1) Definitions We are proposing to add the following definitions to §410.15:

● Detection of any cognitive impairment , for purposes of this section, means assessment of an individual’s cognitive f unction by direct observation, with due consideration of information obtained by way of patient report, concerns raised by family members, friends, caretakers, or others.

● Review of the individual’s functional ability and level of safety , for purposes of this section includes, at a minimum, assessment of the following topics: ++ Hearing impairment; ++ Ability to successfully perform activities of daily living; ++ Fall risk; ++ Home safety.

● Health professional, for purposes of this section means: ++ A physician who is a doctor of medici ne or osteopathy (as defined in section 1861(r)(1) of the Act); or ++ A practitioner as described in clause (i) of section 1842(b)(18)(C) of the Act, that is, a physician assistant, nurse practitioner, or clinical nurse specialist (as defined in section 1861(aa)(5) of the So cial Security Act); or ++ A medical professional (including a health educator, registered dietitian, or nutritionist) or a team of medi cal professionals, who are work ing under the supervision of a physician as defined in this definition.

● Establishment of, or an update to th e individual’s medical and family history, for purposes of this section, means at a min imum the collection and documentation of the following:

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++ Past medical and surgical history, including experiences with illnesses, hospital stays, operations, allerg ies, injuries, and treatments. ++ Use or exposure to medications a nd supplements, including calcium and

vitamins. ++ Medical events experienced by the be neficiary’s parents and any siblings and children, including diseases that may be here ditary or place the individual at increased

risk.

● Eligible beneficiary, for purposes of this section, means an individual who is no longer within 12 months after the effective date of his or her first Medicare Part B coverage period, and has not recei ved either an initial preven tive physical examination or an annual wellness visit providing a persona lized prevention plan within the past 12

months. (2) Requirements of the First Visit fo r Personalized Prevention Plan Services We are proposing that the first annual welln ess visit for purposes of this benefit include the following:

● Establishment of the individua l’s medical and family history;

● Establishment of a list of current pr oviders and suppliers that are regularly involved in providing medi cal care to the individual;

● Measurement of the individual’s he ight, weight, body mass index (or waist circumference, if appropriate), blood pre ssure, and other routine measurements as deemed appropriate, based on the indi vidual’s medical and family history;

● Detection of any cognitive impairment that the individual may have;

● Review of the individual’s potential (risk factors) for depression, including current or past experiences with depression or other mood disorders, based on the use of

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an appropriate screening instrument for persons without a current diagnosis of depression, which the health pr ofessional as defined in this section may select from various available screening questions or st andardized questionnaires designed for this purpose and recognized by national professional medical organizations;

● Review of the individual’s functional ability and level of safety, based on direct observation or the use of appropri ate screening questions or a screening questionnaire, which the health professional as defined in this section may select from various available screening questions or st andardized questionnaires designed for this purpose and recognized by national professional medical organizations;

● Establishment of the following: ++ A written screening schedule, such as a checklist, for the next 5 to 10 years as appropriate, based on recommendations of the USPSTF and the Advisory Committee on Immunization Practices, and the individual’s h ealth status, screening history, and ageappropriate preventive services covered by Medicare; and

++ A list of risk factors and conditions for which primary, secondary or tertiary

interventions are recommended or are underwa y, including any mental health conditions or any such risk factors or conditions that have been identified through an initial preventive physical examination (as desc ribed under §410.16), and a list of treatment options and their associated risks and benefits;

● Furnishing of personalized health a dvice and a referral, as appropriate, to health education or preven tive counseling services or programs aimed at reducing identified risk factors and improving self management, or community-based lifestyle

interventions to reduce health risks a nd promote self-management and wellness, including weight loss, physical activity, smoking cessation, fall pr evention, and nutrition;

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and

● Any other element determined appropriate by the Secretary through the National Coverage Deter mination process. (3) Requirements of Subsequent Visits fo r Personalized Prevention Plan Services We are proposing that subsequent annual wellness visits providing personalized prevention plan services for purposes of this benefit include the following:

● An update of the individual’ s medical and family history;

● An update of the list of current provi ders and suppliers that are regularly involved in providing medical care to the indi vidual, as that list was developed for the first annual wellness visit providing pe rsonalized prevention plan services;

● Measurement of an individual’s we ight, blood pressure, and other routine measurements as deemed appropriate, ba sed on the individual’s medical and family history;

● Detection of any cognitive impairment, as that term is defined in this section, that the individual may have;

● An update to the following: ++ The written screening schedule for the individual as that schedule was developed at the first annual wellness vi sit providing personalized prevention plan services; and

++ The list of risk factors and conditions for which primary, secondary or tertiary

interventions are recommended or are under way for the individual as that list was developed at the first annual wellness vi sit providing personalized prevention plan services;

● Furnishing of personalized health a dvice to the individual and a referral, as

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appropriate, to health educati on or preventive counseling services or programs as that

advice and related services are defined in paragraph (a) of this section;

● Any other element determined appropriate by the Secretary through the National Coverage Dete rmination process. Body-mass index (BMI) should be calculated at the first annual wellness visit and may be recalculated at subsequent vis its, if indicated. Given the ge neral stability of adult height, we would not expect the BMI to meaningful ly change in the absence of significant weight change. We have not in the defin ition of the subsequent annual visit required measurement of the individual’s height. We are proposing to add two distinct elemen ts to the definition of the first annual wellness visit only: depression sc reening and functional status assessment. Our review of the medical literature and the USPSTF recommendations indicates that the optimum frequency for those services is unknown. Thus we believe it woul d be premature and beyond the current evidence to require that they be included in the definition of subsequent visits, but they may be perf ormed at these visits, if indicated. In addition, to facilitate futu re consideration of coverage of additional elements in the definitions of the first and subsequent annual wellness visits in §410.15(a), we are proposing that the determination of other re quired elements for those purposes will be made through the National Coverage Determin ation (NCD) process. The NCD process is evidence based, transparent and furnishes th e opportunity for public comment, and is

described in sections 1862(l)of the Act. While section 4103 of the ACA ultimately requires that an HR A be included in

the new annual wellness vis it benefit beginning January 1, 2011, the HRA guidelines (with standards for interactive telephonic a nd web-based HRAs) and the model HRA tool

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also required by section 4103 are not yet availa ble. As a result, we have not included requirements related to the HRA in this proposed rule. When HRA guidelines and standards have been established, and a model HRA instrument is available and determined by the Secretary to be appropria te for the Medicare population, we will revise these regulations to include the HRA as an element in the definition of the annual

wellness visit. We are requesting public comments on the components of both the first and subsequent annual wellness vis its, as well as the definitions of related terms in the document. We ask that commenters making specific recommendations on this or any related issue provide documentation from the me dical literature, current clinical practice guidelines, or the USPSTF or Advisory Committee on Immunization Practices

recommendations. 3. Payment for the Annual Wellness Visit Providing Personalized Prevention Plan Services (PPPS)

Section 4103 of the ACA created a new be nefit for the “annual wellness visit” with personalized prevention plan services. The Affordable Care Act amends section 1861(s)(2) of the Act by adding a new subsec tion (FF) to provide for coverage of the annual wellness visit beginning January 1, 2011. Section 4103 also adds new subsection (hhh) to section 1861 of the Act to define “p ersonalized prevention plan services” and to specify who may furnish these services. Fi nally, section 4103 amends section 1848(j)(3) of the Act to provide for payment of annual wellness visits under the PFS, and specifically excludes the annual wellness vis it from the hospital outpatient prospective payment system (OPPS). Therefore, a single payment under the PFS will be made when an annual wellness visit is furnished by a physician, physicia n assistant, nurse

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practitioner, or clinical nurse specialist, or by a medical professional or team of medical professionals, as determined appropriate by the Secretary, under the supervision of a physician. To allow for Medicare reporting and paymen t of the annual wellness visit, we are proposing to create two new HCPCS G-codes for reporting the first wellness visit and creation of the PPPS and the subsequent visits available to the beneficiary every 12 months. Specifically, we are proposing to es tablish the following two new HCPCS codes for CY 2011: GXXXA (Annual wellness visit; in cludes a personalized prevention plan

of service (PPPS), first visit) and GXXXB (Annual wellness visit; includes a personalized prevention plan of service (PPPS), subsequent visit). A beneficiary’s first annual wellness visit to a pr actitioner would be reported to Medicare under HCPCS code GXXXA, even if the beneficiary had previously received an initial preventive physical examination (IPPE) that was covered by Medicare. Beneficiaries, in their first 12 months of Part B coverage, will continue to be e ligible only for an IPPE. After the first 12 months of Part B coverage, on and after January 1, 2011, benefi ciaries will be eligible for

an annual wellness visit de scribed by HCPCS code GXXXA or GXXXB, provided that the beneficiary has not received an IPPE or annual wellness visit within the preceding 12- month period. A beneficiary would be eligible for on e initial annual wellne ss visit covered by Medicare that must include all of the required elements that we are proposing for the first visit as described in the preceding section. All other annual wellne ss visits that would include the required elements fo r those visits would be reporte d as subsequent visits, even if a different practitioner furnished the subs equent annual wellness visit. We would expect there to be continuity and communication among the practitioners caring for

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beneficiaries over time with respect to the PPPS, and that would include the case where a different practitioner furnishing a subseque nt annual wellness vi sit would update the information in the patient’s medical record ba sed on the patient’s interval history since the previous annual wellness visit. The first wellness visit described by HCPCS code GXXXA is similar to the IPPE that is currently reported with HCPC S code G0402 (Initial preventive physical examination; face-to-face vis it, services limited to new beneficiary during the first 12 months of Medicare enrollment). We believe that the physician work and nonfacility PE

of the IPPE and the first annua l wellness visit are very similar, given that both represent an initial beneficiary visit focused on preven tion. In the CY 2010 PFS final rule with comment period discussion of payment for the IPPE (74 FR 61767), we noted that in the context of physician work a nd intensity, HCPCS code G 0402 was most equivalent to CPT code 99204 (Level 4 new patient office or ot her outpatient visit). Therefore, for CY 2011, we are proposing to crosswalk the same physician work RVUs of 2.43 from CPT

code 99204 to HCPCS codes G0402 and GXXXA. Similarly, we believe the direct PE inputs for all of these services are similar a nd, therefore, we are proposing to assign the same direct PE inputs to HCPCS code s G0402 and GXXXA as are included for CPT code 99204. We note that currently, the dire ct PE inputs for HCPCS code G0402 also include preventive assessment fo rms, and we are proposing to add this supply to the PE

for HCPCS code GXXXA as well because we believe it would be used in the first wellness visit. The proposed CY 2011 PE and malpractice RVUs for HCPCS code GXXXA are displayed in Addendum B to this pro posed rule. We also note that we are proposing no facility PE RVUs for HCPCS code GXXXA because only a single payment

will be made under the PFS when this service is furnished. There is no separate facility

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payment for GXXXA when a practitioner furnishes this service in the facility setting. Moreover, we believe that a subseque nt annual wellness vi sit described by HCPCS code GXXXB is most similar, from the perspectives of physician work and PE, to CPT code 99214 (Level 4 esta blished patient office or ot her outpatient visit). The subsequent annual wellness visit is a patient visit for PPPS that includes certain required elements, such as updating information regardin g the patient’s history, risk factors, and regular medical care providers and suppliers since the prior annual visit, and obtaining routine measurements. We believe the physic ian work and direct PE of a subsequent

annual wellness visit are simila r, in terms of evaluation and management (E/M) visit level, to the first wellness visit, which we are proposing to value like a level 4 new patient office or other outpatient visit, as we have previously valued the IPPE. However, the subsequent annual wellness vi sit would typically be for an established patient and, as described earlier in this section, we are pr oposing that certain wellness visit elements only must be furnished in the first wellness vis it. As a result, we be lieve it would be most appropriate to value the subs equent annual wellness visit ba sed upon an E/M visit for an established patient. Therefore, for CY 2011 we are proposing to crosswalk the same physician work RVUs of 1.50 from CP T code 99214 to HCPCS code GXXXB. Furthermore, we believe the direct PE input s for these two services are also similar and, therefore, we are proposing to assign the sa me direct PE inputs to HCPCS code GXXXB as are assigned to CPT code 99214. We note th at we are also proposing to add the same preventive assessment forms to the PE for HCPCS code GXXXB as we are proposing to

add for HCPCS code GXXXA because we believe this supply would be used in both the first and subsequent annual wellness visits. The proposed CY 2011 PE and malpractice RVUs for HCPCS code GXXXB are displayed in Addendum B to this proposed rule.

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Similar to our treatment of HCPCS code GXXXA for the first wellness visit, we are proposing no facility PE RVUs for HCPCS code GXXXB as only a single payment will

be made under the PFS when this service is furnished. There is no separate facility payment for GXXXB when a practitioner furnis hes this service in the facility setting.

While we believe there coul d be overlap in the direct PE, malpractice expense, and physician work in both history taking and examination of the patient in the context of the initial or subsequent welln ess visit and another E/M serv ice, we are not proposing to limit the level of a medically necessary E/M visit when furnished and billed with a

wellness visit. As we stated in the CY 2005 PFS final rule with comment period with respect to the IPPE (69 FR 66289 throug h 66290), we do not want to prohibit the reporting of an appropria te level of service when it is necessary to evaluate and treat the beneficiary for acute and chronic conditions. However, at the same time, we believe the practitioner is better able to discuss health promotion, disease prevention, and the educational opportunities av ailable with beneficiaries when their health status has been stabilized and the beneficiary is physically receptive. Therefore, depending on the clinical circumstances, a CPT code for a me dically necessary E/M visit may be reported and appended with CPT modifier -25 (Signifi cant, separately iden tifiable evaluation and management service by the same physician on the same day of the procedure or other service) to designate the E/M visit as a separately identifiable service from the initial or subsequent wellness visit. However, we believe this s cenario would be uncommon, and we expect that no components of an encount er attributable to th e annual wellness visit would be used in determining the level of a separate E/M visit that would also be reported. With respect to beneficiary cost-shari ng, section 4103(c) of the ACA amends

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section 1833(a)(1) of the Act by adding subpara graph (X), referring to the PPPS to state that the amount paid shall be 100 percent of the lesser of the actual charge for the

services or the amount determined under th e payment basis determined under section 1848 of the Act, thereby eliminating coinsuran ce for the annual wellness visit. Finally, section 4103(b)(4) of the ACA ame nds section 1833(b) of the Act to specify that the Part B deductible does not apply to the annual wellness visit. We expect that practitioners

will work to ensure that this valuable new Medicare benefit is furnished to the beneficiaries that they care for in th eir practices, effective January 1, 2011.

R. Section 4104: Removal of Barriers to Preventive Services in Medicare

1. Definition of “Preventive Services”

Section 4104 of the ACA revises secti on 1861(ddd) of the Act to add paragraph (3), which defines the term “preventive services” as follows:

● The specific services currently liste d in section 1861(ww)(2) of the Act with the explicit exclusion of electrocardiogram s (as specified in section 1861(ww)(2)(M) of the Act);

● The initial preventive physical examin ation (IPPE) established by section 611

of the MMA and defined in sec tion 1861(ww)(1) of the Act; and

● The annual wellness visit, as specifi ed by section 1861(hhh) of the Act as added by section 4103 of the ACA. We refer readers to section V.Q. of this proposed rule for the proposed provisions related to the coverage of and payment for the annual wellness visit. The regulations regarding coverage of the IPPE are specified in §410.16 and remain unchanged by the ACA.

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The specific preventive services included in the definition of “preventive services” in section 1861(ddd)(3)(A) of th e Act as cross-referenced to section 1861(ww)(2) of the Act, excluding electro cardiograms, include the following:

● Pneumococcal, influenza, and hepatitis B vaccine and administration.

● Screening mammography.

● Screening pap smear and screening pelvic exam.

● Prostate cancer screening tests.

● Colorectal cancer screening tests.

● Outpatient diabetes self-management training (DSMT).

● Bone mass measurement.

● Screening for glaucoma.

● Medical nutrition th erapy (MNT) services.

● Cardiovascular screening blood tests.

● Diabetes screening tests.

● Ultrasound screening for abdominal aortic aneurysm (AAA).

● Additional preventive services identified for coverage through the national coverage determina tion (NCD) process. We note that currently the only additi onal preventive service identified for coverage through the NCD process is HIV testing. A proposed NCD for smoking cessation services for asympt omatic patients was released in May 2010 on the CMS web

site at: http://www.cms.gov/mcd/index_list.asp?list_type=nca . We will address the applicability of section 1861(ddd)(3)(A) of the Act (as added by section 4104 of the ACA) to these services if an NCD establishing them as additional preventive services is

finalized.

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We are proposing to add the definition of “preventive services” in §410.2 to implement the provisions of section 1861(ddd) (3) of the Act (as amended by section 4104 of the ACA).

2. Deductible and Coinsurance for Preventive Services Section 4104(b)(4) of the ACA amends section 1833(a)(1) of the Act by requiring 100 percent Medicare payment for the IPPE and for those preventive services recommended by the United States Preventive Services Task Force (USPSTF) with a grade of A or B for any indication or popul ation and that are appropriate for the individual. This provision waives any coin surance that would otherwise be applicable under section 1833(a)(1) of the Act for thos e items and services listed in section 1861(ww)(2) of the Act (excluding electrocardiograms) to which the USPSTF has given a grade of A or B. In addition, section 4103(c)(1) of the ACA amends section 1833(c)(1)

of the Act to waive the coinsurance for the annual wellness visit. The coinsurance represents the beneficiary’s share of the paym ent to the provider or supplier for furnished services. Coinsurance generally refers to a percentage (for example, 20 percent) of the Medicare payment rate for which the benefici ary is liable and is applicable under the PFS, while copayment generally refers to an established amount that the beneficiary must pay that is not necessarily related to a partic ular percentage of the Medicare payment, and is applicable under the hospital Outpatient Prospective Payment System (OPPS). We refer readers to the CY 2011 OPPS/ASC proposed rule for proposed provisions related to payment for preventive services, including waiver of the deductible and copayment,

under the OPPS. Section 4104(c) of the ACA amends sec tion 1833(b)(1) of the Act to waive the Part B deductible for preventive services described in subparagraph (A) of section

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1861(ddd)(3) of the Act that have a grade of A or B from the USPSTF. In addition, section 1833(b)(1) of the Act (as amended by section 4103(c)(4) of the ACA) waives the

Part B deductible for the a nnual wellness visit. These provisions are effective for services furnished on and after January 1, 2011. Section 101(b)(2) of the MIPPA amended section 1833(b) of th e Act to waive the deductible for the IPPE effective January 1, 2009. Not all preventive services descri bed in subparagraph (A) of section 1861(ddd)(3) are recommended by the USPSTF with a grade of A or B and, therefore, some of the preventive services do not meet th e criteria in sections 1833(a)(1) and (b)(1)

of the Act for the waiver of the deductible and coinsurance. However, with certain exceptions noted below, the changes made by section 4104 of the ACA do not affect most of the preexisting specific provisions in sections 1833(a) and 1833(b) of the Act (that are codified in regulations in §410.160(b) and §410.152) that waive the deductible and coinsurance for specific services. For example, section 1833(a)(1)(D) of the Act already waives the coinsurance and section 1833(b)(3) of the Act waives the deductible for clinical laboratory tests (including tests furnished for screening purposes). Section 4104 of the ACA does not change this provisi on and, therefore, the waiver of both the deductible and coinsurance remains in place for all laboratory tests, regardless of whether the particular clinical laboratory test meets the USPSTF grading criteria specified in sections 1833(a)(1) and 1833(b)(1) of the Ac t (as amended by section 4104 of the ACA) for waiver of the deductible and coinsurance as a preventive service. The following preventive services liste d in section 1833(ddd)(3)(A) of the Act are not recommended by the USPSTF with a grade of A or B for any indication or population: digital rectal examination furnishe d as a prostate cancer screening service;

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glaucoma screening; DSMT services; and barium enema furnished as a colorectal cancer screening service. Specifically, HCPCS code G0102 (Prostate cancer screening; digital rectal exam), which does not have a grade of A or B from the USPSTF for any indication or population, will continue to be subject to the deductible and coinsurance as there is no statutory provision to the contrary. Howeve r, the deductible and coinsurance for HCPCS code G0103 (Prostate cancer screening; prostate specific antigen test (PSA)) will

continue to be waived in accordance with section 1833(a)(1)(D) of the Act, even though this service also does not have a grade of A or B from the USPSTF. Glaucoma screening services, descri bed by HCPCS codes G0117 (Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist) and G0118 (Glaucoma screening for high risk patie nt furnished under the direct supervision of an optometrist or ophthalmologist), will c ontinue to be subject to the deductible and coinsurance because these services are not recommended with a grade of A or B by the USPSTF for any indication or population and there is no other statutory provision to except them. Similarly, DSMT services are currently not rated by the USPSTF, and there is no other statutory provision to except them from applicability of the deductible and

coinsurance. Therefore the deductible and coinsurance requirements will continue to apply. Barium enemas furnished as colorectal cancer screening tests, described by HCPCS codes G0106 (Colorectal cancer scr eening; alternative to G0104, screening sigmoidoscopy, barium enema) and G0120 (Color ectal cancer screening; alternative to G0105, screening colonoscopy, barium enema), do not have a grade of A or B from the USPSTF for any indication or population. However, the deductible does not apply to

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barium enemas furnished as colorectal cancer screening tests, because colorectal cancer screening tests are explicitly excluded from the deductible in section 1833(b)(8) of the Act. However, there is no specific exclusion of barium enemas from the coinsurance requirement in section 1833(b)(1) of the Ac t and, therefore, this requirement, as applicable, continues to apply to barium enemas. We note that the USPSTF has given a grade of A to screening colonoscopy, screen ing flexible sigmoidoscopy, and fecal occult blood screening tests, and that, as a result, these colorectal cancer screening tests are subject to the statutory waiver of bot h the deductible and coinsurance.

We note also that the USPSTF ceased to make recommendations with regard to

vaccines and vaccine administration after CY 1996, so as not to conflict with the

recommendations of the Centers for Dise ase Control and Prevention’s Advisory

Committee on Immunization Practices. Howeve r, the USPSTF’s most recent vaccine recommendations gave a grade of B to infl uenza and pneumococcal vaccines and their administration and a grade of A to hepatitis B vaccine and its administration. While sections 1833(a)(1) and 1833(b)(1) of the Act re quire that the preventive services receive a grade of A or B from the USPSTF for the coinsurance and deductible to be waived, the statute does not specify that the recommended grade must be furnished by the USPSTF within any given timeframe. The USPSTF grades for these preventive services are the most current USPSTF grade and have never been withdrawn. Therefore, we believe that these preventive services meet the requirements of the statute for the waiver of the

deductible and coinsurance. We also note that the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices currently recommends influenza, pneumococcal, and hepatitis B vaccines.

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We are proposing to update §410.160(b), which lists the services for which expenses incurred are not subject to the Part B annual deductible a nd do not count toward meeting that deductible. Specifically, we are proposing to revise §410.160(b)(2) to include influenza and hepatitis B vaccines and their administration, in addition to pneumococcal va ccine and its administration. In addition, in §410.160(b), we are also proposing to add exceptions for bone mass me asurement, MNT services, and the annual

wellness visit. In §410.152, we are proposing to revise para graph (l) to establish the amount of payment under the applicable payment system fo r providers and suppliers of the services listed in the paragraph and displayed in Ta ble 38. Table 38 displays the HCPCS codes that we are proposing as “preventive servic es” under section 1861(ddd)(3)(A) of the Act

and identifies the HCPCS codes for the IPPE a nd the annual wellness visit. Table 38 also indicates the most recent USPSTF grade, if any, that is the basis for our proposed policy with regard to waiver of th e deductible and coinsurance, as applicable, and the Medicare payment system under which the HCPCS code would be paid when furnished outside of the facility setting. We note that the ch anges made by section 4104 of the ACA with respect to the deductible and coinsurance apply in all settings in which the services are

furnished. In developing recommendations regarding preventive services, we recognize that the USPSTF may make recommendations that are specific to an indication or population, at times including characteristics such as gender and age in its recommendations. While we are proposing to waive the deductible a nd coinsurance for any Medicare covered preventive service recommended with a grade of A or B for any indication or population, with no limits on the indication or population as long as the USPSTF has recommended

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the preventive service for at least one indication and/or popul ation with a grade of A or B, we note that all existing Medicare covera ge policies for such services, including any

limitations based on indication or population, continue to apply. In some cases, national coverage policies may currently limit Medicare coverage based on the indication or population, consistent with the USPSTF recomme ndations with a grade of A or B for the indication or population. In other cases where Medicare does not explicitly noncover preventive services for a sp ecific population or indicati on, we would expect that, particularly in those cases where the USPSTF recommendation grade is a D (that is, the USPSTF recommends against the service because th ere is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits), practitioners would only order those preventive services that are clinically appropriate for the beneficiary. If we have concerns in the future about the appropriateness of preventive services for an indication or population in light of the USPSTF’s recommendations, we may consider using our authority under sec tion 1834(n)(1) of the Act (as added by section 4105 of the ACA) to modify Medicare coverage of any preventive service to be

consistent with the recommendations of the USPSTF. Section 10501(i)(2) of the ACA amended th e definition of Federally Qualified Health Center (FQHC) services as defi ned in section 1861(aa)(3)(A) of the Act by replacing the specific references to servic es provided under secti on 1861(qq) and (vv) of the Act (diabetes outpatient self-managemen t training services and medical nutrition therapy services, respectively) with preventive services as defined in section 1861(ddd)(3) of the Act, as established by s ection 4014(a)(3) of the ACA. These changes are effective for services provided on or after January 1, 2011. Accordingly, we are proposing to conform the regulations to the new statutory requirement by adding a new

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section §405.2449 which would add the new pr eventive services definition to the definition of FQHC services effective for se rvices provided on or after January 1, 2011. Section 1861(ddd)(3) of the Act defines “pre ventive services” as consisting of the following three components:

● Screening and preventive services de scribed in section 1861(ww)(2) of the Act (other than electrocardiograms described in s ubparagraph (M) of that same subsection).

● An initial preventive physical examin ation, as defined in section 1861(ww) of

the Act.

● Personalized prevention plan services as defined in section 1861(hhh)(1) of the

Act. We are proposing to add each of these three components into the new Medicare FQHC preventive services definition in a new §405.2449. Section 4104(b)(1) of the ACA, as ame nded by section 10406 of the same Act, waives coinsurance for preventive services by adding section 1833(a)(1)(Y) to the Act to require, essentially, waiver of coinsurance for preventive services that are recommended with a grade of A or B by the USPSTF for any indication or population. This provision is specifically designed to remove barriers to affording and obtaining such preventive

services under Medicare. In addition, section 10501(i)(3)(B)(ii) of the ACA added section 1833(a)(1)(Z) to the Act to require a 20-percent copay on all FQHC services after implementation of the FQHC prospective payment system. We be lieve we can give both section 1833(a)(1)(Y) and (Z) of the Act, and the definition of FQ HC services (revised to include the broader scope of preventive services) their best effect by permittin g a 100 percent reimbursement

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rate for preventive services as defined at section 1861 (ddd)(3) of Act, effective January 1, 2011. Section 1833(b)(4) of the Act stipulates th at the Medicare Part B deductible shall not apply to Federally qu alified health center services. The ACA makes no change to this provision, therefore Medicare sh all continue to waive the Part B deductible for all Federally qualified health center services, in cluding preventive services added by the

ACA.CMS-1503-P 335TABLE 38: Proposed CY 2011 Deductible and Coinsurance for Preventive Services Under Section 1861(ddd)(3)(A) of the Act(Includes the IPPE and the Annual Wellness Visit)PreventiveServiceCPT/HCPCSCodeLong DescriptorUSPSTFRating1PaymentMethodCY 2010Coins. /DeductibleCY 2011Coins. /DeductibleG0402Initial preventive physicalexamination; face to facevisits, services limited tonew beneficiary duringthe first 12 months ofMedicare enrollmentPFSCoins.applies &ded. iswaivedWAIVEDG0403Electrocardiogram,routine ECG with 12leads; performed as ascreening for the initialpreventive physicalexamination withinterpretation and reportPFSNotWaivedNotWaivedInitialPreventivePhysicalExamination,IPPEG0404Electrocardiogram,routine ECG with 12leads; tracing only,without interpretation andreport, performed as ascreening for the initialpreventive physicalexamination*NotRatedPFSNotWaivedNotWaivedCMS-1503-P 336PreventiveServiceCPT/HCPCSCodeLong DescriptorUSPSTFRating1PaymentMethodCY 2010Coins. /DeductibleCY 2011Coins. /DeductibleG0405Electrocardiogram,routine ECG with 12leads; interpretation andreport only, performed asa screening for the initialpreventive physicalexaminationPFSNotWaivedNotWaivedUltrasoundScreening forAbdominalAorticAneurysm(AAA)G0389Ultrasound, B-scan and/or real time with imagedocumentation; forabdominal aorticaneurysm (AAA)ultrasound screeningB PFSCoins.applies &ded. iswaivedWAIVED80061 Lipid panel CLFS WAIVED WAIVED82465Cholesterol, serum orwhole blood, totalCLFS WAIVED WAIVED83718Lipoprotein, directmeasurement; highdensity cholesterol (hdlcholesterol)CLFS WAIVED WAIVEDCardiovascularDiseaseScreening84478 TriglyceridesACLFS WAIVED WAIVED82947Glucose; quantitative,blood (except reagentstrip)CLFS WAIVED WAIVEDDiabetesScreeningTests82950Glucose; post glucosedose (includes glucose)BCLFS WAIVED WAIVEDCMS-1503-P 337PreventiveServiceCPT/HCPCSCodeLong DescriptorUSPSTFRating1PaymentMethodCY 2010Coins. /DeductibleCY 2011Coins. /Deductible82951Glucose; tolerance test(gtt), three specimens(includes glucose)*NotRatedCLFS WAIVED WAIVEDG0108Diabetes outpatient selfmanagement trainingservices, individual, per30 minutesPFSNotWaivedNotWaivedDiabetesSelfManagementTrainingServices(DSMT)G0109Diabetes outpatient selfmanagement trainingservices, group session (2or more), per 30 minutes*NotRatedPFSNotWaivedNotWaived97802Medical nutrition therapy;initial assessment andintervention, individual,face-to-face with thepatient, each 15 minutesPFSNotWaivedWAIVED97803Medical nutrition therapy;re-assessment andintervention, individual,face-to-face with thepatient, each 15 minutesPFSNotWaivedWAIVEDMedicalNutritionTherapy(MNT)Services97804Medical nutrition therapy;group (2 or moreindividual(s)), each 30minutesBPFSNotWaivedWAIVEDCMS-1503-P 338PreventiveServiceCPT/HCPCSCodeLong DescriptorUSPSTFRating1PaymentMethodCY 2010Coins. /DeductibleCY 2011Coins. /DeductibleG0270Medical nutrition therapy;reassessment andsubsequent intervention(s)following second referralin same year for change indiagnosis, medicalcondition or treatmentregimen (includingadditional hours neededfor renal disease),individual, face to facewith the patient, each 15minutesPFSNotWaivedWAIVEDG0271Medical nutrition therapy,reassessment andsubsequent intervention(s)following second referralin same year for change indiagnosis, medicalcondition, or treatmentregimen (includingadditional hours neededfor renal disease), group(2 or more individuals),each 30 minutesBPFSNotWaivedWAIVEDCMS-1503-P 339PreventiveServiceCPT/HCPCSCodeLong DescriptorUSPSTFRating1PaymentMethodCY 2010Coins. /DeductibleCY 2011Coins. /DeductibleG0123Screening cytopathology,cervical or vaginal (anyreporting system),collected in preservativefluid, automated thin layerpreparation, screening bycytotechnologist underphysician supervisionCLFS WAIVED WAIVEDG0124Screening cytopathology,cervical or vaginal (anyreporting system),collected in preservativefluid, automated thin layerpreparation, requiringinterpretation by physicianAPFSCoins.applies &ded. iswaivedWAIVEDScreeningPap TestG0141Screening cytopathologysmears, cervical orvaginal, performed byautomated system, withmanual rescreening,requiring interpretation byphysicianA PFSCoins.applies &ded. iswaivedWAIVEDCMS-1503-P 340PreventiveServiceCPT/HCPCSCodeLong DescriptorUSPSTFRating1PaymentMethodCY 2010Coins. /DeductibleCY 2011Coins. /DeductibleG0143Screening cytopathology,cervical or vaginal (anyreporting system),collected in preservativefluid, automated thin layerpreparation, with manualscreening and rescreeningby cytotechnologist underphysician supervisionA CLFS WAIVED WAIVEDG0144Screening cytopathology,cervical or vaginal (anyreporting system),collected in preservativefluid, automated thin layerpreparation, withscreening by automatedsystem, under physiciansupervisionA CLFS WAIVED WAIVEDG0145Screening cytopathology,cervical or vaginal (anyreporting system),collected in preservativefluid, automated thin layerpreparation, withscreening by automatedsystem and manualrescreening underphysician supervisionA CLFS WAIVED WAIVEDCMS-1503-P 341PreventiveServiceCPT/HCPCSCodeLong DescriptorUSPSTFRating1PaymentMethodCY 2010Coins. /DeductibleCY 2011Coins. /DeductibleG0147Screening cytopathologysmears, cervical orvaginal, performed byautomated system underphysician supervisionA CLFS WAIVED WAIVEDG0148Screening cytopathologysmears, cervical orvaginal, performed byautomated system withmanual rescreeningCLFS WAIVED WAIVEDP3000Screening papanicolaousmear, cervical or vaginal,up to three smears, bytechnician under physiciansupervisionCLFS WAIVED WAIVEDP3001Screening papanicolaousmear, cervical or vaginal,up to three smears,requiring interpretation byphysicianAPFSCoins.applies &ded. iswaivedWAIVEDCMS-1503-P 342PreventiveServiceCPT/HCPCSCodeLong DescriptorUSPSTFRating1PaymentMethodCY 2010Coins. /DeductibleCY 2011Coins. /DeductibleQ0091Screening papanicolaousmear; obtaining,preparing and conveyanceof cervical or vaginalsmear to laboratoryPFSCoins.applies &ded. iswaivedWAIVEDScreeningPelvic ExamG0101Cervical or vaginal cancerscreening; pelvic andclinical breastexaminationA PFSCoins.applies &ded. iswaivedWAIVED77052Computer-aided detection(computer algorithmanalysis of digital imagedata for lesion detection)with further physicianreview for interpretation,with or withoutdigitization of filmradiographic images;screening mammography(list separately in additionto code for primaryprocedure)B PFSCoins.applies &ded. iswaivedWAIVEDScreeningMammography77057Screening mammography,bilateral (2-view filmstudy of each breast)BPFSCoins.applies &ded. iswaivedWAIVEDCMS-1503-P 343PreventiveServiceCPT/HCPCSCodeLong DescriptorUSPSTFRating1PaymentMethodCY 2010Coins. /DeductibleCY 2011Coins. /DeductibleG0202Screening mammography,producing direct digitalimage, bilateral, all viewsPFSCoins.applies &ded. iswaivedWAIVEDG0130Single energy x-rayabsorptiometry (sexa)bone density study, one ormore sites; appendicularskeleton (peripheral) (eg,radius, wrist, heel)PFSNotWaivedWAIVED77078Computed tomography,bone mineral densitystudy, 1 or more sites;axial skeleton (eg, hips,pelvis, spine)PFSNotWaivedWAIVED77079Computed tomography,bone mineral densitystudy, 1 or more sites;appendicular skeleton(peripheral) (eg, radius,wrist, heel)PFSNotWaivedWAIVEDBone MassMeasurement77080Dual-energy x-rayabsorptiometry (dxa),bone density study, 1 ormore sites; axial skeleton(eg, hips, pelvis, spine)BPFSNotWaivedWAIVEDCMS-1503-P 344PreventiveServiceCPT/HCPCSCodeLong DescriptorUSPSTFRating1PaymentMethodCY 2010Coins. /DeductibleCY 2011Coins. /Deductible77081Dual-energy x-rayabsorptiometry (dxa),bone density study, 1 ormore sites; appendicularskeleton (peripheral) (eg,radius, wrist, heel)PFSNotWaivedWAIVED77083Radiographicabsorptiometry (eg,photodensitometry,radiogrammetry), 1 ormore sitesPFSNotWaivedWAIVED76977Ultrasound bone densitymeasurement andinterpretation, peripheralsite(s), any methodB PFSNotWaivedWAIVEDG0104Colorectal cancerscreening; flexiblesigmoidoscopyPFSCoins.applies &ded. IswaivedWAIVEDColorectalCancerScreeningG0105Colorectal cancerscreening; colonoscopy onindividual at high riskAPFSCoins.applies &ded. iswaivedWAIVEDCMS-1503-P 345PreventiveServiceCPT/HCPCSCodeLong DescriptorUSPSTFRating1PaymentMethodCY 2010Coins. /DeductibleCY 2011Coins. /DeductibleG0106Colorectal cancerscreening; alternative toG0104, screeningsigmoidoscopy, bariumenemaPFSCoins.applies &ded. iswaivedCoins.applies &ded. iswaivedG0120Colorectal cancerscreening; alternative toG0105, screeningcolonoscopy, bariumenema.*NotRatedPFSCoins.applies &ded. iswaivedCoins.applies &ded. iswaivedG0121Colorectal cancerscreening; colonoscopy onindividual not meetingcriteria for high riskPFSCoins.applies &ded. IswaivedWAIVED82270Blood, occult, byperoxidase activity (eg,guaiac), qualitative; feces,consecutiveCLFS WAIVED WAIVEDG0328Colorectal cancerscreening; fecal occultblood test, immunoassay,1-3 simultaneousACLFSCoins.applies &ded. IswaivedWAIVEDProstateCancerScreeningG0102Prostate cancer screening;digital rectal examinationDPFSNotWaivedNotWaivedCMS-1503-P 346PreventiveServiceCPT/HCPCSCodeLong DescriptorUSPSTFRating1PaymentMethodCY 2010Coins. /DeductibleCY 2011Coins. /DeductibleG0103Prostate cancer screening;prostate specific antigentest (PSA)CLFS WAIVED WAIVEDG0117Glaucoma screening forhigh risk patientsfurnished by anoptometrist orophthalmologistPFSNotWaivedNotWaivedGlaucomaScreeningG0118Glaucoma screening forhigh risk patient furnishedunder the directsupervision of anoptometrist orophthalmologistIPFSNotWaivedNotWaived90655Influenza virus vaccine,split virus, preservativefree, when administered tochildren 6-35 months ofage, for intramuscular useDrugPricingFileWAIVED WAIVEDInfluenzaVirusVaccine90656Influenza virus vaccine,split virus, preservativefree, when administered toindividuals 3 years andolder, for intramuscularuseBDrugPricingFileWAIVED WAIVEDCMS-1503-P 347PreventiveServiceCPT/HCPCSCodeLong DescriptorUSPSTFRating1PaymentMethodCY 2010Coins. /DeductibleCY 2011Coins. /Deductible90657Influenza virus vaccine,split virus, whenadministered to children6-35 months of age, forintramuscular useDrugPricingFileWAIVED WAIVED90658Influenza virus vaccine,split virus, whenadministered toindividuals 3 years of ageand older, forintramuscular useDrugPricingFileWAIVED WAIVED90660Influenza virus vaccine,live, for intranasal useDrugPricingFileWAIVED WAIVED90662Influenza virus vaccine,split virus, preservativefree, enhancedimmunogenicity viaincreased antigen content,for intramuscular useDrugPricingFileWAIVED WAIVEDG0008Administration ofinfluenza virus vaccinePFS WAIVED WAIVEDG9141Influenza A (H1N1)immunizationadministration (includesthe physician counselingthe patient/family)PFS WAIVED WAIVEDCMS-1503-P 348PreventiveServiceCPT/HCPCSCodeLong DescriptorUSPSTFRating1PaymentMethodCY 2010Coins. /DeductibleCY 2011Coins. /DeductibleG9142Influenza A (H1N1)vaccine, any route ofadministrationDrugPricingFile (ifnotsuppliedat nocost)WAIVED WAIVED90669Pneumococcal conjugatevaccine, polyvalent, whenadministered to childrenyounger than 5 years, forintramuscular useDrugPricingFileWAIVED WAIVED90670Pneumococcal conjugatevaccine, 13 valent, forintramuscular use.DrugPricingFileWAIVED WAIVED90732Pneumococcalpolysaccharide vaccine,23-valent, adult orimmunosuppressed patientdosage, whenadministered toindividuals 2 years orolder, for subcutaneous orintramuscular useDrugPricingFileWAIVED WAIVEDPneumococcalVaccineG0009Administration ofpneumococcal vaccineBPFS WAIVED WAIVEDCMS-1503-P 349PreventiveServiceCPT/HCPCSCodeLong DescriptorUSPSTFRating1PaymentMethodCY 2010Coins. /DeductibleCY 2011Coins. /Deductible90740Hepatitis B vaccine,dialysis orimmunosuppressed patientdosage (3 dose schedule),for intramuscular useDrugPricingFileNotWaivedWAIVED90743Hepatitis B vaccine,adolescent (2 doseschedule), forintramuscular useDrugPricingFileNotWaivedWAIVED90744Hepatitis B vaccine,pediatric/adolescentdosage (3 dose schedule),for intramuscular useDrugPricingFileNotWaivedWAIVED90746Hepatitis B vaccine, adultdosage, for intramuscularuseDrugPricingFileNotWaivedWAIVED90747Hepatitis B vaccine,dialysis orimmunosuppressed patientdosage (4 dose schedule),for intramuscular useADrugPricingFileNotWaivedWAIVEDHepatitis BVaccineG0010Administration ofhepatitis B vaccineA PFSNotWaivedWAIVEDHIVScreening86689HTLV or HIV antibody,confirmatory test (eg,Western Blot)ACLFS WAIVED WAIVEDCMS-1503-P 350PreventiveServiceCPT/HCPCSCodeLong DescriptorUSPSTFRating1PaymentMethodCY 2010Coins. /DeductibleCY 2011Coins. /DeductibleG0432Infectious agent antigendetection by enzymeimmunoassay (EIA)technique, qualitative orsemi-qualitative, multiplestep method, HIV-1 orHIV-2, screeningCLFS WAIVED WAIVEDG0433Infectious agent antigendetection by enzymelinked immunosorbentassay (ELISA) technique,antibody, HIV-1 or HIV2, screeningCLFS WAIVED WAIVEDG0435Infectious agent antigendetection by rapidantibody test of oralmucosa transudate, HIV-1or HIV-2 , screeningCLFS WAIVED WAIVEDGXXXAAnnual wellness visit,including PPPS, first visitPFS N/A WAIVEDAnnualWellnessVisitGXXXBAnnual wellness visit,including PPPS,subsequent visit*NotRatedPFS N/A WAIVED1 U.S. Preventive ServicesTask Force RecommendationsCMS-1503-P 351A -- The USPSTF strongly recommends that clinicians routinely provide [the service] to eligible patients. (The USPSTF found good evidence that [the service] improvesimportant health outcomes and concludes that benefits substantially outweigh harms.)B -- The USPSTF recommends that clinicians routinely provide [the service] to eligible patients. (The USPSTF found at least fair evidence that [the service] improvesimportant health outcomes and concludes that benefits outweigh harms.)C -- The USPSTF makes no recommendation for or against routine provision of [the service]. (The USPSTF found at least fair evidence that [the service] can improvehealth outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation.)D -- The USPSTF recommends against routinely providing [the service] to asymptomatic patients. (The USPSTF found at least fairevidence that [the service] isineffective or that harms outweigh benefits.)I -- The USPSTF concludes that the evidence is insufficient torecommend for or against routinely providing [the service]. (Evidence that [the service] is effective islacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.)

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4. Extension of Waiver of De ductible to Services Furnished in Connection With or in Relation to a Colorectal Cancer Screening Test that becomes Diagnostic or Therapeutic Section 4104(c) of the ACA amends secti on 1833(b) of the Act to waive the Part B deductible for colorectal cancer screening tests that become diagnostic. Specifically, section 1833(b)(1) of the Act (as amended by section 4104(c)(2) of the ACA) waives the deductible with respect to a colorectal cancer screening test regardless of the code that is billed for the establishment of a diagnosis as a result of the test, or for the removal of

tissue or other matter or other procedure that is furnished in connection with, as a result of, and in the same clinical encounter as a screening test. We are proposing that all surgical services furnished on the same date as a planned screening colonoscopy, planned flexible sigmoidoscopy, or barium enema be considered to be furnished in connection with, as a result of, and in the same clinical encounter as the screening test. In the event of a legislative change to this policy (for example, a statutory change that would waive the coinsurance for these related services in addition to the deductible), we would reassess the appropriatene ss of this proposed definition of services that are furnished in connection with, as a result of, a nd in the same clinical encount er as the colorectal cancer screening test that becomes diagnostic. We also note that the beneficiary’s annual deductible would likely be met when any surgi cal procedure (related or not) is furnished on the same day as the scheduled screening test. We are proposing to implement this provi sion by creating a HCPCS modifier that providers and practitioners would append to the diagnostic procedure code that is reported instead of the screening colonosco py or screening flexible sigmoidoscopy HCPCS code or as a result of the barium enema when the screening test becomes a diagnostic service. The claims processing system would respond to the modifier by

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waiving the deductible for all surgical services on the same date as the diagnostic test. Coinsurance would continue to apply to the diag nostic test and to ot her services furnished in connection with, as a result of, and in the sa me clinical encounter as the screening test. S. Section 5501: Expanding Access to Pr imary Care Services and General Surgery

Services 1. Section 5501(a): Incentive Payment Pr ogram for Primary Care Services a. Background Section 5501(a) of the ACA revises sec tion 1833 of the Act by adding a new paragraph (x), “Incentive Payments for Primary Care Services.” Section 1833(x) of the Act states that in the case of primary care services furnished on or after January 1, 2011 and before January 1, 2016 by a primary care practitioner, there shall also be paid on a monthly or quarterly basis an amount equal to 10 percent of the payment amount for such

services under Part B. Section 1833(x)(2)(A) of the Act (as a dded by section 5501(a) of the ACA) defines a primary care practitioner as: (1) a physician, as described in section 1861(r)(1) of the Act, who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; or (2) a nurse practitioner, clinical nurse specialist, or physician assistant as defined in section 1861(aa)(5) of the Act, and in all cases, for whom primary care services acc ounted for at least 60 percent of the allowed charges under Part B for the practitioner in a prior period as determined appropriate by the Secretary. Section 1833(x)(2)(B) (as added by secti on 5501(a)(2)(B) of the ACA) defines primary care services as those services identified by the following HCPCS codes as of January 1, 2009 (and as subsequently modified by the Secretary, as applicable):

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● 99201 through 99215 for new and establishe d patient office or other outpatient evaluation and management (E/M) visits;

● 99304 through 99340 for initial, subseque nt, discharge, and other nursing facility E/M services; new and established patient domiciliary, rest home (eg, boarding home), or custodial care E/M services; and domiciliary, rest home (eg, assisted living facility), or home care plan oversight services; and

● 99341 through 99350 for new and esta blished patient home E/M visits. These codes are displayed in Table 39. A ll of these codes remain active in CY

2010 and there are no other codes used to describe these services.

TABLE 39: Primary Care Services Eligible for Primary Care Incentive Payments in CY 2011 CPT Codes Description 99201 Level 1 new patient office or other outpatient visit 99202 Level 2 new patient office or other outpatient visit 99203 Level 3 new patient office or other outpatient visit 99204 Level 4 new patient office or other outpatient visit 99205 Level 5 new patient office or other outpatient visit 99211 Level 1 established patient office or other outpatient visit 99212 Level 2 established patient office or other outpatient visit 99214 Level 4 established patient office or other outpatient visit 99215 Level 5 established patient office or other outpatient visit 99304 Level 1 initial nursing facility care 99305 Level 2 initial nursing facility care 99306 Level 3 initial nursing facility care 99307 Level 1 subsequent nursing facility care 99308 Level 2 subsequent nursing facility care 99309 Level 3 subsequent nursing facility care 99310 Level 4 subsequent nursing facility care 99315 Nursing facility discharge day management;. 30 minutes 99316 Nursing facility discharge day ma nagement; more than 30 minutes

99318 Other nursing facility services; eval uation and management of a patient involving an annual nursing facility assessment. 99324 Level 1 new patient domiciliary, rest home, or custodial care visit 99325 Level 2 new patient domiciliary, rest home, or custodial care visit 99326 Level 3 new patient domiciliary, rest home, or custodial care visit f

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CPT Codes Description 99327 Level 4 new patient domiciliary, re st home, or custodial care visit 99328 Level 5 new patient domiciliary, rest home, or custodial care visit 99334 Level 1 established patie nt domiciliary, rest home, or custodial care visit 99335 Level 2 established patie nt domiciliary, rest home, or custodial care visit 99336 Level 3 established patie nt domiciliary, rest home, or custodial care visit 99337 Level 4 established patie nt domiciliary, rest home, or custodial care visit

99339 Individual physician supervision of a patient in home, domiciliary or rest home recurring complex and multidisciplinary care modalities; 30 minutes

99340 Individual physician supervision of a patient in home, domiciliary or rest home recurring complex and multidisciplinary care modalities; 30 minutes or more 99341 Level 1 new patient home visit 99342 Level 2 new patient home visit 99343 Level 3 new patient home visit 99344 Level 4 new patient home visit 99345 Level 5 new patient home visit 99347 Level 1 established patient home visit 99348 Level 2 established patient home visit 99349 Level 3 established patient home visit 99350 Level 4 established patient home visit

b. Proposed Primary Care Incentive Payment Program (PCIP) For primary care services furnished on or after January 1, 2011 and before January 1, 2016, we are proposing to provide a 10 percent incentive payment to primary care practitioners, identified as the following: (1) in the case of physicians, enrolled in Medicare with a primary specialty designation of 08-family practice, 11-internal medicine, 37-pediatrics, or 38- geriatrics; or (2) in the case of nonphysician practitioners (NPPs), enrolled in Medicare with a primary care specialty designation of 50-nurse practitioner, 89-certified clinical nurse specialist, or 97-physician assistant; and (3) for whom the primary care services displayed in Table 39 accounted for at least 60 percent of the allowed charges under Part B for such practitioner during the time period that is specified by the Secretary, and proposed in this section.

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We are proposing to use the most current full year of claims data to identify primary care practitioners eligible for the PCIP for a CY based on the practitioner’s primary specialty (as identified on claims) and the practitioner’s percentage of all allowed charges for the primary care services displa yed in Table 39. We commonly use the most recent full year of claims data for purpo ses of establishing annual payment amounts

under a number of Medicare’s fee-for-service programs. A practitioner with a primary care specialty designation would be eligible for the PCIP in a CY if the percentage of his or her allowed charges for primary care servic es (identified in Table 39) on claims where the practitioner is identified as one of the primary care specialties described above meets or exceeds the 60 percent threshold. We note th at the practitioner’s specialty is applied to the claim by the claims processing system and reflects the physician’s primary specialty designation for purposes of Medicare enrollment on the date the claim is processed, which would usually be close to the date on which the service was actually furnished to the beneficiary. We would identify primary care practitioners eligible for the PCIP for a year by the individual physician/practitione r national provider identifier (NPI) number using the most current full year of claims data available. Therefore, for determining PCIP prac titioner eligibility for CY 2011, we would

use CY 2009 PFS claims data , processed through June 30, 2010. This would ensure analysis of about 99 percent of CY 2009 cla ims to determine practitioner eligibility for PCIP payment beginning January 2011. We note that the MMA changed the requirements for critical access hospital (C AH) billing for practitioners’ professional services and, therefore, modi fications were made to the Medicare claims processing system to require CAHs to identify the practitioner furnishing a service on the CAH claim for that professional service. Howeve r, because the rendering practitioner has only

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been identified on CAH claims since July 1, 2009 , for the first year of the PCIP we are proposing to identify eligible practitioners us ing only 6 months of CAH data for those CAHs paid under the optional method. Th ereafter, we would update the list of practitioners eligible for the PCIP annually ba sed on the most recent available full year of

PFS and CAH claims data. To the extent practitioners were paid unde r the PFS during the historical claims data year for some primary services and, fo r other services, CAHs were paid under the optional method for those same practitioners’ professional se rvices, we would aggregate the historical claims data from all settings by the practitioner’s NPI in order to determine whether the practitioner is eligible for PCIP payments. We note that for all practitioners (both practitioners paid under the PFS and pr actitioners for whose professional services CAHs are paid under the optional method), the period of claims data used for the annual determination of the primary care servi ce percentage of allowed charges with a practitioner specialty of primary care would lag the PCIP payment year by 2 years (for example, CY 2010 claims data would be used for the CY 2012 PCIP). This 2-year lag is

consistent with other areas of the Medicare program where we rely on information from claims data to inform payment in a futu re year, such as the use of CY 2009 PFS

utilization data in the establishment of cer tain aspects of CY 2011 PFS payment rates. Under the proposed PCIP eligibility dete rmination method, it w ould be necessary to revise the list of eligible practitioners based on updated cl aims data regarding primary specialty designation and the percentage of a practitioner’s allowed charges for primary care services each year. The revised list of practitioners developed prior to the beginning of the next CY would establish a practitioner’s eligibility for PCIP payments for the full next CY. That is, once eligible for the PCIP for a given CY, the practitioner would

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receive PCIP payments for primary care services furnished throughout that full CY until we reassess the practitioner’s PCIP eligibility for the next year’s payments. As a result, a practitioner newly enrolling in Medicare during a CY would not be eligible for the PCIP until Medicare claims data reflecting the practitioner’s primary care specialty and a percentage of allowed charges for primary care services that equals or exceeds the 60 percent threshold were available to establish the practitioner’s eligibility for the next PCIP year. Similarly, an enrolled practitioner’s change in primary specialty designation (either to or from a primary care specialty) would not affect that practitioner’s eligibility for the PCIP until the practitioner’s claims reflecting the change were available for analysis in preparation for the next applicab le CY PCIP. Given the statutory requirement that a practitioner’s primary care services acc ount for at least 60 percent of the allowed charges under Part B for the practitioner in a prior period as determined by the Secretary, we see no clear alternative methodologies that would allow PCIP payments to be made to those practitioners newly enrolling in Medica re without the 2-year lag in eligibility

determination that was descri bed previously. However, gi ven our general interest in supporting primary care practitioners and en try into primary care practice by new physicians and NPPs in order to ensure that Medicare beneficiaries have access to these important services, we are seeking public comments on alternative approaches for establishing PCIP eligibility for newly enrolled practitioners that would be consistent with the statutory requirement. We plan to monitor changes in the primary specialties of enrolled practitioners over time and would expect not to see significant changes in the specialties of currently enrolled practitioners as a result of the PCIP payments. We would expect that physicians changing their primary specialty to one of the primary care specialties of family

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medicine, internal medicine, ge riatric medicine, or pediatri c medicine and who would be newly eligible for the PCIP would be furnishing primary care services to the patients in their practices. Consistent with our past policies, we would expect that physicians changing their primary specialty designa tion under Medicare would make such changes only so that their primary specialty designati on is fully consistent with the specific or unique type of medicine they practice. If we find that physicians are changing their specialty designations (for example, cardiologists who designate their primary specialty as internal medicine, although they practice ca rdiology) in order to take advantage of the PCIP payments, we would considering making future revisions to eliminate such an

outcome.

Consistent with the established Me dicare HPSA physician bonus program (Medicare Claims Processing Manual, P ub. 100-04, Chapter 12, Section 90.4.4) and the proposed Health Professional S hortage Area Surgical Incentive Payment Program (HSIP) described in section III.S.2. of this proposed rule, we are proposing that PCIP payments would be calculated by the Medicare contr actors and made quarterly on behalf of the eligible primary care practitioner for the primary care services furnished by the practitioner in that quarter. The primary care practitioners’ professional services may be paid under the PFS based on a claim for profe ssional services or, where the practitioner has reassigned his or her benefits to a C AH paid under the optional method, to the CAH

based on an institutional claim. As discussed above, eligible primary care practitioners would be identified on a claim based on the NPI of the rendering practitioner. If the claim is submitted by a practitioner’s group practice or a CAH, the re ndering practitioner’s NPI must be included on the line-item for the primary care service (i dentified in Table 39 above) in order for a

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determination to be made rega rding whether or not the service is eligible for payment of the PCIP. We note that, in order to be eligib le for the PCIP, physician assistants, clinical nurse specialists, and nurse practitioners must be billing for their services under their own NPI and not furnishing services incident to physicians’ services. Regardless of the specialty area in which they may be practicing, these specific NPPs would be eligible for the PCIP based on their specialty if their hi storical percentage of allowed charges for primary care services equals or exceeds the 60 percent threshold. We note that section 1833(x)(4) of the Act (as added by section 5501(a) of the ACA) specifies “there shall be no administr ative or judicial review under section 1869, 1878, or otherwise, respecting the identifica tion of primary care practitioners.” We

believe that the inclusion of th is language is intended to pr ovide a means for the practical implementation of this provision. That is , because we must develop a process and identify primary care practitioners before we can make payment under the PCIP to the eligible primary care practitioners, the statute gives CMS the authority to make final determinations of eligible primary care practitioners that are not subject to appeal through the various channels normally available to practitioners, in order for the timely payments under the PCIP to occur. In contrast, if the determinations that CMS must make under this provision were subject to appeal, the timely implementation of this provision could be jeopardized and payments under the PCIP could be significantly delayed. However,

we do not believe that the “ no administrative or judicial review” clause precludes CMS from correcting errors resulting from clerical or mathematical mistakes. Therefore, we note that practitioners would have the oppor tunity to notify CMS of clerical or mathematical errors that may have occurred during the process of identifying eligible primary care practitioners for PCIP payment, and which could result in a mistaken

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eligibility determination for the PCIP. In summary, under the PCIP beginning in CY 2011, we are proposing to identify primary care practitioners based on their primary specialty and percentage of allowed charges for primary care services that equals or exceeds the 60 percent threshold based upon the most current full year of Medicare cl aims data, which would be the claims data for 2 years prior to the incentive payment year (for example, CY 2009 claims data processed through June 2010 would be used to identify primary care practitioners for the CY 2011 PCIP). Practitioners id entified as eligible for the PCIP immediately prior to the PCIP payment year would then receive quarterly incentive payments during the PCIP year equal to 10 percent of the payment amount for their primary care services under Part B, in addition to the amount the primary ca re practitioner would otherwise be paid for their professional services under Part B for fu rnishing the primary care services. For example, primary care practitioners identif ied in late CY 2010 for the CY 2011 PCIP would receive quarterly PCIP payments in CY 2011 that equal 10 percent of the Part B payment for the primary car e services those practitioners furnish during CY 2011. We further note that section 1833(x)(3) of the Act (as added by section 5501(a) of the ACA) authorizes payment under the PC IP as an additional payment amount for specified primary care services without regard to any additional payment for the service under section 1833(m) of the Act. Therefor e, an eligible primary care physician furnishing a primary care service in a HPSA may receive both a HPSA physician bonus payment under the established program a nd a PCIP payment under the new program beginning in CY 2011, but the PCIP payment is made without regarding to the HPSA physician bonus payment amount. In additi on, payments for outpatient CAH services under section 1834(g)(2)(B) of the Act (as am ended by section 5501(a) of the ACA) are

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not affected by the PCIP payment amounts ma de to the CAH on behalf of the primary care practitioner. Accordingly, for CY 2011, we are proposing to add a new §414.80 to our regulations to specify the requirements of the PCIP. Proposed §414.80(a) would define primary care practitioners and primary care services . Proposed §414.80(b) would provide eligible primary care practitioners a 10 percent incentive payment with respect to primary care services, in addition to the am ount that would otherwise be paid for their professional services under Part B. Quarterl y PCIP payments would be made to eligible practitioners or to CAHs paid under the opti onal method that are b illing on behalf of practitioners for their professional services for identified primary care services. 2. Section 5501(b): Incentive Payment Program for Major Surgical Procedures Furnished

in Health Professiona l Shortage Areas. a. Background Section 1833(m) of the Act provides fo r an additional 10 percent incentive payment for physicians’ services furnished to a covered individual in an area that is designated as a geographic Health Profe ssional Shortage Area (H PSA) as identified by the Secretary prior to the beginning of such year. Section 5501(b) of the ACA revises section 1833 of the Act by adding the new subparagraph (y), “Incentive Payments for Major Surgical Procedures Furnished in Health Professional Shortage Areas.” In the case of major surgical procedures furnished by a general surgeon on or after January 1, 2011 and before January 1, 2016, in an area designated under section 332(a)(1)(A) of the Public Health Service Act as a geographic HPSA, there shall be paid on a monthly or quarterly basis, an amount e qual to 10 percent of the payment amount for eligible services under Part B. Section 1833(y)(2)(A) of the Act (as added by section

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5501(b) of the ACA) defines a general surgeon as a physician who is described in section 1861(r)(1) of the Act and who has designated a CMS specialty code of 02-General Surgery as his or her primary specialty code in the physician enrollment under section 1866(j) of the Act. Section 1833(y)(2)(B) of the Act (as a dded by section 5501(b) of the ACA) defines major surgical procedures as surgical procedures for which a 10-day or 90-day global period is used for payment under the PFS in section 1848(b) of the Act. In

Addendum B to the CY 2010 PFS final rule with comment period (74 FR 62017 through 62143), as corrected in the correction noti ce (74 FR 65455 through 65457), we identified 489 10-day global procedure c odes and 3,796 90-day global procedure codes for a total of 4,285 surgical procedure codes that would ha ve met the surgical procedure criteria for the incentive payment if it were applicable in CY 2010. b. Proposed HPSA Surgical Incentive Payment Program (HSIP)

For services furnished on or after Janua ry 1, 2011 and before January 1, 2016, we are proposing to provide a 10 percent incentiv e payment to general surgeons, identified by their enrollment in Medicare with a primary specialty code of 02-general surgery, in addition to the amount they would otherwise be paid for their professional services under Part B, when they furnish a major surgical pr ocedure in a location that was defined by the Secretary as of December 31 of the prior year as a geographic HPSA. As with the PCIP described above, we do not believe that surgeons will ch ange their Medicare specialty designation in order to take advantage of th e HSIP payments. However, we will monitor the specialty designations of enrolled phys icians, and if we find that surgeons are changing their primary specialty designation to general surgery in or der to take advantage

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of the HSIP payments, we would consider making future revisions to eliminate such an

outcome.

Consistent with the established Medicar e HPSA physician bonus program, we are proposing that these HSIP payments would be calculated by the Medicare contractors based on the criteria for payment that we have established as discussed earlier in this section, and payments would be made quarter ly on behalf of the qualifying general surgeon for the qualifying major surgical procedures. The surgeons’ professional services may be paid under the PFS based on a claim for professional services or, where the physician has reassigned hi s or her benefits to a criti cal access hospital (CAH) paid under the optional method, to the C AH based on an institutional claim. Qualifying general surgeons would be identified on a claim for a major surgical procedure based on the primary specialty of th e rendering physician, identified by his or her NPI, of 02-general surgery. If the cl aim is submitted by a ph ysician’s group practice or a CAH, the rendering physician’s NPI must be included on the line-item for the major surgical procedure in order for a determinati on to be made regarding whether or not the procedure is eligible for payment under the HSIP. For HSIP payment to be applicable, the major surgical procedure must be furnished in an area designated by the Secretary as of December 31 of the prior year as a geographic HPSA. We would provide HSIP payments for major surgical procedures furnished by general surgeons in the same HPSAs as we currently recognize for purposes of payment of all physicians under the established Medicare HPSA physician bonus program under section 1833(m) of the Act. Each year, we publish a list of zip codes eligible for automatic payment of the HPSA physician bonus payment at:

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http://www.cms.gov/hpsapsaphysicianbonuses/01_overview.asp . We are proposing to use the same list of zip code s for automatic payment of the bonus for eligible services furnished by general surgeons. We are al so proposing to create a new HCPCS code modifier to identify circumstances when genera l surgeons furnish services in areas that are designated as HPSAs as of December 31 of the prior year, but that are not on the list of zip codes eligible for automatic payment. The new modifier would be appended to the major surgical procedure on claims submitted for payment, similar to the current process for payment of the Medicare HPSA physician bonus when the geographic HPSA is not a HPSA identified for automatic payment. Consistent with the statutory requireme nt, we are proposing to define major surgical procedures as those for which a 10-day or 90-day global period is used for payment under the PFS. For CY 2011, appr oximately 4,300 10-day and 90-day global surgical procedures codes are identified in Addendum B to this proposed rule under the far right column labeled “Global” and desi gnated with “010” or “090,” respectively. We further note that section 1833(y)(3) of the Act (as added by section 5501(b)(1) of the ACA) authorizes payment under the HSIP as an additional payment amount for specified surgical services without regard to any additional payment for the service under section 1833(m) of the Act. Therefore, a general surgeon may receive both a HPSA physician bonus payment under the estab lished Medicare HPSA physician bonus program and an HSIP payment under the new program beginning in CY 2011, but the HSIP payment is made without regarding to the HPSA physician bonus payment amount. In addition, payments for outpatient CAH serv ices under section 1834(g)(2)(B) of the Act (as amended by section 5501(b) of the ACA) are not affected by the HSIP payment

amounts made to the CAH on behalf of the general surgeon.

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Accordingly, for CY 2011, we are proposing to amend §414.2 by adding the definitions of “HPSA” and “major surgical proc edure.” We are also proposing to revise §414.67 to move the existing provisions to para graph (a) to be grouped as the “Health Professional Shortage Area (HPSA) physic ian bonus program” and adding a new paragraph (b) for the “HPSA surgical incen tive payment program” provisions. Proposed §414.67(b) would state that general surgeons who furnish identified 10-day and 90-day global period surgical procedures in an area designated by the Secretary as of December 31 of the prior year as a geographic HPSA that is recognized by Medicare for the HPSA physician bonus program as specified under renumbered §414.67(a)(1) would receive a 10 percent incentive payment in addition to th e amount that would otherwise be paid for their professional services under Pa rt B. Physicians furnishing services in areas that are designated as geographic HPSAs prior to th e beginning of the year but not included on the published list of zip codes for which au tomated HPSA surgical bonus payments are made should report a specified HCPCS code modifier to receive the HSIP payment. Quarterly incentive payments would be made to physicians or to CAHs paid under the optional method that are billing on behalf of physicians for their professional services. 3. Sections 5501(a) and (b) of the ACA and Payment for Critical Access Hospital

Professional Services Un der the Optional Method Section 1834(g) of the Act establishes th e payment rules for outpatient services furnished by a CAH. In 1999, section 403(d) of the Balanced Budget Refinement Act of 1999 (Pub. L. 106-113) (BBRA) amended section 1834(g) of the Act to provide for two methods of payment for outpatient services fu rnished by a CAH. Specifically, section 1834(g)(1) of the Act, as amended by the BB RA, specifies that the amount of payment for outpatient services furnished by a CAH is equal to the reasonable costs of the CAH in

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furnishing such services. (The physician or other practitioner furnishing the professional service receives payment under the PFS.) In the alternative, the CAH may make an election, under section 1834(g)(2) of the Act, to receive amounts that are equal to "the reasonable costs" of the CAH for facility serv ices plus, with respect to the professional services, the amount otherwise paid for prof essional services under Medicare, less the applicable Medicare deduc tible and coinsurance amount. The election made under section 1834(g)(2) of the Act is sometimes re ferred to as "method II" or "the optional method." Throughout this section of this pr eamble, we refer to this election as "the optional method." In 2000, section 202 of the Medicare , Medicaid and SCHIP Benefits Improvement and Protection Act of 2000) (Pub. L. 106-554) (BIPA) amended section 1834(g)(2)(B) of the Act to increase the pa yment for professional services under the optional method to 115 percent of the amount ot herwise paid for professional services under Medicare. In addition, in 2003 secti on 405(a)(1) of the MMA amended section 1834(g)(l) of the Act by inserting the phrase "equal to 101 percent of" before the phrase "the reasonable costs." However, section 405 of the MMA did not make a corresponding change to section 1834(g)(2)(A) of the Act re garding the amount of payment for facility services under the optional method. In 2010, Section 3128 of the ACA amended section 1834(g)(2)(A) of the Act by inserting the phras e "101 percent of" before "the reasonable

costs.” Section 5501(a) of the ACA amends sec tion 1833 of the Act by adding a new paragraph (x), “Incentive Payments for Primary Care Services,” that authorizes additional Part B payments to primary care practitioners for primary care serv ices. Section 5501(b)

of the ACA further amends section 1833 of the Act by adding new paragraph (y),

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“Incentive Payments for Major Surgical Procedures Furnished in Health Professional Shortage Areas,” that authorizes additi onal Part B payments for major surgical procedures furnished by general surgeons in HPSAs. Sections 5501(a)(3) and 5501(b)(3) of the ACA make conforming amendments to section 1834(g)(2)(B) of the Act, which refers to payment to the CAH for profe ssional services under the optional method, by adding at the end of section 1834(g)(2)(B) th e following phrase, “Subsections (x) and (y)

of 1833 shall not be taken into account in de termining the amounts that would otherwise be paid pursuant to the preceding sentence.” As such, section 1834(g)(2)(B) of the Act (as amended by sections 5501(a)(2) and 5501(b )(2) of the ACA) requires that under the optional method, the 115 percent adjustment payment to the CAH for professional

services is calculated without considerin g the incentive payments for primary care services furnished by primary care practitione rs and major surgical procedures furnished by general surgeons in HPSAs as these term s are defined under sections 1833(x) and (y)

of the Act. The regulations implementing section 1834(g)(2)(B) of the Act, payment to the CAH for professional services under the opti onal method, are in §413.70(b)(3)(ii)(B). In order to implement the amendments to secti on 1834(g)(2)(B) of the Act as specified by sections 5501(a)(2) and 5501(b)(2) of th e ACA, we are proposing to amend the regulations in §413.70(b)(3)(ii)(B) to state th at, effective for primary care services furnished by primary care practitioners and major surgical procedures furnished by general surgeons in HPSAs on or after January 1, 2011 and before January 1, 2016, the additional incentive payment amounts as specified in §414.67 and §414.80 are not included in the determination of the payment for professional services made to the CAH under the optional method. Accordingly, we are proposing that payment for professional

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services to the CAH at 115 percent of th e PFS amount under the optional method would

not take into account the add itional Part B incentive payments for primary services furnished by primary care practitioners and major surgical procedures furnished by general surgeons in HPSAs as provided in §414.67 and §414.80.

T. Section 6003: Disclosure Requirements for In-Office An cillary Services Exception to the Prohibition on Physician Self-Ref erral for Certain Imaging Services 1. Background

Section 1877 of the Act also known as th e physician self-referral law: (1) prohibits a physician from making referrals for certain “designated health services” (DHS) payable by Medicare to an entity with which he or she (or an immediate family member) has a financial relationship (owner ship or compensation), unless an exception applies; and (2) prohibits the entity from filing claims with Medicare (or billing another individual, entity, or third party payer) for t hose DHS rendered as a result of a prohibited referral. The statute establishes a number of specific exceptions and grants the Secretary the authority to create regulatory exceptions that pose no risk of program or patient

abuse. Section 1877(b)(2) of the Act, entitled “In- office Ancillary Services” sets forth the exception that permits a physician in a solo or group practice to order and provide designated health services (DHS), other than most durable medical equipment and parenteral and enteral nutrients, in the offi ce of the physician or group practice, provided that certain specific criteria are met. Under this exception, the statute limits who can furnish the service, designates where the service must be performed, and limits who can bill for the service. As explained at the end of the statutory exception, the service may also be subject to “such other requirements as the Secretary may impose by regulation as

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needed to protect against program or patient abuse.” The in-office ancillary services exception is interpreted at §411.355(b).

Section 6003 of the ACA amends section 1877(b)(2) of the Act by creating a new disclosure requirement for the in-office ancillary services exception to the prohibition on physician self-referral. Specifically, secti on 6003 provides that, with respect to referrals for magnetic resonance imaging (MRI), co mputed tomography (CT), positron emission tomography (PET), and any other DHS speci fied under section 1877(h)(6)(D) that the Secretary determines appropriate, we must pr omulgate a requirement that the referring physician inform a patient in writing at the time of the referral that the patient may obtain the service from a person other than the referring physician or someone in the physician’s group practice and provide the pa tient with a list of suppliers who furnish the service in the area in which the patient resides. 2. Proposed Disclo sure Requirement We are proposing to implement sec tion 6003 of the ACA by amending §411.355(b) to add new paragraph (b)(7). We describe below our proposal for the new disclosure requirement. a. Services that Trigger the Disclosure Requirement Section 6003(a) of the ACA requires that th e new disclosure requirement apply to MRI, CT, and PET services as well as such other radiology or imaging services included in the DHS category specified in section 1877(h)(6)(D) of the Act that the Secretary determines appropriate. We are consid ering whether to expand this disclosure requirement to other radiology and imaging services. We are not inclined to expand the disclosure requirement but we solicit comme nts regarding whether other radiology or imaging services that fall under section 1877(h )(6)(D) of the Act should be included in

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this requirement, and if so, which services, and the purpose served by extending the disclosure requirement to additional radiology or imaging services.

b. General Disclosu re Requirements In §411.355(b)(7), we are proposing that th e disclosure notice should be written in a manner sufficient to be reasonably underst ood by all patients and must, as the ACA requires, be given to the patient at the time of the referral. This notice must indicate to the patient that the services may be obtai ned from a person other than the referring physician or his or her group practice and incl ude a list of other suppliers who provide the service being referred (MRI, CT, or PET). We believe one purpose of th e disclosure requirement is to inform a patient’s decision-making regarding his or her own ca re. The list of suppliers provided to the patient by the physician is meant to serve as a resource for the patient. Nothing on the disclosure notice or list of suppliers may i ndicate to the patient that he or she must receive imaging from a supplier on the list if not receiving the service from the referring physician. The patient may receive the imaging service from the referring physician, from a supplier identified on the notice, or from another supplier of the patient’s choice. The patient is free to choose the supplier of the service. c. List of Alternate Suppliers Section 6003(a) of the ACA sp ecifies that the referring physician must provide a written list of “suppliers (as de fined in section 1861(d)).” Section 1861(d) of the Act defines supplier as “a physician or other practitioner, a facility, or other entity (other than a provider of services) that furnishes items or services under this title .” We are proposing that only suppliers be included on the written list. We are not proposing to permit or require the list to include “providers of serv ices”, which is define d in section 1861(u) of

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the Act to include hospitals and critical access hospitals, among other facilities. We are soliciting comments regarding whether inclusion of providers of services on the written notice would benefit patients in choosing an alternate entity for an imaging service by providing more, and varied, options. Section 6003(a) of the ACA also requires that the alternate suppliers specified in the notice provided to the patient must furnish the re levant services “in the area in which [the patient] resides.” We are aware that a patient may travel outside the area in which he or she resides in order to receive medical care. We believe that requiring an original written notice for each patient based upon a certain distance from the patient’s residence could place a significant administrative burden on ph ysicians practicing in a solo or group practice. It would be impractical for a physician to prepare a separate list for every area in which his or her patients resi de. Additionally, we believe that if a patient has traveled to see the referring physician, the physician is located in an area convenient to the patient and therefore, a referral within a certain distance of this location would also be convenient for the patient. In order to ease the administrative burden of creating multiple lists while still implementing the requirements of the statut e, we are proposing that the suppliers

included in this notice should be located within a 25-mile radius of th e physician’s office location at the time of the referral. We believe that a 25-mile radius is large enough in most areas to generate a list of suppliers that will be useful to patients. We note that wehave used a 25-mile radius in other physician self-referral exceptions, including the intrafamily rural referrals exception (§411.355(j)) and the physician recruitment exception (§411.357(e)). Even if a patient resides more than 25 miles away, we are proposing that it will be sufficient to provide a list of supplie rs located within a 25- mile radius of the

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physician’s office location at the time the referral is made. As discussed above, we believe that measuring the distance from the physician’s office location will better serve patients who have perhaps traveled from long distances to receive specialized treatment. We are soliciting comments regarding the pr oposed 25-mile radius requirement. In attempting to minimize confusi on and burden related to imple menting this provision, we have proposed the same standard for both urban and rural areas. We realize that in some areas 25 miles may be too small to generate a sufficient list of othe r suppliers. We are interested in hearing whether an alternative distance may be more effective for urban or

rural areas as well as what other criteria shoul d be considered in finalizing regulations for physicians in both urba n and rural areas. In order to help a patient make an inform ed decision regarding other options for the recommended imaging services, we propose that the written notice include no fewer than 10 other suppliers. We considered proposing th at the list include the 10 closest suppliers, but we want to allow physicia ns some flexibility in drafting the list of suppliers. On the other hand, we are concer ned that physicians located in large metropolitan areas will draft a list that includes suppliers located mostly at the edges of the 25-mile radius, thereby increasing the chances that the patient will choose to receive imaging services from the referring physician’s practice. We are soliciting comments regarding whether providing a list of 10 suppliers is sufficient or too bur densome or susceptible to abuse and whether

there are alternate criteria we should use th at would result in an adequate list of convenient suppliers that does not impose an undue burden on physician practices or a

risk of abuse. We recognize that there may be fewer than 10 other suppliers within a 25-mile-radius of the referring physician’s office location. We propose that, under these circumstances,

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the physician shall list all of the other suppliers of the particular imaging service that are present within a 25-mile radius of the referri ng physician’s office location, including up to 10 suppliers as required by these regulati ons. If no other suppliers of the imaging

services ordered exist within the 25-mile radi us of the physician’s office location, the physician need not provide a list of alternative suppliers, but must still disclose to his or her patients that the patients may receive the ima ging services from another supplier. In this last situation, simply providing this di sclosure statement will satisfy the disclosure requirement of this provision even though alternative suppliers are not listed. The physician must maintain documentation of the disclosure. We are proposing that the written no tice be required to include certain information about the listed supplie rs in order to satisfy this disclosure requirement. The list must include the name, address, phone number, and distance fr om the physician’s office location at the time of the referral. We propose to require inclusion of the distance from the physician’s location to the other supp liers in order to emphasize to the patient the relative convenience of the listed suppliers. We are not proposing an exception to the di sclosure requirement for MRI, CT, or PET services furnished on an emergency or time-sensitive basis. We are soliciting comments related to whether there are other pr ocedures or circumstances in which it may be difficult or impractical to provide the wr itten disclosure prior to provision of the imaging services. This proposal sets forth criteria that apply to the disclosure requirement and list of alternative suppliers. These criteria are inte nded to provide clear guidance as to how physicians may comply with the new requirement of the in-office ancillary services exception. We understand that there may be alternative ways to implement these

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statutory requirements. One po ssible alternative is to only require a “reasonable” list of other suppliers with general re quirements for the disclosure to patients, while providing that if the physician meets the more specific requirements set forth in this proposal, he or

she will be deemed to have a “reasonable” disclosure. We seek comments on this specific alternative and any ot her alternative methods of co mpliance that still satisfy the statutory requirements.

d. Documentation of Disclosure

In order to document that this disclosure requirement has been satisfied, we propose that a record of the patient’s signature on th e disclosure notification must be maintained as an element of the patient’s medical record. We are soliciting comments regarding the burden of this recordkeeping requirement. We are also interested in comments that suggest alternative means of recording that the disclosure was made to the patient at the

time of referral.

e. Effective Date As discussed above, secti on 6003(a) of the ACA amends section 1877(b)(2) of the Act by instructing that the new disclosure re quirement be added as one of the additional requirements of the in-office ancillary serv ices exception. The last sentence of the statutory exception preceding this amendment authorizes the Secretary to impose “such other requirements . . . by regulation as needed to protect against program or patient abuse” ( emphasis added ). The amendment specifies that “[s]uch requirements shall. . . include a [disclosure] requirement . . . .” In reading the last sentence of section 1877(b)(2) together with the amendment, we do not believe that the amendment is selfeffectuating. Instead, the new disclosu re requirement of section 6003 must be promulgated by regulation. Therefore, we believe that a correct reading of section

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6003(a) is that this amendment shall not be effective until the Secretary promulgates a final regulation implementing this new requireme nt and the regulation becomes effective. We considered whether, pursuant to s ection 6003 of the ACA, the final rule setting forth the disclosure requirement s hould apply retroactively to all services furnished on or after January 1, 2010. Give n the structure of the amended in-office ancillary services exception and the statute as a whole, however, we believe that retroactive rulemaking is not required. Therefore, we are proposing that the new disclosure requirement shall a pply only to services furnished on or after the effective date of the final regulation implementing secti on 6003 of the ACA. We are proposing an effective date of January 1, 2011 for th e regulation implementing this provision.

U. Section 6404: Maximum Period for Sub mission of Medicare Claims Reduced to Not

More than 12 Months 1. Background Sections 1814(a)(1), 1835(a), and 1842(b)(3 )(B) of the Act establish time limits for filing Medicare Part A and B claims. Prior to the enactment of the ACA, under sections 1814(a)(1) and 1835(a) of the Act, pr oviders could file for Part A and Part B claims, respectively, “...no later than the close of the period of 3 calendar years following the year in which such services are furnished (deeming any services furnished in the last 3 calendar months of any calen dar year to have been furnished in the succeeding calendar year) except that, where the Secretary deems that efficient administration so requires, such period ma y be reduced to not less than 1 calendar year...”. Prior to the enactment of the ACA, CMS was authorized to establish a minimum time limit for provider-submitted Part A and Part B claims of at least 1

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calendar year from the date of service, a nd a maximum time limit not to exceed 4 years

and 3 months after the date of service. Additionally, prior to the enactment of the ACA, under section 1842(b)(3)(B) of the Act, Part B claims for physician and other supplier se rvices could be filed with

Medicare “... no later than the close of the calen dar year following the year in which such service is furnished (deeming any service furn ished in the last 3 months of any calendar year to have been furnished in the succeeding calendar year)...”. Therefore, prior to the enactment of the ACA, CMS was authorized to establish a minimum time limit for filing Part B claims of 15 months and a potential maximum of 27 months after the service was furnished, depending on what month of the year the service was furnished. Section 424.44 implements sec tions 1814(a)(1), 1835(a), and 1842(b)(3)(B) of the Act. In order to effectively administer th e Medicare Program, CMS, through regulations, modified the potential minimum and maximum time periods for filing Part A claims so

that Part A claims would have the same time limits as Part B claims. At §424.44(a), CMS adopted the minimum time limit of 15 months and potential maximum of 27

months after the service was furnished that was permitted under sec tion 1842(b)(3)(B) of the Act for Part B claims and uniformly applied that 15 to 27 month time limit to both Part A and B claims. Also, under §424.44(b), CMS allowed providers and suppliers the opportunity to file claims after the 15 to 27 month deadline for filing claims expired when the failure to file “...was caused by error or misrepresentation of an employee, intermediary, carrier, or agent of the Depar tment that was perfor ming Medicare functions and acting within the scope of its authority.”

2. Provisions of the ACA

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Section 6404 of the ACA amended se ctions 1814(a)(1), 1835(a), and 1842(b)(3)(B) of the Act regarding Medicare fe e-for-service (FFS) claims for services furnished on or after January 1, 2010. Under section 6404(b)(1) of the ACA, all claims for services furnished on or after January 1, 2010 must be filed within 1 calendar year after the date of service. The provisions of the ACA did not amend these sections of the Act for services furnished before January 1, 2010. However, section 6404(b)(2) of the ACA created a new requirement that claims for services furnished before January 1, 2010

must be filed on or before December 31, 2010. Thus, the statutory provisions prior to the

enactment of the ACA remain in effect fo r pre-2010 services, subject to this new requirement. The practical effect of this chan ge is that any claims for services furnished before October 1, 2009 will follow the current ex isting regulations. But for any services furnished during the last three months of 2009, those claims must be filed no later than December 31, 2010. For services furnished between October 1, 2009 and December 31, 2009, providers and suppliers will onl y have 12-15 months to file a claim, whereas before the ACA amendments, they w ould have had an add itional year to file their claims, or 24 to 27 months. Therefore, in order to effectuate the changes made by the ACA, we are proposing to amend §424.44 so that it is consistent with the amended statutory provisions. We are proposing to amend §424.44(a) by replacing the current text with the requirement that claims for services pr ovided on or after January 1, 2010 must be submitted no later than the close of the period ending 1 calendar year after the date of service. As noted above, any services furnished before January 1, 2010 will still be subject to the pre-existing stat utory provisions. Therefore, we are proposing that for pre2010 services, the pre-existing regulatory struct ure will continue to apply. For those

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services furnished before January 1, 2010, claims must be filed on or before December 31 of the following year for services that we re furnished during the first 9 months of a calendar year, and on or before December 31 st 

### of the second following year for services that were furnished during the last 3 months of the calendar year. However, for those services provided in the last three months of 2009, we propose that all claims for those services must be filed no later than December 31, 2010. Section 6404 of the ACA also gives the Secr etary authority to create exceptions to the 1 year timely filing period. In addition to the existing exception to the timely filing requirement due to error or misrepresentation by CMS, our contractors or agents, we propose to create two new exceptions. First, we are proposing to create an exception for those situations where a beneficiary becomes retroactively entitled to Medicare benefits,

but was not entitled at the time the services were furnished. Second, we are proposing to permit providers and suppliers to file claims after the time limit for filing claims has expired in limited dual eligible Medicare/Medicaid beneficiary situations. The first new proposed exception at §424.44(b)(2) will permit providers and suppliers to file claims after the time limit for filing claims expires when CMS or our

contractors determines that the fo llowing conditions have been met:

● At the time the service was furnished the beneficiary was not entitled to Medicare; and

● The beneficiary subsequently recei ved notification of Medicare entitlement effective retroactively to or before the date of the furnished service. In these situations, if CMS or one of our contractors determines that both of the conditions in §424.44(b)(2) are met, then the time to file a claim w ill be extended through the last day of the 6 th 

### calendar month following the m onth in which the beneficiary

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received notification of Medicare entitlement eff ective retroactively to or before the date of the furnished service. Therefore, instead of the beneficiary having to pay out of his or her own pocket for the service or instead of the beneficiary’s other insurance or some other payer that is secondary to Medicare havi ng to pay primary for the service, Medicare may pay primary (or secondary or tertiary) for the service since the beneficiary was entitled to Medicare (although retroactively) at the time the service was furnished. All of Medicare’s payment rules including Medicare’s Secondary Payer rules still apply in these

retroactive entitlement situations. The second proposed new exception at §424.44(b)(3) will permit providers and suppliers to file claims for dually-eligible beneficiaries after the time limit for filing claims expires when CMS or our contract ors determine that all of the following

conditions have been met:

● At the time the service was furnished the beneficiary was not entitled to Medicare;

● The beneficiary subsequently recei ved notification of Medicare entitlement effective retroactively to or before th e date of the furnished service; and

● A State Medicaid agency recovered th e Medicaid payment for the furnished service from the provider or supplier 11 mont hs or more after the date of service. This proposed exception applies to situa tions where a provider or supplier bills (and receives payment from) Medicaid for the services that a dual eligible

Medicare/Medicaid benefi ciary receives from the provider or supplier. However, at the time the services were furnished, the patient was not a dual eligible Medicare/Medicaid beneficiary yet because Medicare entitlement was granted to the individual retroactively after the service was actually furnished to the individual. In addition, after the State

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Medicaid Program discovers that the indi vidual was granted Medicare entitlement retroactively, the State Medicaid Program r ecovers its payments from the provider or supplier for that individual’s services instru cting the provider or supplier that Medicare should be billed for the services (not Medicai d). If all three of the conditions outlined

above occur within 11 months of the date th e service was furnished, then the provider or supplier will have enough time to bill Medicare for the service. However, if Medicaid recovers their incorrect payment 11 months or more after the date the service was furnished, then the provider or supplier will not have enough time to file a claim with Medicare for the covered services because the time limit for filing claims expires 1 calendar year after the date of service. In these situations, if CMS or one of our

contractors determines that a ll of the conditions at §424.44(b)(3) are met, then the time to file a claim will be extended through the last day of the 6 th 

### calendar month following the month in which the State Medicaid agency recovered the Medicaid payment for the furnished service from the provider or supplie r. Therefore, we are proposing that this exception along with the aforementioned retroactive entitlement exception be added to §424.44. We are proposing that for the one existing exception due to error or misrepresentation by CMS, our contract ors or agents (see §424.44(b)(1)) that no extension of time will be granted beyond 4 year s from the date of service. Limiting the exception for this timely filing extension is consistent with current CMS policy. Moreover, we believe that limiting this exception to 4 years after the date of service strikes an appropriate balance between fair ness and equity for providers, suppliers, and beneficiaries and administrative finality for the Medicare program. We recognize that limiting the exceptions process could have potential impacts on those that wish to avail

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themselves of this exception. Therefore, we are soliciting comments on how this proposed four year limitation on the excep tion at §424.44(b)(1) will impact providers, suppliers and beneficiaries and the frequency of such occurrences. In addition, we are soliciting comments on whether the proposed fo ur year limitation for this particular exception is appropriate, or what changes, if any, should be made to the limitation on the exceptions process, including a rationale or justification for an a lternative time limitation. CMS is not proposing a definition of the term “date of service” in this regulation. Yet we recognize that the definition of this te rm is very important to providers, suppliers,

and beneficiaries because the “date of servic e” will ultimately determine when the claim

has to be filed in order to meet the new 1 calendar year requirement. In most cases the “date of service” will be the date that the item or service is actually furnished to the beneficiary; however, we recognize that for ma ny Part A and B services it is difficult to craft a uniform rule that will apply a consistent date of service standard. It is our intention to provide sub-regulatory guidance on what constitutes the date of service for

different Part A and B services. We ar e soliciting comments regarding whether CMS should provide a regulatory defi nition of “date of service” a nd, if so, how should it define

this term. We are also clarifying the exception that appears at §424.44(e). We are making clear that this regulation does not supersede the restriction on retrospective billing that appears in §§ 424.520 and 424.521. Under these provisions certain newly-enrolled suppliers, such as physicians, non-physicia n practitioners, physician or non-physician practitioner organizations and IDTFs, have only a limited ability to submit claims for items or services furnished prior to the effective date of their Medicare billing privileges

even if these claims would otherwise be cons idered timely. In add ition, we want to make

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clear that the one calendar year timely filin g limit in section 424.44(a) does apply to any retrospective claims permitte d by sections 424.520 and 424.521 and to claims for items or services furnished after the effective date of the supplier’s billing privileges. V. Section 6410 and MIPPA: Adjustments to the Metropolitan Statistical Areas (MSA)

for Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Competitive Acquisition Program We are proposing a number of revisions to the DMEPOS CBP as a result of changes to the statute made by both the Medicare Improvements for Patients and Provider Act of 2008 (MIPPA) and the ACA. Since both MIPPA and the ACA specify requirements for MSA selec tion for round 2 and beyond we are outlining our proposals for implementing the statutory requirements re lated to MSA selection in both MIPPA and the ACA in this section. First, we propose to use the authority provi ded by the statute at section 1847(a)(1)(D)(ii) of the Act, as am ended by MIPPA to subdivide Metropolitan Statistical Areas (MSAs) with populati ons of greater than 8,000,000 under Round 2 of the DMEPOS CBP. Second, we propose to exclude certain areas from competitive bidding after round 2 as mandated by section 1847(a)(1)(D)(iii) of the Act, as amended by MIPPA. Third, we propose to implement the requirement of section 6410 of the ACA to expand Round 2 of the program by adding 21 of the largest MSAs based on total population to the original 70 already selected for round 2. 1. Background Section VI.H of this proposed rule provides background on the DMEPOS CBP, including a description of many of the changes made to the program by section 154 of MIPPA. In this section, we provide additi onal information regarding changes made by

both MIPPA and Section 6410 of the ACA. In addition to the changes discussed

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previously in this proposed rule, MIPPA also added subparagraph (D) to section 1847(a)(1) of the Act. Section 1847(a)(1)(D )(ii), as added by MI PPA, addresses Round 2 of the DMEPOS CBP, and section 1847(a)(1)(D )(iii) addresses subsequent rounds of the Program. Section 1847(a)(1)(D)(ii)(II) of the Act specifies that the Secretary shall implement DMEPOS competitive bidding in the areas previously selected for round 2 of the program and also allows the Secretary, in implementing round 2 of the program, to subdivide metropolitan statistical areas (M SAs) with populations of greater than 8,000,000 into separate CBAs. Previously, we believe the statute could have been interpreted to allow CMS to subdivide large MSAs but MIPPA gave CMS the explicit authority to subdivide large MSAs. Secti on 1847(a)(1)(D)(iii) imposes new requirements on the Secretary for competitions occurring before 2015 in subsequent rounds of the program. For such competitions (other than national mail order), the following areas are to be excluded from the program: (I) rural ar eas; (II) MSAs not selected under Round 1 or 2 with a population of less than 250,000; a nd (III) certain areas with low population density within a selected MSA. These requi rements do not apply to a national mail order

program. Finally, MIPPA required that we impleme nt Round 2 of the DMEPOS CBP in the same MSAs that were designated as of June 1, 2008. In 2010, section 6410(a) of the ACA amended sections 1847(a)(1)(B)(i)(II) a nd (D)(ii) of the Act to expand Round 2 of the program from 70 MSAs to 91 MSAs by a dding the next 21 largest MSAs by total population not already select ed for Rounds 1 or 2. 2. Subdividing Large MSAs under Round 2

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We have selected MSAs for Round 1 and for Round 2 consistent with MIPPA’s requirement. For round 1 CBAs generally we re comparable to MSAs, however, for round 2 we are proposing to subdivide MS As of 8,000,000 or more in population. The authority to subdivide MSAs in to separate areas for compe titive bidding purposes is set forth in section 1847(a)(1)(D)(ii)(II) of th e Act which states, “[t]he Secretary may subdivide metropolitan statistical areas with populations (based upon the most recent data from the Census Bureau) of at least 8,000,000 into separate areas for competitive acquisition purposes.” We have identif ied three MSAs which, based on the 2009

estimate from the Census Bureau data , could be subdivided under section 1847(a)(1)(D)(ii)(II): (1) Chicago-Naperville-J oliet, Illinois-Indiana-Wisconsin (IL-INWI) MSA with a population of 9,569,624; (2) Los Angeles-Long Beach-Santa Ana, California (CA) MSA with a population of 12,872,808; and (2) New York-Northern New Jersey-Long Island, New York-New Jersey -Pennsylvania (NY-NJ-PA) MSA with a population of 19,006,798. We are proposing to divi de these MSAs into separate CBAs because we believe this approach would create more manageable CBAs for contract suppliers to serve and allow more small suppliers to be considered for participation in the

program.

We considered certain factors when c onsidering whether to propose subdividing the MSAs with populations of at least 8,000,000. We considered the geographic, social, and economic integration of each of the MSAs. We apply all of these factors when grouping counties into CBAs considered at a county level in each MSA and we believe it is also appropriate to use these factors to de termine: (1) whether or not to subdivide an MSA into separate CBAs, and (2) once the de cision is made to subdivide the MSA, how

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to subdivide the MSA. We considered the fo llowing factors, generally in the order in which they are listed:

● Geographic size of the MSA and the location of the counties within each MSA compared to neighboring counties;

● The driving distances from north to south and east to west within each MSA and county;

● The total population and the population of FFS Medicare beneficiaries using DMEPOS items subject to competitive bidding;

● The DMPOS allowed charges for items subject to competitive bidding;

● Comparably sized Round 1 and Round 2 MSAs based on beneficiary counts and allowed charges for competitive bid items;

● The interstate highway infrastructures of the MSAs; and

● The current service patterns of suppliers in each county of the MSA.

We used each of the factors to the extent practical to develop initial proposals for

reasonable and workable subdivisions of th ese highly and densely populated MSAs. We

believe considera tion of these factors will help us meet our goal of subdividing large and densely populated MSAs and creating CBAs that are attractive to suppliers and incentivize them to bid competitively for a contract. With this goal in mind, we are trying to establish CBAs that provide for a good volume of DMEPOS business for winning bidders, avoid obvious geographic obs tacles, mimic existing supplier service patterns, and, to the extent possible, do not cr oss State lines. We believe the factors we have selected will achieve those objectives. We found that counties clearly delineate ar eas within a MSA, and as we have done for Round 1 by identifying CBAs by c ounties and zip codes, we are proposing to

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subdivide the MSAs at a county level. Si nce the Office of Management and Budget (OMB) defines the MSAs by counties and c ounty-based subdivisions are stable, we use

counties to subdivide CBAs. When subdividi ng an MSA into counties, we consider counties that share social, economic and geographic integration. The ChicagoNaperville-Joliet IL-IN-WI MSA comprises 14 counties within 3 States: Illinois, Indiana, and Wisconsin. This MS A has 207,106 beneficiaries and $218,161,562 of DMEPOS allowed charges subj ect to the DMEPOS CBP. Using the factors that we indentified, we would subdivide the Chicago-Naperville-Joliet, IL-IN-WI MSA into four separate CBAs: Indiana-Chicago Metr o CBA; South-West-Chicago-Metro CBA; Central-Chicago Metro CBA; and Northern-Chicago Metro CBA. The counties, DMEPOS allowed charges, and the number of beneficiaries subject to competitive bidding, and the general population that co mprise each of these proposed CBAs are

shown in Table 40.

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TABLE 40: Chicago-Naperville-Joliet, IL-IN-WI

CBA Name County DMEPOS Allowed Charles* DMEPOS Beneficiary Count Subject to Competitive Bidding* General Population**

Indiana- Chicago Metro CBA Lake,IN $18,600,917 16,637 493,800 Jasper,IN $1,238,119 1,191 32,544 Newton,IN $580,842 393 13,933

Porter,IN $4,856,838 4,526 162,181 CBA TOTAL $25,276,716 22,747 702,458South-West- ChicagoMetro CBA Will,IL $13,523,185 12,522 681,097 Grundy,IL $1,417,511 1,405 47,958 Kendall,IL $978,215 1,052 103,460 DeKalb,IL $2,358,319 2,323 106,321 Kane,IL $9,273,504 9,082 507,579 CBA TOTAL $27,550,734 26,384 1,446,415 Central-Chicago Metro CBA Cook,IL $124,854,279 116,360 5,294,664 DuPage,IL $16,945,135 18,492 930,528 CBA TOTAL $141,799,414 134,852 6,225,192 Northern- Chicago Metro CBA Lake,IL $12,352,802 12,482 712,453 McHenry,IL $7,020,768 6,852 318,641 Kenosha,WI $4,161,128 3,789 164,465 CBA TOTAL $23,534,698 23,123 1,195,559 MSA TOTAL $218,161,562 207,106 9,569,624 *Source: Medicare claims from 10/1/08 to 9/30/09 for items subject to competitive bidding. ** Source U.S. Census Bureau 2009 population estimates.



### Figure 1 shows the boundaries of each proposed CBA.

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FIGURE 1:

The Indiana-Chicago Metro CBA would incl ude all four of the Indiana counties that are part of the MSA. The othe r CBAs in the MSA would be as follows:

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● The South-West-Chicago Metro CB A would include counties in Illinois

located to the south and west of the Central-Chicago Metro CBA.

● The Central-Chicago Metr o CBA would include the city of Chicago covering both Cook and DuPage counties.

● The Northern-Chicago Metro CBA wh ich is north of the Central-Chicago

Metro CBA subdivision that enco mpasses the city of Chicago. The Los Angeles-Long Beach-Santa Ana, CA MSA comprises two counties: Los Angeles County and Orange County. The MSA has 173,631 fee-for-service beneficiaries receiving DMEPOS subj ect to competitive bidding and $244,523,957 in DMEPOS allowed charges subject to the DMEPOS CBP. We propose to subdivide the Los Angeles-Long Beach-Santa Ana, CA MSA into two CBAs: Los Angeles County CBA and Orange County CBA. The DMEPOS allo wed amount and benefi ciary count subject to competitive bidding, and the general popul ation that comprise these two proposed

CBAs are shown in Table 41. TABLE 41: Los Angeles-Long Beach-Santa Ana, CA

CBA Name DMEPOS Allowed Amount* DMEPOS Beneficiary Count* General Population **

Los Angeles County CBA $201,244,121 137,408 9,862,049

CBA TOTAL $201,244,121 137,408 9,862,049* Orange County CBA $ 43,279,836 36,223 3,010,759

CBA TOTAL $43,279,836 36,223 3,010,759

MSA TOTAL $244,523,957 173,631 12,872,808 *Source: Medicare claims from 10/1/08 to 9/30/09 for items subject to competitive bidding. ** Source U.S. Census Bureau 2009 population estimates.



### Figure 2 shows the boundaries of each proposed CBA.

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FIGURE 2:

As mentioned earlier, we propose to subdi vide MSAs using counties, and since the Los Angeles-Long Beach-Santa Ana, CA MSA only has two counties, it offers only one subdivision along the county lines. Hence, we have proposed to divide the MSA by the two counties creating two CBAs. We also propose to use the authority in section 1847(a)(3)(A)of the Act to

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exclude certain areas within the Los Angeles-Long Beach-Santa Ana, CA MSA. We believe these areas meet the requirement of section 1847(a)(3)(A); they are rural areas with a low population density within an urban ar ea that are not competitive. In the final rule CMS-1270 F §414.410(c) published in Ap ril 2007, we defined the factors we consider when determining an area is consid ered a low population density area or an area that would not be competitive. Based on our review of the County Subdivision Population from the 2000 Census from the U.S. Census Bureau, and using the factors set forth in the April 2007 proposed rule, we pr opose to exclude the area of Los Angeles County north of the San Gabriel mountains. This large geographic area has a population of about 357,000, which is only 4 percent of th e total population of Los Angeles County, and is separated from the rest of the county by the San Gabriel Mountains. The area

north of the San Gabriel Mount ains has one major road a nd many terrains which make this area remote. The majority of the population in LA County lives south of the San

Gabriel Mountain. We believe that excluding this area will create a more manageable CBA that still provides sufficient volume of DM EPOS items while avoiding the geographic obstacle of the mountains. We believe including this area in the DMEPOS CBP would result in fewer small suppliers being considered for participation under the program, because we would not expect small suppliers to have the resources to serve these more remote areas. As a result, we expect that if this proposal is finalized it will increase the number of bids submitted for the CBAs within the Los Angeles-Long Beach-Santa Ana, CA MSA. The Los Angeles County includes the tw o islands of Sant a Catalina and San Clemente off the west coast. We are proposin g that the two islands be included as a part of the Los Angeles County CBA in order to en sure that beneficiaries presently residing

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on these islands or who move to these isla nds in the future are ensured access to competitively bid items by contract suppliers . San Clemente Island is a military base with a current population of zero, and therefor e, the inclusion of this area in the CBA would not result in an increase the supplier service area at this time. We also propose to subdivide the New York-Northern New Jersey-Long Island,

NY-NJ-PA MSA into five CBAs. This MSA co mprises 23 counties in three States: New York, New Jersey and Pennsylvania. Th e MSA has 344,879 FFS beneficiaries receiving DMEPOS subject to th e DMEPOS CBP and $350,449,795 in allowed charges for DMEPOS items subject to competitive bidding . The counties, DMEPOS allowed amount and beneficiary count subject to competitiv e bidding and the general populations that comprise each of these proposed CBAs are shown in Table 42. TABLE 42: New York-Northern New Jersey-Long Island, NY-NJ-PA

CBA Name County DMEPOS Allowed Amount* DMEPOS Beneficiary

Count* General Population ** Nassau-Brooklyn-Queens County Metro CBA Nassau,NY $30,888,889 29,857 1,351,625

Kings,NY $47,044,915 44,893 2,556,598 Queens,NY $33,406,236 32,798 2,293,007 CBA TOTAL $111,340,040 107,548 6,201,230 Suffolk County CBA Suffolk,NY $31,950,806 31,476 1,512,224 CBA TOTAL $31,950,806 31,476 1,512,224 Bronx -Manhattan NY CBA Bronx,NY $19,791,646 17,002 1,391,903 New York,NY $26,483,792 26,414 1,634,795 CBA TOTAL $46,275,438 43,416 3,026,698 North-West NY Metro CBA Hudson,NJ $13,622,910 12,644 595,419 Bergen,NJ $19,948,837 20,278 894,840 Passaic,NJ $10,266,137 10,233 490,948 Putnam,NY $1,997,668 1,876 99,244 Rockland,NY $6,421,317 6,265 298,545 Essex,NJ $1,392,770 1,379 770,675 Morris,NJ $9,094,758 9,830 487,548 Sussex,NJ $2,905,240 2,819 150,909

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CBA Name County DMEPOS Allowed Amount* DMEPOS Beneficiary

Count* General Population ** Pike,PA $1,393,003 1,475 59,664 Westchester,NY $16,971,210 17,220 953,943

CBA TOTAL $84,013,850 84,019 4,801,735 Southern NY Metro CBA Hunterdon,NJ $2,709,880 2,356 129,031 Richmond,NY $7,054,863 6,626 487,407 Union,NJ $10,466,838 10,654 523,249 Middlesex,NJ $15,803,473 16,649 789,102 Monmouth.NJ $14,979,747 15,110 642,448 Ocean,NJ $20,913,022 21,600 569,111 Somerset,NJ $4,941,838 5,425 324,563 CBA TOTAL $76,869,661 78,420 3,464,911 MSA TOTAL $350,449,795 344,879 19,006,798

*Source: Medicare claims from 10/1/08 to 9/30/09 for items subject to competitive bidding. ** Source U.S. Census Bureau 2009 population estimates.



### Figure 3 shows the boundaries of each proposed CBA.

FIGURE 3:

### CMS-1503-P 395

The Nassau-Brooklyn-Queens CBA would be contiguous to Suffolk County and would consist of the western part of Long Island and extend to the eastern part of New York City. The Suffolk County CBA would consist of the eastern part of Long Island and would encompass most of Long Is land. The Bronx-Manhattan NY CBA would

include the entire area of Manhattan and the Bronx. The North-West NY Metro CBA

would be situated north and west of New Yo rk City and would extend into New Jersey and Pennsylvania. The Southern NY Metro CBA would include Staten Island and would extend south to Ocean County, New Jersey. At the March 17, 2010 meeting of th e Program Advisory and Oversight Committee (PAOC), we presented these propos als for subdividing these three large

MSAs. Various members of the PAOC had the following suggestions for subdividing

these MSAs:

● Draw the boundaries of CBAs using the interstate highways rather than the divisions by County;

● Determine the current servicing ar eas of suppliers by MSA and product category by using a scatter plot;

● Use the Hudson River to divide the CBAs for the New York MSA;

● Carve out Pike and Putnam Countie s from the New York MSA due to their location and their low population density;

● Include Manhattan as a separate CBA, due to its unique nature as a self contained area;

● Consider State licensure requirements wh en we divide the MSAs into CBAs;

● In the LA County CBA, exclude the ar ea north of the San Gabriel Mountains from the CBA; and

### CMS-1503-P 396

● Consider traffic patterns when divi ding the Los Angeles MSAs into CBAs. We are considering the PAOC’s advice a nd recommendations and invite further comments on the proposed subdivisions and PAOC’s advice of these three MSAs.

3. Exclusions of Certain Areas after Round 2 and Prior to 2015 The MIPPA amended the statute by requiring that competition under Round 2 takes place in 2011 and by adding secti on 1847(a)(1)(D)(iii) that requires CMS to exclude the following areas from the competitive bid program for competitions after Round 2 of the program and before 2015:

● Rural Areas;

● Metropolitan Statistical Areas not se lected under Round 1 or Round 2 with a population of less than 250,000; and

● Areas with a low population density with in a MSA that is otherwise selected consistent with section 1847(a)(3)(A). We propose to incorporate these require ments and timeframes in proposed §414.410(c). 4. Expansion of Round 2 Section 6410(a) of the ACA expanded the ar eas to be included in Round 2 of the program. As amended by section 6410(a) of the ACA, section 1847(a)(1)(B)(i)(II) requires that the competition for Round 2 of th e program occur in 91 of the largest MSAs in 2011. Prior to this change, Round 2 was to include 70 MSAs. Section 1847(a)(1)(D)(ii)(II), as added by section 6410( a), specifies that the additional 21 MSAs

to be included in Round 2 “include the next 21 largest metropolitan statistical areas by total population” (after those already se lected Round 2). The 2009 annual population

estimates from the U.S. Census Bureau are th e most recent estimates of population that will be available prior to the Round 2 comp etition mandated to take place in 2011. We

### CMS-1503-P 397

therefore propose to use these estimates to determine the additional 21 MSAs to be included in Round 2 of the program. Table 43 is a list of the additional 21 MSAs added

to Round 2.

TABLE 43: Additional 21 MSAs Added to Round 2

W. Section 10501(i)(3)—Proposed Collecti on of HCPCS data fo r Development and Implementation of a Prospective Payment System for the Medicare Federally Qualified Health Center Program The Omnibus Budget Reconciliation Act (OBRA) of 1989 amended the Social Security the Act by creating new FQHC benefit programs under both Medicare and Medicaid. The Medicare FQHC benefit provide s coverage for a full range of primary care services, including physician and certain nonphysician services (PAs, NPs), clinical 21 Additional MSAs 2009 Total Population Philadelphia-Camden-Wilmington, PA-NJ-DE-MD 5,968,252 Washington-Arlington-Alex andria, DC-VA-MD-WV 5,476,241 Boston-Cambridge-Quincy, MA-NH 4,588,680 Phoenix-Mesa-Scottsdale, AZ 4,364,094 Seattle-Tacoma-Bellevue, WA 3,407,848 St. Louis, MO-IL 2,828,990 Baltimore-Towson, MD 2,690,886 Portland-Vancouver-Beaverton, OR-WA 2,241,841 Providence-New Bedford-Fall River, RI-MA 1,600,642 Buffalo-Niagara Falls, NY 1,123,804 Rochester, NY 1,035,566 Tucson, AZ 1,020,200 Honolulu, HI 907,574 Albany-Schenectady-Troy, NY 857,592 Worcester, MA 803,701 Oxnard-Thousand Oaks-Ventura, CA 802,983 Springfield, MA 698,903 Bradenton-Sarasota-Venice, FL 688,126 Poughkeepsie-Newburgh-Middletown, NY 677,094 Stockton, CA 674,860 Boise City-Nampa, ID 606,376

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social worker, psychologist services, and preventive services. FQHCs are “safety net” providers (for example, community health cen ters and programs serving migrants, the homeless, public housing centers, and tribal groups). The main purpose of the FQHC program is to enhance the provision of prima ry care services in underserved urban and rural communities. FQHCs typically enhance the availability of care to vulnerable populations, including Medicare, Medicaid, SC HIP, and the uninsured. Most of these health centers receive HRSA grants for services to the uninsured. Medicare pays FQHCs on the basis of reasonable cost, subject to an upper payment limit on the reasonableness of incurred cost. Actual Medicare reasonable cost is determined based upon a Medicare cost report filed by the FQHC after the end of its fiscal year. Prior to the start of the ye ar, an interim all-inclusive per-visit payment amount, based upon an estimate of Medicare re asonable costs, is calculated for each Medicare FQHC. During the year, this inte rim all-inclusive per-visit payment amount is paid for each covered visit between a Medicare beneficiary and an FQHC health professional. After the end of the Medicare FQHC’s cost reporting year, interim per-visit payments are reconciled to actual Medicare reasonable costs based upon the Medicare cost report filed by the FQHC. Section 10501( i)(3) of the ACA now amends this current Medicare FQHC payment policy with an entirely different payment system, effective with cost reporting periods begi nning on or after October 1, 2014. Section 10501(i)(3)(A) of th e ACA amended section 1834 of the Act by adding a new subsection (o), Development and Implem entation of Prospective Payment System. This subsection provides the statutory framew ork for development a nd implementation of a prospective payment system for Medicare FQHCs. Section 1834(o)(1)(B) of the Act, as established by the ACA, addresses coll ection of data necessa ry to develop and

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implement the new Medicare FQHC prospectiv e payment system. Specifically, section 1834(o)(1)(B) of the Act, Collection of Data and Evaluation, grants the Secretary of HHS the authority to require FQHCs to submit such information as may be required in order to develop and implement the Me dicare FQHC prospective pa yment system, including the reporting of services using HCPCS codes. Section 1834(o)(1)(B) of the Act requires that the Secretary impose this data collecti on submission requirement no later than January 1, 2011. Accordingly, we are proposing to add a new paragraph (d) to §405.2470 to require Medicare FQHCs to begin re porting all services furnished and using HCPCS codes for these services starting January 1, 2011. Beginning January 1, 2011, the Medicare FQHC would be required to repor t on Medicare FQHC claims all pertinent service(s) provided for each Medicare FQHC visit (defined in §405.2463). This additional reporting would include the inform ation needed to develop and implement a PPS for FQHCs. For example, corresponding HCPCS code(s) would be required to be reported along with the presently required Medicare revenue code(s) for the Medicare FQHC visit(s). CMS’ Medicare FQHC claims processing system would be revised to accept the addition of the new reporting re quirements effective January 1, 2011. The proposed new data collection effort would be for informational and data gathering purposes only, and would not be utilized to determine Medicare payment to the FQHC. Until the FQHC prospective payment system is implemented in 2014 and the Medicare claims processing system is revised to reflect such a system, Medicare FQHC payment would continue in the current manner (utilizing revenue codes and the interim per-visit payment rate methodology). We further note that Medicare FQHCs would be required to adhere to the information collection requirements in accordance with the content and terms of their Medicare

### CMS-1503-P 400

agreement as stipulated at §405.2434. Failure to do so could result in the termination of the FQHC’s Medicare agreement in acco rdance with §405.2436 of the Medicare FQHC regulations. At this time, we do not foresee additional claims or other information collection needs beyond collection of HCPCS codes. A ccordingly, we are not proposing additional information collection requireme nts at this time. However, we invite public comment on any additional information F QHCs believe may be necessary in order to develop and implement a prospective payment system for Medicare FQHCs.

VI. Other Provisions of the Proposed Regulation A. Part B Drug Payment: Average Sales Price (ASP) Issues 1. "Carry Over" ASP The ASP payment methodology is authoriz ed under section 303(c) of the MMA which amends Title XVIII of the Act by addi ng section 1847A of the Act. This section establishes the use of the ASP methodology for payment for drugs and biologicals described in section 1842(o)(1)( C) of the Act furnished on or after January 1, 2005. For purposes of this part, the term "drugs" will hereafter refer to both drugs and biologicals. The ASP methodology applies to most drugs furn ished incident to a physician's service, drugs furnished under the durable medical e quipment (DME) benefit, certain oral anticancer drugs, and oral immunosuppressive drugs. Sections 1847A and 1927(b) of the Act specify quarterly ASP data reporting requirements for manufacturers. Specific A SP reporting requirements are set forth in section 1927(b) of the Act. Although delays in reporting have been uncommon, they create a risk that: (1) could result in the publication of payment limits which do not reflect prices for drug products, and (2) coul d result in inaccurate payments, the need for

### CMS-1503-P 401

correction of files and unintentional ASP payment limit variability. As a result of these concerns, we are seeking to establish a process for addressing situations where manufacturers fail to report manufacturer ASP data in a timely fashion. This proposal is intended to allow us to calculate and report ASP payment limits for a given quarter within the existing timelines and does not affect the CMS or OIG's authority to assess civil monetary penaltie s associated with untimely or false ASP reporting. Manufacturers who misrepresent or fail to report manufacturer ASP data will remain subject to civil moneta ry penalties, as applicable a nd described in sections 1847A and 1927(b) of the Act. For the purposes of reporting under section 1847A of the Act, the term manufacturer is defined in section 1927(k)(5) of the Act and means any entity engaged in the following: production, preparati on, propagation, compounding, conversion or processing of prescription drug product, either directly or indirectly by extraction from substances of natural origin, or independently by means of chemical synthesis, or by a combination of extraction and chemical synthe sis; or packaging, repackaging, labeling, relabeling, or distribution of prescription drug products. The term manufacturer does not include a wholesale distributor of drugs or a retail pharmacy licensed under State law. However, manufacturers that also engage in certain wholesaler activities are required to report ASP data for those drugs that they manufacture. Note that the definition of manufacturers for the purposes of ASP da ta reporting includes repackagers.

In accordance with section 1847A of the Ac t, manufacturers are required to report data on the NDC level, which include the following elements: the manufacturer ASP for drugs; the Wholesale Acquisition Cost (WAC) in effect on the last day of the reporting period; the number of ASP units sold; and th e NDC. Currently, when manufacturer ASP

### CMS-1503-P 402

data or specific data elements are not available, we calculate an ASP price for a billing code based on other applicab le and available pricing data from manufacturers for that drug. This includes WAC prices from compe ndia if manufacturer data are not available for a billing code. WAC prices tend to be higher than manufacturer ASP prices. Although problems with reporting have been uncommon, we have recently encountered situations where delays in ma nufacturer ASP reporting could have led to significant ASP payment limit fluctuations for highly utilized HCPCS codes. The greatest potential impact occurs when data for high volume drug products within a HCPCS code that is represented by a limited number of NDCs have not been reported

and cannot be included in the ASP volume we ighted calculations described in section 1847A(b) of the Act. For multisource drugs, su ch a situation is likely to artificially increase or decrease Medicare ASP payment limits, which in turn would affect beneficiary cost sharing amounts. Such ar tificial fluctuations of the ASP payment limit could provide the appearance of instability unrelated to market forces and could also create access issues for providers and beneficiaries and confusion that could ultimately affect product demand in the marketplace. In order to minimize the possibility of ASP payment limit fluctuations due to missing data, we are proposing a process, consistent with our authority in section 1847A(c)(5)(B), to update A SPs, based on the manufacturer's ASP calculated for the most recent quarter for which data is availa ble. Specifically, we are proposing to carry over the previously reported manufactur er ASP for an NDC(s) when missing

manufacturer ASP and/or WAC da ta could cause significant changes or fluctuations in ASP payment limits, and efforts by us to obtain manufacturer reported ASP before Medicare ASP payment limits publication deadlin es have not been successful. For

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example, the most recently reported manufacturer ASP prices for products on the market would be carried over to the next quarter if an entire manufacturer's submission was not received, manufacturer ASP price data for specific NDCs has not been reported, or only WAC data has been reported; however, NDCs that have zero sales or are no longer being manufactured will not be subjected to this pr ocess. Also, we are proposing to apply the carryover process only in cases where missing data results in a 10 percent or greater change in the ASP payment limit compared to the previous quarter. Based on experience with ASP methodology since 2006, we believe th at this percentage threshold meets the definition of significant. We are specifical ly seeking comments on our use of 10 percent

as the threshold amount. In order to better re present actual market trends, that is actual

increases or decreases in manufacturer reported ASP for the group of NDCs that represent the HCPCS code, we are propos ing that the manufacturer ASP payment

amounts for the individual NDCs th at are carried over will be adjusted by the weighted average of the change in the manufacturer ASP for the NDCs that were reported during both the most recently available quarter and the current quarter. We would appreciate

comments about whether other methods to acc ount for marketplace price trends to the carried over NDCs could be a better substitute for applying the weighted average change. The previous quarter's sales volumes will be carried over. An example of the proposed process appears in Table 44. We propose to apply this process to bot h single source drugs and multiple source drugs. However, we are concerned that incl uding single source drugs in the carry over process could create an incentive for non-repor ting in situations where ASP prices for a single source drug are falling and the manuf acturer stops reporting ASP in an effort to preserve a higher payment amount despite the risk of significant statutory penalties for

### CMS-1503-P 404

such an action. Therefore, we are specifically requesting comments on this option and the effect of limiting this proposal to multiple source drugs only. We will consider these comments carefully before including both single source and multisource drugs in this

process.

TABLE 44: Proposed ASP Carryover Exampl e for NDCs in a Specific HCPCS Code

Previous Quarter Reported NDCs Previous Qtr Reported Volume Previous Qtr ASP Price Current Qtr Reported NDCs Current Qtr Reported Volume Current Qtr ASP Price Current Qtr NDCs for Calculation Current Qtr Volume for Calculation Current qtr price for Calculation 12345- 6789-10 2000 $1.000 12345- 6789-10 2500 $0.980 12345- 6789-10 2500 $0.980

12345- 6789-11 3000 $1.000 12345- 6789-11 1700 $0.980 12345- 6789-11 1700 $0.980

12345- 6789-12 5000 $1.000 12345- 6789-12 5500 $0.980 12345- 6789-12 5500 $0.980

45678- 1234-90 9000 $1.100 missing missing missing 45678- 1234-90 9000 $1.078*

45678- 1234-99 27000 $1.100 missing missing missing 45678- 1234-99 27000 $1.078* * This result is obtained by calculating the weighted aver age price change in NDCs available (that is, 12345-6789-10 thru 12345-6789-12) in both the previous and current quarters, which is -2% [(0.98-1.00)*100], and applying that change to the previous quarter's manufacturer ASP for the missing NDCs (that is, 45678-1234-90 and 45678-1234-99). The last two columns on the right would be used to calculate the weighted ASP and payment limits for the 5 NDCs as a HCPCS code and accounts for missing prices for two high volume NDCs that represent most of the units sold within the HCPCS code and therefore heavily influence the price calculation for the HCPCS code.



### Our proposed approach is intended to esta blish a straightforward and transparent

solution that minimizes the effect of missi ng manufacturer ASP data on Medicare ASP payment limits. We believe that the availab ility of a mechanism to minimize non-market related price fluctuations is desirable when efforts to obtai n manufacturer's ASP data by deadlines have not been successful. Our propos ed mechanism is not intended to alter or adjust reported prices and will not be used to do so, but instead is intended to more accurately represent prices in the marketplace if manufacturer ASP data for particular drug product(s) is missing. Based on our experience with ASP reporting since 2004, we do not believe that this process will be used frequently. However, as we stated previously, recent concerns with delays in reporting of manufacturer ASP data have led

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to this proposal. We also remind manufacturers that significant civil monetary penalties for not reporting or misrepresenting manufacturer ASP data are authorized under sections 1847A(d)(4) and 1927(b)(3)(C) of the Act and co dified in regulations at §414.806. This proposal should not be interpreted to mean that CMS and the OIG will refrain from collecting such penalties for ASP reporting violations. Late or missing reports will not be tolerated. This proposed polic y would be implemented regardless of any efforts by the

OIG to enforce Civil Moneta ry Penalties for non-reporting.

We would also like to remind manufacturer s that additional specific information about reporting ASP data to us is available. (See for example.: 69 FR 17936, 69 FR 66299, 70 FR 70215, 71 FR 69665, 72 FR 66256, 73 FR 69751, and 74 FR 61904.) Also, Frequently Asked Questions are posted in the Related Links In side CMS Section of the ASP Overview Web page at http://www.cms.hhs.gov/McrPartBDrugAvgS alesPrice/01_overview.asp#TopOfPage , and the Downloads section of the same webpa ge contains a link to the ASP Data Form (addendum A), which includes examples of how ASP data must be reported and formatted for submission. In particular, we would like to remind manufacturers to report sales volume in quantities of NDC units sold (not vials or other units of sale), and to use a zero (that is the character "0") instead of a blank when reporting items that did not have any sales in a particular quarter. In a ddition, manufacturers should report both the ASP and the WAC for each NDC, the expiration date for the last lot sold, if applicable, and the

date of first sale for an NDC. In summary, in situations where any curr ent quarter's manufacturer ASP data is unavailable, we are proposing, consistent with our authority in section 1847A(c)(5)(B), to

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use the most recent data available in the ASP payment limit calculation for single source and multiple source drugs. We look forw ard to comments on this proposal and the proposed changes to §414.904(i). 2. Partial Quarter ASP Data Section 1847A(c)(4) of the Act states that "In the case of a drug or biological during an initial period (not to exceed a full cal endar quarter) in which data on the prices for sales for the drug or biological is not sufficiently available from the manufacturer to compute an average sales price for the drug or biological, the Secretary may determine the amount payable under this section for the drug or biological based on—(A) the wholesale acquisition cost; or (B) the me thodologies in effect under this part on November 1, 2003, to determine payment amounts for drugs or biologicals." When a new drug product enters the market, the first date of sale rarely coincides with the beginning of a calendar quarter. Therefore, the ASP data for many new drug products falls into par tial quarter status during the first quarter of sales. We are taking this opportunity to describe our policy rega rding how reported data is used in the calculation of ASP payment limits during the first quarter of sales for single source and multiple source drugs. In accordance with section 1847A(c)(4)(A) of the Act, it has been our policy to price new single source drugs at WAC for the firs t quarter (unless the da te of first sale is on the first day of the quarter), and to add new NDCs for multisource drugs and product line expansions of single source drugs to the ASP calculation for a quarter as soon as these products are reported. We believe that the approaches for both single source and multisource drugs are consistent with the statute, particularly sec tion 1847A(c)(4) of the Act, and we intend to

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continue this policy. 3. Determining the Payment Amount for Drugs and Biologicals Which Include

Intentional Overfill The methodology for developing Medicare drug payment allowances based on the

manufacturers' submitted ASP da ta is specified in 42 CFR part 414, subpart K. We initially established this regulatory text in the CY 2005 PFS final rule with comment period (69 FR 66424). We further described th e formula we use to calculate the payment amount for each HCPCS billing code in the CY 2006 PFS proposed rule (70 FR 45844) and final rule with comment period (70 FR 70217). With the enactment of the Medicare, Medicaid and SCHIP Extension Act (MMSEA ) (Pub. L. 110-173), the formula we use changed beginning April 1, 2008. Section 112(a) of the MMSEA requires us to calculate payment amounts using a specified volume-we ighting methodology. In addition, section 112(b) of the MMSEA sets forth a special ru le for determining the payment amount for certain drugs and biologicals. We addres sed these changes in the CY 2009 PFS proposed and final rules (73 FR 38520 and 69571, respectively). For each billing code, we calculate a volume-weighted, ASP-based payment amount using the ASP data submitted by manuf acturers. Manufactur ers submit ASP data to us at the 11-digit National Drug Code (N DC) level, including the number of units of the 11-digit NDC sold and the ASP for those units. We determine the number of billing units in an NDC based on the amount of drug in the package. For example: A manufacturer sells a box of 4 vials of a drug. Each vial contains 20 milligrams (mg); the billing code is per 10 MG. The number of billing units in this NDC for this billing code is (4 vials x 20mg)/10mg = 8 billable units. Beginning April 1, 2008, we use a two-step formula to calculate the payment

### CMS-1503-P 408

amount for each billing code. We sum the product of the manufac turer's ASP and the number of units of the 11-digit NDC sold for each NDC assigned to the billing and payment code, and then divide this total by the sum of the product of the number of units of the 11-digit NDC sold and the number of billing units in that NDC for each NDC assigned to the billing and payment code. The provisions in section 112 of the MMSEA were self-implementing for services on and after April 1, 2008. Because of the limited time between enactment and the implementation date , it was not practical to undertake and complete rulemaking on this issue prior to implementing the required chan ges. As a result of the legislation, we revised §414.904 to codify the changes to the determination of payment amounts

consistent with section 112 of the MMSEA. Since that time, we have become aware of situations where manufacturers, by design, include a small amount of "intentiona l overfill" in containe rs of drugs. We

understand that this "intentiona l overfill" is intended to co mpensate for loss of product when a dose is prepared and administered prop erly. For instance, a hypothetical drug is intended to be delivered at a 0.5 mg dose whic h must be drawn into a syringe from a vial labeled for single use only. The vial is la beled to contain 0.5 mg of product but actually contains 1.5mg of product. The additional 1.0 mg of product is incl uded, by design, and is intended to be available to the provide r so as to ensure a full 0.5 mg dose is administered to the patient. Our ASP payment calculations are based on data reported to us by manufacturers. This data includes the "volume per item". In our "Appendix A – Average Sales Price Reporting Data Elements " available on our web site at http://www.cms.gov/McrPartBDrugAvgSalesPrice/ , we define "volume per item" as "The

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amount in one item. (ex., 10 ml in one vial, or 500 tablets in one bottle) Enter "1" for certain forms of drugs (for example, powders and sheets) when "Strength of the Product" indicates the amount of the product per item." In order to accurately calculate Medicare ASP payment limits under section 1847A, we interp ret "the amount in one item" to be the amount of product in the vial or other containe r as indicated on the FDA-approved label. It has been longstanding Medicare polic y that in order to meet the general requirements for coverage under the "inciden t to" provision, services or supplies should represent an expense incurred by the physician or entity billing for the services or supplies (See Medicare Benefit Policy Ma nual (Publication # 100-02), Chapter 15, Sections 50.3, 60.1.A). Such physicians' se rvices and supplies include drugs and biologicals under section 1861(s)(2)(A). In accordance with this policy, providers may only bill for the amount of drug product actua lly purchased and that the cost of the product must represent an expense to the physician. We further understand that when a provid er purchases a vial or container of product, the provider is purchasing an amount of drug defined by the product packaging or label. Any excess, free product (that is, overfill) is pr ovided without charge to the provider. In accordance with our policy, providers may not bill Medicare for overfill harvested from containers, including overfill amounts pooled from more than one container, because that overfill does not represent a cost to the provider. Claims for drugs and biologicals that do not represent a cost to the provider are not reimbursable, and providers who submit such claims may be subject to scrutiny and follow up action by CMS, its contractors, and OIG. Because such overfill is not included in the calculation of payment limits under the methodology in section 1847A of the Act a nd does not represent an incurred cost to a

### CMS-1503-P 410

provider, we are proposing to update our re gulations at 42 CFR part 414 Subpart J to clearly state that Medicare ASP payment limits are based on the amount of product in the

vial or container as reflected on the FDA-a pproved label. We are also proposing to update our regulations to clearly state that payment for amounts of free product, or product in excess of the amount reflected on th e FDA-approved label, will not be made

under Medicare.

4. WAMP/AMP Section 1847A(d)(1) of the Act states that "the Inspector General of HHS shall conduct studies, which may include surveys to determine the widely available market prices (WAMP) of drugs and biologicals to wh ich this section applies, as the Inspector General, in consultation with the Secretary, determines to be a ppropriate." Section 1847A (d)(2) of the Act states that, "Based upon such studies and other data for drugs and biologicals, the Inspector General shall comp are the ASP under this section for drugs and biologicals with --

● The widely available market price (W AMP) for these drugs and biologicals (if any); and

● The average manufacturer price (AMP ) (as determined under section 1927(k) (1) of the Act) for such drugs and biologicals." Section 1847A(d)(3)(A) of the Act states that, "The Secretary may disregard the ASP for a drug or biological that exceeds the WAMP or the AMP for such drug or biological by the applicable threshold perc entage (as defined in subparagraph (B))." Section 1847A(d)(3)(C) of the Act states that if the OIG finds that the ASP for a drug or biological is found to have exceeded the WA MP or AMP by this threshold percentage, the OIG "shall inform the Secretary (at such times as the Secretary may specify to carry

### CMS-1503-P 411

out this subparagraph) and the Secretary shall, effective as of the next quarter, substitute for the amount of payment otherwise determin ed under this section for such drug or biological, the lesser of -- (i) the widely ava ilable market price for th e drug or biological (if any); or (ii) 103 percent of the average manufacturer price...." The applicable threshold percentage is specified in section 1847A(d)(3)(B)(i) of the Act as 5 percent for CY 2005. For CY 2006 and subsequent years, section 1847A(d)(3)(B)(ii) of the Act esta blishes that the applicable th reshold percentage is "the percentage applied under this subparagraph s ubject to such adjustment as the Secretary may specify for the WAMP or the AMP, or both." In the CY 2006 (70 FR 70222), CY 2007 (71 FR 69680), CY 2008 (72 FR 66258), CY 2009 (73 FR 69752), and CY 2010 (74 FR 61904) PFS final rules with comme nt period, we specified an applicable threshold percentage of 5 percent for both th e WAMP and AMP. We based this decision on the fact that data was too limited to support an adjustment to the current applicable threshold percentage. For CY 2011, we are proposing to specify two separate adjustments to the applicable threshold percentages. When making comparisons to the WAMP, we propose the applicable threshold percentage to remain at 5 percent. The applicable threshold percentage for the AMP is addressed below in this section of the preamble. Although the latest WAMP comparison was published in 2008, the OIG is continuing to perform studies comparing ASP to WAMP. Based on available OIG reports that have been published comparing WAMP to ASP, we do not have sufficient information to determine that the 5 percent threshold percentage is in appropriate. As a result, we believe that continuing the 5 percent applicable threshold percentage for the WAMP is appropriate for CY 2011. Therefore we are proposing to revise § 414.904(d)(3) to include the CY 2011

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date.

As we noted in the CY 2010 PFS final rule with comment period (74 FR 61904), we understand that there are complicated operati onal issues associated with this policy. We continue to proceed cautiously in th is area. We remain committed to providing stakeholders, including providers and manufact urers of drugs impacted by potential price substitutions with adequate notice of our intentions regarding such, including the opportunity to provide input with regard to the processes for substituting the WAMP for

the ASP. We welcome comments on our proposal to continue the applicable threshold percentage at 5 percent for the WAMP for 2011.

5. AMP Threshold and Price Substitutions

a. AMP threshold As mentioned elsewhere in this proposal , when making comparisons of ASP to AMP, the applicable threshold percentage for CY 2005 was specified in statute as 5 percent. Section 1847A(d)(3) of the Act allo ws the Secretary to specify adjustments to this threshold percentage for years subseque nt to 2005, and to specify the timing for any price substitution. For CY 2006 (70 FR 70222), CY 2007 (71 FR 69680), CY 2008 (72 FR 66258), CY 2009 (73 FR 69752), and CY 2010 (74 FR 61904), the Secretary made no adjustments to the threshold percentage; it remained at 5 percent. For CY 2011, we are proposing with respect to AMP substitution to apply the applicable percentage subject to certain adjustment such that comparisons of ASP to AMP will only be made when the ASP exceeds the AMP by 5 percent in two consecutive quarters immediately prior to the current pricin g quarter, or three of the previous four quarters immediately prior to the current quarter.

### CMS-1503-P 413

In general, the ASP methodology reflects av erage market prices for Part B drugs for a quarter. The ASP is based, in part, on th e average sales price to all purchasers for a calendar quarter; the AMP, in turn, represents the average price paid by certain wholesalers. Accordingly, while the ASP payment amount for a billing code may exceed its AMP for that billing code for any given quarter, this may only reflect a temporary fluctuation in market prices that would be otherwise corrected in a subsequent quarter. We believe this fluctuation is demonstrated by how few billing codes exceed the applicable threshold percentage over multiple quarters. For example, in the Inspector General's report "Comparison of Average Sale s Prices and Average manufacturer Prices: An Overview of 2008", only 33 of 482 exa mined billing codes exceeded the applicable threshold percentage over multiple quarters. This figure also included billing codes that exceeded the threshold based on partial price comparisons (OEI-03-09-00350). We are concerned that comparisons of a single quarter's ASP to AMP will not adequately account for these temporary fluctuations and und erlying market trends. We believe that applying this threshold percentage adjusted to reflect data from multiple quarters will account for continuing differences between A SP and AMP, and allow us to better identify those drugs that consistently trigger the substitution threshold. We further propose to apply the applicable AMP threshold percentage only for those situations where AMP and ASP compar isons are based on the same set of NDCs for a billing code (that is, "complete" AMP data). Prior to 2008, the OIG calculated a volume-weighted AMP and made ASP and AMP comparisons for only billing codes with such "complete" AMP data. In such comparisons, a volume-weighted AMP for a billing

code was calculated when NDC-level AMP data was available for the same NDCs used by us to calculate the volume-weighted ASP. Beginning in the first quarter of 2008, the

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OIG also began to make ASP and AMP comp arisons based on "partia l" AMP data (that is, AMP data for some, but not all NDCs in a billing code). For these comparisons, the volume-weighted AMP for a billing code is calculated even when only such limited AMP data is available. That is, the volume-weig hted AMP calculated by the Inspector General is based on fewer NDCs than the volume-weig hted ASP calculated by CMS. Moreover, volume-weighted ASPs are not adjusted by the Inspector General to reflect the fewer number of NDCs in the volume-weighted AMP. Because the OIG's partial AMP data comparison does not reflect all the NDCs used in our volume-weighted ASP calculati ons, we have some concerns using the volume-weighted AMP. We believe that such AMP data may not adequately account for market-related drug price changes and may lead to the substitution of incomplete and inaccurate volume-weighted prices. Such substitutions may impact physician and beneficiary access to drugs. Therefore, in accordance with our authority as set forth in section 1847A(d)(1) and (3) of the Act, we are proposing the substitution of 103 percent of AMP for 106 percent of ASP should be limited to only those drugs with ASP and AMP comparisons based on th e same set of NDCs. We are proposing to revise §414.904(d)(3) to reflect corresponding regula tory text changes, and we welcome comments on all aspects of this proposal.

b. AMP Price Substitution (1) Inspector General Studies Section 1847A(d) of the Act requires the In spector General to conduct studies of the widely available market price for drugs and biological to which section 1847A of the Act applies. However, it does not specify th e frequency of when such studies should be conducted. The Inspector General has con ducted studies comparing AMP to ASP for

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essentially each quarter since the ASP syst em has been implemented. Since 2005, the OIG has published 18 reports pertaining to the price substitution issue (see Table 45), of

which 16 have identified billin g codes with volume-weighted ASPs that have exceeded their volume-weighted AMPs by the a pplicable threshold percentage. TABLE 45: Published OIG Reports on Price Substitutions Date Report Title 7/2008 A Comparison of Average Sales Price to Widely Available Market Prices for Inhalation Drugs (OEI-03-07-00190) 6/2006 A Comparison of Average Sales Price to Widely Available Market Prices: Fourth Quarter 2005 (OEI-03-05-00430) 4/2010 Comparison of Third-Quarter 2009 Average Sales Price and Average Manufacturer Prices: Impact on Medica re Reimbursement for First Quarter 2010 (OEI-03-10-00150) 2/2010 Comparison of Average Sales Prices and Average Manufacturer Prices: An overview of 2008 (OEI-03-09-00350)

1/2010 Comparison of Second-Quarter 2009 Av erage Sales Price and Average Manufacturer Prices: Impact on Medi care Reimbursement for Fourth Quarter 2009 (OEI-03-09-00640)

8/2009 Comparison of First-Quarter 2009 Av erage Sales Price and Average Manufacturer Prices: Impact on Me dicare Reimbursement for Third Quarter 2009 (OEI-03-09-00490)

8/2009 Comparison of Fourth-Quarter 2008 Average Sales Price and Average Manufacturer Prices: Impact on Me dicare Reimbursement for Second Quarter 2009 (OEI-03-09-00340)

4/2009 Comparison of Third Quarter 2008 Av erage Sales Prices and Average Manufacturer Prices: Impact on Medica re Reimbursement for First Quarter 2009 (OEI-03-09-00150)

2/2009 Comparison of Second Quarter 2008 Av erage Sales Prices and Average Manufacturer Prices: Impact on Medi care Reimbursement for Fourth Quarter 2008 (OEI-03-09-00050)

12/2008 Comparison of First Quarter 2008 Av erage Sales Price and Average Manufacturer Prices: Impact on Me dicare Reimbursement for Third Quarter 2008 (OEI-03-08-00530) 12/2008 Comparison of Average Sales Prices and Average Manufacturer Prices: An Overview of 2007 (OEI-03-08-00450)

8/2008 Comparison of Fourth-Quarter 2007 Average Sales Price and Average Manufacturer Prices: Impact on Me dicare Reimbursement for Second Quarter 2008 (OEI -03-08-00340)

5/2008 Comparison of Third-Quarter 2007 Av erage Sales Price and Average Manufacturer Prices: Impact on Medica re Reimbursement for First Quarter 2008 (OEI-03-08-00130) 12/2007 Comparison of Second-Quarter 2007 Average Sales Price and Average

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Date Report Title Manufacturer Prices: Impact on Medi care Reimbursement for Fourth Quarter 2007 (OEI-03-08-00010)

9/2007 Comparison of First-Quarter 2007 Av erage Sales Price and Average Manufacturer Prices: Impact on Me dicare Reimbursement for Third Quarter 2007 (OEI-03-07-00530)

7/2007 Comparison of Third-Quarter 2006 Av erage Sales Price and Average Manufacturer Prices: Impact on Medica re Reimbursement for First Quarter 2007 (OEI-03-07-00140)

7/2006 Comparison of Fourth-Quarter 2005 Average Sales Price and Average Manufacturer Prices: Impact on Me dicare Reimbursement for Second Quarter 2006 (OEI-03-06-00370) 4/2006 Monitoring Medicare Part B Drug Pr ices: A Comparison of Average Sales Price to Average Manufacturer Prices (OEI-03-04-00430)

For example, in their latest report comparing AMP to ASP entitled "Comparison of Third-Quarter 2009 Average Sales Price a nd Average Manufacturer Prices: Impact on Medicare Reimbursement for First Quar ter 2010" (OEI-03-10-00150), the Inspector

General found that of 356 billin g codes with complete AMP da ta in the third quarter of 2009, 16 met the 5 percent threshold, that is, AS P exceeded AMP by at least 5 percent. Eight of these 16 billing codes were also eligible for price adjustments in one or more of the previous four quarters, with three drugs meeting the 5-percent threshold in all five quarters under review. This Inspector Gene ral report further indicates that, "If

reimbursement amounts for all 16 drugs had been based on 103 percent of the AMPs, we estimate that Medicare expenditures would have been reduced by over half a million dollars in the first quarter of 2010." These drugs and the savings found by the Inspector General constitute potential savings for the Medicare program and beneficiaries. (2) Regulatory, Judicial, and Legislative Changes Since 2005, regulatory and le gislative changes, as well as litigation, have had a direct impact on this price substitution issue. In 2007, we published a final rule that, in accordance with section 6001(c) of the Deficit Reduction Act, was designed to clarify the

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definition of AMP (72 FR 39142). On Dece mber 19, 2007, the United States District Court for the District of Columbia issued a preliminary injunction in National Association of Chain Drug Stores et al. v. Health and Human Services , Civil Action No. 1:07-cv-02017(RCL) that enjoins CMS, in part, from posting any AMP data on a public website or otherwise disclosing any AMP data to certain individuals or entities, including, but not limited to, States or their representatives. (For additional information on this injunction, please see our web site at http://www.cms.hhs.gov/DeficitReducti onAct/Downloads/AMPPIOrder.pdf ). In 2010, section 2503 of ACA amended the defi nition of AMP, in part, to reflect the average price paid for covered outpatie nt drugs: (1) by wholesalers for drugs distributed to retail community pharmacies; and (2) by retail community pharmacies that purchase drugs directly from the manufacture r. The statute defines retail community pharmacies, in part, as independent, ch ain, and supermarket pharmacies. (3) Proposal Overall, we are cognizant that any policy must reflect market-related pricing changes. Additionally, we continue to reco gnize the need, in light of the statute, to implement a price substitution policy. As discussed previously, section 1847A(d)(3 ) of the Act provides authority for us to determine the applicable percentage subject to "such adjustment as the Secretary may specify for the widely available market price or the average manufacturer price, or both." We also have authority to specify the timin g of any ASP substitution. Consistent with this authority, we are proposing a policy to substitute 103 percent of AMP for 106 percent of ASP where the applicable percentage has been satisfied for a number of calendar quarters, as discussed elsewhere in this rule. This policy would apply to both

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single source and multiple source drugs and biologicals as defined respectively at section 1847A(c)(6)(C) and (D) of the Act. We acknowledge the limitation of the pr eliminary injunction on our ability to publicly disclose AMP data and until that injunction is modified, we will not implement this price substitution policy. Because of the lack of data regarding WAMP to ASP comparisons, we are explicitly excluding WAMP from this pr ice substitution proposal though we are proposing to maintain the WAMP threshold at 5 percent for CY 2011 in a separate section of this rule. Overall, we are interested in implementing a price substitution policy that reflects market-related pricing changes and which focuses on those drugs that consistently exceed the price substitution th reshold over multiple quarters. Unlike the OIG's AMP studies, the published WAMP studies have recommended price substitutions based on specific timeframes that do not illustrate whether such pricing discrepancies are singular or consistent across multiple quarter s. We will reconsider proposing a policy for

the substitution of WAMP at a later date. (4) Timeframe for and Duration of Price Substitutions As stated in §414.804(a)(5), a manufactur er's average sales price must be submitted to CMS within 30 days of the close of the quarter. We then calculate an ASP for each billing code as per the process outlined at §414.904. Then, as per our CY 2005 PFS final rule (69 FR 66300) , we implement these new prices through program instructions or otherwise at the first opportuni ty after we receive the data, which is the calendar quarter after receipt. Section 1847A(d)(3)(C) of the Act indicat es that a price substitution would be implemented "effective as of the next quarter" after the OIG has informed us that the ASP

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for a drug or biological exceeds its AMP by the applicable percentage threshold. The OIG does not receive new ASP prices for a gi ven quarter until after we have finalized them. Also, the results of their pricing comparisons are not available until after the ASP prices for a given quarter have gone into effect. Therefore, we anticipate that there will be a three quarter lag for substituted prices from the quarter in which manufacturer sales occurred, though this will depend in great part upon the timeframe in which we obtain comparison data from the OIG. Table 46 provides an example of this timeframe. TABLE 46: Example Price Substitution Timeframe Q2-10 Q3-10 Q4-10 Q1-11

Manufacturer

sells drug. Manufacturer submits Q2-10

pricing data. CMS calculates

ASP payment limits for Q4-10. CMS publishes Q4-10 payment limits.

ASP Process CMS calculates ASP payment limits for Q1- 11. Compares

calculated payment limits to OIG substitute

prices. Publishes Q1- 11 prices that may include OIG substitute prices.

OIG Process OIG receives Q4- 10 pricing from CMS and compares it to Q2-10 volumeweighted AMP data. Notifies CMS of eligible HCPCS for substitution.

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Given this lag in time, the ASP price for a billing code may have decreased since the OIG's comparison. Therefore, consistent with our authorities in section 1847A(d)(3) of the Act and our desire to provide accurate payments consistent with these provisions, we believe that the timing of any substitu tion policy should permit a final comparison between the OIG's volume-weighted 103 percen t AMP for a billing code (calculated from the prior quarter's data) and the billing c ode's volume-weighted 106 percent ASP, as calculated by CMS, for the current quarter. This final comparison would assure the Secretary that the 106 percent ASP payment limit continues to exceed 103 percent of the

OIG's calculated AMP in order to avoid a situation in which the Secretary would inadvertently raise the Medicare payment limit through this price substitution policy. We specifically request comments on this proposal. ASP payment limits are calculated on a quarterly basis as per section 1847A(c)(5)(A) of the Act, and we are partic ularly mindful that the ASP-based payment allowance for a billing code may change from quarter to quarter. As such, we propose that any price substitution would last for one quarter. Overall, we believe that our proposal as outlined above to substitute 103 percent of AMP for 106 percent of ASP provides us with a viable mechanism for generating savings for the Medicare program and its beneficiaries since it will allow Medicare to pay based off lower market prices for those drugs and biologicals that consistently exceed the applicable threshold percentage. Moreover, it will enable us to address a programmatic vulnerability identified by the OIG. We welcome comments on all aspects of our proposal.

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We are also seeking comment on other issues related to the comparison between ASP and AMP, such as--

● Any effect of definitional differences between AMP and ASP, particularly in light of the revised definition of AMP per ACA;

● The impact of any differences in AM P and ASP reporting by manufacturers on price substitution comparisons; and

● Whether and/or how general differences and similarities between AMP and manufacturer's ASP would affect comparisons between these two.

B. Ambulance Fee Schedule Issue: Po licy for Reporting Units when Billing for Ambulance Fractional Mileage Under the ambulance fee schedule, the Me dicare program pays for transportation

services for Medicare beneficiaries wh en other means of transportation are contraindicated and all other applicable medical necessity requirements are met.

Ambulance services are cl assified into different levels of ground (including water) and air ambulance services based on the medically necessary treatment provided during transport. These services include the following levels of service:

● For Ground-- ++ Basic Life Support (BLS)(emergency and nonemergency). ++ Advanced Life Support, Level 1 (A LS1) (emergency and nonemergency). ++ Advanced Life Support, Level 2 (ALS2). ++ Specialty Care Transport (SCT). ++Paramedic ALS Intercept (PI).

● For Air-- ++ Fixed Wing Air Ambulance (FW).

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++ Rotary Wing Air Ambulance (RW). 1. History of Medicare Ambulance Services a. Statutory Coverage of Ambulance Services Under sections 1834(l) and 1861(s)(7 ) of the Act, Medicare Part B (Supplementary Medical Insurance) covers and pays for ambulance services, to the extent prescribed in regulations, when the use of other methods of transportation would be contraindicated by the beneficiary's me dical condition. The House Ways and Means Committee and Senate Finance Committee Repor ts that accompanied the 1965 Social Security Amendments suggest that the Congress intended that--

● The ambulance benefit cover transporta tion services only if other means of transportation are contraindicated by th e beneficiary's medical condition; and

● Only ambulance service to local fac ilities be covered unless necessary services are not available locally, in which case, transportation to the nearest facility furnishing those services is covered (H.R. Rep. No. 213, 89 th 

### Cong., 1 st 

### Sess. 37 and Rep. No. 404,

89 th 

### Cong., 1 st 

### Sess. Pt 1, 43 (1965)). The reports indicate that transportation may also be provided from one hospital to another, to the beneficiary's home, or to an extended care facility. b. Medicare Regulations for Ambulance Services Our regulations relating to ambulance services are set forth at 42 CFR part 410, subpart B, and 42 CFR part 414, subpart H. Section 410.10(i) lists ambulance services as one of

the covered medical and other health services under Medicare Part B. Therefore,

ambulance services are subject to basic conditions and limitations set forth at §410.12 and to specific conditions and limitations as specified in §410.40 and §410.41. Part 414, subpart H, describes how payment is made for ambulance services covered by Medicare.

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2. Mileage Reporting a. Background and Current Process for Reporting Ambulance Mileage Historically, the Medicare fee-for-service (FFS) claims processing system lacked the capability to accept and process fractional unit amounts reported in any claim format. Therefore, the standard for reporting units for ambulance mileage was to bill in whole number increments. Thus, if the total units of service for ambulance mileage included a fractional amount, providers and suppliers of ambulance servi ces (hereafter referred to collectively as “providers and suppliers”) we re instructed to round the fraction up to the next whole number. Claims billed with fractional units of service were, at that time, returned as unprocessable as CMS' claims processing systems could not accept nor adjudicate fractional unit amounts properly. Consequently, in Change Request ( CR) 1281 (Transmittal AB-00-88, issued on September 18, 2000), we instituted an opera tional procedure requiring whole-unit reporting of mileage on ambulance claims. Specifically, we instructed providers and suppliers that “If mileage is billed, the miles must be whole numbers. If a trip has a fraction of a mile, round up to the nearest whole number.” Our instructions also stated that “1” should be reported for trips totalin g less than a single mile. This was an operational instruction based on Medicare's FFS system limitations and capabilities at the time, as our claims processing systems were not capable of accepting and processing claims submitted with fractional units of service. Since then, our claims processing system functionality has evolved to the point where this rounding process is no longer necessary for most ambulance transports, as it is now possible for our FFS systems to capture and accurately process fractional units on both paper and electronic forms. Under our current instructions, providers and suppliers continue to report loaded

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mileage as whole-number units on both paper and electronic claims. Providers and suppliers utilize the appropriate Healthcare Common Procedure Coding System (HCPCS)code for ambulance mileage to report the number of miles traveled during a Medicarecovered trip rounded up to the nearest whol e mile at a minimum of 1 unit for the purpose of determining payment for mileage. Transmittal AB-00-88 established a list of HCPCS codes accepted by Medicare for the purpose of billing mileage. Providers and suppliers were instructed to use these specific HCPCS codes and enter the total number of covered miles in the “units” field of the claim form. For example, if a covered trip from the point of pickup (POP) to the Medicare-approved destination (see §414.40 for a list of approved destinations) totaled 9.1 miles, the provider would enter the appropriate HCPCS code for covered mileage and a “10” in the units field. Providers and suppliers billing for trips totaling, for example, 0.5 covered miles, would enter “1” in the units field along with the appropriate HCPCS code for mileage. b. Concerns Regarding the Potential for Inaccuracies in Reporting Units and Associated

Considerations Often an ambulance provider will transport a distance that is either not an exact whole number of miles or less than one whole mile during a covered trip. Currently, providers and suppliers billing for ambulance services must round up the total billable mileage to the nearest whole mile for trips that include a fraction of a mile or less than

one whole mile. Under our current instructions , a provider or supplier is required to bill as much as .9 of a mile more than what was actually traveled. We have been contacted by suppliers on several occasions with concerns regarding our current instructions for re porting ambulance mileage. Certain suppliers

believe that our instructions require them to bill inaccurately . One company in particular

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stated that they routinely need to bill for tr ips totaling less than 1 mile. The beneficiaries that are being transported by this company live in the immediate vicinity of the facility to which they are being transported, and therefore, the number of loaded miles for each trip totals approximately one half of a mile. The company was concerned that since Medicare requires that they enter a “1” in the units field of their claims for mileage, they are being overpaid by Medicare for mileage based on the service they actually provided. However, the company's main concern revolved around the risk of creating an appearance of impropriety. Although our in structions clearly state that providers and suppliers should, as a matter of procedure, round up frac tional mileage amounts to the nearest whole mile, some provide rs and suppliers indicated that they wanted to bill as accurately as possible and that they only wanted to be paid for the service they actually provided. We thoroughly considered these c oncerns while reevaluating the procedure for reporting units for fractional mileage amounts. Our first priority in considering the issues raised by ambulance providers and suppliers was to ascertain the basis for the current mileage reporting instructions. As previously discussed, the original instructions for reporting fractional mileage were published in Transmittal AB-00-88, issued on September 18, 2000. We instructed providers and suppliers to round fractiona l mileage amounts “up to the nearest whole mile” and to enter “1” for fractional mileage totaling less than one mile. This particular process had also been in place prior to issu ance of the transmittal. The reason for the procedure was that our claims processing systems were not capable of accepting and processing claims submitted with fractional units of service – even if the service was commonly measured in fractional am ounts, as with ambulance mileage. We then explored whether a change in our procedure would be: (a) appropriate,

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(b) possible considering our current system capabilities and industry standards of measurement, and (c) applicable to any service other than ambulance mileage. As to the appropriateness of changing the procedure fo r reporting units of service on provider claims for fractional ambulance mileage, we be lieve that we should make every effort to create and implement policies a nd processes that create the best opportunity for accuracy in billing. It is not our intention to put providers and suppliers in a position where they are required to bill inaccurately for the service they provide. We continue to strive toward ensuring that providers and suppliers bill and are paid only for services actually provided. We believe that changing our curre nt procedure for reporting units of service to require reporting of fractiona l mileage will help to ensure that providers and suppliers can submit claims that more precisely reflect actual mileage, and are reimbursed more accurately for the services they actually provided. We originally instituted a policy of accepting and processing only whole units because at that time, system limitations prevented us from accepting and processing fractional ambulance mileage. Second, we considered whether it is curren tly possible for our claims processing systems to accept and process fractional unit amounts on both paper and electronic claims. Upon reevaluating our system capabilities, we found th at technological advancements in Optical Character Recognition (OCR) and electronic claim submission have made it possible for our FFS systems to capture and accurately process fractional units on both paper and electronic claims. We note that our systems currently have the capability to accept fractional units with accuracy up to as much as one thousandth of a unit (that is, to 3 decimal places).

We also considered whether ambulance providers and suppliers have the capability to measure fractional mileage. Th is was an important point because if

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providers and suppliers are not able to meas ure mileage with any more specificity than the nearest whole number mile, then there would be no need to modify the current procedure for billing fractional mileage. In that case, providers and suppliers would continue to report mileage as whole numbers since they could measure no more accurately than that. However, both analog and digital motor vehicle odometers are designed to measure mileage accurately to w ithin a minimum of a tenth of a mile. While

we found that some vehicle odometers measure mileage more accurately than a tenth of a mile, most odometers are accurate to the neares t tenth of a mile. Additionally, aircraft geographic positioning system (GPS) tec hnology provides the means to accurately determine billable mileage to the tenth of a mile. Third, we considered whether a policy of billing fractional units would be applicable to any other service besides ambulance mileage. The units of service field on both the electronic and paper claim is used to report the quantity of services or supplies provided to Medicare beneficiaries and is used to report a wide range of services and supplies including, but not limited to: number of office visits; anesthesia minutes; quantity of drugs administere d; covered miles. Although Medicare currently makes payment based on fractional units for some se rvices (for example, calculation of payment

after conversion of anesthesia time reported in minutes to time units), there is currently no requirement that providers bill fractional units on the claim. If we were to implement a policy of requiring reporting of fractional un its for other types of services or supplies

we would first need to evaluate whether it is possible to do so considering industry standards of measurement. As previous ly discussed, providers and suppliers of ambulance services have the capability to determine fractional mileage using standard onboard equipment, that is, an odometer, GPS, and/or other similar equipment used to

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measure distance traveled. Th is would enable us to readily implement a fractional unit billing policy for ambulance mileage; whereas applicability to other areas (such as anesthesia, drugs, etc.) would require more analysis to determine whether a fractional unit billing policy is feasible, efficacious, and co st effective. Additionally, this issue was first raised by ambulance suppliers who were concerned about overbilling and being overpaid by Medicare. Therefore, we believe it is most reasonable to first address the area where concerns have been raised (that is, ambulance mileage) and consider applicability of this procedure to other types of services and items in the future. Finally, and perhaps most importantly, we considered that our claims processing system should be configured to process claims as accurately as possible so as to provide for more accurate payments and to safeguar d Medicare dollars. As previously discussed, ambulance providers and suppliers currently have the capability to measure mileage accurately to within a minimum of a tenth of a mile using devices (for example, odometers, GPS technology, etc.) already e quipped onboard their vehicles. We believe that requiring ambulance providers and s uppliers to round (and report) fractional ambulance mileage up to the next tenth of a mile strikes a proper balance between ensuring that the claims processing system adjudicates a claim as accurately as the system will permit without unduly bur dening the ambulance community.

Based on all of the above considerations, we have decided that our claims processing instructions for submission of claims for ambulance mil eage should be revised to reflect the current functionality of our claims processing systems so as to maximize the accuracy of claims payment, as further discussed below in this section. c. Billing of Fractional Units for Mileage It is both reasonable and prudent that, in order to ensure accuracy of payment, we

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facilitate and allow submi ssion of the most accurate information on all Medicare ambulance claims. Furthermore, since our claims processing systems are currently capable of accepting and processing fracti onal units of service, we believe that ambulance mileage should be billed to and pa id by Medicare in fractional amounts to enhance payment accuracy. Based on all the considerations discu ssed above, we are proposing to require that claims for mile age submitted by ambulance providers and suppliers for an ambulance transport (ground and air) be billed in fractional units, by rounding up to the nearest tenth of a mile (with the exception discussed below). As discussed above, we believe that requiring ambulance providers and suppliers to round (and report) fractional mileage up to the next tenth of a mile would allow us to provide for more accurate claims payment wit hout unduly burdening the ambulance community. Therefore, we are proposing that, effective for claims with dates of service on and after January 1, 2011, ambulance providers and suppliers would be required to report mileage rounded up to the nearest tenth of a mile for all claims for mileage totaling up to

100 covered miles. Provider s and suppliers would sub mit fractional mileage using a decimal in the appropriate place (for exampl e, 99.9). Since standard vehicle mileage (analog, digital, and GPS) is or can be calculated accurately to the nearest tenth of a mile, we are proposing that the mileage billed to Medicare by ambul ance providers and suppliers be reported by rounding up to the next tenth of a mile. Although the electronic claim formats can accommodate fractional mileage when mileage is equal to or greater than 100 covered miles (for example, 100.0), the paper claim cannot. Because the Form CMS-1500 pa per claim currently only supports four characters (including the decimal point) in the units field (Item 24G), we also propose that mileage equal to or greater than 100 cove red miles continue to be reported in whole

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number miles on both paper and electronic cl aims. We propose that providers and suppliers would round up fracti onal mileage to the next whole number for mileage that exceeds 100 covered miles and report the resultin g whole number in the units' field. We

would revise the instructions set forth in our Claims Processing Manual to reflect the revised procedures for submitting and pa ying claims for fractional ambulance. C. Clinical Laboratory Fee Schedule: Signature on Requisition In the March 10, 2000 Federal Register , we published the “Medicare Program; Negotiated Rulemaking: Coverage and Administrative Policies for Clinical Diagnostic Laboratory Services” proposed rule ( 65 FR 13082) announcing a nd soliciting comments on the results of our negotiated rulemaking committee tasked to establish national coverage and administrative po licies for clinical diagnostic laboratory tests under Part B

of Medicare. In our final rule published in the November 23, 2001 Federal Register (66 FR 58788), we explained our policy on or dering clinical diagnostic laboratory services and amended §410.32 to make our policy more explicit. Our regulation at §410.32(a) states the requirement that “[a]ll di agnostic x-ray tests, diagnostic laboratory tests, and other diagnostic te sts must be ordered by the physician who is treating the beneficiary.” In the November 23, 2001 fina l rule, we added paragraph (d)(2) to §410.32 to require that the physicia n or qualified nonphysic ian practitioner (NPP) (that is, clinical nurse specialists, clinical psychologists, clin ical social workers, nurse-midwives, nurse practitioners (NPs), and physician assistants (PAs)) who orders the service must maintain documentation of medical necessity in the be neficiary's medical record (66 FR 58809). In the preamble discussions to the Marc h 10, 2000 proposed rule and November 23, 2001 final rule (65 FR 13089 and 66 FR 58802, respec tively), we noted that “[w]hile the signature of a physician on a requisition is one way of documenting that the treating

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physician ordered the test, it is not the only pe rmissible way of documenting that the test has been ordered.” In those preambles, we described the policy of not requiring physician signatures on requisitions for clini cal diagnostic laboratory tests, but implicitly left in place the existing requirements for a wr itten order to be signed by the ordering physician or NPP for clinical diagnostic la boratory tests, as well as other types of diagnostic tests. We further stated in the preambles of the proposed and final rules that we would publish an instruction to Medicare c ontractors clarifying that the signature of the ordering physician is not required for Me dicare purposes on a requisition for a clinical diagnostic laboratory test (65 FR 13089 and 66 FR 58802). On March 5, 2002, we published a pr ogram transmittal implementing the administrative policies set forth in the final rule, including the following instruction: “Medicare does not require the signature of th e ordering physician on a laboratory service requisition. While the signature of a ph ysician on a requisition is one way of documenting that the treating physician ordered the service, it is not the only permissible way of documenting that the service has been ordered. For example, the physician may document the ordering of specific services in the patient's medical record.” (Transmittal AB-02-030, Change Request 1998, dated March 5, 2002). On January 24, 2003, we published a progra m transmittal in or der to manualize the March 5, 2002 Transmittal. (Trans mittal 1787, Change Re quest 2410, dated January 24, 2003). The cover note to the tr ansmittal states, “Section 15021, Ordering Diagnostic Tests, manualizes Transmitta l AB-02-030, dated March 5, 2002. In accordance with negotiated rulemaking for outpatient clinical diagnostic laboratory services, no signature is required for the orde ring of such services or for physician pathology services.” In the manual instructions in that transmittal in a note, we stated:

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“No signature is required on orders for clini cal diagnostic services paid on the basis of the physician fee schedule or for physician pat hology services.” The manual instructions did not explicitly reference clinical diagnos tic laboratory tests as the cover note did. Rather, the transmittal seemed to extend the policy set forth in the Federal Register (that no signature is required on requisitions for c linical diagnostic laboratory tests paid under the Clinical Laboratory Fee Sc hedule (CLFS)) to also apply to clinical diagnostic tests paid on the basis of the Phys ician Fee Schedule (PFS) and ph ysician pathology services. In addition, the manual instructions used the term “order” instead of “requisition,” which some members of the industry have asserted caused confusion. When we transitioned from pa per manuals to the current electronic Internet Only Manual system, these manual instructions were inadvertently omitted from the new Benefit Policy Manual (BPM). In August 2008, we issued a program tr ansmittal (Transmittal 94, Change Request 6100, dated August 29, 2008) to update the BP M to incorporate language that was previously contained in section 15021 of th e Medicare Carriers Manual. The reissued language states, “No signature is required on orders for clinical diagnostic tests paid on the basis of the clinical laboratory fee sc hedule, the physician fee schedule, or for physician pathology services.” Based on furt her review, we have determined that there are no clinical diagnostic laboratory tests paid under the PFS. After Transmittal 94 was published, we received numerous inquiries from laboratory, diagnostic testing, and hospital representatives who had questions about whether the provision applied to all diagnostic services, including x-rays, MRIs, and other nonclinical laboratory fee schedule diagnostic services.

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To resolve any existing confusion surroundi ng the implementation of the policy in 2001 and subsequent transmitta ls, we restated and solic ited public comments on our policy in the CY 2010 PFS proposed rule (74 FR 33641). Our current policy is that a physician's signature is not required on a re quisition for clinical diagnostic laboratory tests paid on the basis of the CLFS; however, it must be evident, in accordance with our regulations at §410.32(d)(2) and (3), that the physician ordered the services.

We note that we solicited and received comments on this signature requirement during the notice and comment period for the March 10, 2000 proposed rule in the context of our proposal to add paragra ph (d)(2)(i) to §410.32 to require that the practitioner who orders a diagnostic laboratory test must maintain documentation of medical necessity in the beneficiary's me dical record. The majority of comments supported the adoption of a policy that the signature of the practitioner on a requisition for a clinical diagnostic laboratory test pa id under the CLFS is not the only way of documenting that the test has been ordere d and, thus, should not be required provided

such documentation exists in an alternate form. This policy regarding requisitions for clin ical diagnostic laboratory tests does not supersede other applicable Medicare require ments (such as those related to hospital Conditions of Participation (CoP s)) which require the medical record to include an order signed by the physician who is treating the be neficiary. Nor do we believe that anything in our policy regarding signatures on requisiti ons for clinical diagnostic laboratory tests supersedes other requirements mandated by professional standards of practice or obligations regarding orders and medical re cords promulgated by Medicare, the Joint Commission, or State law; nor do we believe the policy would require providers to change their business practices.

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We also restated and solicited public comment on our long-standing policy consistent with the principle in §410.32(a) that a written order for diagnostic tests including those paid under the CLFS and thos e that are not paid under the CLFS (for example, that are paid under the PFS or under the OPPS), such as X-rays, MRIs, and the TC of physician pathology services, must be signed by the ordering physician or NPP. That is, the policy that signatures are not required on requisitions for clinical diagnostic laboratory tests paid based on the CLFS app lies only to requisitions (as opposed to written orders) (74 FR 33642). Additionally, we solicited public comments about the distinction between an order and a requisition (74 FR 33642). We note that an “order” as defined in our IOM, 100-02, Chapter 15, Section 80.6.1, is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. The order may conditionally request an add itional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physician/practitioner (for example, if test X is negative, then perform test Y). As set forth in the CY 2010 MPFS final rule (FR 74 61930), an order may be delivered via any of the following forms of communication:

● A written document signed by the treating physician/practitioner, which is hand-delivered, mailed, or faxed to the testing facility.

● A telephone call by the trea ting physician/practitioner or his or her office to the testing facility.

● An electronic mail, or other electronic means, by the treating physician/practitioner or his or her office to the testing facility.

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If the order is communicated via telephone, both the treating physician/practitioner, or his or her office, and the testing facility must document the telephone call in their respective copies of the beneficiary's medical records. In the proposed rule (74 FR 33642), we de fined a “requisition” as the actual paperwork, such as a form, which is provided to a clinical diagnostic laboratory that identifies the test or tests to be performed for a patient. It may contain patient information, ordering physician inform ation, referring institution information, information about where to send reports, billing information, specimen information, shipping addresses for specime ns or tissue samples, and checkboxes for test selection. We believe it is ministerial in nature, assisting laboratories with billing and handling of results, and serves as an administrative c onvenience to providers and patients. We believe that a written order, which may be part of the medical record, and the requisition are two different documents, although a requisition that is signed may serve as an order.

We welcomed comments from th e public about the distincti on between requisitions and

orders. During the proposed and final rulemaki ng process for CY 2010, we received numerous comments on these issues, including, among others: expressions of continued confusion over the difference between an “order” and a “requisition”; requests that CMS develop a single policy for a ll outpatient laboratory services, without the distinction for those paid under the CLFS or the PFS; and concerns about reference laboratory technicians who felt compelled to perform a test in order to protect the viability of the specimen although they did not have the proper documentation. See 74 FR 61930-32 for a complete discussion of the comments received and responses to these issues. In the CY

2010 PFS final rule with comment period (74 FR 61931), we stated that, in light of the

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issues and concerns raised during the comment period, and our desire to create policy that will address the concerns in a meaningful, cl ear and thoughtful way, we would continue to carefully consider the issues of physician signatures on requisitions and orders and that we plan to revisit these issues in the future pa ying particular attenti on to the definitions of order and requisition. Since the publication of the CY 2010 PFS final rule with comment period, we have considered an approach that would a ddress the concerns raised. We are proposing to require a physician’s or NPP’s signat ure on requisitions for clinical diagnostic laboratory tests paid on the basis of the CLFS. We believe that this policy would result in a less confusing process. We believe that it would be less confusing because a phys ician’s signature would then be required for all requisitions and orders, eliminating uncertainty over whether the documentation is a requisition or an order, whether the type of test being ordered re quires a signature, or which payment system does or does not require a physician or NPP signature. We also believe that it would not increase the burden on physicians because it is our understanding that, in most instances, physic ians are annotating the patient's medical record with either a signature or an initial (the "order"), as well as providing a signature on the paperwork that is provided to the clinical diagnostic laboratory that identifies the test or tests to be performed for a patient (the "requisition") as a matter of course. Further, this policy would make it easier for the reference laboratory technicians to know whether a test is appropriately requeste d, and potential compliance problems would be minimized for laboratories during the course of a subsequent Medicare audit because a signature would be consistently required. As already discussed, this minimizes confusion and provides a straightforward dir ective for laboratories to meet.

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We welcome comments on this proposal. D. Discussion of Chiroprac tic Services Demonstration Section 651 of MMA requires the Secretary to conduct a 2-year demonstration to evaluate the feasibility and advisability of expanding coverage for chiropractic services

under Medicare. Medicare c overage for chiropractic se rvices is limited to manual manipulation of the spine to correct a subl uxation described in section 1861(r)(5) of the Act. The demonstration expanded current Medicare coverage to include "care for neuromusculoskeletal conditions typical amon g eligible beneficiaries and diagnostic and other services that a chiropractor is legall y authorized to perform by the State or jurisdiction in which such treatment is provided" and 

### was conducted in four geographically diverse sites, two rural and tw o urban regions, with each type including a

Health Professional S hortage Area (HPSA). The two urban sites were 26 counties in Illinois and Scott County, Iowa, and 17 counties in Virginia. The two rural sites were the

States of Maine and New Mexico. The demonstration, which ended on March 31, 2007, was required to be budget neutral as s ection 651(f)(1)(B) of MMA mandates the Secretary to ensure that "the aggregate payments made by the Secretary under the Medicare program do not exceed the amount wh ich the Secretary would have paid under the Medicare program if the demonstrati on projects under this section were not implemented." In the CY 2006, 2007, and 2008 PFS final rules with comment period (70 FR 70266, 71 FR 69707, 72 FR 66325, respectively), we included a discussion of the strategy that would be used to assess budget neutrality (BN) and the method for adjusting chiropractor fees in the event the demonstrati on resulted in costs higher than those that

would occur in the absence of the demonstration

. We stated BN would be assessed by

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determining the change in costs based on a pre-post comparison of Medicare costs for

beneficiaries in the demonstr ation and their counterparts in the control groups and the rate of change for specific diagnoses that are treated by chiropractors and physicians in

the demonstration sites and contro l sites. We also stated that our analysis would not be limited to only review of chiropractor claims because the costs of the expanded chiropractor services may have an impact on other Medicare costs.

In the CY 2010 PFS final rule with comme nt period (74 FR 61926), we discussed

the evaluation of this demons tration conducted by Brandeis University and the two sets of analyses used to evaluate budget neutrality. In the "All Neuromusculoskeletal Analysis," which compared the Medicare costs of all beneficiaries who received services

for a neuromusculoskeletal condition in the demonstration areas with those of beneficiaries with similar characteristics from similar geographic areas that did not participate in the demonstra tion, the total effect of the demonstration to Medicare was $114 million. In the "Chiropractic User Analysis," which compared the Medicare costs

of beneficiaries who used ex panded chiropractic services to treat a neuromusculoskeletal condition in the demonstration areas, with those of beneficiaries with similar characteristics who used chiropractic services as currently covered by Medicare to treat a neuromusculoskeletal condition from similar geographic areas that did not participate in the demonstration, the total effect of th e demonstration to Medicare was $50 million. As explained in the CY 2010 PFS final rule, we based the BN estimate on the "Chiropractic User Analysis" because of its fo cus on users of chiropractic services rather

than all Medicare beneficiarie s with neuromusculoskeletal conditions, including those who did not use chiropractic services a nd who would not have become users of chiropractic services even with expande d coverage for them (74 FR 61926 through

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61927). Users of chiropractic services are mo st likely to have been affected by the expanded coverage provided by th is demonstration. Cost increases and offsets, such as reductions in hospitalizations or other types of ambulatory care, are more likely to be observed in this group. As explained in the CY 2010 PFS final rule (74 FR 61927), because the costs of this demonstration were higher than expected and we did not anticipate a reduction to the PFS of greater than 2 percent per year, we finalized a policy to recoup $50 million in expenditures from this demonstrati on over a 5-year period, that is, CYs 2010 through 2014 (74 FR 61927). Specifi cally, we are recouping $10 million for each such year through adjustments to the chiropractic CPT codes. Payment under the PFS for these codes will be reduced by approximately 2 percent. We believe that spreading this adjustment over a longer period of time will minimize its potential negative impact on chiropractic practices. We are continuing the implementati on of the required budget neutrality adjustment by recouping $10 million in CY 2011. Our Office of the Actuary estimates chiropractic expenditures in CY 2011 to be approximate ly $524 million based on actual Medicare spending for chiropractic services fo r the most recent available year. To recoup $10 million in CY 2011, the payment amount under the PFS for the chiropractic CPT codes (that is, CPT codes 98940, 98941, and 98942) will be reduc ed by approximately 2 percent. We are reflecting this reduction onl y in the payment files used by the Medicare contractors to process Medicare claims ra ther than through adjusting the RVUs. Avoiding an adjustment to the RVUs would preserve the integrity of the PFS, particularly since many private payers also base payment on the RVUs.

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E. Provisions Related to Pa yment for Renal Dialysis Services Furnished by End-Stage Renal Disease (ESRD) Facilities Since August 1, 1983, payment for dialysis services furnished by ESRD facilities has been based on a composite rate payment system that provides a fixed, prospectively determined amount per dialysis treatment, ad justed for geographic differences in area wage levels. The composite rate is designed to cover a package of goods and services needed to furnish dialysis treatments that include, but not be limited to, certain routinely provided drugs, laboratory tests, supplies, and equipment. Unless specifically included in the composite rate, other injectable drugs and laboratory tests medically necessary for the care of patients on dialysis are separately billable. Other than periodic updates, there were no significant changes to the composite rate payment system until the implementation of the basic case-mix adjusted composite rate payment system beginning January 1, 2005. The Congress has enacted a number of adjustments to the composite rate since th at time. As a result of the July 15, 2008 enactment of MIPPA, we are required to imple ment an end-stage renal disease (ESRD) bundled proposective payment system effective January 1, 2011 (referred to as the “ESRD PPS”). Below we briefly discuss the ESRD PPS, the basic case-mix composite payment system, as well as our proposed updat es to the composite rate portion of the blended payment for CY 2011.

a. MIPPA - The ESRD PPS On September 29, 2009 , we published in the Federal Register a proposed rule entitled “End-Stage Renal Disease Prospective Payment System” (74 FR 49922). In that rule, we proposed to implement a case-mix adjusted bundled PPS for renal dialysis services beginning January 1, 2011, in accordan ce with the statutory provisions set forth

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in section 153(b) of MIPPA. The ESRD PPS would replace the current basic case-mix adjusted composite payment system and th e methodologies for the reimbursement of separately billable outpatient ESRD services. As explained in the ESRD PPS proposed rule (74 FR 50019), section 1881(b)(14)(E)(i) of the Act requires a 4-year transition (phase-in) from the current composite payment system to the ESRD PPS, and section 1881(b)(14)(E)(ii) of the Act

allows ESRD facilities to make a one-time election to be excluded from the transition. Electing to be excluded from the 4-year tran sition means that the ESRD facility receives payment for renal dialysis services based on 100 percent of the payment rate established under the ESRD PPS, rather than a blended rate under each year of the transition based in part on the payment rate under the current payment system and in part on the payment rate under the ESRD PPS. As of January 1, 2011, ESRD facilities that elect to go through the transition would be paid in the fi rst year a blended amount that will consist of 75 percent of the basic case-mix adjusted composite payment system and the remaining 25 percent would be based on the ESRD PPS payment. Thus, we must continue to update the basic case-mix composite payment system for purposes of determining the composite rate portion of the blended payment amount during the ESRD PPS 4-year transition (CYs 2011 through 2013.) Accordingly, in this proposed rule, we are proposing the composite rate portion of the bl end, which includes an update to the drug add-on and the application of the wage index, as well as the payment amount for the firstyear (CY 2011) of the ESRD PPS transition. We anticipate that the final rule for the ESRD PPS will be pub lished this summer. b. Medicare Modernization Act (MMA) – Th e Basic Case-Mix Adjusted Composite Payment System

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Section 623 of the MMA amended section 1881 of the Act to require changes to the composite rate payment methodology, as well as to the pricing methodology for separately billable drugs and biologicals furnished by ESRD facilities. Section 1881(b)(12) of the Act, as added by section 623(d) of the MMA, requires the establishment of a basic case-mix adjusted composite payment system that includes services comprising the composite rate and an add-on to the composite rate component to account for the difference between current pa yments for separately billed drugs and the revised drug pricing specified in the statut e. In addition, section 1881(b)(12)(A) of the Act requires that the composite rate be adju sted for a number of patient characteristics (case-mix) and section 1881(b)(12)(D) of the Ac t gives the Secretary discretion to revise the wage indices and the urban and rural defi nitions used to develop them. Finally, section 1881(b)(12)(E) of the Act imposed a bud get neutrality (BN) requirement, so that aggregate payments under the basic case-mix adjusted composite payment system equal the aggregate payments for the same period if section 1881(b)(12) of the Act did not apply.

1. CY 2005 Revisions

In the CY 2005 PFS final rule with comment period (69 FR 66319 through 66334), we implemented section 1881(b)(12) of the Act, as added by section 623 of the MMA, and revised payments to ESRD facilities. These revisions th at were effective January 1, 2005, included an update of 1.6 percen t to the composite rate component of the payment system; a drug add-on adjustment of 8.7 percent to the composite rate to account for the difference between pre-MMA pa yments for separately billable drugs and payments based on revised dr ug pricing for 2005 which used acquisition costs. Also, to implement section 1881(b)(13) of the Act, we revised payments for drugs

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billed separately by independent ESRD f acilities, paying for the top 10 ESRD drugs based on acquisition costs (as determined by the OIG) and for other separately billed drugs at the average sales price +6 percent (ASP+6). In addition, effective April 1, 2005, we imp lemented the case-mix adjustments to the composite rate for certain patient characteristics (that is, age, low body mass index, and body surface area). For further explanati on of the development of the basic case-mix adjusted composite payment system, see the CY 2005 PFS final rule with comment period (69 FR 66319 through 66334).

2. CY 2006 Revisions

In the CY 2006 PFS final rule with comment, we implemented additional revisions to payments to ESRD facilities required under section 623 of the MMA. We revised the drug payment methodology applicable to drugs furnished by ESRD facilities. Effective January 1, 2006, all separately billed drugs and biologicals furnished by both hospital-based and independent ESRD facilities were paid based on ASP+6 percent. The drug add-on adjustment was upda ted to 14.5 percent to reflect the expected growth in expenditures for separately billable drugs in CY 2006. We also implemented a revised geographi c adjustment authorized by section 1881(b)(12)(D) of the Act. This adjustment re vised the labor market areas to incorporate the Core-Based Statistical Area (CBSA) designations established by the Office of Management and Budget (OMB) by providing a 4-year transition from the previous wage-adjusted composite rates. Effectiv e January 1, 2006, 25 percent of the payment was based on the revised geographic adjus tments, and the remaining 75 percent of payment was based on the metropolitan statistical area-based (MSA-based) adjustments. Other adjustments included the elimination of the wage index ceiling, and reducing the

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wage index floor to 0.8500, as well as a revise d labor portion of the composite rate to which the geographic adjustment is applied. In addition, section 5106 of the DRA (Pub. L. 109-171) provided for a 1.6 percent update to the composite rate component of the basic case-mix adjusted composite payment system, effective January 1, 2006. For further explanation of the revisions to the basic case-mix adjusted composite paym ent system, see the CY 2006 PFS final rule with comment period (70 FR 70161 through 70771).

3. CY 2007 Revisions

In the CY 2007 PFS final rule with co mment period, we imp lemented a method to annually calculate the growth update to the drug add-on adjustment required by section 1881(b)(12) of the Act, as well as a growth update of 0.5 percent to the drug add-on adjustment. Also, section 103 of the MI EA-TRHCA (Pub. L. 109-432) established a 1.6 percent update to the composite rate porti on of the payment system, effective April 1, 2007. The effect of this increase in the compos ite rate was a reducti on in the drug add-on adjustment to 14.9 percent, effective Apr il 1, 2007. As a result, the drug add-on adjustment to the composite rate increased from 14.5 to 15.1 percent. Since we compute the drug add-on adjustment as a percentage of the weighted average base composite rate, increases in the composite rate portion of the payment reduce the drug add-on percentage. We provided an update to the wage i ndex adjustments to reflect the latest hospital wage data, including a BN adjustment factor. We also implemented the second year of the transition to the CBSA-based wage index, where 50 percent of the payment was based on the CBSA-based geographic adju stments, and the remaining 50 percent of payment was based on the MSA-based adjustme nts. In addition, we reduced the wage

index floor 0.85 to 0.80.

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For further explanation of the development of the basic case-mix adjusted composite payment system, see the CY 2007 PF S final rule with comment period (71 FR 69681 through 69688).

4. CY 2008 Revisions

In the CY 2008 PFS final rule with comment period (72 FR 66280), we implemented a growth update to the drug ad d-on adjustment of 0.5 percent. As a result, the drug add-on adjustment to the composite payment rate increased from 14.9 percent to 15.5 percent. In addition, we updated the wa ge index adjustments to reflect the latest hospital wage data, including a wage index BN adjustment of 1.055473 to the wage index for CY 2008, and finally, for CY 2008, we impleme nted the third year of the transition to the CBSA-based wage index, where 75 percent of the payment was based on the the CBSA-based adjustments and the remaining 25 percent of payment was based on the MSA-based adjustments. In addition, we reduced the wage index floor from 0.80 to 0.75.

5. CY 2009 Revisions For CY 2009, section 153(a) of the MI PPA updated sections 1881(b)(12)(G) and 1881(b)(12)(A) of the Act to revise pa yments to ESRD facilities effective for services furnished on or after January 1, 2009 and January 1, 2010. The revisions included an update of 1 percent to the compos ite rate, and the establishment of a site neutral composite rate to both hospital-based and independent dialysis facilities that reflects the labor share applicable to i ndependent dialysis fa cilities (53.711). The 1 percent increase to the inde pendent dialysis facility’s CY 2008 composite rate of $132.49

resulted in a CY 2009 base com posite rate for hospital-base d and independent dialysis facilities of $133.81. The one percent increase in the composite rate portion of the payment system effective January 1, 2009, re duced the drug add-on adjustment from 15.5

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to 15.2 percent. Also, we updated the wage index adjustment s to reflect the latest available wage data, including a wage index BN adjustme nt of 1.056672 to the wage index for CY 2009. Finally, we completed the 4-year transition to the CBSA-based geographic adjustments and reduced the wage index floor from 0.7500 to 0.700. For further detail, regarding the ESRD provisions, see the 2008 PFS final rule with comment period (73 61921 through 61926).

6. CY 2010 Revisions For CY 2010, we updated the case-mix adjusted composite rate payment system by updating the drug add-on component of the co mposite rate system, as well as the wage index values used to adjust the labor compone nt of the composite rate. Specifically, to update the drug add-on adjustment, we conduc ted a trend analysis of CY’ 2006 through 2008, we implemented a zero growth update to the drug add-on adjustment to the composite rates for 2010 required by se ction 1881(b)(12)(F) of the Act. Also, section 1881(b)(12)(G)(iv) of the Act, as added by section 153(a)(1) of the MIPPA, increased the composite rate by 1.0 pe rcent for ESRD services furnished on or after January 1, 2010. The 1.0 percent increase resulted in a base composite rate of $135.15 per treatment and reduced the drug add- on adjustment from 15.2 to 15.0 percent. Lastly, we updated the wage index to re flect the latest available wage data, including a revised BN adjustment factor of 1.057888. We applied a reduction to the wage index floor from 0.700 to 0.6500. For further detail, regarding the ESRD provisions, see the 2009 final rule with comment period (74 FR 33634 through 33639). 7. CY 2011 Proposals

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For purposes of establishing the composite rate portion of the blended payments under the ESRD PPS for those facilities electing to go through the transition in CY 2011, CMS is proposing the following:

• An update to the drug add-on adjus tment to the composite rate, using a refined methodology for projecting grow th in drug expenditures; and

• An update to the wage index adjustment to reflect the latest available wage data, including a revised BN adjustment.

• A reduction in the ESRD wage index floor from 0.6500 to 0.600.

8. The Affordable Care Act Section 1881(b)(14)(F) of the Act, as added by section 153( b) of MIPPA and amended by section 3401(h) of ACA, governs the ESRD market bask et increase factor (that is., the ESRD market basket). As explained in the ESRD PPS proposed rule (74 FR 4997), we described how the ESRD B undled market basket would be used to update the composite rate portion of the ES RD payments during the PPS transition. Ordinarily in updating the composite paym ent system, we discuss any updates to the composite rate. However, beginning in 2011, the composite payment would be used as part of the blended payments during the ESRD PPS transition. Since the publication of the ESRD PPS proposed rule, and as explained in the ESRD PPS final rule, which we anticipate will be published this summer, we interpret this pr ovision as requiring that the composite rate portion of the blended paym ent amount be increased in CY 2011 by the ESRD market basket percentage increase factor (the “ESRD market basket”). For purposes of this proposed rule, fo r CY 2011, we anticipate an estimate of a 2.5 percent increase to the ESRD composite rate portion of the blended payment amount, resulting in a CY 2011 composite rate of $138.53 ($135.15*1.025). This 2.5 percent

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increase does not apply to the drug add-on adju stment to the composite rate. Also, we note that the drug add-on percentage woul d be reduced from 15.0 to 14.7 as a result of the proposed increase to the composite rate in CY 2011 (A detailed explanation of the reduction to the drug add-on adju stment is dicussed below). 9. Proposed Update to the Drug Add-on Adjustment to the Composite Rate a. Estimating Growth in Expenditures for Drugs and Biologicals in CY 2011 Section 1881(b)(12)(F) of the Act specifie s that the drug add-on increase must reflect “the estimated growth in expenditures for drugs and biologicals (including erythropoietin) that are separately billabl e .......”By referring to “expenditures”, we believe the statute contemplates that the upda te would account for both increases in drug prices, as well as increases in utilization of those drugs. Since we now have 4 years of drug expe nditure data based on ASP pricing, we propose to continue estimating growth in drug expenditures based on the trends in available data. Therefore, for CY 2011, we ar e proposing to use trend analysis from drug expenditure data to update th e per treatment drug add-on ad justment. We then removed growth in enrollment for the same time period from the expenditure growth, so that the residual reflects per pa tient expenditure growth, (which includes price and utilization combined). We further propose to use the per patient growth update to the drug add-on adjustment for CY 2011. To estimate drug ex penditure growth using trend analysis, we looked at the average annual growth in to tal drug expenditures between 2006 and 2009. First, we estimated the total drug expenditures for all ES RD facilities in CY 2009. For this proposed rule, we used the final CY 2006, through CY 2008 ESRD claims data and

the latest available CY 2009 ESRD fac ility claims, updated through December 31, 2009

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(that is, claims with date s of service from January 1 through December 31, 2009, that were received, processed, pa id, and passed to the National Claims History File as of December 31, 2009). For the CY 2011 PFS final rule, we plan to use additional updated

CY 2009 claims with dates of service for the same time frame. This updated CY 2009 data file will include claims received, proces sed, paid, and passed to the National Claims History File as of June 30, 2010.

While the CY 2009 claims file used in th is proposed rule is the most current available, we recognize that it does not reflect a complete year, as claims with dates of service towards the end of the year have not all been processed. To more accurately estimate the update to the drug add-on, aggregate drug expend itures are required. Based on an analysis of the 2008 claims data, we are proposing to inflate the CY 2009 drug expenditures to estimate the June 30, 2010 update of the 2009 cl aims file. We used the relationship between the December 2008 and th e June 2009 versions of 2008 claims to estimate the more complete 2009 claims that will be available in June 2010 and applied

that ratio to the 2009 claims data from the December 2009 claims file. The net adjustment to the CY 2009 claims data is an increase of 12.22 percent to the 2009 expenditure data. This adju stment allows us to more accurately compare the 2008 and 2009 drug expenditure data to estimate per patient growth. As stated earlier in this section, we plan to use add itional updated CY 2009 claims in the CY 2011 PFS final rule. Using the full-year 2009 drug expenditure figure, we calculated the average annual change in drug expenditures fro m 2006 through 2009. This average annual change showed an increase of 2.1 percent fo r this timeframe. We propose to use this 2.1 percent increase to project dr ug expenditures for both 2010 and 2011. b. Estimating Per Patient Growth

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Once we had the projected growth in drug expenditures from 2010 to 2011, which is what we believe that section 1881(b)(12)(F) of the Act requires us to use to update the drug add-on adjustment. To calculate th e per patient growth between CYs 2010 and 2011, we removed the enrollment component by using the estimated growth in

enrollment data between CY 2010 and CY 2011. This was a pproximately 3.6 percent. To do this, we divided the total drug ex penditure change be tween 2010 and 2011 (1.021) by enrollment growth of 3.6 percent (1.036) fo r the same timeframe. The result is a per patient growth factor equal to 0.986, ( 1.021/1.036=0.986). Thus, we are projecting a 1.4 percent decrease in per patient growth in drug expenditures between 2010 and 2011. c. Applying the Proposed Growth Upda te to the Drug Add-On Adjustment In CY 2006, we applied the projected gr owth update percentage to the total amount of drug add-on dollars established for CY 2005 to establish a dollar amount for the CY 2006 growth update. In addition, we pr ojected the growth in dialysis treatments for CY 2006 based on the projected growth in ESRD enrollment. We divided the projected total dollar amount of the CY 2006 gr owth by the projected growth in total dialysis treatments to develop the per trea tment growth update amount. This growth update amount, combined with the CY 2005 pe r treatment drug a dd-on amount, resulted in an average drug add-on amount per tr eatment of $18.88 (or a 14.5 percent adjustment to the composite rate) for CY 2006.

In the CY 2007 PFS final rule with co mment period (71 FR 69684), we revised our update methodology by applying the growth update to the per tr eatment drug add-on amount. That is, for CY 2007, we applied the gr owth update factor of 4.03 percent to the $18.88 per treatment drug add-on amount for an updated amount of $19.64 per treatment (71 FR 69684). For CY 2008, the per treatme nt drug add-on amount was updated to

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$20.33. In the CY 2009 and 2010 PFS final ru le with comment period (73 FR 69755 through 69757 and 74 FR 61923), we applied a ze ro update to per treatment drug add-on amount which left it at $20.33. As discussed in detail below, for CY 2011, we are again proposing no update to the per treatment dr ug add-on amount of $20.33 established in

CY 2008. d. Proposed Update to th e Drug Add-on Adjustment As discussed previously in this sec tion, we estimate a 2.1 percent increase in drug expenditures between CY 2010 and CY 2011. Combining this reduction with a 3.6 percent increase in enrollment, as describe d in above, we are projecting a 1.4 percent decrease in per patient growth of drug expenditures between CY 2010 and CY 2011. Therefore, we are projecting that the combined growth in per patient utilization and pricing for CY 2011 would result in a negative update equal to 0.2 percent. However, similar to last year and as indicated above , we are proposing a zer o update to the drug add-on adjustment. We believe this approach is consistent with the language under section 1881(b)(12)(F) of the Act which states in part that “the Secretary shall annually increase” the drug add-on amount based on th e growth in expenditures for separately billed ESRD drugs. Our understanding of the statute contemplates “annually increase” to mean a positive or zero update to the drug ad d-on. Therefore, we propose to apply a zero update, and to maintain the $20.33 per trea tment drug add-on amount for CY 2011. e. Proposed Update to the Geographic Adjustments to the Composite Rate The purpose of the wage index is to ad just the composite rates for differing wage levels covering the areas in which ESRD facilities are located. The wage indexes

are calculated for each urban and rural area. In addition, we generally have followe d wage index policies related to these

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definitions as used under the inpatient hospital prospective payment system (IPPS), but without regard to any approved geographic reclassification author ized under sections 1886(d)(8) and (d)(10) of the Act or other pr ovisions that only apply to hospitals paid under the IPPS (70 FR 70167). For purposes of the ESRD wage index methodology, the hospital wage data we use is pre-classified, pre-floor hos pital data and unadjusted for occupational mix. f. Proposed Updates to Core-Based Statistical Area (C BSA) Definitions

In the CY 2006 PFS final rule with comment period (70 FR 70167), we announced our adoption of the OMB’s CBSA -based geographic area designations to develop revised urban/rural definitions and corresponding wage index values for purposes of calculating ESRD composite ra tes. The CBSA-based geographic area designations are described in OMB Bulletin 03-04, originally issued June 6, 2003, and is

available online at http://www.whitehouse.gov/omb/bulletins/b03-04.html . In addition, OMB has published subsequent bulletins regard ing CBSA changes, including changes in CBSA numbers and titles. We wish to point out that this and all subsequent ESRD rules and notices are considered to incorporate the CBSA changes published in the most recent OMB bulletin that applies to the hospital wage index used to determine the current ESRD wage index. The OMB bulletins may be accessed online at http://www.whitehouse.gov/omb/bulletins/index.html

. g. Updated Wage Index Values

In the CY 2007 PFS final rule with comment period (71 FR 69685), we stated that we intended to update the ESRD wage index values annually. The ESRD wage index values for CY 2011 were developed from FY 2007 wage and employment data obtained from the Medicare hospital cost reports. As we indicated, the ESRD wage index values

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are calculated without regard to geographi c classifications authorized under sections 1886(d)(8) and (d)(10) of the Act and utilize pre -floor hospital data that is unadjusted for occupational mix. We propose to use th e same methodology for CY 2011, with the exception that FY 2007 hospital data would be used to develop the CY 2011 wage index values. For a detailed description of th e development of the proposed CY 2011 wage index values based on FY 2007 hospital data, see the FY 2011 IPPS proposed rule (75 FR 23944). Section III.G, of the preamble to the FY 2011 IPPS proposed rule, “Method for Computing the Proposed FY 2011 Un adjusted Wage Index,” describes the cost report schedules, line items, data el ements, adjustments, and wage index computations. The wage index data affecting the ESRD composite rate for each urban and rural locale may also be accessed on the CMS Web site at http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp . The wage data are located in the section entitled, “FY 2011 Proposed Rule Oc cupational Mix Adjusted and Unadjusted Average Hourly Wage and Pre-reclassified Wage Index by CBSA.” i. Reduction to the ESRD Wage Index Floor

In the CY 2010 PFS final rule with comment period, we stated our intention to continue to reassess the need for a wage inde x floor (74 FR 61924). We also stated that a gradual reduction in the floor is needed to s upport continuing patient access to dialysis in areas that have low wage index values, especially in Puerto Rico where the wage index values are below the current wage index floor. In the ESRD PPS prposed rule (74 FR 49968), we stated out intent to continue to reduce the wage index floor to the composite rate during the transition. For CY 2011, we propose that the ESRD wage index floor would be reduced from 0.65 to 0.60. j. Proposed Wage index Values for Areas With No Hospital Data

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As discussed in the CY 2010 PSF final rule (74 FR 61925), and the ESRD PPS proposed rule (74 FE 49969) we have a methodology fo r identifying the small number of ESRD facilities in both urban and rural geographic areas where there are no hospital wage data from which to calculate ESRD wage index values. At that time those rules were published, the affected areas were rural Puer to Rico, and the urban area Hinesville-Fort Stewart, GA (CBSA 25980), and rural Massachusetts. In the case of Massachusetts, the entire rural area consists of Dukes and

Nantucket Counties. We dete rmined that the borders of Dukes and Nantucket counties are contiguous with CBSA 12700, Barnstable Town, MA, and CBSA 39300, ProvidenceNew Bedford-Fall River, RI-MA. We inte nd to use the same methodology for CY 2011. Under this methodology, this results in a proposed CY 2011 wage index value of 1.3577 for the composite rate portion of the ble nd, and a wage index value of 1.2844 for the ESRD PPS portion of the blend for Barnst able Town, MA (CBSA 12700) and also results in a proposed CY 2011 wage index va lue of 1.1343 for the composite rate portion of the blend, and a wage index value of 1.0731 for the ESRD PPS portion of the blend for (Providence-New Bedford-Fall River, RI-M A (CBSA 39300) These averages results in an imputed proposed wage index value of 1.2460 for rural Massachusetts in CY 2011, for the composite rate portion of the blend, a nd a wage index value of 1.1788 for the ESRD PPS portion of the blend. For Hinesville-Fort Stewart, GA (CBSA 25980) , which is an urban area without specific hospital wage data, we propose to a pply the same methodology used to impute a wage index value that we used in CYs 2006 through 2010. Specifically, we compute the average wage index value of all urban areas within the State of Georgia. This results in a CY 2011 wage index value of 0.9465 for the co mposite rate portion of the blend, and a

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wage index value of 0.8954 for the ESRD PPS portion of the blend for Hinesville-Fort Stewart, GA (CBSA 25980). For CY 2011, there is an additional urba n area – Anderson, SC - with no hospital data. For this urban area, Anderson, SC (CBSA 11340), we propose to use the same methodology we have used for the other urba n area with not hospital data, that is, Hinesville-Fort Stewart, GA (CBSA 25980). Un der the methodology used for that area, we compute the average of all urban areas w ithin the State of South Carolina. This approach would result in a CY 2011 wage in dex value of 0.9480 for the composite rate portion of the blend, and a wage index va lue of 0.8839 for the ESRD PPS portion of the blend for the Anderson, SC CBSA (CBSA 11340). For Puerto Rico, because all geographic areas in Puerto Rico were subject to the wage index floor in CYs 2006 through 2010, we applied the ESRD wage index floor to rural Puerto Rico as well. Therefore, for CY 2011, all urban areas in Puerto Rico that have a wage index are eligible for the ESRD wage index floor of 0.60. Currently there

are no ESRD facilities located in rural Puerto Rico, however, should any facilities open in rural Puerto Rico, we intend to apply th e CY 2011 proposed wage index floor of 0.60 to

facilities that are located in rural Puerto Ric o. The proposed reduction to the wage index floor of 0.60 remains higher than the actu al wage index values for ESRD facilities located in Puerto Rico, which currently range from 0.3674 to 0.4828. Also, in the

CY 2010 PFS final rule with comment period (74 FR 61925), we stated that we would continue to evaluate existing hospital wage data and possibly wage data from other

sources such as the Bureau of Labor Statistic s, to determine if ot her methodologies might be appropriate for imputing wage index values for areas without hospital wage data for CY 2011 and subsequent years. To date, no da ta from other sources, superior to that

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currently used in connection with the IPPS wage index has emerged. For ESRD purposes, we continue to believe this is an appropriate policy. Finally, for CY 2011, we are proposing to use the FY 2011 wage index data (collected from cost reports submitted by hospitals for cost reporting periods beginning FY 2007) to compute the ESRD composite pa yment rates effective beginning January 1,

2011. k. Budget Neutrality Adjustment We have previously interpreted the st atute as requiring that the geographic adjustment be made in a budget neutral ma nner. Given our application of the ESRD wage index, this means that aggregate paym ents to ESRD facilitie s in CY 2011 would be the same as aggregate payments that would have been made if we had not made any changes to the geographic adjusters. We note that this BN adjustment only addresses the impact of changes in the geographic adjus tments. A separate BN adjustment was developed for the case-mix adju stments required by the MMA. As we are not proposing any changes to the case-mix measures for CY 2011, the current case-mix BN adjustment of 0.9116 would remain in effect for CY 2011. Consistent with prior rulemaking, For CY 2011, we propose to apply the wage-index BN adjustment factor of 1.057057 directly to the ESRD wage index values to the composite rate portion of the blend. Because the ESRD wage index is only applied to the laborrelated portion of the composite rate, we computed the BN adjustment factor based on that proportion (53.711 percent). To compute the proposed CY 2011 wage i ndex BN adjustment factor (1.057057), we used the FY 2007 pre-floor, pre-reclassi fied, non-occupational mix-adjusted hospital data to compute the wage index values, 2009 out patient claims (paid and processed as of

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December 31, 2009), and geographic location information for each facility which may be found through Dialysis Facility Compar e Web page on the CMS Web site at http://www.cms.hhs.gov/DialysisFacilityCompare/ . The FY 2011 hospital wage index data for each urban and rural locale by CBSA may also be accessed on the CMS Web site

at http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp . The wage index data are located in the section entitled, ”FY 2011 Propos ed Rule Occupational Mix Adjusted and Unadjusted Average Hourly Wage and Pre-Reclassified Wage Index by CBSA.” Using treatment counts from the 2009 claims and facility-specific CY 2010 composite rates, we computed the estima ted total dollar amount each ESRD provider

would have received in CY 2010. The total of these payments became the target amount of expenditures for all ESRD facilities for CY 2011. Next, we computed the estimated dollar amount that would have been paid fo r the same ESRD facilities using the proposed ESRD wage index for CY 2011. The total of these payments becomes the new CY 2011 amount of wage-adjusted com posite rate expenditures fo r all ESRD facilities. After comparing these two dollar amounts (target amount divided by the new CY 2011 amount), we calculated an adjustment fact or that, when multiplied by the applicable CY 2011 ESRD wage index value, would result in aggregate payments to ESRD facilities that would remain within the target amount of composite rate expenditures. When making this calculation, the ESRD wage inde x floor value of 0.6000 is applied whenever appropriate. The proposed wage BN ad justment factor for CY 2011 is 1.057057. To ensure BN, we also must apply the BN adjustment factor to the wage index floor of 1.057057 which results in an adjusted wage index floor of 0.6343 (0.6000 x 1.057057) for CY 2011. This budget neutrality factor is not applied to the wage index values for the ESRD PPS portion of the blend.

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l. ESRD Wage Index Tables The CY 2011 ESRD proposed wage index ta bles are located in Addenda K and L of this proposed rule. The wage index tables lists two separate columns of wage index values. The first column lists the wage in dex values will be app lied under the composite rate portion and includes the budget neut rality adjustment of 1057057. The second column lists the wage index values th at will be applied under the ESRD PPS. F. Issues Related to the Medicare Improve ments for Patients and Providers Act of 2008 (MIPPA) 1. Section 131: Physician Payment, Efficiency, and Quality Improvements - Physician Quality Reporting Initiative (PQRI) a. Program Background and Statutory Authority The Physician Quality Reporting Initiative (PQRI) is a voluntary reporting program, first implemented in 2007, that provi des an incentive payment to identified EPs (EPs) who satisfactorily report data on quality measures for c overed professional services furnished during a specified reporting pe riod. We propose to add §414.90 to title 42 of the Code of Federal Regulati ons to implement the provisions of the PQRI discussed in this section of the proposed rule. Under section 1848(k)(3)(B) of the Act, the term "EP" means any of the following: (1) a physician; (2) a practitione r described in secti on 1842(b)(18)(C); (3) a physical or occupational therapist or a qualified speech-language pathologist; or (4) a qualified audiologist. The PQRI was first implemented in 2007 as a result of section 101

of Division B of the Tax Relief and He alth Care Act of 2006 – the Medicare Improvements and Extension Act of 2006 (Pub.L. 109-432) (MIEA-TRHCA), which was enacted on December 20, 2006. The PQRI was extended and further enhanced as a result

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of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Pub. L. 110-173) (MMSEA), which was enacted on December 29, 2007, and the MIPPA, which was enacted on July 15, 2008. Changes to the PQRI as a result of these laws, as well as information about the PQRI in 2007, 2008, 2009, and 2010 are discussed in detail in the CY 2008 PFS proposed and final rules (72 FR 38196 through 38204 and 72 FR 66336 through 66353, respectively), CY 2009 PFS proposed and final rules (73 FR 38558 through 38575 and 73 FR 69817 through 69847, respectively), and CY 2010 PFS proposed and final rules (74 FR 33559 through 33600 and 74 FR 61788 through 61861, respectively). Further detailed information, about the PQRI progra m, related laws, and help desk resources, is ava ilable on the CMS Web site at http://www.cms.gov/PQRI

. The ACA makes a number of changes to the PQRI, including authorizing incentive payments through 2014, and requiring a penalty beginning in 2015 for EPs who do not satisfactorily report da ta on quality measures in the applicable reporting period for the year. The various provisions of the ACA, with re spect to PQRI, are further discussed in sections VI.F.1.b., VI.F.1.k., and VI.F.1.l. of this proposed rule. Prior to the enactment of the ACA, PQRI incentive payments were only authorized through 2010. As discussed furt her in sections VI.F.1.b. and VI.F.1.l. below, under section 1848(m)(1)(A) of the Act, as amended by section 3002(a) of the ACA, PQRI incentive payments are extended through 2014 for EPs that satisfactorily report data on PQRI quality measures for th e applicable reporting period. Section 1848(m)(1)(B) of the Act, as amended by s ection 3002(a) of the ACA, authorizes a 1.0 percent incentive payment for program year 2011 and a 0.5 percent incentive payment for program years 2012 through 2014 for qualifie d EPs who satisfactorily submit PQRI

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quality measures data. Beginning in 2015, an incentive payment adjustment will be implemented for EPs who do not satisfactoril y report quality measures as required by section 1848(a)(8) of the Act and added by section 3002(b) of the ACA. Section 3002(e) of the ACA amends sec tion 1848(m)(5) of the Act to require the Secretary to provide timely feedback to EPs on the performance of the EP with respect to satisfactorily submitting data on quality measures. This is discussed further in section VI.F.1.l.(4) below. Section 3002(f)(2) amends section 1848(m)(5) of the Act by adding a requirement with respect to an informal appeals proce ss. Specifically, section 1848(m)(5)(I) of the Act, as discussed further in section VI.F.1.l .(5) below, requries that the Secretary establish and have in place an informal process by January 1, 2011, whereby EPs may seek a review of the determination that an EP did not satisfactorily submit data on quality measures for purposes of qualifying for a PQRI incentive payment. Section 1848(m)(7) of the Act ("Additiona l Incentive Payment"), as added by section 10327(a) of the ACA, provides that for years 2011 through 2014, the applicable quality percent under PQRI for EPs satisfactor ily reporting PQRI quality measures data will be increased by 0.5 percentage points, if the EP also meets certain requirements, including satisfactorily reporting data on qua lity measures for a year and having such data submitted on their behalf through a Main tenance of Certifica tion Program (MOCP) (as defined under section 1848(m)(7) of the Ac t) and participating in an MOCP practice assessment more frequently than is required to qualify for or maintain board certification status. Section 1848(m)(7) of the Act ("Add itional Incentive Payment") is discussed in more detail in section VI.F.1.l.( 2). Furthermore, section 3002(c) of the ACA, as amended by section 10327(b) of the ACA authorizes the Secretary to incorporate participation and

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successful completion in an MOCP and su ccessful completion of a qualified MOCP practice assessment into the composite of m easures of quality of care furnished under the PFS payment modifier. Also discussed further in section VI.F.1.k. below, section 10331 of the ACA requires the Secretary to develop a Phys ician Compare Internet web site by January 1, 2011, on which information on physic ians enrolled in the Medicare program and other EPs who participate in the PQRI program would be posted. With respect to measures collected under the PQ RI program, to the extent practicable, the Secretary will implement a plan by January 1, 2013, to repo rt 2012 PQRI information on the Physician Compare Web site. Finally, section 1848(m)(7) of the Ac t ("Integration of Physician Quality Reporting and EHR Reporting"), as added by section 3002 of the ACA requires that not later than January 1, 2012, the Secretary sha ll develop a plan to integrate reporting on quality measures under subsection (o) relating to the meaningful use of electronic health records (EHRs), as discussed further in section VI.F.1.l.(3) below. b. Incentive Payments for the 2011 PQRI As stated above, for years 2011 through 2014, section 3002(a) of the ACA extends the opportunity for EPs to earn a PQRI incentive payment for satisfactorily reporting PQRI quality measures. For 2011 PQ RI, section 1848(m)(2)(B) of the Act, as amended by section 3002(a) of the ACA, aut horizes a 1.0 percent incentive, and for 2012 through 2014, a 0.5 percent incentive, for qualif ied EPs who satisfact orily submit PQRI quality measures data. Regardless of the re porting mechanism, and/or the associated reporting period (both disc ussed in detail below) an EP c hooses to report quality data for

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purposes of PQRI, if the EP meets the respectiv e criteria for satisfactory reporting, the EP may receive a 1.0 percent incentive. The PQRI incentive payment amount is cal culated using estimate d Medicare Part B PFS allowed charges for a ll covered professiona l services, not just those charges associated with the reported quality measures. "Allowed charges" refers to total charges, including the beneficiary deductible and coinsurance, and is not limited to the 80 percent paid by Medicare or the portion covered by Medicare where Medicare is secondary payer. Amounts billed above the PFS amounts for assigned and non-assigned claims will

not be included in the calculation of the incen tive payment amount. In addition, since, by definition under section 1848(k)(3)(A) of the Act, "covered professional services" are limited to services for which payment is made under, or is based on, the PFS and which are furnished by an EP, other Part B services and items that may be billed by EPs, but are not paid under or based upon the Medicare Part B PFS, are not included in the calculation of the incentive payment amount. As mentioned above, we are proposing a number of reporting mechanisms that EPs may choose in order to participate in PQRI. Our proposals for claims-based reporting, registry-based reporting, and EH R-based reporting are discussed below with respect to the opportunity for individual EPs to participate in PQRI. For satisfactory reporting at the individual level in 2011, 1.0 perc ent of qualified charges would be paid at the TIN/NPI level. These proposed reporting mechanisms are addressed in section G.1.d. below. Our proposed criteria for satisfact orily reporting using the various reporting

mechanisms are discussed in further detail in sections VI.F.1.e. and VI.F.1.f. below. Our proposals with respect to the reporting m echanisms and criteria for satisfactorily reporting for group practices are also addresse d below, in section VI.F.1.g. Those group

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practices that satisfactorily report will also be paid a 1.0 percent incentive payment based upon the qualified charges for the group practice TIN. c. Proposed 2011 Reporting Periods for Individual EPs Under section 1848(m)(6)(C) of the Act, the "reporting period" for the 2008 PQRI and subsequent years is defined to be the en tire year, but the Secretary is authorized to revise the reporting period for years after 2009 if the Secretary determines such revision is appropriate, produces valid results on measures reporte d, and is consistent with the goals of maximizing scientific validity a nd reducing administrative burden. For the 2011 PQRI, we propose the following reporting pe riods: (1) 12-month reporting period for claims-based reporting and registry-based reporting (that is, January 1, 2011 through December 31, 2011); (2) 12-month reporting peri od for EHR-based reporting (that is, January 1, 2011 through December 31, 2011; and (3) 6-month reporting period for claims-based reporting and registry-based reporting(that is, July 1, 2011 through December 31, 2011). Additionally, as discu ssed further below in their respective sections, we propose the 12-month repor ting period for the group practice reporting option (GPRO) for both PQRI and the eRx Prescribing Incentive Program (January 1, 2011 through December 31, 2011). The proposed 2011 PQRI reporting periods are consistent with the 2010 reporting periods. In addition, in prior program year s, we received input from stakeholders in support of partial year repor ting for all reporting mechanisms, to give more EPs the opportunity to begin reporting later in the year . We agree that having the same reporting periods for all mechanisms may be less comp lex, and may facilitate participation in 2011 PQRI for certain EPs. In an effort to be c onsistent with prior prog ram years, and move in the direction of maintaining program stability and continuing program flexibility, while

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increasing successful reporting of 2011 PQRI measures, we propose to retain 2010 PQRI reporting periods as described above. We invite comments on the proposed reporting periods for 2011 PQRI. d. Proposed 2011 PQRI Reporting Mechanisms for Individual EPs When the PQRI was first implement ed in 2007, there was only 1 reporting mechanism available to submit data on PQRI quality measures. For the 2007 PQRI, EPs had to submit quality data codes (QDCs) on Medicare Part B claims (claims-based reporting). QDCs are Current Procedural Te rminology (CPT) Category II codes or Gcodes (where CPT Category II codes are not ye t available). CPT Ca tegory II codes and

G-codes are Healthcare Common Procedure C oding System (HCPCS) codes for reporting quality data. For the 2008 PQRI, we added re gistry-based reporting as an alternative reporting mechanism as required by section 1848(k)(4) of the Act. Under this option, EPs may submit data on PQRI quality measures to a qualified PQRI registry and request the registry to submit PQRI quality measures results and numerator and denominator data on the 2008 PQRI quality measures or measures groups. For the 2009 PQRI, we retained the 2 reporting mechanisms used in the 2008 PQRI (that is, claims-based reporting and registry-based reporting) for reporting individual PQRI quality measures and for reporting measures groups. Finally, to promote the adoption of EHRs, and to facilitate quality measure data reporting, we sought to establish an EH R reporting option by c onducting limited testing of EHR reporting for the 2008 and 2009 PQRI. Th is involved the submission of clinical quality data extracted from an EHR, or the EHR-based reporting mechanism. No incentive payment was available to those EPs who participated in testing the EHR-based reporting mechanism.

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For the 2010 PQRI, we retained the claims-based reporting mechanism, the registry-based reporting mechanism, and established EHR reporting for a limited subset of the 2010 PQRI quality measures, as identif ied in Table 14 of the CY 2010 PFS final rule with comment period(74 FR 61831), c ontingent upon the successful completion of

our 2009 EHR data submission tes ting process and a determina tion based on that testing process that accepting data from EHRs on quality measures for the 2010 PQRI was practical and feasible. In the 2010 PQRI, fo llowing the successful completion of the

2009 EHR data submission testin g process, it was determined that it is practical and feasible to accept data from EHRs on quality measures for the 2010 PQRI. For the 2011 PQRI, we are proposing to retain the claims-based reporting mechanism and the registry-based reporting m echanism. We also propose to retain the 2010 EHR-based reporting mechanism, by wh ich we will continue to accept quality measures data extracted from a qualifie d EHR product for a limited subset of the proposed 2011 PQRI quality measures, as identified in Tables 55 and 56. Under the 2011 PQRI, we propose that the EHR submission is optional. For the 2011 PQRI, we are not proposing to offer additional reporting options for individual EPs beyond those discussed above. In contrast to prior program years (2008 PQRI, 2009 PQRI, and 2010 PQRI), we believe that other options would not facilitate reporting of quality data for PQ RI by EPs. However, we seek public comment on these proposals and invite suggestions as to other op tions that could be included in the PQRI. We recognize that there continues to be a number of limitations associated with claims-based reporting since the claims processing system was developed for billing purposes and not for the submission of qualit y data. Claims submission, however, is

available to all EPs. We have observe d that only about half of those EPs who

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participated in PQRI via the claims-based reporting mechanism satisfied the criteria for satisfactory reporting (that is, reported at least 3 PQRI measures or 1-2 measures if there were fewer than 3 applicable measures, for at least 80 percent of the EP's Medicare Part B FFS patients for whom services were fu rnished during the reporting period to which the measure applies) and qualifie d for the incentive. We have also found that measures with complex specifications, such as those that require multiple diagnosis codes are not as conducive to claims-based reporting and ma y be associated with a greater number of invalidly reported QDCs. Similarly, when multiple measures share the same codes it may be difficult to determine which measure(s) the EP intended to report through claims. Finally, for pragmatic efficiency it is not practical to allow resubmission of claims for the sole purpose of adding QDCs. This mean s that claims-based reporting must be concurrent with billing. By contrast, our experience with th e registry-based reporting mechanism continues to be a favorable option, as the dr awbacks discussed above do not apply. Data has shown that not only have the particip ation rates for registry-based reporting increased, but also satisfactory reporting, resulting in an incentive payment for EPs, has also increased. Furthermore, the availabl e number of qualified registries has also increased since 2008, and we expect additional registries to become qualified in future years. For these reasons, we maintain that the registry-based reporting option remains viable, and furthermore, we antic iapte continuing to expand this option in future years.

We also believe that EHR- based reporting c ontinues to be a viable option for overcoming the limitations associated with claims-based reporting of quality measures, as clinical quality data is extracted from the EHR for submission. We believe further that retaining the EHR-based reporting mechanis m for 2011 PQRI will continue to promote

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the adoption and use of EHRs and further alig n with the provision in the ACA related to the integration of PQRI EHR measures and the EHR incentive program measures in years after 2011, which is discussed in further de tail in section VI.F.1.l.(3) below. In summary, we propose that for 2011, an EP may choose to report data on PQRI quality measures through claims, a qualifie d registry (for the proposed qualification requirements for registries, see section VI.F.1.d.( 4) of this proposed rule), or through a qualified EHR product (for the proposed qualification requi rements for the EHR vendors and their products, see section VI.F.1.d.(5) of this proposed rule). As in previous years, depending on which PQRI individual quality meas ures or measures groups an EP selects, one or more of the proposed reporting mechan isms may not be available for reporting a particular 2011 PQRI individua l quality measure or measures group. For example, the EHR reporting mechanism currently is not av ailable for reporting measures groups and specifications for the electronic transmisison of a measure via an EHR are not available for all of the individual PQRI measures. In addition, as discussed previously the specifications for some measures are too co mplex for claims-based reporting. The proposed 2011 reporting mechanisms through which each proposed 2011 PQRI individual quality measure and measures group co uld be reported are id entified in Tables 47 and 48. We invite comments on our proposal for the 2011 reporting mechanisms. While we propose to retain the claims-based reporting mechanism for 2011, we note that we continue to consider significantly limiting the claims-based mechanism of reporting clinical quality measures in future program years. This limitation continues to be contingent upon there being an adequate number and variety of registries available and/or the continuation and/or expansion of the EHR reporting option. Potentially, we

would continue to retain claims-based re porting in years after 2011 principally for the

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reporting of structural measures, such as Measure #124 Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR), and in circumstances where claims-based reporting is the only available mechanism for certain categories of EPs to report on PQRI quality measures. Continuing to reduce our reliance on the claims-based reporting mechanism after

2011 would allow us and EPs to continue to devote available resources towards maximizing the potential of registries and EHRs for quality measurement reporting. Both mechanisms hold the promise of more sophi sticated and timely reporting of clinical quality measures. Clinical data registries allow the collection of more detailed data, including outcomes, without the necessity of a single submission contemporaneously with claims billing, which overcomes some of the limitations of the claims-based reporting mechanism. Registries can also provide feedback and quality improvement information based on reported data. Finally, clinical data registries can also receive data from EHRs, and therefore, serve as an altern ative means to reporting clinical quality data

extracted from an EHR. As we continue to qualify additional registries (qualified registries are listed on the CMS PQRI Web site http://www.cms.gov/PQRI/20_AlternativeR eportingMechanisms.asp#TopOfPage ), we believe there may be a sufficient number of registries by 2012 to make it possible to reduce the claims-based reporting mechanism for many measures after 2011. We again

invite comments on our intent to lessen our reliance on the claims-based reporting mechanism for the PQRI program beyond 2011. As in previous years, regardless of th e reporting mechanism chosen by an EP, there is no requirement for the EP to sign up or register to participate in the PQRI. However, there may be some requirements fo r participation through a specific reporting

### CMS-1503-P 469

mechanism that are unique to that particular reporting mechanism. In addition to the proposed criteria for satisfactory reporting of individual measures and measures groups

described in section VI.F.1.e. a nd section VI.F.1.f., respectively, of this proposed rule, EPs must ensure that they meet all requirements for their chosen reporting mechanism for

2011. (1) Proposed Requirements for Individual EPs Who Choose the Claims-based Reporting

Mechanism For EPs who choose to participate in the 2011 PQRI by submitting data on individual quality measures or measures groups through the claims-based reporting mechanism, we propose the EP would be re quired to submit the appropriate PQRI QDCs on the professionals' Medicare Part B claims . QDCs for the EP's selected individual PQRI quality measures or measures group ma y be submitted to CMS at any time during 2011. Please note, however, that as required by section 1848(m)(1)(A) of the Act, all

claims for services furnished between January 1, 2011 and December 31, 2011, would need to be processed by no later than February 28, 2012, to be included in the 2011 PQRI analysis. (2) Proposed Requirements for Individual EP s Who Choose the Registry-based Reporting

Mechanism We propose that in order to report quality data on the 2011 PQRI individual quality measures, or measures groups, through a qualified clinical registry, an EP must

enter into and maintain an appropriate legal arrangemen t with a qualified 2011 PQRI registry. Such arrangements would provide for the registry's receipt of patient-specific data from the EP and the registry's disclosure of quality measures results and numerator and denominator data on PQRI quality measures or measures groups on behalf of the EP

### CMS-1503-P 470

to CMS. Thus, the registry would act as a Health Insurance Portability and Accountability Act of 1996 (Pub. L. 104-191) (H IPAA) Business Associate and agent of the EP. Such agents are referred to as "d ata submission vendors." The "data submission vendors" would have the requis ite legal authority to provide clinical quality measures

results and numerator and deno minator data on individual qua lity measures or measures groups on behalf of the EP for the PQRI. We propose that the registry, acting as a data submission vendor, would submit CMS-defined re gistry-derived measures information to our designated database for the PQRI, using a CMS-specified record layout, which would be provided to the registry by CMS. To maintain compliance with applicable statutes and regulations, our program and our data system must maintain compliance with the HIPAA requirements for requesting, processing, storing, and tran smitting data. EPs that conduct HIPAA covered transactions also would need to maintain compliance with the HIPAA requirements. We propose that EPs choosing to participat e in PQRI through the registry-based reporting mechanism for 2011 would need to se lect a qualified PQRI registry and submit information on PQRI individual quality measur es or measures groups to the selected registry in the form and manner and by the deadline specified by the registry. We propose to post on the PQRI section of the CMS Web site at http://www.cms.gov a list of qualified registries for the 2011 PQRI, including the registry name, contact information, and the 2011 measur e(s) and/or measures group(s) and eRx reporting (if qualified) for which the registry is qualified and intends to report. As in the 2010 PQRI, we propose for the 2011 PQRI to pos t the names of the 2011 PQRI qualified registries in 3 phases, which are discussed belo w. In any event, even though a registry is listed as "qualified," we cannot guarantee or assume res ponsibility for the registry's

### CMS-1503-P 471

successful submission of the required PQRI qu ality measures results or measures group results or required data elements submitted on behalf of a given EP. In the first phase, we propose to post, by December 31, 2010, a list of those registries qualified for the 2011 PQRI base d on the following: (1) being a qualified registry for a prior PQRI program year that successfully submitted 2008 and/or 2009 PQRI quality measures results and numerat or and denominator data on the quality measures; (2) having received a letter indicating their continued interest in being a PQRI registry for 2011 by October 31, 2010; and (3) the registry's compliance with the 2011 PQRI registry requirements. This list may be modified if any given registry fails to meet any new requirement(s) proposed for 2011. Th e testing of any additional requirements will be completed as soon as possible but by the end of the first quarter of 2011 at the latest. By posting this first list of qualified registries for the 2011 PQRI, we seek to make available the names of registries that can be used at the start of the 2011 reporting period. We propose in the second phase, to add th e names of the registries that were initially qualified in 2010 and submitted actual quality data on behalf of their EPs to CMS for the first time in early 2011. Successful submission of data to CMS for the year in which a registry is qualified is the fi nal step in the qualification process and a necessary requirement if the registry desire s to continue to participate in PQRI in subsequent years. We propose that thes e registries also must meet any new 2011 requirements and will also underg o testing, which will be co mpleted by the end of the first quarter of 2011 at the latest. In the third phase, we propose to comp lete posting of the list of qualified 2011 registries as soon as we have completed vettin g the additional registries interested in and capable of participating in the 2011 PQRI. We anticipate this will be completed no later

### CMS-1503-P 472

than the summer of 2011. An EP's ability to report PQRI quality measures data and

numerator and denominator data on PQRI quality measures or measures groups using the registry-based reporting mechanism should not be impacted by the complete list of qualified registries for the 2011 PQRI being made available after the start of the reporting period. First, registries would not begin submitting EPs' PQRI quality measures results

and numerator and denominator data on the quality measures or measures groups to CMS until 2012. Second, if an EP decides that he or she is no longer interested in submitting quality measures data and numerator and de nominator data on PQ RI individual quality measures or measures group through the regi stry-based reporting mechanism after the complete list of qualified registries becomes available, this would not preclude the EP from attempting to meet the criteria for sa tisfactory reporting through another 2011 PQRI reporting mechanism, such as claims or EHR-based data submission. In addition to meeting the above proposed requirements specific to registry-based reporting, we propose that EPs who choose to participate in PQRI through the registrybased reporting mechanism would need to meet the relevant criteria proposed for satisfactory reporting of individual measures or measures groups that all EPs must meet in order to satisfactorily report for PQRI 2011. However, in 2011, we propose not to count measures that are reported through a registry or EHR that have a zero percent performance rate. That is, if the recommended clinical quality action is not performed on at least 1 patient for a particular measure or measures group reported by the EP via a registry or EHR, we will not count the m easure (or measures gr oups) as a measure (or measures group) reported by an EP. We propose to disregard measures (or measures groups) that are reported through a registry or EHR that have a zero percent performance rate in the 2011 PQRI because we are assumin g that the measure was not applicable to

### CMS-1503-P 473

the EP and was likely reported from EHR-deri ved data (or from da ta mining) and was unintentionally submitted from the registry or EHR to CMS. We also seek to avoid the possibility of intentional submission of spurious data solely for the purpose of receiving an incentive payment for reporting. (3) Proposed Requirements for Individua l EPs Who Choose the EHR-based Reporting

Mechanism For 2011, in addition to meeting the criteria for satisfactory reporting of at least 3 individual measures, we propose the following requirements associat ed with EHR-based reporting: (1) selection of a PQRI qualified EHR product; and (2) submission of clinical quality data extracted from the EHR to a CMS clinical data warehouse in the CMSspecified manner and format. These propos ed requirements are identical to the 2010 requirements for individual EPs who choose the EHR-based requirements. We are proposing to retain the 2010 requireme nts because results from 2010 EHR data

submission will not be available until 2011. A test of quality data submission from EPs who wish to report 2010 quality measure data directly from their qualified EHR product will be required and occur in early 2011 immedi ately followed by the submission of the EP's actual 2010 PQRI data. This entire final test/production 2010 data submission timeframe is expected to be January 2011 th rough March 2011. As discussed in the CY 2010 PFS final rule with comment period (74 FR 61800), throughout most of 2010, we will continue to vet newly se lf-nominated EHR vendor produc ts for possible qualification for the 2011 PQRI program year. We expect to list any additional PQRI qualified EHR products by January 2011. It is expected that these newly qualified products would be able to submit 2011 PQRI data in early 2012.

### CMS-1503-P 474

Measures group reporting is not an option for EHR based quality measure reporting for 2010. We propose to continue this policy for 2011 and therefore, propose not to include measures group reporting via EHRs for the 2011 PQRI. We will receive 2010 production data in early 2011 and since this will be th e first time we have an opportunity to receive direct EHR data sub mission for quality reporting and to calculate the results, we believe it is best not to a dd another reporting option using EHRs at this time. We propose that EPs who choose the EHR-based reporting mechanism for the 2011 PQRI would be required to (in additi on to meeting the criteria for satisfactory reporting of individual measures)--

● Have a qualif ied EHR product;

● Have an active Individuals Authoriz ed Access to CMS Computer Services (IACS) user account with a data submission ro le or be able to use the surrogate data submission method (if one exists) that will be used to submit clinical quality data

extracted from the EHR to a CMS clinical data warehouse or another CMS approved means of securely transmitting the quality measures data to CMS such as a CMS/OCSQ approved HIE (health information exchange) if we are able to collect data from HIEs in 2012 using the NHIN (national health informa tion network) or NHIN direct network;

● Submit a test file containing real or test clinical quality data extracted from the

EHR to a CMS clinical data warehouse via an approved data submission method such as IACS, an HIE, or the NHIN between July 1, 2011 and September 30, 2011 (if technically feasible); and

● Submit a file containing the EP's 2011 PQRI clinical quality data extracted from the EHR for the entire reporting period (that is January 1, 2011 through

### CMS-1503-P 475

December 31, 2011) via IACS or an acceptabl e surrogate (if technically feasible) between January 1, 2012, through February 28, 2012. However, as stated above, the 2010 EHR Testing Program is still ongoing. Since we are proposing that only EHR vendors that self-nominated to participate in the 2011 EHR Testing Program and successfully comp lete the 2011 EHR Testing Program would be considered qualified EHR vendors for the 2011 PQRI, there is no guarantee that there will be any additionally qua lified EHR vendors available fo r the 2011 PQRI. In addition, as we complete the 2010 EHR Testing Program and are better able to determine what is technically feasible, the actual dates on which EPs are required to submit their test files and/or to begin submitting their actual 2011 PQ RI data are subject to change. We cannot assume responsibility for the successful submission of data from an EP's EHR. Any EP who chooses to submit PQRI data extracted from an EHR should contact the EHR product's vendor to determine if the produc t is qualified and has been updated to facilitate PQRI quality measures data sub mission. Such professionals also should begin attempting submission soon after th e opening of the clinical data warehouse in order to assure the professional has a reasonable period of time to work with his or her EHR and/or its vendor to correct any pr oblems that may preclude successful quality measures data submission through that EHR. As we indicated above, we are proposing that data submission for the 2011 PQRI would need to be completed by February 28, 2012. The specifications for th e electronic transmission of the 2011 PQRI measures, identified in Tables 55 and 56 of this propos ed rule as being available for EHR-based reporting in 2011, will be posted on the Alternative Reporting Mechanisms page of the PQRI section of the CMS Web site during the summer of 2010.

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(4) Proposed Qualification Re quirements for Registries In order to be "qualified" to submit quality measures results and numerator and denominator data on PQRI quality measures and measures groups on behalf of EPs pursuing a PQRI incentive for the 2008, 2009, and 2010 PQRI, we required registries to complete a self-nomination process and to meet certain technical and other requirements. For the 2010 PQRI, registries that were qu alified for 2009 did not need to be "requalified" for 2010 unless they were unsuccessf ul at submitting 2009 PQRI data (that is, failed to submit 2009 PQRI data per the 2009 PQ RI registry requirements). Registries that were "qualified" for 2009 and wished to continue to particip ate in 2010 were only required to communicate their desire to c ontinue participation for 2010 by submitting a letter to CMS indicating their continued inte rest in being a PQRI registry for 2010 and their compliance with the 2010 PQRI registry requirements by March 31, 2010. For the 2011 PQRI, we are proposing to re quire a self-nomination process for registries wishing to submit 2011 PQRI quality measures or measures groups on behalf of EPs for services furnished during the app licable reporting periods in 2011. We propose that the registry self-nomination process fo r the 2011 PQRI would be based on a registry meeting specific technical and other re quirements, as discussed below. To be considered a qualified registry for purposes of submitting individual quality measures and measures groups on behalf of EP s who choose to report using this reporting mechanism under the 2011 PQRI, we propose that all registries (new to PQRI and those previously qualified) must:

● Be in existence as of January 1, 2011;

● Have at least 25 participants by January 1, 2011;

● Provide at least 1 feedback repo rt per year to participating EPs;

### CMS-1503-P 477

● Not be owned and managed by an i ndividual locally-owned single-specialty group (in other words, single-specialty prac tices with only 1 practice location or solo practitioner practices would be prohibited fro m self-nominating to become a qualified PQRI registry);

● Participate in ongoing 2011 PQRI manda tory support conference calls hosted by CMS (approximately 1 call per month), including an in-person registry kick-off meeting to be held at CMS headquarters in Baltimore, MD. Registries that miss more than one meeting will be precluded from submitting PQRI data for the reporting year (2011);

● Be able to collect all needed data elements and transmit to CMS the data at the

TIN/NPI level for at least 3 measures in the 2011 PQRI program (according to the posted 2011 PQRI Measure Specifications);

● Be able to calculate and submit measure-level reporting rates or the data elements needed to calculate the reporting rates by TIN/NPI;

● Be able to calculate and submit, by TIN/NPI, a performance rate (that is, the percentage of a defined population who receive a particular process of care or achieve a particular outcome) for each measure on which the TIN/NPI reports or the data elements needed to calculate the reporting rates;

● Be able to separate out and repor t on Medicare Part B FFS patients;

● Provide the name of the registry;

● Provide the reporting period start date the registry will cover;

● Provide the reporting period end date the registry will cover;

● Provide the measure numbers for the PQRI quality measures on which the registry is reporting;

### CMS-1503-P 478

● Provide the measure title for the PQRI quality measures on which the registry is reporting;

● Report the number of eligible instances (reporting denominator);

● Report the number of instances of qu ality service performed (numerator);

● Report the number of performance exclusions;

● Report the number of reported instan ces, performance not met (EP receives credit for reporting, not for performance);

● Be able to transmit this data in a CMS-approved XML format. We expect that this CMS-specified record layout will be substantially the same as for the 2008, 2009, and 2010 PQRI if aggregate leve l data is continued but will likely change if individual data elements are required, as discussed below. This layout will be provided to registries in 2011;

● Comply with a CMS-specified secure method for data submission, such as submitting the registry's data in an XML file through an IACS user account or another approved method such as over the NHIN (na tional health inform ation network) if technically feasible;

● Submit an acceptable "validation strategy" to CMS by March 31, 2011. A validation strategy ascertains whether EPs ha ve submitted accurately and on at least the minimum number (80 percent) of their eligible patients, visits, procedures, or episodes for a given measure. Acceptable validation stra tegies often include such provisions as the registry being able to conduct random samplin g of their participant's data, but may also be based on other credible means of verifying the accuracy of data content and completeness of reporting or adherence to a required sampling method;

### CMS-1503-P 479

● Perform the validation outlined in the strategy and send the results to CMS by June 30, 2012 for the 2011 reporting year's data;

● Enter into and maintain with its participating professionals an appropriate Business Associate agreement that provides for the registry's receipt of patient-specific data from the EPs, as well as the registry's disclosure of quality measure results and

numerator and denominator data on behalf of EPs who wish to participate in the PQRI

program;

● Obtain and keep on file signed documentation that each holder of an NPI whose data are submitted to the registry has authorized the registry to submit quality

measures and numerator and denominator data to CMS for the purpose of PQRI participation. This documenta tion must be obtained at the time the EP signs up with the registry to submit PQRI quality measures data to the registry and must meet any applicable laws, regulations, and contra ctual business associate agreements;

● Provide CMS access (if requested for validation purposes) to review the Medicare beneficiary data on which 2011 PQRI registry-based submissions are founded or provide to CMS a copy of the actual data (if requested);

● Provide the reporting option (reporting period and reporting criteria) that the EP has satisfied or chosen;

● Provide CMS a signed, written attestation statement via mail or e-mail which states that the quality measure results and any and all data including numerator and denominator data provided to CM S are accurate and complete;

● Indicate the reporting period chosen fo r each EP who chooses to submit data

on measures groups;

### CMS-1503-P 480

● Base reported information on meas ures groups only on patients to whom services were furnished during the 12 -month reporting period of January through December 2011 or the 6-month reporting period of July 1, 2011 through December 31, 2011;

● Agree that the registry's data may be inspected or a copy requested by CMS and provided to CMS under our oversight authority;

● Be able to report data on all applicab le measures in a given measures group on

either 30 or more Medicare Part B FFS patients from January 1, 2011 through December 31, 2011, or on 80 percent of applicable Medicare Part B FFS patients for each EP (with a minimum of 15 patients during the January 1, 2011, through December 31, 2011, reporting period or a minimum of 8 patients during the July 1, 2011, through December 31, 2011, reporting period). These proposed qualificati on requirements for 2011 regi stries are similar to the PQRI qualification requirements for registries for previous years. However, we note, that registries would no l onger be permitted to include non-Medicare patients for measures group reporting (see section VI.F.1. f. of this proposed rule for further discussion of the criteria for satisfactory repor ting of measures groups by individual EPs). In addition, in prior years registries were permitted to develop their own algorithms to calculate measure results (that is, reporting and performance rates) from the data provided to them from their EP member s. For the 2011 PQRI, we propose that all current and future registries would have to meet the following new requirements proposed for 2011:

• Use PQRI measure specifications and the CMS provided measure calculation algorithm to calculate reporting rates or pe rformance rates unless otherwise stated if

### CMS-1503-P 481

aggregated measures data is continued fo r 2011 PQRI registry reporting. CMS will provide registries a calculati on algorithm for each measure and/or measures group they intend to report in 2011.

• Provide a calculated result using the CMS supplied algorithm and XML file for each measure that the registry intends to calculate (as described below). This applies to all registries; those that are new to the progra m, and those that were previously qualified. The registries will be required to show that they can calculate the proper measure results (that is, reporting and performa nce rates) using the CMS-s upplied algorithm and send the calculated data back to CMS in the specified format.

• Provide us the individual data elements used to calculate the measures if so requested by CMS for validation purposes, if aggregated data submission is still

the selected method of data collection. Re gistries that are subject to validation will be asked to send discrete data elements for a measure (determined by CMS) in the required data format for us to re calculate the registries' reported results.

Validation will be conducted for several m easures at a randomly selected sample of registries in order to validate their data submissions. While registries allow EPs to collect data over a broader timeframe enabling us to implement more sophisticated measures in PQ RI and despite their apparent success as a vehicle for quality reporting (over 90.0 percen t of EPs who participated in the 2008 PQRI through registry-based reporting were incentive eligible), registry data results have been

inconsistent when we have validated the re gistry data against claims. Even though qualified registries go through a thorough vetting and testing pro cess, we have found differences in measure results (that is, perform ance rates) reported by the registries when compared to measure results calculated from claims data for the same EP. This makes it

### CMS-1503-P 482

difficult for EPs to analyze their performance results for practice improvement in that the information may not be reliable and reproducible from registry to registry. This also makes possible physician comparison difficult and inconsistent. We believe there are likely several reasons for these inconsistencies, including the fact that some registries are getting their data from an EP's EHR, the use of non-Medicare patients by registries for measures groups, and the use of different algor ithms by registries to calculate measures. We believe the proposed new re quirements for registries disc ussed above will help us in validating the registry data we receive by a ddressing some of the reasons leading to the inconsistencies. The proposal for 2011 to retain many of the 2010 requirements while introducing some new requireme nts is intended to improve the registry-based reporting mechanism by capitalizing on some of the registry's existing quality improvement functions, maximizing the registry's ability to successfully submit EP's quality measure

results and numerator and de nominator data on PQRI indi vidual quality measures or measures groups to CMS, and discouraging sma ll physicians' offices or an individual EP from self-nominating to become a qualified regi stry. We continue to be concerned that an individual EP or a small practice does not have either the resources, or the capabilities, to successfully submit quality measures results and numerator and denominator data on PQRI individual measures or measures gr oups through the registry data submission process. We invite comments on the process and requirements that we propose to use to determine whether a registry is qualified to submit quality measures results (performance rates and reporting rates) and numerator and denominator data on PQRI quality measures or measures groups on an EP's behalf. As stated previously, registries currently calculate the measure results (that is reporting and performance rates) from the data submitted to them by their EP members

### CMS-1503-P 483

and send us the measure results for each participating EP, which are aggregated, nonpatient identifiable data. An advantage of this approach is that less data will need to be transmitted to CMS (since we only receive a ggregated data), which means there is less data for CMS to analyze. Another option that we considered was ch anging the requirements with respect to the type of data that registries send us. For 2011, we considered requiring registries, instead, to send discrete data elements for a measure (as determined by CMS) in the required data format for us to calculate the EP 's measure results. Thus, the registry would be required to send CMS benefi ciary-level data provided to the registry by the EP and

CMS would use the data to calculate the EP 's measure results (that is, reporting and performance rates). This approach is similar to the approach that was contemplated when registry data submission began in 2008 and was referred to as "Option 2" in the CY 2008 PFS proposed rule (72 FR 38203). An advantage of this approach is that it allows us to

calculate the measure results and reduces the va riation that occurs when registries try to aggregate their data and calculate the measure results themselves. Reducing the variation would facilitate compar ison of EPs' results should we move towards public reporting of performance results in the future. Also, if the measure specifications change from year to year, this approach would require the regist ry to make fewer systems changes. The registry would not need to update the algorith ms used to calculate the measure's results.

We invite comments on this alternative that was considered. We propose to post the final 2011 PQRI regi stry requirements, including the exact date by which registries that wish to qualif y for 2011 must submit a self-nomination letter and instructions for submitting the self-nomination letter, on the PQRI section of the

CMS Web site at http://www.cms.gov/PQRI by November 15, 2010. We anticipate that

### CMS-1503-P 484

new registries that wish to self-nomin ate for 2011 would be required to do so by January 31, 2011. Similar to 2010 PQRI, we propose that regist ries that were "qualified" for 2010 and wish to continue to pa rticipate in 2011 will not need to be "re-qualified" for 2011 except to the extent that the requirements ch ange for 2011 (as proposed above). If this occurs, we propose that all previously qualified registries would need to demonstrate that they can meet the new 2011 data submission re quirements. Additionally, we propose that registries that are unsuccessful submitting 2010 PQRI data (that is, fail to submit 2010 PQRI data per the 2010 PQRI registry requireme nts) will need to go through a full selfnomination vetting process for 2011. Successful 2010 PQRI registries that choose to report on new or different 2011 PQRI measures would also need to qualify for these

additional measures and/or methods. We also propose that registries that are "qualified" for 2010, who were successful in submitting 2010 PQRI data, and wish to continue to participate in 2011 would need to indicate thei r desire to continue participation for 2011 by submitting a letter to CMS indicating their continued interest in being a PQRI registry for 2011 and their compliance with the 2011 PQRI registry requirements by no later than October 31, 2010. Instructions regarding the pr ocedures for submitting this letter will be provided to qualified 2010 PQRI registries on the 2010 PQRI registry support conference

calls. Similar to 2010 PQRI, we propose that if a qualified 2010 PQRI registry fails to submit 2010 PQRI data per the 2010 PQRI regist ry requirements, the registry would be considered unsuccessful at submitting 2010 PQRI data and would need to go through the full self-nomination process again to participate in the 2011 PQRI. By March 31, 2011, registries that are unsuccessful at submitting quality measures results and numerator and

### CMS-1503-P 485

denominator data for 2010 would need to be able to meet the 2011 PQRI registry requirements and go through the full vetting process again. This would include CMS receiving the registry's self-nomination by March 31, 2011. As discussed further under section VI.F.2. of this proposed rule, we pr opose that the above registry requirements would apply not only for the purpose of a regi stry qualifying to report 2011 PQRI quality

measure results and numerator and denomin ator data on PQRI individual quality measures or measures groups, but also for th e purpose of a registry qualifying to submit the proposed electronic prescribing measure for the 2011 Electronic Prescribing Incentive Program. We invite comments on the proposed qualification requirements for registries for the 2011 PQRI. (5) Proposed Qualification Requireme nts for EHR Vendors and Their Products In 2010 PQRI, EHR products were listed on the PQRI section of the CMS Web

site at http://www.cms.hhs.gov/PQRI as a "qualified" EHR produ ct (that is, the name of the vendor software product and the version that was qualified), a nd were available for the product's users to submit quality data on Me dicare beneficiaries to CMS directly from their system for the 2010 PQRI. This lis t of qualified EHR vendor s and products was posted upon completion of the 2009 EHR Te sting Program in January 2010. Vendors' EHR products that were listed as "qualified" products for the 2010 PQRI

were selected because the vendor self-nominat ed to participate in the 2009 EHR Testing Program and demonstrated that their produc ts met the "Requirements for Electronic Health Record (EHR) Vendors to Participat e in the 2009 PQRI EHR Testing Program" that were posted on the Alternative Reporting Mechanisms page of the PQRI section of

the CMS Web site at http://www.cms.gov/PQRI/20_AlternativeR eportingMechanisms.asp#TopOfPage on

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December 31, 2008. Additionally, a vendor's EHR system was required to be updated according to the Final 2010 EHR specificati ons, which were posted in January 2010 on the Alternative Reporting Mechanisms page of the PQRI section of the CMS Web site in order for an EHR vendor and its product to be qualified to submit information on 2010 PQRI measures. The EHR vendor qualificati on process for the 2011 PQRI was finalized in the 2010 PFS final rule with comment period ( 74 FR 61800 through 61802) and is currently underway. We anticipate th e EHR vendor vetting process for the 2011 PQRI will be complete in early 2011. At the conclu sion of the 2011 PQRI EHR vendor vetting process, those EHR products that meet a ll of the 2011 EHR vendor requirements will be listed on the PQRI section of the CMS Web site as a "qualified" PQRI EHR product, which indicates that the product's users ma y submit quality data to CMS for the 2011 PQRI. We continue to caution there is no guarantee that there will be any qualified EHR vendors available for the 2011 PQRI. Howe ver, since seven EHR vendors and their programs were "qualified" to submit quality data to CMS directly from their EPs for 2010 PQRI reporting, we are optimistic that for 2011 PQRI and subsequent years there will continue to be multiple "qualified" EHR vendors available for EPs. During 2011, we propose to use the same se lf-nomination process described in the "Requirements for Electronic Health Record (EHR) Vendors to Participate in the 2011 PQRI EHR Testing Program" posted on the PQRI section of the CMS Web site at http://www.cms.gov/PQRI/20_AlternativeR eportingMechanisms.asp#TopOfPage , to qualify additional EHR vendors and their EHR products to submit quality data extracted from their EHR products to the CMS clinical quality data warehouse for 2012 PQRI. We propose that any EHR vendor interested in ha ving one or more of their EHR products

### CMS-1503-P 487

"qualified" to submit quality data extracted from their EHR products to the CMS clinical quality data warehouse for 2012 a nd subsequent years will be required to submit their self-nomination letter by January 31, 2011. Instructions for submitting the selfnomination letter will be pr ovided in the 2012 EHR vendor requirements, which we expect to post in the 4 th 

### quarter of CY 2010. Specifically, for the 2012 PQRI, we propose that only EHR vendors that self-nominate to participate in the 2012 EHR Test Program will be considered qualifie d EHR vendors for the 2012 PQRI. We propose that the 2011 PQRI EHR test vendors, who, if their testing is successful, may report 2012 PQRI data to CMS, must meet the following requirements:

● Be able to collect and transmit all re quired data elements according to the 2012 EHR Specifications.

● Be able to separate out and repor t on Medicare Part B FFS patients only.

● Be able to include TIN/NPI information submitted with an EP's quality data.

● Be able to transmit this data in the CMS-approved format.

● Comply with a secure method for data submission.

● Not be in a beta test form.

● Have at least 25 active users. Additionally, we propose that previous ly qualified PQRI EHR vendors and 2012 EHR test vendors must also pa rticipate in ongoing PQRI mandatory support conference calls hosted by CMS (approximately one ca ll per month). These requirements would apply not only for the purpose of a vendor's EHR product being qua lified so that the product's users may submit data extracted from the EHR for the 2012 PQRI in 2013, but also for the purpose of a vendor's EHR product being qualified so that the product's users may electronically submit data extracted from the EHR for the electronic prescribing

### CMS-1503-P 488

measure for the 2012 eRx Incentive Program in 2013. We propose that if a vendor misses more than one mandatory support ca ll or meeting, the ve ndor and their product would be disqualified for the PQRI reporting year, which is covered by the call. We propose that previously qualifie d vendors and new vendors will need to incorporate any new EHR measures (measures electronically-specified) added to PQRI for the reporting year they wish to mainta in their PQRI qualification, as well as update

their electronic measur e specifications and data trans mission schema s hould either or both change. This proposed requirement en sures that all PQRI qualified EHR products can be used by EPs to report any PQRI EHR measure. We invite comments on the proposed qualification requirements for EH R Vendors and their products for the 2012 PQRI. e. Proposed Criteria for Satisfactory Repor ting of Individual Quality Measures for

Individual EPs Section 1848(m)(3)(A) of the Act esta blished the criteria for satisfactorily submitting data on individual quality measures as at least 3 measures in at least 80 percent of the cases in which the measure is applicable. If fewer than 3 measures are applicable to the services of the profession al, the professional may meet the criteria by submitting data on 1 or 2 measures for at least 80 percent of applicable cases where the measures are reportable. This section estab lishes the presumption that if an EP submits quality data codes for a par ticular measure the measure applies to the EP. For years after 2009, section 1848(m)(3 )(D) of the Act pr ovides additional authority to the Secretary, in consultation w ith stakeholders and experts, to revise the criteria for satisfactorily reporting data on qua lity measures. Based on this authority and

### CMS-1503-P 489

the input we have previously received from stakeholders, we propose, for 2011, the following 2 criteria for claims-based reporting of individual measures by individual EPs:

• Report on at least 3 measures that appl y to the services furnished by the professional; and

● Report each measure for at least 50 percent of the EP's Medicare Part B FFS patients for whom services were furnishe d during the reporting period to which the measure applies.

To the extent that an EP has fewer than 3 PQRI measures that apply to the EP's services, then we propose the EP would be ab le to meet the criteria for satisfactorily reporting data on individual quality measures by meeting the following 2 criteria:

● Report on all measures that apply to th e services furnished by the professional (that is 1 to 2 measures); and

● Report each measure for at least 50 percent of the EP's Medicare Part B FFS patients for whom services were furnishe d during the reporting period to which the measure applies. We also propose for 2011 the requirement th at an EP who reports on fewer than 3 measures through the claims-based reportin g mechanism may be subject to the Measure Applicability Validation (MAV) process, which would allow us to determine whether an EP should have reporte d quality data codes for additiona l measures. This process was applied in prior years. Under the proposed MAV process, when an EP reports on fewer than 3 measures, we propose to review whet her there are other closely related measures (such as those that share a common diagnosis or those that are representative of services typically provided by a particular type of EP ). We further propose that if an EP who reports on fewer than 3 measures in 2011 reports on a measure that is part of an identified

### CMS-1503-P 490

cluster of closely related measur es and did not report on any ot her measure that is part of that identified cluster of closely related me asures, then the EP would not qualify as a satisfactory reporter in 2011 PQRI or earn an incentive payment. In 2011, we propose that these criteria for satisfactorily reporting data on fewer than 3 individual quality measures would apply for the claims-b ased reporting mechanism only. We note that the proposed 2011 criteria fo r satisfactory reporting of individual quality measures through claims submission are different from the 2010 criteria, which required reporting on at least 80 percent of the EP's Medicare Part B FFS patients for whom services were furnished during the repor ting period to which the measure applies. The rationale for an 80 percent reporting rate is that this sample size would prevent selective reporting to achieve higher performance rates. However, we now have experience with claims based reporting, which has proved challenging for EPs, as discussed above. In 2007, a pproximately half of PQRI participants (defined as submitting at least one QDC), qualified for the PQRI incentive payment. Following the 2007 program completion, we perf ormed an extensive review and made a number of analytic changes that we detailed in our 2007 PQRI Experience Report. For 2008, the analytic changes that we made following the completion of the 2007 program resulted in substantial increases in valid QDC reporting and the number of professionals qualifying for an incentive payment. However, the number who qualified for the incentive for the 2008 program year remained at about half of those who participated. A major reason for this was reporting at less than the required 80 percent reporting requi rement. As a result of our review of the 2007 and 2008 program re sults, we believe that we can reduce the reporting sample requirement to 50 percent for claims-based submission without increasing the likelihood that professionals w ill selectively report based on whether the

### CMS-1503-P 491

performance expectation of a measure is met for that particular patient. Inasmuch as we do not allow resubmission of a claim solely for the purpose of resubmission of a QDC, EPs will still need to submit QDCs contemporaneously with the claim. Therefore, we believe that even at a 50 pe rcent reporting it would be difficult to selectively report for the purpose of better performance. Based on our review, we further believe that by reducing the reporting sample, there will be substantial increases in the portion of participating professiona ls who qualify for the PQRI incentive. Thus, we believe we can encourage significantly broader participa tion which otherwise might be deterred if physicians and other EPs do not believe that they are likely to qualify for the incentive. As previously stated, we propose that the 50 percent reporting sample would apply only to the 2011 PQRI claims-based re porting mechanism available for reporting individual PQRI quality measures and not registry-based reporting or EHR-based reporting. For the 2011 PQRI, we propose the following 2 criteria for satisfactory reporting of data on individual PQRI quality measures fo r registry-based and EHR-based reporting:

● Report on at least 3 measures that a pply to the services furnished by the professional; and

● Report each measure for at least 80 percent of the EP's Medicare Part B FFS patients for whom services were furnishe d during the reporting period to which the measure applies. We do not believe that reducing the repor ting sample to 50 percent for registrybased reporting or EHR-base d reporting would substantially impact the portion of participating professionals w ho qualify for the PQRI incentive. As stated previously, over 90.0 percent of EPs submitting data throug h registries were incentive eligible.

### CMS-1503-P 492

The proposed 2011 criteria for satisfactory reporting of data on individual PQRI quality measures are summarized in Table 47 and are arranged by reporting mechanism and reporting period. We seek public comment on these proposed reporting criteria. We are particularly interested in receiving co mments on our proposal to lower the reporting criteria for claims-based reporting of individua l measures from 80 percent to 50 percent. We seek input on whether 50 percent is an a ppropriate threshold or if another threshold would be more appropriate. We had considered lowering the reporting criteria to a higher threshold (such as 60 percent or 75 pe rcent) but we found that differences in the performance rates at 50 percent and 80 percen t reporting were not substantial while differences in the proportion of EPs satisfactor ily reporting at the two different thresholds

were substantial. TABLE 47: Proposed 2011 Criteria for Satisfactory Reporting of Data on Individual PQRI Quality Measures, by Reporting Mechanism and Reporting Period

Reporting Mechanism Reporting Criteria Reporting Period

Claims-based reporting • Report at least 3 PQRI measures, or 1-2 measures if less than 3 measures apply to the EP; and

• Report each measure for at least 50% of the EP's Medicare Part B FFS patients seen during the reporting period to which the measure applies. January 1, 2011 – December 31, 2011

Claims-based reporting • Report at least 3 PQRI measures, or 1-2 measures if less than 3 measures apply to the EP; and

• Report each measure for at least 50%of the EP's Medicare Part B FFS patients seen during the reporting period to which the measure applies. July 1, 2011 – December 31, 2011

Registry-based reporting • Report at least 3 PQRI measures; and

• Report each measure for at least 80% of the EP's Medicare Part B FFS patients seen during the reporting period to which the measure applies. January 1,2011 – December 31, 2011

Registry-based reporting • Report at least 3 PQRI measures; and

• Report each measure for at least 80% of the EP's Medicare Part B FFS patients seen during the reporting period to which the measure applies. July 1, 2011 – December 31, 2011

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Reporting Mechanism Reporting Criteria Reporting Period

EHR-based reporting • Report at least 3 PQRI measures; and

• Report each measure for at least 80 % of the EP's Medicare Part B FFS patients seen during the reporting period to which the measure applies. January 1, 2011 – December 31, 2011



### Table 47 illustrates that there are a tota l of 5 proposed reporting options for 2011, or ways in which an EP may meet the crite ria for satisfactorily reporting on individual quality measures for the 2011 PQRI. Each proposed reporting option consists of the criteria for satisfactorily reporting such data and results on individual quality measures relevant to a given reporting mechanism and reporting period. EPs may potentially qualify for an incentive as satisfactorily re porting individual quality measures under more than one of the proposed reporting criteria, proposed reporting mechanism, and or for more than one proposed reporting period; how ever, only one incentive payment will be made to an EP based on the longest repor ting period for which the EP satisfactorily

reports. f. Proposed Criteria for Satisfactory Repor ting Measures Groups for Individual EPs We also propose that individual EPs have the option to report measures groups instead of individual quality measures to qualify for the 2011 PQRI incentive, using claims or registries. As stated previous ly, we do not propose to make the EHR-based reporting mechanism available for reportin g on measures groups in 2011. The criteria that we propose for 2011 for satisfactory repo rting of measures groups through claimsbased or registry-based reporting for either the 12-month or 6-month reporting period are as follows: (1) for claims-based reporting, th e reporting of at least 1 measures group for at least 50 percent of patients to whom th e measures group applies, during the reporting period; or (2) for registry-based reporting, th e reporting of at least 1 measures group for at least 80 percent of patients to whom the measures group applies during the reporting

### CMS-1503-P 494

period. EPs, for both claims-based and regi stry-based reporting under these criteria, would be required to submit data on a minimum of 15 unique Medicare Part B FFS patients for the 12-month reporting period a nd a minimum of 8 Medicare Part B FFS patients for the 6-month reporting period. We note that the proposed criteria for 2011 are the same criteria as for 2010 PQRI reporting on measures groups, with the exception of our reducing the reporting sa mple from 80 percent to 50 percent for claims-based submission of measures groups. We propose to reduce the reporting sample requirement

for claims-based submission of measures groups for the same reasons discussed in section VI.F.1.e. of this proposed rule for claims-based submission of individual measures. In other words, we believe that reducing the reporting sample from 80 percent to 50 percent will substantially increase the portion of participating EPs who qualify for a 2011 PQRI incentive without encouraging EPs to selectively report only those cases that will increase their performance rates. Additionally for 2011, we propose to retain the criteria, available only for the 12-month re porting period, based on re porting on at least 1 measures group for at least 30 patients for whom services were furnished between January 1, 2011, and December 31, 2011, to whom the measures group applies. We also propose that the 30 patients on which an EP w ould need to report a measures group for 2011 would not need to be consecutive patients. We propose that the EP may report on any 30 unique patients seen during the reporting period to which the measures group applies. As in previous years, we propos e that for 2011, the patients, for claims-based reporting, would be limited to Medicare Part B FFS patients. Finally, for registry-based reporting in 2011, in contrast to prior program years, we propose to require that the minimum patient numbers or percentages must be met by Medicare Part B FFS patients exclusively and not non-Medicare Part B FFS patients.

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The reason for this is the difficulty of analyzing data we receive from registries, where patients other than Medicare Part B FFS patients are included. For example, under our proposal we would be able to compare cla ims data with regist ry submitted data to compare patients in the denominator of the measure for validation. The proposed 2011 criteria for satisfactory reporting of data on measures groups are summarized in Table 48 and are arranged by reporting mechanism and reporting period. TABLE 48: Proposed 2011 Criteria for Satisfactory Reporting on Measures Groups, by Reporting Mechanism and Reporting Period

Reporting Mechanism Reporting Criteria Reporting Period

Claims-based reporting • Report at least 1 PQRI measures group;

• Report each measures group for at least 30 Medicare Part B FFS patients. January 1, 2011– December 31, 2011

Claims-based reporting • Report at least 1 PQRI measures group;

• Report each measures group for at least 50 % of the EP's Medicare Part B FFS patients seen during the reporting period to whom the measures group applies; and

• Report each measures group on at least 15 Medicare Part B FFS patients seen during the reporting period to which the measures group applies. January 1, 2011 – December 31,2011

Claims-based reporting • Report at least 1 PQRI measures group;

• Report each measures group for at least 50 % of the EP's Medicare Part B FFS patients seen during the reporting period to whom the measures group applies; and

• Report each measures group on at least 8 Medicare Part B FFS patients seen during the reporting period to which the measures group applies. July 1, 2011– December 31, 2011

Registry-based reporting • Report at least 1 PQRI measures group;

• Report each measures group for at least 30 Medicare Part B FFS patients. January 1, 2011 – December 31, 2011

### CMS-1503-P 496

Reporting Mechanism Reporting Criteria Reporting Period Registry-based reporting • Report at least 1 PQRI measures group;

• Report each measures group for at least 80 % of the EP's Medicare Part B FFS patients seen during the reporting period to whom the measures group applies; and

• Report each measures group on at least 15 Medicare Part B FFS patients seen during the reporting period to which the measures group applies. January 1, 2011 – December 31, 2011

Registry-based reporting • Report at least 1 PQRI measures group;

• Report each measures group for at least 80 % of the EP's Medicare Part B FFS patients seen during the reporting period to whom the measures group applies; and

• Report each measures group on at least 8 Medicare Part B FFS patients seen during the reporting period to which the measures group applies. July 1, 2011 – December 31, 2011



### As illustrated in Table 48, there are a total of 6 proposed reporting options, or ways in which EPs may meet the criteria for satisfactory reporting of measures groups for the 2011 PQRI. Each proposed reporting option consists of the criteria for satisfactory reporting relevant to a give n reporting mechanism and reporting period. As stated previously, EPs may potentially qualify as satisfactorily reporting for 2011 PQRI on measures groups under more than one of th e reporting criteria, reporting mechanisms, and/or for more than one reporting period; however, only one incentive payment will be made to an EP based on the longest repor ting period for which the EP satisfactorily reports. Similarly, an EP could also potentially qualify for the PQRI incentive payment by satisfactorily reporting both individual m easures and measures groups. However, only one incentive payment will be made to the EP based on the longest reporting period for which the EP satisfactorily reports. We invite comments on the proposed criteria for satisfactory reporting measures groups for individual EPs.

### CMS-1503-P 497

g. Proposed Reporting Option for Satisfact ory Reporting on Quality Measures by Group

Practices (1) Background and Authority Section 1848(m)(3)(C)(i) of the Act require s the Secretary to establish and have in place a process by January 1, 2010 under which EPs in a group practice (as defined by the Secretary) shall be treated as satisfactorily submitting data on quality measures under PQRI if, in lieu of reporting measures under PQRI, the group practice reports measures determined appropriate by the Secretary, such as measures that target high-cost chronic conditions and preventive care, in a form and manner, and at a time specified by the Secretary. Section 1848( m)(3)(C)(ii) of the Act requires th at this process provide for the use of a statistical sampling model to submit data on measures, such as the model used under the Medicare Physician Group Practice (PGP) demonstr ation project under section 1866A of the Act. A group practice reportin g option (GPRO) was established for the 2010 PQRI in the CY 2010 PFS final rule with comment period (74 FR 61807 through 61811). In addition, payments to a group practi ce under section 1848(m) of the Act by reason of the process proposed herein shall be in lieu of the PQRI incentive payments that would otherwise be made to EPs in the group practice for satisfactorily submitting data on quality measures (that is, prohibits double payments). Therefore, for the 2011 PQRI, we propose to continue to allow a gr oup practice, as a whole (that is, for the TIN(s)), to participate in 2011 PQRI and to submit PQRI quality measures for 2011 and qualify to earn an incentive. If, however, an individual EP is affiliated with a group practice participating in the GPRO and the group practice satisfactorily reports under the GPRO, the EP will be considered as satisfactorily reporting PQRI quality measures data

### CMS-1503-P 498

at the individual level under that same TIN(s) (that is, for the same TIN/NPI combination). (2) Definition of "Group Practice" As stated above, section 1848(m)(3)(C)(i) of the Act authorizes the Secretary to define "group practice." For purposes of determining whether a group practice satisfactorily submits PQRI quality measures data, we propose that for the 2011 PQRI a "group practice" would consist of a physician gr oup practice, as defined by a TIN, with 2 or more individual EPs (or, as identified by NPIs) who have reassigned their billing rights to the TIN. This proposed definition for group practice is different from the 2010 PQRI definition of group practice in that we pr opose to change the minimum group size from 200 to 2 to enable more group practices to participate in the PQRI GPRO in 2011. Generally, our intent continues to be to build on an existing quality reporting program that group practices may already be familiar with by modeling some aspects of the the PQRI GPRO after the PGP demonstr ation while concurrently expanding the availability of the GPRO to more group practices. Since the PGP demonstration is a demonstration program for large group pr actices, one of the requirements for group practices participating in the PGP demonstration is for each practice to have 200 or more

members. To be consistent with the PGP demonstration, we propos e one GPRO process,

which we refer to as "GPRO I" that w ould be available only to similar large group practices. For group practices that have fewer than 200 members, we propose, if technically feasible, an alternative GPRO proc ess which we refer to as "GPRO II". We invite comments on the proposed definition of "group practice" a nd our proposal to expand the definition of group practice to incl ude groups with 2 or more members.

### CMS-1503-P 499

In order to participate in the 2011 PQRI through the GPRO, we propose to require group practices to complete a self-nomination pro cess and to meet certain technical and other requirements. The proposed sel f-nomination process and participation requirements for GPRO I and GPRO II are separately discussed below.

As discussed further in section VI.F.2. of th is proposed rule , participation in the Electronic Prescribing (eRx) Incentive Progra m is voluntary for group practices selected to participate in the PQRI group practi ce reporting option. However, for 2011, we propose that group practices must participat e in the PQRI group practice reporting option in order to be eligible to participate in the eRx group practice reporting option for 2011 PQRI. This is the current requirement under the 2010 PQRI and ERx Incentive programs. Therefore, we propose that a group practice that wishes to participate in both the PQRI group practice reporting option and the elect ronic prescribing group practice reporting option must notify CMS of its desire to do so at the time that it self-nominates to participate in the PQRI group practice reporting option. In addition, we propose that group practices that are participating in Medicare demonstration projects, as a pproved by the Secretary, would also be considered group practices for purposes of the 2011 PQRI GP RO. Specifically, for the 2011 PQRI we propose to deem group practices participatin g in the PGP, Medicare Care Management Performance (MCMP), and EHR demonstrations to be participating in the PQRI GPRO since many of the measures being reporte d under these demonstration programs aresimilar to PQRI measures. As a result, such practices do not need to separately selfnominate to participate in the PQRI GPRO, although it would be necessary for such groups to meet the requirements for incen tive qualification under their respective approved demonstration project. For example, the MCMP demonstra tion sites would be

### CMS-1503-P 500

required to meet the requirements for ea rning a PQRI incentive specified under the

MCMP demonstration. For purposes of the 2011 eRx Incentive Program, however, we propose that group practices participating in CMS-approved demonstr ation projects discussed above would be required to meet the proposed 2011 eRx In centive Program GPRO requirements or the proposed 2011 eRx Incentive Program requirement s for individual EPs in order to qualify for a 2011 eRx incentive. Such group practices would not be able to qualify for a 2011 eRx incentive via participation in an approve d demonstration project since there is no eRx requirement under thes e demonstrations. (3) Proposed Process for Physic ian Group Practices to Participate as Group Practices and Criteria for Satisfactory Reporting (i ) Group Practice Reporting Option for phys ician group practices with 200 or more

NPIs-GPRO I As stated above, we propose that group pr actices interested in participating in GPRO I must self-nominate to do so. Speci fically, we propose that the 2011 PQRI selfnomination letter for group practices interested in participating in the 2011 PQRI through the GPRO I must be accompanied by an electr onic file submitted in a format specified by CMS (such as, a Microsoft Excel file) that includes the group practice's TIN(s)and name of the group practice, the name and e-mail address of a si ngle point of contact for handling administrative issues, as well as the na me and email address of a single point of contact for technical support purposes. This in formation was also required as part of the self-nomination process for the 2010 PQRI GPRO. One change that we propose from the 2010 PQRI GPRO is that we propose for 2011 PQRI GPRO I to validate that the group practice consists of a minimum of 200

### CMS-1503-P 501

NPIs and we will supply group practices with this list. We invite comment on this proposed change for self nomination criteria. In addition, we propose that the selfnomination letter must also indicate the gr oup practice's compliance with the following requirements:

● Have an active IACS user account;

● Agree to attend and participate in a ll mandatory GPRO tr aining sessions; and

● Have billed Medicare Part B on or after January 1, 2010 and prior to October 29, 2010. We propose to post the final 2011 PQRI partic ipation requirements for group practices, including instructions for submitting the self-nomination letter and other requested information, on the PQRI section of the CMS Web site at http://www.cms.gov/PQRI by November 15, 2010. Group practices that wi sh to self-nominate for 2011 would be required to do so by January 31, 2011. Upon r eceipt of the self-nomination letters we propose to assess whether th e participation requirement s were met by each selfnominated group practice using 2010 Medicare claims data. We do not propose to preclude a group practice from par ticipating in the GPRO I if we discover, from analysis of the 2010 Medicare claims data, that there are some EPs (identified by NPIs) that are not established Medicare providers (that is, have not billed Medicare Part B on or after January 1, 2010 and prior to October 29, 2010) as long as the group has at least 200 established Medicare providers. NPIs w ho are not established Medicare providers, however, would not be included in our incen tive payment calculations. We propose that group practices that were selected to participate in the 2010 PQRI GPRO would automatically be qualified to participate in the 2011 PQRI GPRO I and would not need to complete the 2011 PQRI GPRO I self-nomination process.

### CMS-1503-P 502

For physician groups selected to par ticipate in the PQRI GPRO I for 2011, we propose to retain the existing 12-month re porting period beginning January 1, 2011. We propose that group practices participating in GPRO I submit information on these measures using a data collection tool base d on the GPRO Tool used in 2010 PQRI GPRO by 36 participating group practices to re port quality measures under PQRI. The 2010 PQRI GPRO Tool will be updated as n eeded to include the 2011 PQRI GPRO I

measures. We believe that use of the GPRO data collection tool allows group practices the opportunity to calculate their own performan ce rates for reporting quality measures. We propose that physician groups selected to participate in the 2011 PQRI through the GPRO I report on a proposed common set of 26 NQF-endorsed quality measures that are based on measures currently used for 2010 PQ RI GPRO. We believe these measures target high-cost chronic conditions and prev entive care. The proposed quality measures

are identified in Table 71. The proposed 2011 PQRI GPRO I quality measures are based on a subset of the Doctor's Office Quality (DOQ) quality measur es set developed under the direction of

CMS and were used in the PGP and/or MCMP demonstr ation programs, and have subsequently been used in 2010 PQRI GPRO. Contributors to the development of the DOQ measures set included the American Me dical Association's Physician Consortium for Performances Improvement (AMA-PCPI), the American College of Cardiology (ACC), the American Heart Association (AHA), the National Diabetes Quality Improvement Alliance, the National Committee for Quality Assurance (NCQA), and the Veterans Health Administration (VA). In most instances, these measures overlap with the proposed 2011 PQRI measures for reportin g by individual EPs, however, there are some measures proposed for GPRO I that are not proposed for individual EPs.

### CMS-1503-P 503

These quality measures are grouped into four disease modules: coronary artery disease; diabetes; heart failure; and preven tive care services. On February 2, 2010, we hosted a 2011 PQRI listening session to solicit input on a number of aspects of the PQRI, including measures for the 2011 PQRI GPRO. Since we received no suggestions for

additional disease modules fo r the GPRO I from this listening session, we are not proposing any additional measures for the 2011 PQRI GPRO I. We invite comments on our proposal to use the 26 measures identif ied in Table 71 for inclusion in 2011 PQRI GPRO I. We specifically request comme nts on whether these measures can and/or should be expanded for the group practice repor ting option for future program years.

Disease modules and meas ures should address high cost cond itions and/or a gap in care.

Further detail on criteria for measure selecti on can be found in section VI.F.1.h. below. The proposed process that group practices will be required to us e to report data on quality measures for the 2011 PQRI GPRO I and the proposed associated criteria for satisfactory reporting of data on quality measures by group practices, are summarized in Table 49. Under our proposed 2011 program, group practices participating in PQRI GPRO I as a group practice would be required to report on all of the measures listed in

Table 71. As part of the data submission process for 2011 GPRO I, we propose that during 2012, each group practice would be requi red to report quality measures with respect to services furnished during the 2011 reporting period (that is, January 1, 2011, through December 31, 2011) on an assigned sa mple of Medicare beneficiaries. We propose to analyze the January 1, 2011 through October 31, 2011 (that is, the last business day of October 2011) National Claims History (NCH ) file to assign Medicare beneficiaries to each physician group prac tice using a patient assignment methodology

### CMS-1503-P 504

modeled after the patient a ssignment methodology used in the PGP demonstration. Based on our desire to model the PQRI GP RO I after the PGP de monstration, we will also consider applying any refinements made to the patient assignment methodology used in the PGP demonstration prior to January 1, 2011 to the 2011 PQRI GPRO I. Assigned

beneficiaries would be limited to those Medicare FFS beneficiaries with Medicare Parts A and B for whom Medicare is the primary pa yer. Assigned beneficiaries would not include Medicare Advantage enrollees. A bene ficiary would be assigned to the physician group that provides the plurality of a benefi ciary's office or othe r outpatient evaluation and management allowed charges (based on Medicare Part B claims submitted for the beneficiary for dates of services be tween January 1, 2011, and October 31, 2011). Beneficiaries with only 1 visit to the group practice between January 1, 2011 and October 31, 2011, would be eliminated from the group practice's assign ed patient sample for purposes of 2011 PQRI GPRO I. For inclus ion in the sample, a ssigned beneficiaries would be required to have at least 2 vi sits to the group practice between January 1, 2011, and October 31, 2011. Once the beneficiary assignment has been made for each physician group during the fourth quarter of 2011, we propose to provide each physician group selected to participate in the PQRI GPRO I with access to a database (that is, a data collection tool) that will include the group's assigned beneficiary samples and the quality measures listed in Table 71. We propose to pre-populate the data collection tool with the assigned beneficiaries' demographic and utilization information based on all of their Medicare claims data. We intend to pr ovide the selected physician gr oups with access to this prepopulated database by no later than the fi rst quarter of 2012. The physician group would be required to populate the remaining data fiel ds necessary for capturing quality measure

### CMS-1503-P 505

information on each of the assigned beneficiaries. Numerators for each of the quality

measures would include all be neficiaries in the denominator population who also satisfy the quality performance criteria for that measure. Denominators for each quality measure would include a sample of the assigned beneficiaries who meet the eligibility criteria for that disease module or each preventive care qualit y measure. All of the assigned patients' inpatient, outpatient, and phys ician claims would be used in determining clinical eligibility for each module, regardless if th ey were submitted by the group practice or other providers. Identical to the sampling method used in the PG P demonstration, we propose that the random sample must consist of at least 411 assigned beneficiaries. If the pool of eligible assigned be neficiaries is less than 411, then the group practice must report on 100 percent, or all, of the assigned beneficiaries to satisf actorily participate in the group practice reporting option. For each disease module or preventive care measure, the physician group would be re quired to report information on the assigned patients in the order in which they appear in the group 's sample (that is, consecutively). These proposed reporting criteria are identical to the reporting criteria used in the PGP demonstration and in the 2010 PQRI GPRO. By building on an existing demonstration program that large group practices may alre ady have experience with, we hope to minimize burden on both group practices and CMS.

TABLE 49: 2011 Proposed Process for Physician Group Practices to Participate as Group Practices and Criteria for Satisfactory Reporting of Data on Quality Measures by Group Practices for GPRO I

Reporting Mechanism Reporting Criteria Reporting PeriodA prepopulated data collection tool provided by CMS • Report on all measures included in the data collection tool (26 measures); and

• Complete the tool for the first 411 consecutively ranked and assigned beneficiaries in the order in which they appear in the group's sample for each disease module or preventive care measure. If the pool of eligible assigned beneficiaries is less than 411, then report on 100% of assigned beneficiaries. January 1, 2011 – December 31, 2011

### CMS-1503-P 506

For 2011, we propose an exclusive reporting mechanism for EPs identified as part of the group practice with respect to the group as identified by the TIN. However, EPs who are part of the group practice, and who separately practice with respect to another TIN to which the EP has reassigned benefits , could separately qua lify as individual EPs with respect to the other practice (TIN). As discussed above, we propose that each physician group selected to par ticipate in the PQRI GPRO I would have access to a data base (that is a data collection tool) that w ould include the assigned beneficiary sample and the quality measures. This data collecti on tool was originally developed for use in the PGP demonstration, updated for use in th e MCMP demonstrati on, and will continue to be updated as needed for use in the PQRI . The assigned beneficiaries' demographic and utilization information is pre-populated ba sed on claims data. We anticipate being able to provide the selected physician groups with access to this pre-populated database by the first quarter of 2012. The physician group would be required to populate the remaining data fields necessary for capturing quality measure information on each of the assigned beneficiaries. Numerators for ea ch of the quality measures would include all

beneficiaries in the denomin ator population who also satisfy the quality performance criteria for that measure. Denominators for each quality measure would include a sample of the assigned beneficiaries who meet the eligibility criteria for that quality measure module or preventive care measure. We expect that use of the PQRI GPRO I data collection tool allows group practices the opportunity to calculate their own performance rates for reporting quality measures. This provides group practices with the chance to preview their information prior to the public posting of performance da ta should we choose to do so in future

program years.

### CMS-1503-P 507

We invite comment on our proposal for 2011 to retain 200 as the number of NPIs for a TIN required for each group practice under the GPRO I. We also invite comment on our proposal to allow those "qualified" fo r 2010 GPRO to be rolled over for automatic qualification for 2011 GPRO I. (ii) Group Practice Reporting Option for Group Practices of 2 – 199 NPIs – GPRO-II As discussed previously, section 1848(m)(3)(C) of the Act authorizes us to define the term "group practice" and requires us to establish a process under which EPs in group practices shall be treated as satisfactorily submitting data on PQRI quality measures, but is not prescriptive with regard to the charac teristics of this process. Although for 2010 we did not provide a process for groups of less than 200 NPIs to report under the GPRO, we believe that there are sign ificant potential benefits to a llowing reporting at the group level generally. At present, for example, where more than one individual professional sees the same patient, each may have to report separately with respect to the patient even for processes of care that do not need to be repeated at each visit. Thus, there is significant duplication of reporting. Additiona lly, while we are not proposing to report performance information with respect to the 2011 PQRI GPRO, the public reporting of performance information at the group level rais es substantially fewer issues, such as privacy, and the potential adverse impact of public reporting on the individual physician, and the lack of sufficient numbers of patie nts for any one physician to meaningfully differentiate performance resu lts. Finally, we believe that many process-of-care measures depend on general functioning of th e practice, such as in coordinating and tracking care, as opposed to a quality of a particular profe ssional in the group, particularly for measures related to prevention and care of chronic illnesses. As a result, based on our authority unde r section 1848(m)(3)(C) of the Act to

### CMS-1503-P 508

establish a process for group practices and our discretion to define "group practice" under this section we are proposing multiple pr ocesses for reporting at the group level for groups of EPs of all sizes for purposes of qualifying for a PQRI incentive payment. The proposed process for groups of 200 or more EPs, known as GPRO I, was discussed above. If technically feasible, we propos e a new group practice reporting option (GPRO II) for groups of 2-199 NPIs in a TIN for 2011. For GPRO II in 2011, we propose to require groups of EPs who decide to repo rt as a group to self-nominate. The self-nomination process would c onsist of sending a letter with the name of the group, the TIN, an email address of the contact person, and the names and NPIs of all of the EPs practicing under that group's TIN. We do not propose to preclude a group practice from participating in the GPRO II if we discover, from analysis of the 2010 Medicare claims data, that there are some EPs (identified by NPIs) that are not established Medicare providers (that is, have not billed Medicare Part B on or after January 1, 2010 and prior to

October 29, 2010) as long as the group has at leas t 2 established Medicare providers. NPIs who are not established Medicare provi ders, however, would not be included in our incentive payment calculations. We also propose that self-nominating groups would need to indicate in this letter if the group intends to report as a group for the eRx Incentive Program and the reporting mechanism the group intends to use to report as a group for the eRx Incentive Program. We would require that this information be sent to: GPRO II, c/o CMS, 7500 Security Blvd., Mail Stop S3-02-01, Baltimore, MD 21244, and must be postmarked by January 31, 2011, for consideration in the program. Since GPRO II would be a new proce ss available to groups in 2011, we propose to initially pilot the GPRO II process w ith a limited number of groups. We propose to

### CMS-1503-P 509

select the first 500 groups that meet the propos ed eligibility requirement s to participate in the 2011 GPRO II. We propose to use the pos tmark to determine the order in which groups self-nominated for GPRO II. We propos e to consider only self-nomination letters postmarked between January 3, 2011 and January 31, 2011. We do not propose to consider letters postmarked prior to Janua ry 3, 2011 to prevent groups from selfnominating before the GPRO II requirements are finalized and to discourage groups from self-nominating for GPRO II prior to revi ewing the final GPRO II requirements. For purposes of quality data submission, we propose, for the GPRO II, to allow EPs to submit their data through claims or through a qualified GPRO registry to the extent registries are technically capable of collecting, calculating and transmitting the required data to CMS and that we are able to accept such data from registries. For GPRO II, as discussed in greater deta il below, we propose that in addition to reporting a specific number of individual measures, the gr oup would have to report one or more proposed 2011 PQRI measures groups id entified in Tables 57 through 70 of this proposed rule depending on the size of the group practice. In this way we seek to address a concern expressed regarding PQRI for indivi dual reporting that EPs are able to select any three of a large array of measures making comparison data difficult whether for the same individual or among prof essionals. We believe that by having a smaller set of measures to choose from, we hope to focus on topics of major significance, and make the information obtained with respect to quality more meaningful. For purposes of satisfying the requireme nts under section 1848(m)(3)(C)(i) of the Act for groups of 2-199 NPIs, we propose that in order to be treated as satisfactorily reporting under GPRO II, the group practice woul d be required to report on 50 percent or more (if submitting through claims) of all Medicare Part B patients who fit into the

### CMS-1503-P 510

measures group denominator or 80 percent or more of Medicare patients if using a registry to report. Additionally, to earn a PQRI incentive payment for all allowed Medicare Part B services that are provided by the TIN, we propose that a group practice must report on three to six individual 2011 PQRI measures , depending on the size of the group. We propose that the group practice may select fr om among any of the 2011 PQRI measures on which to submit data, provided the measur es selected are not duplicated in the measures group(s) reported. We propose that, to satisfactorily report individual PQRI measures, a group must report each measure at the same rate (per centage) as determined by the method of submission as individual EPs. For example, if reporting via claims, to satisfactorily report individual measures, each measure would need to be reported on at least 50 percent of eligible Medicare Part B FFS patients.

An alternative which we considered was to require that the individual measures be

selected from a more limited set of measur es, such as measures closely linked to improved population health, or other measures perceived to address the greatest potential benefit from improved performance. While there are potential benefits to this approach of encouraging broad reporting of a more limited set of measures, we are concerned that any limited measures set may not be applicable to all groups, such as single specialty groups. Further we are concerne d that this would diminish an important strength of the overall PQRI measures set, which is its broad applicability. We invite comments on the potential benefits of a core measures set, as opposed to allowing groups to select from among the array of PQRI measures, what m easures should be included in that set, whether there are any PQRI measures that all professionals in group practices should

### CMS-1503-P 511

report, where the measure applie s to patients of the group.

A second alternative that we considered wa s to require group practices, as part of the self-nomination process, to designate wh ether they were a multispecialty group with primary care, a multispecialty group without primary care, or a single specialty group, and if so, the specialty. Depending on what type of specialty the group is, we would identify a set of PQRI measures pertaining to the group's specialty and require the group practice to report on the identified set of spec ialty-specific PQRI measures. We invite comments on the potential benefits of this approach as opposed to allowing groups to select from among the array of PQRI measur es or requiring all groups, regardless of specialty, to report on the same core set of measures. Table 50 sets forth the proposed criteri a for satisfactory reporting under the 2011 PQRI GPRO II and requirements for each group based on their respective group size (number of EPs). If a group does not satisfactorily report as a GPRO II group, we propose to analyze the individual professiona l's data to see if they satisfactorily reported at the

individual TIN/NPI level. If the EP satisfact orily reported at the i ndividual level, he or she would receive a PQRI incentive, which is calculated using the EP's TIN/NPI Medicare Part B allowed charges. If a group practice participating in the 2011 PQRI GPRO II wants to also participate in the 2011 eRx Incentive Prog ram as a small group, we propose that the group would need to indicate that preference in their self-nomin ation letter and would need to report on the number of unique enc ounters based on their group size as listed in Table 50 below. For the 2011 eRx reporting for GPRO II, we propose the following reporting mechanisms: claims, a GPRO eRx qualified registry or a GPRO qualified EHR.

### CMS-1503-P 512

As with the 2011 eRx Incentive Program for i ndividual EPs and the 2011 eRx GPRO I, at least 10 percent of a GPRO II group's charges would need to be comprised of codes in the denominator of the electronic prescribing me asure and the group would need to use an electronic prescribing system that meets the requirement s of the 2011 eRx measure. Similar to proposed GPRO I, if a GPRO II group self-nominates to report the eRx measure as a group, we propose that all me mbers of the group practicing under the group's TIN would be ineligible to report as an individual electronic prescriber.

TABLE 50: 2011 Proposed Process for Physician Gr oup Practices to Participate as Group Practices and Criteria for Satisfactory Reporting of Data on Quality Measures by Group Practices for GPRO II

Group size (number of EPs) Number of MGs required

to be reported Percent of Medicare Pt B

patients in denominator for successful reporting via claims Percent of Medicare Pt B

patients in denominator for successful reporting via

registries Minimum number of patients in each measures

group Number of required individual measures to report Required number of unique visitswhere an eprescription was generated to be

a successful

electronic prescriber 2-10 1 50% 80% 35 3 75 11-25 1 50% 80% 50 3 225 26-50 2 50% 80% 50 4 475 51-100 3 50% 80% 60 5 925 101-199 4 50% 80% 100 6 1875 

### The required number of unique visits where an electronic prescription was generated to be a successful electronic prescr iber was determined by taking the midpoint of the group size range and multiplying the number by 12.5 and then rounding this number to the nearest multiple of 5. This is consistent with how the 2010 eRx GPRO requirements, which requires that the group practice report that at least 1 prescription during an encounter was generated and transmitted using a qualified electronic prescribing system in at least 2,500 instances during the reporting period, were derived. For the 2010 eRx Incentive Program, we assume d that half the members of an average sized-group (which we assumed to be 200 EPs) do not furnish the services represented by

### CMS-1503-P 513

the electronic prescribing measure's denominat or codes, and thus, would not have an opportunity to report the electronic prescribin g measure. For the remaining EPs within the group who do have an opportunity to repor t the electronic prescribing measure, we sought to hold those EPs to the same standard as individual EPs. Thus, for an average 200 EP group, each of the 100 EPs with an opportunity to report the electronic prescribing measure would be expected to have 25 unique electronic prescribing events for a total of 2,500 unique electronic prescribing events for the group. We propose posting the information require d by section 1848(m)(5)(G) of the Act for those group practices that are selected to participate in the 2011 PQRI under the GPRO II. That is, we propose to post the names of group practices that satisfactorily report under GPRO II as we propose to do for group practices that satisfactorily report under the 2011 PQRI GPRO I. We invite comment on our proposal to add this second option (GPRO II) for group practices to report PQRI qua lity data measures and the GPRO II process. We also invite comments regarding our proposal to publicly report GPRO II information with respect to satisfactory PQRI participation. (iii) Alternatives Considered for Expanding the GPRO in 2011 In addition to the GPRO II, another opti on that we considered for expanding the GPRO for 2011 was to expand GPRO I to incl ude smaller group practices. Specifically, we considered allowing groups of 100 or mo re EPs to participate in the PQRI under GPRO using the same reporting mechanis m and reporting criteria required under the 2010 PQRI GPRO and proposed for the 2011 PQRI GPRO I. We also considered modifying the definition of "group practice" to include groups that have and use multiple

TINs. We invite comments on these alternatives.

### CMS-1503-P 514

h. Statutory Requirements and Other C onsiderations for 2011 PQRI Measures (1) Statutory Requirements for 2011 PQRI Measures Under section 1848(k)(2)(C)(i) of the Act, the PQRI quality measures shall be such measures selected by the Secretary from measures that have been endorsed by the entity with a contract with the Secretary unde r subsection 1890(a) of the Act (that is, the National Quality Forum, or NQF). However, in the case of a specified area or medical topic determined appropriate by the Secretary for which a feasible and practical measure has not been endorsed by the NQF, section 1848(k)(2)(C)(ii) of the Act authorizes the Secretary to specify a measure that is not so endorsed as long as due consideration is given to measures that have been endorse d or adopted by a consensus organization identified by the Secretary, such as the AQA alliance. In light of these statutory requirements, we believe that, except in the circumstances specified in the statute, each proposed 2011 PQRI quality measure would need to be endorsed by the NQF. The NQF endorsement status of each of the proposed m easures is identified for each measure. The basis for including certain measures that ar e not endorsed by NQF is discussed further

below. Additionally, section 1848(k)(2)(D) of the Act requires that for each 2011 PQRI quality measure, "the Secretary shall ensure that EPs have the opportunity to provide input during the development, endorsement, or selection of measures applicable to services they furnish." We believe that this requirement is met for all proposed measures in several ways. Measure developers genera lly include a public comment phase in their measure development process. As part of the measures development process, measures developers typically solicit public comments on measures that they are testing in order to

determine whether additional refi nement of the measure(s) is needed prior to submission

### CMS-1503-P 515

for consensus endorsement. For example, information on the measure development process, employed by us when CMS or our contractor is the measure developer, is available in the "Measures Management Sy stem Blueprint" found on the CMS Web site

at http://www.cms.gov/apps/QMIS/mmsBlueprint.asp . EPs also have the opportunity to provide input on a measure as the measure is being vetted through the NQF consensus endorsement process. The NQF employs a public comment period for measures vetted through its consensus endorsement proce ss (and previously, for the AQA consensus adoption process). Additionally, we have invited suggestions for measures during the last 3 years, including most recently via the Listening Session held at CMS on February 2, 2010. The goal of the Listening Session was to discuss and solicit feedback on suggestions received on individual quality me asures and measures groups for possible inclusion in the proposed set of quality me asures for use in the 2011 PQRI program. Finally, as in previous program years, EPs also have an opportunity to provide input on the measures proposed for inclusion in the 2011 PQRI through this proposed rule, which provides a 60-day comment period. Accordin gly, with regard to the 2011 PQRI, we believe we have satisfied this requirement in multiple ways. The statutory requirements under section 1848( k)(2)(C) of the Act, subject to the exception noted above, require only that the m easures be selected from measures that have been endorsed by the entity with a cont ract with the Secretary under section 1890(a) (that is, the NQF) and are silent with respect to how the measures that are submitted to the NQF for endorsement were developed. The basic steps for developing measures applicable to physicians and other EPs prior to sub mission of the measures for endorsement may be carried out by a variet y of different organizations. We do not believe there needs to be any special rest rictions on the type or make up of the

### CMS-1503-P 516

organizations carrying out this basic deve lopment of physician measures, such as restricting the initial development to physician-controlled organizations. Any such restriction would unduly limit the basic development of qualit y measures and the scope and utility of measures that may be consid ered for endorsement as voluntary consensus

standards. (2) Other Considerations for Measures Proposed for Inclusion in the 2011 PQRI As stated previously, in addition to reviewing the 2010 PQRI measures for purposes of developing the proposed 2011 PQRI measures, we reviewed and considered measure suggestions including comments r eceived in response to the CY 2010 PFS proposed rule and final rule with comment period. Additi onally, suggestions and input received through other venues, such as an invitation for measures suggestions via the Listening Session held February 2, 2010, were also reviewed and considered for purposes of our development of the lis t of proposed 2011 PQRI quality measures. A summary of the measures suggestions received via the Listening Session is included in the background paper that was provided to Listen ing Session participants. The Listening Session background paper is posted on CMS Spon sored Calls page of the PQRI section

of the CMS Web site at: http://www.cms.gov/PQRI/04_CM SSponsoredCalls.asp#TopOfPage

. With respect to the selection of new meas ures (that is, measures that have never been selected as part of a PQRI quality measure set for 2010 or any prior year), we propose to apply the following considera tions, which include many of the same considerations applied to the selection of 2009 and 2010 PQRI quality measures for inclusion in the 2011 PQRI quality measure set described above:

● High Impact on Healthcare.

### CMS-1503-P 517

++ Measures that are high impact a nd support CMS and HHS priorities for improved quality and efficiency of care for Me dicare beneficiaries. These current and long term priority topics include the followi ng: prevention; chronic conditions; high cost and high volume conditions; elimination of health disparities; healthcare-associated

infections and other cond itions; improved care coordina tion; improved outcomes; improved efficiency; improved patient and family experience of care; improved end-oflife/palliative care; effective management of acute and chronic episodes of care; reduced unwarranted geographic variation in quality and efficiency; and adoption and use of interoperable HIT.

● Measures that are included in, or facilitate alignment with, other Medicare, Medicaid, and CHIP programs in furtherance of overarching healthcare goals.

● NQF Endorsement. ++ Measures must be NQF-endorsed by June 1, 2010, in order to be considered for inclusion in the 2011 PQRI quality meas ure set except as provided under section 1848(k)(2)(C)(ii) of the Act. ++ Section 1848(k)(2)(C)(ii) of the Act pr ovides an exception to the requirement that the Secretary select meas ures that have been endorsed by the entity with a contract under section 1890(a) of the Act (that is, the NQ F). As long as an area or medical topic for which a feasible and practical NQF-e ndorsed measure is not available has been

identified and due consid eration has been given to measur es that have been adopted by the AQA or other consensus organization identif ied by Secretary. As discussed above, we anticipate not including measures whic h only have AQA adoption for future program

years.

### CMS-1503-P 518

++ The statutory requirement s under section 1848(k)(2)(C) of the Act, subject to the exception noted above, require only that the measures be selected from measures that have been endorsed by the entity with a cont ract with the Secretary under section 1890(a) (that is, the NQF) and are silent with respect to how the measures that are submitted to the NQF for endorsement are developed. Th e basic steps for developing measures applicable to physicians and other EPs prior to sub mission of the measures for endorsement may be carried out by a variet y of different organizations. We do not believe there needs to be any special rest rictions on the type or make up of the organizations carrying out this basic deve lopment of physician measures, such as restricting the initial development to physician-controlled organizations. Any such restriction would unduly limit the basic development of qualit y measures and the scope and utility of measures that may be consid ered for endorsement as voluntary consensus standards. The requirements under section 1848(k)(2)(C) of the Act pertain only to the

selection of measures and not to the development of measures.

● Address Gaps in PQRI Measure Set. ++ Measures that increase the scope of applicability of the PQRI measures to

services furnished to Me dicare beneficiaries and ex pand opportunities for EPs to participate in PQRI. We continue to seek the broad ability to assess the quality of care furnished to Medicare beneficiaries, and ultimately to compare performance among professionals. We seek to increase the circumstances where EPs have at least three measures applicable to their practice and measures that help expand the number of measures groups with at least four measures in a group.

### CMS-1503-P 519

● Measures of various aspects of clin ical quality including outcome measures, where appropriate and feasib le, process measures, structural measures, efficiency measures, and measures of pa tient experience of care. Other considerations that we propose to apply to the selection of measures for 2011, regardless of whether the measure was a 2010 PQRI measure or not, were:

● Measures that are functional, which is to say measures that can be technically implemented within the capacity of the CMS infrastructure for data collection, analysis, and calculation of reporting and performance rate s. This leads to preference for measures that reflect readiness for implementation, su ch as those that are currently in the 2010 PQRI program or have been through testing. The purpose of measure testing is to reveal the measure's strengths and weaknesses so that the limitations can be addressed and the measure refined and strengthened prior to implementation. For any new measures considered for 2011 PQRI, preference is given to those that can be most efficiently implemented for data collecti on and submission. Therefore, any measures that have previously been found to be technically imprac tical to report because they are analytically challenging due to any number of factors, including those that are claims-based, will again not been included for 2011 PQRI. For ex ample, in some cases, we are proposing to replace existing 2010 PQRI measures with upda ted and improved measures that are less technically challenging to report. For exam ple, we are proposing to replace existing 2010 PQRI measures #114 and #115 with updated a nd improved measure #TBD (Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention), which is less technically challenging to report.

● In 2011 PQRI, as in 2010 PQRI, for some measures that are useful, but where data submission is not feasible through all otherwise available PQRI reporting

### CMS-1503-P 520

mechanisms, a measure may be included for reporting solely through specific reporting mechanism(s) in which its submission is feasible. For the 2011 PQRI, we propose to retain those measures that had previously been available for claims-based reporting and registry-based reporting, which were changed for 2010 PQRI to registry-based reporting only because they were technically challeng ing to report and/or analyze through the claims-based reporting mechanism. We welcome comments on the implication of including or excluding any given measure or measures for our proposed 2011 PQRI quality measure set, as well as feedback relative to our proposed approach in selecting measures. We recognize that some commenters may also wish to recommend additional measures for inclusion in the 2011 PQRI measures that we are not proposin g. While we welcome all constructive comments and suggestions, and may consider such recommended measures for inclusion in future measure sets for PQRI and/or othe r programs to which such measures may be relevant, we will not be able to consider such additional measures for inclusion in the

final 2011 measure set. As discussed above, section 1848(k)(2)(D) of the Act requires that the public have the opportunity to provide input during the sel ection of measures. We also are required by other applicable statutes to provide opportunity for public comment on provisions of policy or regulation that are established vi a notice and comment rulemaking. Measures that were not included in this proposed ru le for inclusion in the 2011 PQRI that are recommended to CMS via comments on this pr oposed rule cannot be included in the

2011 measure set. As discussed above, section 1848(k)(2)(D) of the Act requires that the public have the opportunity to provide input during the sel ection of measures. We also are required

### CMS-1503-P 521

by other applicable statutes to provide opportunity for public comment on provisions of policy or regulation that are established vi a notice and comment rulemaking. Measures that were not included in this proposed ru le for inclusion in the 2011 PQRI that are recommended to CMS via comments on this propos ed rule have not been placed before the public to comment on the selection of those measures within the rulemaking process. Even when measures have been published in the Federal Register , but in other contexts and not specifically proposed as PQRI meas ures, such publication does not provide true opportunity for public comment on those measur es' potential inclusion in PQRI. Thus,

such additional measures recommended for selection for the 2011 PQRI via comments on this proposed rule cannot be included in th e 2011 measure set. However, as discussed above, we will consider comments and recommendations fo r measures, which may not be applicable to the final set of 2011 PQRI meas ures, for purposes of identifying measures for possible use in future years' PQRI or ot her initiatives to which those measures may be pertinent. In addition, as in prior years, we ag ain note that we do not use notice and comment rulemaking as a means to update or modify measure specifications. Quality measures that have completed the consensus pr ocess have a designated party (usually, the measure developer/owner) who has accepted responsibility for maintaining the measure. In general, it is the role of the measure owne r, developer, or mainta iner to make changes to a measure. Therefore, comments reques ting changes to a specific proposed PQRI measure's title, definition, and de tailed specifications or coding should be directed to the measure developer identified in Tables 52 through 70. Contact information for the 2010 PQRI measure developers is listed in the " 2010 PQRI Quality Measures List," which is available on the PQRI section of the CMS Web site at http://www.cms.gov/PQRI

.

### CMS-1503-P 522

However, we stress that inclusion of m easures that are not NQF endorsed or AQA adopted is an exception to the requirement under section 1848(k)(2)(C)(i) of the Act that measures be endorsed by the NQF. We ma y exercise this exception authority in a specified area or medical topic for which a feasible and practical measure has not been endorsed by NQF, so long as due considera tion is given to measures that have been endorsed by the NQF. i. Proposed 2011 PQRI Quality Measures for Individual EPs As in 2010 PQRI, individual EPs have the choice of repor ting PQRI quality measures data on either individual qualit y measures or on measures groups for 2011 PQRI. Consistent with statutory requirements fo r identifying and including measures for 2011 PQRI, the individual quality measures identified for use in the 2011 PQRI will be selected from those we propose in this rule a nd will ultimately be fina lized as of the date the CY 2011 PFS final rule with comment peri od is available for public inspection at the Office of the Federal Register. No changes (t hat is, additions or de letions of measures) will be made after publication of the CY 2011 PFS final rule with comment period. However, as was the case in previous prog ram years, we may make modifications or refinements, such as revisions to measures titles and code additions, corrections, or revisions to the detailed specifications for the 2011 measures until the beginning of the reporting period. The 2011 measures specifi cations for individual quality measures will be available on the PQRI sec tion of the CMS Web site at http://www.cms.gov/PQRI when they are sufficiently developed or fi nalized. We are targ eting finalization and publication of the detailed specifications for all 2011 PQRI measures on the PQRI section of the CMS Web site by November 15, 2010 and will, in no event, publish these

### CMS-1503-P 523

specifications later than December 31, 2010. The detailed specif ications will include instructions for reporting and will identify th e circumstances in which each measure is applicable. For 2011, we are proposing that for the most part, final PQRI quality measures will be selected from the 2010 PQRI measures. In response to the February 2, 2010 Listening Session, CMS received 146 individual measure suggestions and 9 meas ures groups suggestions, one of which included modifications to an existing measur es group, for possible inclusion in the 2011 PQRI. We propose to include a total of 198 m easures (this includes both individual measures and measures that are part of a proposed 2011 measures group) on which individual EPs can report for the 2011 PQRI. The individual PQRI quality measures proposed for the 2011 PQRI are listed in Tabl es 52 through 56 and fa ll into four broad categories as set forth the below. The four categories are the following:

● Proposed 2011 Individual Quality Measures Selected From the 2010 PQRI Quality Measures Set Available for Claims-based Reporting and Registry-based Reporting;

● Proposed 2011 Individual Quality Measures Selected From the 2010 PQRI Quality Measures Set Available for Registry-based Reporting Only;

● New Individual Quality Measures Proposed for 2011; and

● Proposed 2011 Measures Availa ble for EHR-based Reporting. In addition, we are also proposing the in clusion of 1 new measures group for 2011 PQRI. The measures proposed for 2011 measures groups are listed in Tables 57 through 70. Please note Table 51 includes 2010 PQRI measures that are not proposed for inclusion in 2011 PQRI.

### CMS-1503-P 524

TABLE 51: 2010 PQRI Quality Measures Not Proposed for Inclusion in the 2011 PQRI

Measure Number Measure Title 114 Preventive Care and Screening: Inquiry Regarding Tobacco Use 115 Preventive Care and Screening: Advising Smokers and Tobacco Users to Quit 135 Chronic Kidney Disease (CKD): Influenza Immunization 136 Melanoma:Follow-Up Aspects of Care 139 Cataracts: Comprehensive Preoperative Assessment for Cataract Surgery with Intraocular Lens (IOL) Placement



### After careful consideration of 2010 PQRI measures, we propose to retire these 5 measures because they did not meet one or mo re of the considerations for selection of proposed 2011 measures discussed in secti on VI.F.1.h. above. Specifically, we are proposing to retire PQRI measures #135, #136, and #139, for 2011 because they have been considered by NQF for possible endorsement but u ltimately were not NQF-endorsed. In addition we propose to replace existing 2010 PQRI measures #114 and #115 with an updated and improved m easure (#TBD "Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention"), which is less technically challenging to report. We inv ite comments on our proposal to retire the 2010 measures listed in Table 51 for the 2011 PQRI. (1) Proposed 2011 Individual Quality Measures Selected From the 2010 PQRI Quality

Measures Set Available for Claims-based Reporting and Registry-based Reporting For 2011, we propose to retain 170 measures currently used in the 2010 PQRI. These 170 proposed measures include 45 regist ry-only measures currently used in the 2010 PQRI, but do not include any measures that are proposed to be included as part of the 2011 Back Pain measures group (see section VI.F.1.i.(5) of this proposed rule). Similar to the 2010 PQRI, for 2011, we propose that any 2011 PQRI measures that are

### CMS-1503-P 525

included in the Back Pain measures group woul d not be reportable as individual measures through claims-based reporting or registry-based reporting. The 125 individual 2010 PQRI measures pr oposed for inclusion in the 2011 PQRI quality measure set as individual quality measures for either claims-based reporting or registry-based reporting are listed by their Measure Number and T itle in Table 52, along with the name of the measure's develope r/owner, and the NQF measure number, if applicable. The PQRI Measure Number is a unique identifier assigned by CMS to all measures in the PQRI measure set. Once a PQRI Measure Number is assigned to a measure, it will not be used again to identify a different measure, even if the original measure to which the number was assigned is subsequently retired from the PQRI measure set. A description of the measures listed in Table 52 can be found in the "2010 PQRI Quality Measures List," which is ava ilable on the Measures and Codes page of the PQRI section of the CMS Web site at http://cms.gov/PQRI

. The 2010 measures that are proposed to be available for registry-based reporting only for the 2011 PQRI are discussed and iden tified in section VI.F.1.i.(2) of this proposed rule. TABLE 52: Proposed 2011 Measures Selected From the 2010 PQRI Quality Measure Set Available for Either Claims-based Reporting or Registry-based Reporting

Measure Number Measure Title Measure Developer NQF Measure Number 1 Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus NCQA 0059 2 Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus NCQA 0064 3 Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus NCQA 0061 6 Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CAD AMA-PCPI 0067

9 Major Depressive Disorder (MDD): Antidepressant Medication During Acute Phase for Patients with MDD NCQA 0105

### CMS-1503-P 526

Measure Number Measure Title Measure Developer NQF Measure Number 10 Stroke and Stroke Rehabilitation: Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) Reports AMAPCPI/NCQA 0246

12 Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation AMAPCPI/NCQA 0086 14 Age-Related Macular Degeneration (AMD): Dilated Macular Examination AMAPCPI/NCQA 0087 18 Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy AMAPCPI/NCQA 0088

19 Diabetic Retinopathy: Communication with the Physician Managing On-going Diabetes Care AMAPCPI/NCQA 0089 20 Perioperative Care: Timing of Antibiotic Prophylaxis – Ordering Physician AMAPCPI/NCQA 0270 21 Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin AMAPCPI/NCQA 0268

22 Perioperative Care: Discontinuation of Prophylactic Antibiotics (Non-Cardiac Procedures) AMAPCPI/NCQA 0271

23 Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) AMAPCPI/NCQA 0239

24 Osteoporosis: Communication with thePhysician Managing On-going Care PostFracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older AMAPCPI/NCQA 0045

28 Aspirin at Arrival for Acute Myocardial Infarction (AMI) AMAPCPI/NCQA 0092 30 Perioperative Care: Timely Administration of Prophylactic Parenteral Antibiotics AMAPCPI/NCQA 0270 31 Stroke and Stroke Rehabilitation: Deep Vein Thrombosis Prophylaxis (DVT) for Ischemic Stroke or Intracranial Hemorrhage AMAPCPI/NCQA 0240

32 Stroke and Stroke Rehabilitation: Discharged on Antiplatelet Therapy AMAPCPI/NCQA 0325 35 Stroke and Stroke Rehabilitation: Screening for Dysphagia AMAPCPI/NCQA 0243

36 Stroke and Stroke Rehabilitation: Consideration of Rehabilitation Services AMAPCPI/NCQA 0244 39 Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older AMAPCPI/NCQA 0046 40 Osteoporosis: Management Following Fracture of Hip, Spine or Distal Radius for Men and Women Aged 50 Years and Older AMAPCPI/NCQA 0045

41 Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years and Older AMAPCPI/NCQA 0049 43 Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery Society of Thoracic Surgeons (STS) 0516 or 0134

44 Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery STS 0127 or 0236

45 Perioperative Care: Discontinuation of Prophylactic Antibiotics (Cardiac Procedures) AMAPCPI/NCQA 0637

### CMS-1503-P 527

Measure Number Measure Title Measure Developer NQF Measure Number 46 Medication Reconciliation: Reconciliation After Discharge from an Inpatient Facility AMAPCPI/NCQA 0097

47 Advance Care Plan AMAPCPI/NCQA 0326 48 Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older AMAPCPI/NCQA 0098

49 Urinary Incontinence: Characterization of Urinary Incontinence in Women Aged 65 Years and Older AMAPCPI/NCQA 0099

50 Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older AMAPCPI/NCQA 0100

51 Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation AMA-PCPI 0091 52 Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy AMA-PCPI 0102 53 Asthma: Pharmacologic Therapy AMA-PCPI 0047 54 12-Lead Electrocardiogram (ECG) Performed for Non-Traumatic Chest Pain AMAPCPI/NCQA 0090 55 12-Lead Electrocardiogram (ECG) Performed for Syncope AMAPCPI/NCQA 0093 56 Community-Acquired Pneumonia (CAP): Vital Signs AMAPCPI/NCQA 0232 57 Community-Acquired Pneumonia (CAP): Assessment of Oxygen Saturation AMAPCPI/NCQA 0094 58 Community-Acquired Pneumonia (CAP): Assessment of Mental Status AMAPCPI/NCQA 0234 59 Community-Acquired Pneumonia (CAP): Empiric Antibiotic AMAPCPI/NCQA 0096

64 Asthma: Asthma Assessment AMA-PCPI 0001 65 Treatment for Children with Upper Respiratory Infection (URI): Avoidance of Inappropriate Use NCQA 0069

66 Appropriate Testing for Children with Pharyngitis NCQA 0002 67 Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic Testing Performed on Bone Marrow AMAPCPI/American Society of Hematology (ASH) 0377

68 Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients Receiving Erythropoietin Therapy AMAPCPI/ASH 0378

69 Multiple Myeloma: Treatment with Bisphosphonates AMAPCPI/ASH 0380 70 Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry AMAPCPI/ASH 0379

### CMS-1503-P 528

Measure Number Measure Title Measure Developer NQF Measure Number 71 Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer AMAPCPI/American Society of Clinical Oncology (ASCO)/Nationa l Comprehensive Cancer Network (NCCN) 0387

72 Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients AMAPCPI/ASCO/NC CN 0385

76 Prevention of Catheter-Related Bloodstream Infections (CRBSI): Central Venous Catheter (CVC) Insertion Protocol AMA-PCPI 0464

79 End-Stage Renal Disease (ESRD): Influenza Immunization in Patients with ESRD AMA-PCPI 0227 84 Hepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating Treatment AMA-PCPI 0395 85 Hepatitis C: HCV Genotype Testing Prior to Treatment AMA-PCPI 0396 86 Hepatitis C: Antiviral Treatment Prescribed AMA-PCPI 0397 87 Hepatitis C: HCV Ribonucleic Acid (RNA) Testing at Week 12 of Treatment AMA-PCPI 0398 89 Hepatitis C: Counseling Regarding Risk of Alcohol Consumption AMA-PCPI 0401 90 Hepatitis C: Counseling Regarding Use of Contraception Prior to Antiviral Therapy AMA-PCPI 0394 91 Acute Otitis Externa (ACE): Topical Therapy AMA-PCPI AQA adopted Currently under NQF review 92 Acute Otitis Externa (ACE): Pain Assessment AMA-PCPI AQA adopted Currently under NQF review 93 Acute Otitis Externa (ACE): Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use AMA-PCPI AQA adopted Currently under NQF review 94 Otitis Media with Effusion (OME): Diagnostic Evaluation – Assessment of Tympanic Membrane Mobility AMA-PCPI AQA adopted Currently under NQF review 99 Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade AMAPCPI/College of American Pathologists (CAP) 0391

100 Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grace AMA-PCPI/CAP 0392

102 Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low-Risk Prostate Cancer Patients AMA-PCPI 0389

104 Prostate Cancer: Adjuvant Hormonal Therapy for High-Risk Prostate Cancer Patients AMA-PCPI 0390

### CMS-1503-P 529

Measure Number Measure Title Measure Developer NQF Measure Number 105 Prostate Cancer: Three-Dimensional (3D) Radiotherapy AMA-PCPI 0388 106 Major Depressive Disorder (MDD): Diagnostic Evaluation AMA-PCPI 0103 107 Major Depressive Disorder (MDD): Suicide Risk Assessment AMA-PCPI 0104 108 Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy NCQA 0054

109 Osteoarthritis: Function and Pain Assessment AMA-PCPI 0050 110 Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years Old AMA-PCPI 0041 111 Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and Older NCQA 0043 112 Preventive Care and Screening: Screening Mammography NCQA 0031 113 Preventive Care and Screening: Colorectal Cancer Screening NCQA 0034

116 Antibiotic Treatment for Adults with Acute Bronchitis: Avoidance of Inappropriate Use NCQA 0058 117 Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient NCQA 0055 119 Diabetes Mellitus: Urine Screening for Microalbumin or Medical Attention for Nephropathy in Diabetic Patients NCQA 0062

121 Chronic Kidney Disease (CKD): Laboratory Testing (Calcium, Phosphorous, Intact Parathyroid Hormone (iPTH) and Lipid Profile) AMA-PCPI Combined: 0570, 0571, 0572, 0626

122 Chronic Kidney Disease (CKD): Blood Pressure Management AMA-PCPI AQA adopted 123 Chronic Kidney Disease (CKD): Plan of Care – Elevated Hemoglobin for Patients Receiving Erythropoiesis-Stimulating Agents (ESA) AMA-PCPI AQA adopted

124 Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR) CMS/Quality Insights of Pennsylvania (QIP) 0488

126 Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation American Podiatric Medical Association (APMA) 0417

127 Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear APMA 0416

128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up CMS/QIP 0421

130 Documentation and Verification of Current Medications in the Medical Record CMS/QIP 0419

131 Pain Assessment Prior to Initiation of Patient Therapy and Follow-Up CMS/QIP 0420134 Screening for Clinical Depression and FollowUp Plan CMS/QIP 0418 140 Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement AMAPCPI/NCQA 0566

### CMS-1503-P 530

Measure Number Measure Title Measure Developer NQF Measure Number 141 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of Plan of Care AMAPCPI/NCQA 0563

142 Osteoarthritis (OA): Assessment for Use ofAnti-Inflammatory or Analgesic Over-theCounter (OTC) Medications AMA-PCPI 0051

145 Radiology: Exposure Time Reported for Procedures Using Fluoroscopy AMAPCPI/NCQA 0510 146 Radiology: Inappropriate Use of "Probably Benign" Assessment Category in Mammography Screening AMAPCPI/NCQA 0508

147 Nuclear Medicine: Correlation with Existing Imaging Studies for All Patients Undergoing Bone Scintigraphy AMA-PCPI 0511

153 Chronic Kidney Disease (CKD): Referral for Arteriovenous (AV) Fistula AMA-PCPI AQA adopted

154 Falls: Risk Assessment AMAPCPI/NCQA AQA adopted

155 Falls: Plan of Care AMAPCPI/NCQA AQA adopted 156 Oncology: Radiation Dose Limits to Normal Tissues AMA-PCPI 0382 157 Thoracic Surgery: Recording of Clinical Stage for Lung Cancer and Esophageal Cancer Resection STS 0455

158 Carotid Endarterectomy: Use of Patch During Conventional Carotid Endarterectomy Society of Vascular Surgeons (SVS) 0466

163 Diabetes Mellitus: Foot Exam NCQA 0056172 Hemodialysis Vascular Access DecisionMaking by Surgeon to Maximize Placement of Autogenous Arterial Venous (AV) Fistula SVS 0259

173 Preventive Care and Screening: Unhealthy Alcohol Use – Screening AMA-PCPI AQA adopted 175 Pediatric End-Stage Renal Disease (ESRD): Influenza Immunization AMA-PCPI AQA adopted 176 Rheumatoid Arthritis (RA): Tuberculosis Screening AMAPCPI/NCQA AQA adopted 177 Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity AMAPCPI/NCQA AQA adopted 178 Rheumatoid Arthritis (RA): Functional Status Assessment AMAPCPI/NCQA AQA adopted 179 Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis AMAPCPI/NCQA AQA adopted 180 Rheumatoid Arthritis (RA): Glucocorticoid Management AMAPCPI/NCQA AQA adopted 181 Elder Maltreatment Screen and Follow-Up Plan CMS/QIP AQA adopted

182 Functional Outcome Assessment in Chiropractic Care CMS/QIP AQA adopted 183 Hepatitis C: Hepatitis A Vaccination in Patients with HCV AMA-PCPI 0399 184 Hepatitis C: Hepatitis B Vaccination in Patients with HCV AMA-PCPI 0400

### CMS-1503-P 531

Measure Number Measure Title Measure Developer NQF Measure Number 185 Endoscopy & Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use AMAPCPI/NCQA AQA adopted Currently under NQF review 186 Wound Care: Use of Compression System in Patients with Venous Ulcers AMAPCPI/NCQA AQA adopted

188 Referral for Otologic Evaluation for Patient with Congenital or Traumatic Deformity of the Ear. Audiology Quality Consortium (AQC) Not applicable

189 Referral for Otologic Evaluation for Patient with History of Active Drainage from the Ear within the previous 90 days. AQC Not applicable

190 Referral for Otologic Evaluation for Patient with a history of Sudden or Rapidly Progessive Hearing Loss AQC Not applicable

193 Perioperative Temperature Management AMA-PCPI 0454194 Oncology: Cancer Stage Documented AMAPCPI/ASCO 0386 195 Stenosis Measurement in Carotid Imaging Studies AMAPCPI/NCQA 0507 201 Ischemic Vascular Disease (IVD): Blood Pressure Management Control NCQA 0084 202 Ischemic Vascular Disease (IVD): Complete Lipid Profile NCQA 0073 203 Ischemic Vascular Disease (IVD): Low Density Lipoprotein (LDL-C) Control NCQA 0075 204 Ischemic Vascular Disease (IVD): Use of Aspirin or Another Anti-thrombotic NCQA 0068



### It is our understanding that measur es #188, #189, and #190 were considered by NQF for possible endorsement but were not ultimately NQF-endorsed. However, since we are not aware of any other NQF-endorsed me asures that are available to audiologists, we propose to exercise our exception authority under section 1848(k)(2)(C)(ii) of the Act. Therefore, we propose to use measures #188, #189, and #190 for the 2011 PQRI despite the fact that they are neither NQF-endorsed nor AQA adopted. Please note that detailed measure specifications, including the measure's title, for 2010 individual PQRI quality measures may ha ve been updated or modified during the NQF endorsement process or for other reasons prior to 2011. The 2011 PQRI quality measure specifications for any given indi vidual quality measure may, therefore, be

### CMS-1503-P 532

different from specifications for the same qu ality measure used for 2010. Specifications for all 2011 individual PQRI quality measures , whether or not included in the 2010 PQRI program, must be obtained from the specifi cations document for 2011 individual PQRI quality measures, which will be available on the PQRI section of the CMS Web site on or before December 31, 2010. (2) Proposed 2011 Individual Quality Measures Selected From the 2010 PQRI Quality Measures Set Available for Registry-based Reporting Only For the 2011 PQRI, we propose to include 45 registry-only individual measures from the 2010 PQRI. As in 2010 PQRI, we are proposing to designate these measures as registry-only measures for 2011 to relieve ongoing analytical difficulties encountered with claims-based reporting of these measures in prior program years. We encourage comments on our proposal to designate these 45 2010 measures as registry-only measures for the 2011 PQRI. Although we are proposing to designate certain measures as registry-only measures for 2011, we cannot guar antee that there will be a registry qualified to submit each registry-only measure for 2011. We rely on registries to self-nominate and identify the types of measures for which they would like to be qualified to submit quality

measures results and numerator and denominator data on quality measures. If no registry

self-nominates to submit measure results and numerator and denominator data on a particular type of measure for 2011, then an EP would not be able to report that particular measure type via a registry. The Measure Number and Measure Title for these proposed registry-only measures are listed in Table 53 along with the NQF measure number, if applicable, and the name of the measure's developer/owner. As mentioned above, a description of the measures listed in Tabl e 53 can be found in the "2010 PQRI Quality

### CMS-1503-P 533

Measures List," which is available on the Me asures and Codes page of the PQRI section

of the CMS Web site at http://www.cms.gov/PQRI

. TABLE 53: 2011 Proposed Measures Selected From the 2010 PQRI Quality Measure Set Available for Registry-based Reporting Only

Measure Number Measure Title Measure Developer NQF Measure Number 5 Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) AMA-PCPI 0081

7 Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI) AMA-PCPI 0070 8 Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) AMA-PCPI 0083 33 Stroke and Stroke Rehabilitation: Anticoagulant Therapy Prescribed for Atrial Fibrillation at Discharge AMAPCPI/NCQA 0241 81 End-Stage Renal Disease (ESRD): Plan of Care for Inadequate Hemodialysis in ESRD Patients AMA-PCPI 0323 82 End-Stage Renal Disease (ESRD): Plan of Care for Inadequate Peritoneal Dialysis AMA-PCPI 0321 83 Hepatitis C: Testing for Chronic Hepatitis C – Confirmation of Hepatitis C Viremia AMA-PCPI 0393118 Coronary Artery Disease (CAD): AngiotensinConverting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Patients with CAD and Diabetes and/or Left Ventricular Systolic Dysfunction (LSVD) AMA-PCPI 0066

137 Melanoma: Continuity of Care – Recall System AMAPCPI/NCQA 0650

138 Melanoma: Coordination of Care AMAPCPI/NCQA 0561 143 Oncology: Medical and Radiation – Pain Intensity Quantified AMA-PCPI 0384 144 Oncology: Medical and Radiation – Plan of Care for Pain AMA-PCPI 0383159 HIV/AIDS: CD4+ Cell Count or CD4+ Percentage AMAPCPI/NCQA 0404 160 HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis AMAPCPI/NCQA 0405

161 HIV/AIDS: Adolescent and Adult Patients with HIV/AIDS Who Are Prescribed Potent Antiretroviral Therapy AMAPCPI/NCQA 0406

162 HIV/AIDS: HIV RNA Control After Six Months of Potent Antiretroviral Therapy AMAPCPI/NCQA 0407 164 Coronary Artery Bypass Graft (CABG): Prolonged Intubation (Ventilation) STS 0129 165 Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate STS 0130 166 Coronary Artery Bypass Graft (CABG): Stroke/Cerebrovascular Accident (CVA) STS 0131 167 Coronary Artery Bypass Graft (CABG): Postoperative Renal Insufficiency STS 0114

### CMS-1503-P 534

Measure Number Measure Title Measure Developer NQF Measure Number168 Coronary Artery Bypass Graft (CABG): Surgical Reexploration STS 0115 169 Coronary Artery Bypass Graft (CABG): Antiplatelet Medications at Discharge STS 0116 170 Coronary Artery Bypass Graft (CABG): Beta-Blockers Administered at Discharge STS 0117 171 Coronary Artery Bypass Graft (CABG): Lipid Management and Counseling STS 0118 174 Pediatric End-Stage Renal Disease (ESRD): Plan of Care for Inadequate Hemodialysis AMA-PCPI AQA adopted Currently under NQF review 187 Stroke and Stroke Rehabilitation: Thrombolytic Therapy AHA/ASA/ TJC 0437 191 Cataracts: 20/40 or Better Visual Acuity Within 90 Days Following Cataract Surgery AMAPCPI/NCQA 0565 192 Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures AMAPCPI/NCQA 0564

196 Coronary Artery Disease (CAD): Symptom and Activity Assessment AMA-PCPI 0065 197 Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-Cholesterol AMA-PCPI 0074 198 Heart Failure: Left Ventricular Function (LVF) Assessment AMA-PCPI 0079

199 Heart Failure: Patient Education AMA-PCPI 0082 200 Heart Failure: Warfarin Therapy Patients with Atrial Fibrillation AMA-PCPI 0084 205 HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia and Gonorrhea AMAPCPI/NCQA 0409206 HIV/AIDS: Screening for High Risk Sexual Behaviors AMAPCPI/NCQA 0413207 HIV/AIDS: Screening for Injection Drug Use AMAPCPI/NCQA 0415 208 HIV/AIDS: Sexually Transmitted Disease Screening for Syphilis AMAPCPI/NCQA 0410 209 Functional Communication Measure - Spoken Language Comprehension American Speech Language Haring Association (ASHA) 0445

210 Functional Communication Measure - Attention ASHA 0449 211 Functional Communication Measure - Memory 0448 212 Functional Communication Measure - Motor Speech ASHA 0447 213 Functional Communication Measure - Reading ASHA 0446 214 Functional Communication Measure - Spoken Language Expression ASHA 0444 215 Functional Communication Measure - Writing ASHA 0442 216 Functional Communication Measure - Swallowing ASHA 0443



### Please note, as previously discussed above, detailed measure specifications, including a measure's title, for 2010 PQRI qualit y measures may be updated or modified

### CMS-1503-P 535

during the NQF endorsement process or for other reasons during 2010. Therefore, the 2011 PQRI quality measure specifications for any given quality measure may be different from specifications for the same quality meas ure used for 2010. Specifications for all 2011 individual PQRI quality measures, whether or not included in the 2010 PQRI program, must be obtained from the specifi cations document for 2011 individual PQRI quality measures, which will be available on the PQRI section of the CMS Web site on or before December 31, 2010. (3) New Individual Quality Measures Proposed for 2011 We propose to include in the 2011 PQRI quality measure set 20 measures that were not included in the 2010 PQRI quality measures set provided that each measure obtains NQF endorsement by June 1, 2010 and its detailed specifications are completed and ready for implementation in PQRI by August 15, 2010. Besides having NQF endorsement, we again propose that the de velopment of a measure is considered complete for the purposes of the 2011 PQRI if by August 15, 2010: (1) the final, detailed specifications for use in data collection for PQRI have been completed and are ready for implementation, and (2) a ll of the Category II Current Procedural Terminology (CPT II) codes required for the measure have been established and will be effective for CMS

claims data submission on or before Ja nuary 1, 2011. The titles of these proposed additional, or new, measures are listed in Ta ble 54 along with the name of the measure developer and the proposed reporting mechan ism (that is, whether the measure is proposed to be reportable using claims, regi stries, or both). For these 20 proposed measures, a PQRI Measure Number will be assigned to a measure if and when the measure is included in the final set of 2011 PQRI measures.

### CMS-1503-P 536

Due to the complexity of their measure specifications, we propose that 8 of these 20 measures would be available as regist ry-only measures for the 2011 PQRI. The remaining 15 measures are proposed to be ava ilable for reporting through either claimsbased reporting or registry-based reporting. TABLE 54: New Individual Quality Measures Proposed for 2011

Measure title NQF measure number Measure Developer Reporting Mechanism(s) Change in Risk-Adjusted Functional Status for Patients with Knee Impairments: 0422 FOTO Registry

Change in Risk-Adjusted Functional Status for Patients with Hip Impairments: 0423 FOTO Registry

Change in Risk-Adjusted Functional Status for Patients with Lower Leg, Foot or Ankle Impairments: 0424 FOTO Registry

Change in Risk-Adjusted Functional Status for Patients with Lumbar Spine Impairments: 0425 FOTO Registry

Change in Risk-Adjusted Functional Status for Patients with Shoulder Impairments: 0426 FOTO Registry

Change in Risk-Adjusted Functional Status for Patients with Elbow, Wrist or Hand Impairments: 0427 FOTO Registry

Change in Risk-Adjusted Functional Status for Patients with a Functional Deficit of the Neck, Cranium, Mandible, Thoracic Spine, Ribs or other General Orthopedic Impairment: 0428 FOTO Registry

Care Transitions: Reconciled Medication List Received by Discharged Patients (Inpatient Discharges to Home/Self Care or Any Other Site of Care): Currently under NQF review Society of Hospital Medicine

(SMH)AMAPCPI/NCQA Claims, Registry

Care Transitions: Transition Record with Specified Elements Received by Discharged Patients (Inpatient Discharges to Home/Self Care or Any Other Site of Care): Currently under NQF review Society of Hospital Medicine

(SMH)AMAPCPI/NCQA Claims, Registry

Care Transitions: Timely Transmission of Transition Record (Inpatient Discharges to Home/Self Care or Any Other Site of Care): Currently under NQF review Society of Hospital Medicine

(SMH)AMAPCPI/NCQA Claims, Registry

### CMS-1503-P 537

Measure title NQF measure number Measure Developer Reporting Mechanism(s) Care Transitions: Transition Record with Specified Elements Received by Discharged Patients (Emergency Department Discharges to Ambulatory Care [Home/Self Care] or Home Health Care): Currently under NQF review Society of Hospital Medicine

(SMH)AMAPCPI/NCQA Claims, Registry

Hypertension (HTN): Plan of Care: 0017 AMA-PCPI Claims, Registry Heart Failure (HF): Left Ventricular Function (LVF) Testing: 79 CMS Registry

Melanoma: Overutilization of Imaging Studies in Stage 0-IA Melanoma: 0562 AMA-PCPI Claims, Registry

Radiology: Reminder System for Mammograms 0509 AMA-PCPI Claims, Registry

Asthma: Assessment of Asthma Risk – Emergency Department/Inpatient Setting: Currently under NQF review AMA-PCPI Claims, Registry

Asthma: Discharge Plan – Emergency Department/Inpatient Setting: Currently under NQF review AMA-PCPI Claims, Registry

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 0028 AMA-PCPI Claims, Registry

Recording of Performance Status Prior to Lung or Esophageal Cancer Resection: 0457 Society of Thoracic Surgery (STS) Claims, Registry

Pulmonary Function Tests Before Major Anatomic Lung Resection: 0458 Society of Thoracic Surgery (STS) Claims, Registry



### These measures are being proposed for the 2011 PQRI because they meet one or more of

the considerations for measure selection di scussed in section VI.F.1.h. of this proposed

rule. (4) Proposed 2011 Measures Availa ble for EHR-based Reporting For 2011, we propose to again accept PQRI data from EHRs for a limited subset of the proposed 2011 PQRI quality measures, contingent upon the successful completion

of our 2010 EHR data submissi on process and a determinati on that accepting data from EHRs on quality measures for the 2011 PQRI co ntinues to be practical and feasible. We propose to make a total of 22 measures available for EHR-based reporting in the 2010 PQRI. These include the 10 measures available for EHR-based reporting in the

### CMS-1503-P 538

2010 PQRI, which are identified in Table 55 and 12 additional measures identified in Table 56 that overlap with the clinical quality measures used in the EHR incentive program established by the American Recove ry and Reinvestment Act (ARRA). Again, this year, we propose to make these measures available for electronic submission via an EHR because these measures target preven tive care or common chronic and high-cost

conditions. TABLE 55: Proposed 2011 Measures Available for EHR-based Reporting from 2010 PQRI Measure Number Measure Title Measure Developer NQF Measure Number 1 Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus NCQA 0059

2 Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus NCQA 0064

3 Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus NCQA 0061

5 Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) AMA-PCPI 0081

7 Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI) AMA-PCPI 0070

110 Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years Old AMA-PCPI 0041 111 Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and Older NCQA 0043 112 Preventive Care and Screening: Screening Mammography NCQA 0031 113 Preventive Care and Screening: Colorectal Cancer Screening NCQA 0034 124 Health Information Technology (HIT): Adoption/Use of Electronic Health Records (EHR) CMS/QIP 0488

### CMS-1503-P 539

TABLE 56: Proposed 2011 Medicare ARRA --HITECH Measures Available for EHR-based Reporting

Measure Number Measure Title Measure Developer NQF Measure Number TBD Hypertension (HTN): Blood Pressure Measurement AMA-PCPI 0013

128 Preventive Care and Screening : Body Mass Index(BMI) Screening and Follow-up CMS/Quality Insights of Pennsylvania 0421

TBD Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention AMA-PCPI 0028

TBD Childhood Immunization Status NCQA 0038 TBD Body Mass Index (BMI) 2 through 18 years of age National Initiative for

Children's Healtcare

Quality 0024

39 Screening or Therapy for Osteoporosis for Women Aged 65 Year and Older AMAPCPI/NCQA 0046

47 Advance Care Plan AMAPCPI/NCQA 0326 48 Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older AMAPCPI/NCQA 0098

173 Preventive Care & Screening: Unhealthy Alcohol Use - Screening AMA-PCPI AQA Adopted TBD Drugs to be Avoided in the Elderly NCQA 0022

41 Osteoporosis: Pharmacologic Therapy for Men and Women Aged 50 Years & Older 0049

142 Osteoarthritis: Assessment of Use of AntiInflammatory or Analgesic OTC Meds AMA-PCPI 0051



### (5) Measures Proposed for Inclusion in 2011 Measures Groups We propose to retain the following 13 2010 PQRI measures groups for the 2011 PQRI: (1) Diabetes Mellitus; (2) CKD; (3 ) Preventive Care; (4) CABG; (5) Rheumatoid Arthritis; (6) Perioperative Care; (7) Back Pa in; (8) CAD; (9) Heart Failure; (10) IVD; (11) Hepatitis C; (12) HIV/AI DS; and (13) CAP. We ar e proposing to include these measures groups in 2011 PQRI because they each contain at least 4 PQRI quality

measures that share a comm on denominator definition. For 2011, we propose that the CABG, CAD, Heart Failure, HIV/AIDS measures groups continue to be reportable through the registry-based reporting mechanism only,

### CMS-1503-P 540

while the remaining Diabetes Mellitus, CKD, Preventive Care, Rheumatoid Arthritis, Perioperative Care, Back Pain, IVD, Hepatitis C, and CAP measures groups will continue to be reportable through either claims-based reporting or registry-based reporting for the 2011 PQRI. The 4 2011 proposed measures gr oups reportable via registry-based reporting only are identified with an asterisk (*) below. For 2010, the 13 measures groups that we propose to retain in the 2011 PQRI,

combined with the one additional measures group we are proposing for 2011, makes a total of 14 measures groups for 2011 PQRI. The 1 additional measures group we propose for the 2011 PQRI, identified in Table 70, is an Asthma Measures Group. The Ashtma Measures Group is proposed to be reportable through either claims-based reporting or registry-based reporting. We believe that the measure groups proposed for 2011 PQRI address gaps in quality reporting and are those that have a hi gh impact on HHS and CMS priority topics for improved quality and efficiency for Medi care beneficiaries (such as prevention, chronic conditions, improved care coordinati on, improved efficiency, improved patient and family experience of care, and effective management of acute and chronic episodes). Finally, as in previous program years, for 2011, we continue to propose that except for the measures include d in the Back Pain measures group, the measures included in any proposed 2011 measures group be reportab le either as individual measures or as part of a measures group. For 2011, we propose that the measures proposed for inclusion in the Back Pain measures group will c ontinue to be reportable only as part of a measures group and not as individual meas ures in 2011. We propose that measures selected for inclusion in all 2011 PQRI m easuresgroups (except for the Back Pain

### CMS-1503-P 541

measures group) are reportable either as indi vidual measures or as part of a measures

group. The measures proposed for inclusion in each of the 2011 measures groups are identified in Tables 57 through 70. As stated previously, the PQRI Measure Number is a unique identifier assigned by CMS to all measures in the PQRI measure set. Once a PQRI Measure Number is assigned to a measure, it will not be used again, even if the measure is subsequently retired from the PQ RI measure set. Measures that are not preceded by a number (in other words, those preceded by "TBD") in Tables 57 through 71 were never part of a PQRI measure set prior to 2011. A number will be assigned to such measures for 2011, if we finalize inclus ion of the measures in the 2011 PQRI. As with measures group reporting in the 2008, 2009, and 2010 PQRI, we propose that each EP electing to report a group of m easures for 2011 must report all measures in the group that are applicable to each patient or encounter to which the measures group applies at least up to the minimum number of patients required by the applicable reporting criteria. TABLE 57: Measures Proposed for 2011 Diabetes Mellitus Measures Group

Measure Number Measure Title NQF measure number Measure Developer 1 Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus 0059 NCQA

2 Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus 0064 NCQA

3 Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus 0061 NCQA 117 Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient 0055 NCQA 119 Diabetes Mellitus: Urine Screening for Microalbumin or Medical Attention for Nephropathy in Diabetic Patients 0062 NCQA

163 Diabetes Mellitus: Foot Exam 0056 NCQA

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TABLE 58: Measures Proposed for 2011 CKD Measures Group

Measure Number Measure Title NQF measure number Measure Developer 121 Chronic Kidney Disease (CKD): Laboratory Testing (Calcium, Phosphorus, Intact Parathyroid Hormone (iPTH) and Lipid Profile) 0570,0571, 0572,0626 AMA-PCPI

122 Chronic Kidney Disease (CKD): Blood Pressure Management AQA adopted AMA-PCPI 123 Chronic Kidney Disease (CKD): Plan of Care – Elevated Hemoglobin for Patients Receiving Erythropoiesis-Stimulating Agents (ESA) AQA adopted AMA-PCPI

153 Chronic Kidney Disease (CKD): Referral for Arteriovenous (AV) Fistula AQA adopted AMA-PCPI



### TABLE 59: Measures Proposed for 2011 Preventive Care Measures Group

Measure Number Measure Title NQF measure number Measure Developer 39 Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older 0046 AMAPCPI/NCQA 48 Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older 0098 AMAPCPI/NCQA

110 Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years Old 0041 AMA-PCPI 111 Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and Older 0043 NCQA 112 Preventive Care and Screening: Screening Mammography 0031 NCQA 113 Preventive Care and Screening: Colorectal Cancer Screening 0034 NCQA 128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up 0421 CMS/QIP 173 Preventive Care and Screening: Unhealthy Alcohol Use – Screening AQA adopted AMA-PCPI TBD Preventive Care and Screening : Tobacco Use: Screening and Cessation Intervention 0028 AMA-PCPI



### TABLE 60: Measures Proposed for 2011 CABG Measures Group *

Measure Number Measure Title NQF measure number Measure Developer 43 Coronary Artery Bypass Graft (CABG): Use of Internal Mammary Artery (IMA) in Patients with Isolated CABG Surgery 0516, 0134 Society of Thoracic Surgeons (STS) 44 Coronary Artery Bypass Graft (CABG): Preoperative Beta-Blocker in Patients with Isolated CABG Surgery 0127, 0236 STS

164 Coronary Artery Bypass Graft (CABG): Prolonged Intubation (Ventilation) 0129 STS

### CMS-1503-P 543

Measure Number Measure Title NQF measure number Measure Developer 165 Coronary Artery Bypass Graft (CABG): Deep Sternal Wound Infection Rate 0130 STS

166 Coronary Artery Bypass Graft (CABG): Stroke/Cerebrovascular Accident (CVA) 0131 STS

167 Coronary Artery Bypass Graft (CABG): Postoperative Renal Insufficiency 0114 STS

168 Coronary Artery Bypass Graft (CABG): Surgical Re-exploration 0115 STS 169 Coronary Artery Bypass Graft (CABG): Antiplatelet Medications at Discharge 0116 STS

170 Coronary Artery Bypass Graft (CABG): Beta-Blockers Administered at Discharge 0117 STS

171 Coronary Artery Bypass Graft (CABG): Lipid Management and Counseling 0118 STS

* 

### This measures group is reportable through registry-based reporting only.

TABLE 61: Measures Proposed for 2011 Rheumatoid Arthritis Measures Group

Measure Number Measure Title NQF measure number Measure Developer 108 Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy 0054 NCQA

176 Rheumatoid Arthritis (RA): Tuberculosis Screening AQA adopted AMAPCPI/NCQA 177 Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity AQA adopted AMAPCPI/NCQA 178 Rheumatoid Arthritis (RA): Functional Status Assessment AQA adopted AMAPCPI/NCQA 179 Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis AQA adopted AMAPCPI/NCQA 180 Rheumatoid Arthritis (RA): Glucocorticoid Management AQA adopted AMAPCPI/NCQA



### TABLE 62: Measures Proposed for 2011 Perioperative Care Measures Group

Measure Number Measure Title NQF measure number Measure Developer 20 Perioperative Care: Timing of Antibiotic Prophylaxis – Ordering Physician 0270 AMAPCPI/NCQA 21 Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin 0268 AMAPCPI/NCQA 22 Perioperative Care: Discontinuationof Prophylactic Antibiotics (Non0271 AMAPCPI/NCQA

### CMS-1503-P 544

Measure Number Measure Title NQF measure number Measure Developer Cardiac Procedures) 23 Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) 0239 AMAPCPI/NCQA



### TABLE 63: Measures Proposed for 2011 Back Pain Measures Group

Measure Number Measure Title NQF measure number Measure Developer 148 Back Pain: Initial Visit 0322 NCQA 149 Back Pain: Physical Exam 0319 NCQA 150 Back Pain: Advice for Normal Activities 0315 NCQA 151 Back Pain: Advice Against Bed Rest 0313 NCQA



### TABLE 64: Measures Proposed for 2011 CAD Measures Group *

Measure Number Measure Title NQF measure number Measure Developer 6 Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CAD 0067 AMA-PCPI 196 Coronary Artery Disease (CAD): Symptom and Activity Assessment 0065 AMA-PCPI 197 Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-Cholesterol 0074 AMA-PCPI TBD Preventive Care and Screening : Tobacco Use: Screening and Cessation Intervention 0028 AMA-PCPI

* 

### This measures group is reportable through registry-based reporting only.

TABLE 65: Measures Proposed for 2011 Heart Failure Measures Group *

Measure Number Measure Title NQF measure number Measure Developer 5 Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) 0081 AMA-PCPI

8 Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) 0083 AMA-PCPI 198 Heart Failure: Left Ventricular Function (LVF) Assessment 0079 AMA-PCPI

199 Heart Failure: Patient Education 0082 AMA-PCPI TBD Preventive Care and Screening : Tobacco Use: Screening and Cessation Intervention 0028 AMA-PCPI

* 

### This measures group is reportable through registry-based reporting only.

### CMS-1503-P 545

TABLE 66: Measures Proposed for 2011 IVD Measures Group

Measure Number Measure Title NQF measure number Measure Developer 201 Ischemic Vascular Disease (IVD): Blood Pressure Management Control 0073 NCQA 202 Ischemic Vascular Disease (IVD): Complete Lipid Profile 0075 NCQA 203 Ischemic Vascular Disease (IVD): Low Density Lipoprotein (LDL-C) Control 0075 NCQA 204 Ischemic Vascular Disease (IVD): Use of Aspirin or Another Anti-thrombotic 0068 NCQA TBD Preventive Care and Screening : Tobacco Use: Screening and Cessation Intervention 0028 AMA-PCPI



### TABLE 67: Measures Proposed for 2011 Hepatitis C Measures Group

Measure Number Measure Title NQF measure number Measure Developer 84 Hepatitis C: Ribonucleic Acid (RNA) Testing Before Initiating Treatment 0395 AMA-PCPI 85 Hepatitis C: HCV Genotype Testing Prior to Treatment 0396 AMA-PCPI 86 Hepatitis C: Antiviral Treatment Prescribed 0397 AMA-PCPI 87 Hepatitis C: HCV Ribonucleic Acid (RNA) Testing at Week 12 of Treatment 0398 AMA-PCPI 89 Hepatitis C: Counseling Regarding Risk of Alcohol Consumption 0401 AMA-PCPI 90 Hepatitis C: Counseling Regarding Use of Contraception Prior to Antiviral Therapy 0394 AMA-PCPI 183 Hepatitis C: Hepatitis A Vaccination in Patients with HCV 0399 AMA-PCPI 184 Hepatitis C: Hepatitis B Vaccination in Patients with HCV 0400 AMA-PCPI



### TABLE 68: Measures Proposed for 2011 HIV/AIDS Measures Group *

Measure Number Measure Title NQF measure number Measure Developer159 HIV/AIDS: CD4+ Cell Count or CD4+ Percentage 0404 AMAPCPI/NCQA 160 HIV/AIDS: Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis 0405 AMAPCPI/NCQA 161 HIV/AIDS: Adolescent and Adult Patients with HIV/AIDS Who Are Prescribed Potent Antiretroviral Therapy 0406 AMAPCPI/NCQA

162 HIV/AIDS: HIV RNA Control After Six Months of Potent Antiretroviral Therapy 0407 AMAPCPI/NCQA 205 HIV/AIDS: Sexually Transmitted Disease Screening for Chlamydia and Gonorrhea 0409 AMAPCPI/NCQA 206 HIV/AIDS: Screening for High Risk Sexual Behaviors 0413 AMAPCPI/NCQA207 HIV/AIDS: Screening for Injection Drug Use 0415 AMAPCPI/NCQA

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Measure Number Measure Title NQF measure number Measure Developer 208 HIV/AIDS: Sexually Transmitted Disease Screening for Syphilis 0410 AMAPCPI/NCQA * 

### This measures group is selected to be reportable through registry-based reporting only.

TABLE 69: Measures Proposed for 2011 CAP Measures Group

Measure Number Measure Title NQF measure number Measure Developer 56 Community-Acquired Pneumonia (CAP): Vital Signs 0232 AMAPCPI/NCQA 57 Community-Acquired Pneumonia (CAP): Assessment of Oxygen Saturation 0094 AMAPCPI/NCQA 58 Community-Acquired Pneumonia (CAP): Assessment of Mental Status 0234 AMAPCPI/NCQA 59 Community-Acquired Pneumonia (CAP): Empiric Antibiotic 0096 AMAPCPI/NCQA 

### TABLE 70: Measures Proposed for 2011 Asthma Measures Group

Measure Number Measure Title NQF measure number Measure Developer 53 Asthma: Pharmacologic Therapy 0047 AMA-PCPI 64 Asthma: Asthma Assessment 0001 AMA-PCPI TBD Asthma: Assessment of Asthma Risk – Emergency Department/Inpatient Setting Currently under NQF review AMA-PCPI TBD Asthma: Discharge Plan-Emergency/Inpatient Setting Currently under NQF review AMA-PCPI



### We note that the specifications for measur es groups do not necessarily contain all the specification elements of each individual measure making up the measures group.

This is based on the need for a common set of denominator specifications for all the measures making up a measures group in order to define the applicability of the measures group. Therefore, the specifications and inst ructions for measures groups will again be provided separately from the specifications a nd instructions for the individual 2011 PQRI measures. We will post the detailed specifications and specific instructions for reporting measures groups on the PQRI section of the CMS Web site at http://www.cms.gov/PQRI by no later than December 31, 2010.

### CMS-1503-P 547

Additionally, the detailed measure specifications and instructions for submitting data on those 2011 measures groups that we re also included as 2010 PQRI measures groups may be updated or modified prior to 2011. Therefore, the 2011 PQRI measure specifications for any given m easures group could be differe nt from specifications and

submission instructions for the same meas ures group used for 2010. These measure specification changes are not expected to materially impact the intended meaning of the measures or the strength of the measures. j. Proposed 2011 PQRI Quality Measures for Ph ysician Groups Selected to Participate in the Group Practice Reporting Option (GPRO I) As discussed in section VI.F.1.g.(3).(i ) of this proposed rule, we propose that physician groups selected to participate in the 2011 PQRI GPRO I would be required to report on 26 proposed measures. We are proposing these measures because they are NQF-endorsed measures currently collected as part of the PGP and/or MCMP demonstrations and in the 2010 PQRI GPRO. These proposed measures are listed in

Table 71. To the extent that a measure is an existing PQRI measure available for reporting by individual EPs, the Measure Title is preceded by the measure's PQRI Measure Number. If there is no number in the PQRI Measure Number column of the table, then the measure is not an existin g PQRI measure and will be added to the 2011 PQRI for purposes of the GPRO I. Measur es proposed for GPRO II are discussed in section VI.F.1.g.(3).(ii) of this proposed rule. As in the 2010 PQRI, a separate meas ures specifications manual and other supporting documents will be available for group practices participating in the 2011 PQRI GPRO I. We anticipate that the gr oup practice measures specifications manual will

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be available by November 15, 2010 on the PQ RI section of the CMS Web site at http://www.cms.gov/PQRI

.

TABLE 71: Measures for Physician Groups Participating in the 2011 PQRI Group Practice Reporting Option (GPRO I)

PQRI Measure Number Measure Title Measure Developer NQF Number 1 Diabetes Mellitus: Hemoglobin A1c Poor Control in Diabetes Mellitus NCQA 0059 2 Diabetes Mellitus: Low Density Lipoprotein (LDL-C)Control NCQA 0064 3 Diabetes Mellitus: High Blood Pressure Control in Diabetes Mellitus NCQA 0061 5 Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) AMA-PCPI 0081

6 Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CAD AMA-PCPI 0067

7 Coronary Artery Disease (CAD): BetaBlocker Therapy for CAD Patients with Prior Myocardial Infarction (MI) AMA-PCPI 0070

8 Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) AMA-PCPI 0083 110 Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years Old AMA-PCPI 0041 111 Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and Older NCQA 0043 112 Preventive Care and Screening: Screening Mammography NCQA 0031 113 Preventive Care and Screening: Colorectal Cancer Screening NCQA 0034 117 Diabetes Mellitus: Dilated Eye Exam in Diabetic Patient NCQA 0055118 Coronary Artery Disease (CAD): AngiotensinConverting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) for Patients with CAD and Diabetes and/or Left Ventricular Systolic Dysfunction (LVSD) AMA-PCPI 0066

119 Diabetes Mellitus: Urine Screening for Microalbumin or Medical Attention for Nephropathy in Diabetic Patients NCQA 0062

163 Diabetes Mellitus: Foot Exam NCQA 0056 GPRO DM-1 Diabetes Mellitus: Hemoglobin A1c Testing NCQA 0057 GPRO DM-9 Diabetes Mellitus: Lipid Profile NCQA 0063 GPRO HF-2 Heart Failure: Left Ventricular Function (LVF) Testing CMS 198 Heart Failure: Left Ventricular Function (LVF) Assessment AMA-PCPI 0079

### CMS-1503-P 549

PQRI Measure Number Measure Title Measure Developer NQF Number GPRO HF-3 Heart Failure: Weight Measurement CMS AMA-PCPI not maintaining 0085

199 Heart Failure: Patient Education AMA-PCPI 0082 200 Heart Failure: Warfarin Therapy for Patients with Atrial Fibrillation AMA-PCPI 0084 197 Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-Cholesterol AMA-PCPI 0074

GPRO HTN1 Hypertension: Blood Pressure Measurement AMA-PCPI 0013

GPRO HTN2 Hypertension (HTN): Blood Pressure Control NCQA 0018 GPRo HTN-3 Hypertension (HTN): Plan of Care AMA-PCPI 0017 

### k. Public Reporting of PQRI Data Section 1848(m)(5)(G) of the Act require s the Secretary to post on the CMS Web site, in an easily understandable format, a lis t of the names of EPs (or group practices) who satisfactorily submitted data on quality measures for the PQRI and the names of the EPs (or group practices) who are successful electronic prescrib ers. In addition, section 10331(a)(1) of the ACA, requires the Secretary to develop a Physician Compare Internet Web site by January 1, 2011, on which info rmation on physicians enrolled in the Medicare program and other EPs who participat e in the PQRI program would be posted. To meet the ACA deadline of January 1, 2011, with respect to establishing the Physician Compare Web site, we propose, fo r 2011 PQRI, to use the current Physician

and Other Health Care Profe ssional Directory as a foundation for the Physician Compare Web site. As in 2010 PQRI, we propose to c ontinue to make public the names of EPs and group practices that satisfactorily submit quality data for the 2011 PQRI. Previously, this was posted on the Physicia n and Other Health Care Prof essionals Directory. Our intent for the 2011 PQRI is to post the info rmation on the Physician Compare Web site that must be developed by January 1, 2011. Specifically, we propose to post the names of EPs who: (1) submit data on the 2011 PQ RI quality measures through one of the

### CMS-1503-P 550

reporting mechanisms available for the 2011 PQRI; (2) meet one of the proposed satisfactory reporting criteria of individual measures or measures groups for the 2011 PQRI as described above; and (3) qualify to earn a PQRI incentive payment for covered professional services furnis hed during the applicable 2011 PQRI reporting period, for purposes of satisfying the requirements under section 1848(m)(5)(G)(i) of the Act, on the Physician Compare Web site. Similarly, for purposes of publicly repor ting the names of group practices, on the Physician Compare Web site, for 2011, we pr opose to post the names of group practices that: (1) submit data on the 2011 PQRI qualit y measures through one of the proposed group practice reporting options; (2) meet the proposed criteria for satisfactory reporting under the respective group practice reporting option; and (3) qualify to earn a PQRI incentive payment for covered professional se rvices furnished during the applicable 2011 PQRI reporting period for purposes of sa tisfying the requirements under section 1848(m)(5)(G)(i) of the Act. We do not propose to require as a condition of participation in the 2011 PQRI that performance information be made publicly av ailable at either the group practice or individual level for 2011 PQRI. However, we note that section 10331 of the ACA requires that not later than January 1, 2013, a nd with respect to reporting periods that begin no earlier than January 1, 2012, we implement a plan for making publicly available through Physician Compare, information on ph ysician performance, including measures collected under PQRI. Consistent with s ection 10331 of the ACA, we expect, in the future, to publicly report performan ce information based on PQRI. We will be working on a plan to expand th e information that is publicly posted on the Physician Compare in future years. This will be further described in future

### CMS-1503-P 551

rulemaking. We solicit comments on our pl an for implementation of a Physician Compare Web site for 2011.

l. Other Relevant ACA Provisions (1) Section 3002 (b) - Incentive Payment Adjustment for Quality Reporting Beginning 2015, a payment adjustment will apply under the PQRI. Specifically, under section 1848(a)(8) of the Ac t, as added by section 3002(b) of the ACA, with respect to covered professional services furnished by an EP during 2015 or any subsequent year, if the EP does not satisfactorily submit data on quality measures for covered professional services for the qua lity reporting period for the year, the fee schedule amount for services furnished by su ch professionals durin g the year shall be equal to the applicable percent of the fee schedule amount that would otherwise apply to such services. The applicable percent for 2015 is 98.5 percent and for 2016 and each subsequent year it is 98.0 percent. We will address this provision of the ACA in future notice and comment rulemaking. (2) Section 3002(c) – Maintenance of Ce rtification Programs and Section 10327 Improvements to the Physician Quality Reporting System Section 3002(c) of the ACA amends sec tion 1848(k)(4) of the Act to require a mechanism whereby an EP may provide da ta on quality measures through an MOCP operated by a specialty body of the American Board of Medical Specialties (ABMS). In addition, section 1848(m)(7)of the Act ("Add itional Incentive Payment"), as added by section 10327(a) of the ACA, provides for an additional 0.5 percent incentive payment for years 2011 through 2014 if certain requireme nts are met. In accordance with section 1848(m)(7)(B) of the Act, in order to qualify for the additional incentive payment, an EP

### CMS-1503-P 552

must--

• Satisfactorily submit data on quality m easures under PQRI for a year and have

such data submitted-- ++ On their behalf through an MOCP that meets the criteria for a registry under PQRI (see section VI.F.1.d.(4) of this proposed rule); or ++ In an alternative form and manner determined appropriate by the Secretary;

and

• More frequently than is required to qualify for or maintain board certification

status-- ++ Participate in such an MOCP for a year; and ++ Successfully completes a qualified MOCP for such year. Section 1848(m)(7)(C)(i) of the Act de fines "Maintenance of Certification Program" as a continuous asse ssment program, such as a qualified ABMS MOCP, or an equivalent program (as deter mined by the Secretary), that advances quality and the lifelong learning and self-assessm ent of board certified specialty physicians by focusing on the competencies of patient care, me dical knowledge, prac tice-based learning, interpersonal and communications skills and professionalism. Such a program shall require a physician to do the following:

• Maintain a valid, unrestricted medical license in the United States.

• Participate in educa tional and self-assessment pr ograms that require an

assessment of what was learned.

• Demonstrate, through a formalized, s ecure examination, that the physician has the fundamental diagnostic skills, medical knowle dge, and clinical judgment to provide quality care in their respective specialty.

### CMS-1503-P 553

• Successful completion of a qualif ied MOCP practice assessment. As defined in section 1848(m)(7)(C)(ii) of the Act, a "qualified Maintenance of Certification Program practice assessment" m eans an assessment of a physician's practice

that – (1) Includes an initial assessment of an EP's practice that is designed to demonstrate the physician's use of evidence-based medicine; (2) Includes a survey of patient experience with care; and (3) Requires a physician to implement a quality improvement intervention to address a practice weakness identified in the initial assessment and then to remeasure to assess performance after such intervention. To qualify for the additional incentive pa yment, section 1848(m)(7)(B)(iii) of the Act also requires the MOCP Program to submit to CMS, on behalf of the EP,

information: (1) In a form and manner specified by the Secretary, that the EP has successfully completed a qualified MOCP practice assessment for such year; (2) If requested by the Secretary, info rmation on the survey of patient experience with care; and (3) As the Secretary may require, on th e methods, measures, and data used under the MOCP and the qualified MO CP practice assessment. Section 10327(b) of the ACA amends s ection 3002(c) of the ACA further to specify that the additional 0.5 percent incentive payment is available only for years 2011, 2012, 2013, and 2014. For years after 2014, if the Secretary determines it to be appropriate, the Secretary may incorporate participation in an MOCP and successful completion of a qualified MOCP practice assessm ent into the composite of measures of

### CMS-1503-P 554

quality for care furnished pursuant to the ph ysician fee schedule payment modifier. To implement the provisions under sec tions 3002(c) and 10327 of the ACA, CMS proposes for 2011 to require the following:

• An EP wishing to be eligible for the additional PQRI incentive payment of 0.5 percent must meet the proposed requireme nts for satisfactory PQRI reporting, for program year 2011, based on the 12-month reporti ng period. We propose to require that EPs seeking the additional PQRI incentive payment satisfactorily report for a 12-month reporting period rather than only a 6 mont h reporting period, based on the statutory language that the EP must satisfactorily report "for a year." For purposes of satisfactory reporting under PQRI, we propose that the EP ma y participate as an individual EP using either individual PQRI measures or measures groups and submitting the PQRI data via claims, a registry, or an her or participat e under one of the GPRO options (I or II),. Alternatively, EPs may satisfactorily repo rt under PQRI based on submission of PQRI data by an MOCP, provided that the MOCP has qualified as a PQRI registry for 2011. As indicated previously, an EP would not necessarily have to qualify for PQRI through an MOCP serving as a registry. Rather, we propose that an EP may qualify for the additional incentive, without reqard to the method by which the EP has met the basic requirement of satisfactor y reporting under PQRI.

• In addition to meeting the proposed re quirements for satisfactory reporting under PQRI for program year 2011, the EP must have data submitted on his or her behalf through an MOCP, for the MOCP in which th e EP participates. Although the MOCP need not become a qualified registry for data submission for PQRI purposes, the MOCP must meet the criteria for a registry for submi ssion of the MOCP data as specified below.

• An EP must, more frequently than is re quired to qualify for or maintain board

### CMS-1503-P 555

certification, participate in an MOCP for a year and successfully complete a qualified MOCP practice assessment for such year. We believe that the "more frequently" requirement applies both to the elements of the MOCP itself and the requirement to successfully complete a qualified MOCP prac tice assessment. With regard to the elements other than completing a qualifie d MOCP practice assessment, we propose to require that the MOCP certify that the EP has "more frequently" than is required to qualify for or maintain board certification "participated in a MOCP for a year" as required by section 10327 of the ACA. We do not propose to specify with respect to participation how an EP must meet the more frequently requirement, but rather that the MOCP so certify that EP has met this require ment. We note that we do not believe that the "more frequently" requirement is applicable to the licensure requirement, given that one cannot be licensed "more frequently" than is required. However, we do believe that the "more frequently" requirement applies to the required elements under sections 1848(m)(7)(C)(i)(II) and 1848(m)(7)(C)(i)(III) of the Act. In other words, we believe that the EP must "more frequently" than is required to qualify for or maintain board certification, participate in e ducational and self-assessmen t programs that require an assessment of what was learned; demonstrate, through a formalized, secure examination, that the physician has the f undamental diagnostic skills, me dical knowledge, and clinical judgment to provide quality care in their re spective specialty; and successfully complete a qualified MOCP practic e assessment. With respect to the MOCP practice assessment, which is specifically delineated in section 1848(m)(7)(B)(ii) of the Act as be ing required more often than is necessary to qualify for or maintain board certification, we believe we need to be more specific regarding our interpretation of the phrase “m ore frequently.” Additionally, we are

### CMS-1503-P 556

aware that some specialty boards have vary ing MOCP requirements for physicians to maintain board certification, based on the date of original certification. Some, we believe, may not be required to participate in an MOCP program at all in order to maintain board certifications. Accordingly, we recognize that "more often" may vary among physicians certified by the same spec ialty board. We interpret the statutory provisions as requiring particip ation in and successful comp letion of at least one MOCP practice assessment. Therefore, we propose, as a basic requireme nt, participation in and successful completion in at least one MOCP practice assessment. For physicians who are not required to participate in an MO CP to maintain board certification, "more often" would be more than 0, and theref ore only once. For physicians, however, who are otherwise required by the specialty board to participate in an MOCP to maintain board certification status, these physicians would need to complete the MOCP practice

assessment a second time in orde r to qualify for the additional incentive payment. If an MOCP practice assessment were required more than once during a particular cycle, the EP would be required to comp lete the MOCP practice assessment a third time in order to qualify for the additional incentive. We are also aware that ABMS boards are at various stages in implementing the practice assessment modules, and some may not have such assessment modules in place. However, inasmuch as we interpret the statute to require an MOCP practice assessment at least once as part of the MO CP, EPs who do not have available, through their boards or otherwise, an MOCP practi ce assessment are not eligible for the 0.5 percent incentive.

• We believe that the experience of care su rvey provides particularly valuable

### CMS-1503-P 557

information and propose that a qualified MO CP practice assessment must include a survey of patient experience with care. The Secretary may request information on the survey of patient experience with care, unde r section 1848(m)(7)(B)(iii) of the Act. In view of the importance of this information, a nd the lack of readily available alternative sources, we propose to require that MOCPs submit information as to the survey of patient experience with care for the EP regarding w hom information is being submitted by the

MOCP. We propose that MOCPs, who wish to enable their members to be eligible for anadditional PQRI incentive payment for the 2011 PQRI, will need to go through a selfnomination process by January 31, 2011. We pr opose the board will need to include all of the following information in their self-nomination letter to CMS:

• Provide detailed information regarding the MOCP with reference to the statutory requirements for such program.

• Indicate the organization sponsoring th e MOCP, and whether the MOCP is sponsored by an ABMS board. If not an AB MS board, indicate whether the program is substantially equivalent to the ABMS MOCP process.

• The frequency of a cycle of MOC for the specific MOCP of the sponsoring organization; including what constitutes "more frequently" for the MOCP practice assessment for the specific MOCP of the sponsoring organization.

• What was, is, or will be the first year of availability of the MOCP practice assessment for completion by an EP.

• What data is collected under the patient experience of care survey and how this information would be provided to CMS.

• How the MOCP monitors that an EP has implemented a quality improvement

### CMS-1503-P 558

process for their practice.

• Describe the methods, and data used unde r the MOCP, and provide a list of all

measures used in the MOCP for 2010 and to be used for 2011, including the title and descriptions of each measure, the owner of the measure, whether the measure is NQF endorsed, and a link to a website containing the detailed speci fications of the measures, or an electronic file containing the de tailed specifications of the measures. We propose that sponsoring organizations who desire to participate as an MOCP will need to be able to provide CMS the following information in a CMS-specified file format by no later than the end of the first quarter of 2012:

• The name, NPI and applicable TIN(s) of th e EP who would like to participate in this process;

• Attestation from the board that the information provided to CMS is accurate and complete;

• The board has signed documentation from the EP that the EP wishes to have their

• information released to CMS; Information from the experience of care survey;

• Information certifying that the EP has participated in an MOCP for a year, more frequently than is required to qualify for or ma intain board certification status, including the year that the physician met the board certification requirements for the MOCP, and the year the EP participated in an MOCP "more frequently" than is required to maintain or qualify for board certification; and

• Information certifying that the EP has completed the MOCP practice assessment

one additional time more than is required to qualify for or maintain board certification, including the year of the original MOCP practice assessment or that an MOCP practice

### CMS-1503-P 559

assessment is not required for the EP, and the year of the additional MOCP practice assessment completion. We propose that specialty boards that also desire to send PQRI information to

CMS on behalf of their EP s hould be able to meet the requirements for registry data submission proposed in section VI.F.1.d.(4) of this rule and should follow the directions for self-nomination to become a qualified re gistry. Boards may also participate as registries for PQRI data provided that they meet the registry requirements. As an alternative to requiring boards to either operate a qualified PQRI registry or to self-nominate to submit MOCP data to CMS on behalf of their members, we also considered having the various boards submit the MOCP data to the ABMS and having

ABMS channel the information from the various boards to CMS. We invite comments on the proposed mechanism for receiving MOCP data from the specialty boards as well

as on the alternative mechanism that we considered. (3) Section 3002(d) – Integra tion of PQRI and EHR Reporting Section 1848(m)(7) of the Act ("Integrati on of Physician Qua lity Reporting and EHR Reporting), as added by section 3002(d) of the ACA re quires us to move towards the integration of EHR measures with respec t to the PQRI program. Section 1848(m)(7) of the Act specifies that by no later than January 1, 2012, the Secretary shall develop a plan to integrate reporting on quality measur es under PQRI with reporting requirements under subsection (o) relating to the meaningf ul use of EHRs. Such integration shall consist of the following: (A) The selection of measures, the repo rting of which would both demonstrate— (i) Meaningful use of an EHR for purposes of the EHR incentive program; and (ii) Quality of care furnishe d to an individual; and

### CMS-1503-P 560

(B) Such other activities as specified by the Secretary

. In an effort to align PQRI with the EHR incentive program, we propose to include many ARRA core clinical quality measures in the PQRI program, to demonstrate meaningful use of EHR and quality of care furnished to individuals. We propose the selection of these measures to meet the requi rements of planning the integration of PQRI and EHR reporting. We are working toward s a plan to integrate reporting on quality measures to make available by January 1, 2012. We solicit comments on this approach to integrate PQRI EHR measures with the clinical quality measures adopted for the EHR incentive program. Specifically, we encourage comments on how CMS plans to a lign the measures, and how the plan for integration will optimally improve quality of care for individuals and provide meaningful

use of EHRs. (4) Section 3002(e) - Feedback Section 3002 (e) of the ACA amends s ection 1848(m)(5) of the Act by adding subparagraph (H), which require s the Secretary to provide timely feedback to EPs on the performance of the EP with respect to satisfactorily submitting data on quality measures. Since the inception of the program in 2007, the PQRI program has provided EPs who have reported PQRI data on quality measures feedback reports at the TIN/NPI level detailing participation in PQRI, including reporting rate and performance rate information. For 2008, we improved the format and content of feedback reports based on stakeholder input. We also developed an alternate report distribution method whereby each EP can directly request and receive a fee dback report. We will continue to provide feedback reports to individuals and group practices that satisf actorily submit PQRI quality measure and thus qualify to earn a PQRI incentive.

### CMS-1503-P 561

We believe that the requi rements under section 1848(m )(5)(H) of the Act, as added by section 3002(e) of the ACA, for " timely" feedback reports with respect to satisfactorily submitting data on quality measures is met by providing the feedback reports on or about the time of issuance of the incentive payments. Thus, we propose to provide 2011 feedback reports on or about the time of issuance of the 2011 incentive payments, consistent with our current practice. In addition, we also propose to provide interim feedback reports for EPs reporting 2011 measures groups through the claims-based reporting mechanism. Specifically, we propose to develop interim feedba ck reports that are similar in content and format to the reports that we currently provide for such EP s using claims for dates of service between January 1, 2011 and February 28, 2011. We expect that we would be able to make these interim feedback reports ava ilable to EPs in June 2011. We believe interim feedback reports would be particularly valuable to EPs reporting measures group because, unlike with individual measures reporting, EPs w ould not be required to report on a certain percentage of eligible cases to satisfactor ily report the 2011 PQRI measures groups. EPs could just report on 30 eligible cases to sa tisfactorily report using measures groups. Interim feedback regarding the number of ca ses reported as of Fe bruary 28, 2011 would be valuable since an EP would know how many more cases he or she needs to report to satisfy the criteria for satisfactory reporting for claims-based reporting of measures

groups. We also intend to continue to explore methods to facilitate PQRI feedback report distribution. Additionally, based on feedba ck from the 2011 PQRI Listening Session that was held on February 2, 2010, we are consider ing a process by which we could respond to interim feedback report requests at the individual leve l for claims-based submission,

### CMS-1503-P 562

based upon first quarter claims data for the a pplicable program year. The goal of this would be to provide information to EPs as to errors in claims-based QDC submission while the reporting period is ongoing and pr ior to the start of the 6-month reporting period. We welcome comments with respect to our proposal to provide timely feedback reports for PQRI. (5) Section 3002(f) - Appeals Section 1848(m)(5)(I) of the Act, as am ended and added by section 3002(f)(2) of the ACA, requires an informal review process. Specifically, the statute requires that the Secretary establish and have in place, no la ter than January 1, 2011, an informal process for EPs to seek a review of the determination that an EP did not satisfactorily submit data on quality measures under the PQRI. We note that except as provided under the informal process under section 1848(m)(5)(I) of the Act, section 1848(m)(5)( E) of the Act, as amended by section 3002(f) of the ACA, specifies that, with respect to the PQRI, there shall be no administrative or judicial review under s ection 1869, section 1878, or otherwise, of: (1) The determination of measures applic able to services furnished by EPs under PQRI; (2) The determination of satis factory reporting under PQRI; and (3) The determination of any PQRI incentive payment and PQRI payment adjustment. We propose to base the informal proce ss on our current inquiry process whereby an EP can contact the Quality Net Help Desk (via phone or e-mail) for general PQRI and eRx Incentive Program information, informati on on PQRI feedback report availability and access, and/or information on PQRI Port al password issues. We believe that the

### CMS-1503-P 563

current inquiry process provides a good basis fo r an informal review process because EPs currently can utilize the inquiry process if th ey have questions on wh ether they qualified for an incentive. However, the current i nquiry process does not have timelines nor is it restricted to questions solely on whether th e EP qualified for an incentive. Thus, for purposes of the informal process required under section 1848(m)(5)(E) of the Act, we propose the following process:

• An EP electing to utilize the informal process must request an informal review within 90 days of the release of his or her feedback report.

• An EP can request the informal review by notifying the Quality Net Help Desk

via email at qnetsupport@sdps.org . The email requesting the initiation of the informal review process should summarize the concer n(s) of the EP and the reason(s) for requesting an informal review.

• We propose to provide the EP with a response to his or her request for an informal review within 60 days of receiving the original request.

• As this process is informal and the statute does not require a formal appeals process, we will not include a hearing or ev idence submission process, although the EP may submit information to assist in the review.

• Based on our informal review, we w ill provide a written re sponse. Where we find that the EP did satisfactorily report, we propose to provide the applicable incentive

payment.

• Given that this is an informal review process and given the limitations on review under section 1848(m)(5)(E) of the Act, decisions based on the informal review will be final, and there will be no further review or appeal.

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• By December 31, 2011, we propose to post on the CMS PQRI Web site, further information regarding the operational aspect s of the informal review process for 2011 PQRI. We invite public comme nt on this proposed process.

2. Section 132: Incentives for Electronic Pr escribing (eRx)– The Electronic Prescribing Incentive Program a. Program Background and Statutory Authority As defined in §423.159(a), eRx is the tran smission using electronic media, of prescription or prescription-related informa tion between prescriber, dispenser, pharmacy benefit manager (PBM), or h ealth plan, either directly or through an intermediary, including an eRx network. Included in eRx, but not limited to, are two-way transmissions between the point of care and the dispenser. Section 1848(m)(2) of the Act promotes the us e of electronic prescribing by authorizing incentive payments to EPs or group practices w ho are "successful electronic prescribers." The intention of the 2011 eRx Incentive Program, which is separate from, and in addition to, any incentive payment that EPs may earn through the PQRI program, is to continue to encourage significant expansion of the use of electronic prescribing by authorizing a combination of financial incentives and pa yment adjustments. Individual EPs do not have to participate in PQRI in order to participate in the eRx Incentive Program (and vice versa). We propose to add §414.92 to title 42 of the Code of Fede ral Regulations to implement the provisions of the eRx Incentive Program discussed in this section of the proposed rule. For 2011, which is the third year of the eRx Incentive Program, the Secretary is authorized to provide successful electr onic prescribers, as defined in section 1848(m)(3)(B) of the Act and further discu ssed below in this section, an incentive

### CMS-1503-P 565

payment equal to 1.0 percent of the total es timated Medicare Part B PFS allowed charges (based on claims submitted not later than 2 months after the end of the reporting period) for all covered professional services furn ished during the 2011 reporting period. Covered professional services are defined under the stat ute to be services for which payment is made under, or is based on, th e PFS and which are furnished by an EP. The applicable electronic prescribing percent (1.0 percen t) authorized for the 2011 eRx Incentive Program is different from that authorized for the 2009 and 2010 eRx Incentive Program. Under section 1848(m)(2)(C) of the Act, the incentive payments for successful electronic prescribers for future years are authorized as follows:

● 1.0 percent for 2012.

● 0.5 percent for 2013. However, section 1848(m)(2)(D) of the Act, as added by section 4101(f)(2)(B) of

Title IV of Division B of the American R ecovery and Reinvestme nt Act of 2009(Pub.L. 111-5) (ARRA-HITECH), specifies that the eR x incentive does not apply to an EP (or group practice), if, for the EHR reporting pe riod, the EP (or group practice) earns an incentive payment under the Medicare EHR incentive program. The Medicare EHR incentive program begins in 2011. Therefore, EPs who earn an incentive under the Medicare EHR Incentive Program, with respec t to certified EHR technology that has eRx capabilities, will not be eligible to earn a separate incentive payment for being a successful electronic prescriber under the eRx Incentive Program. For eRx, when reporting any of the G-codes for purposes of qualifying for the incentive payment for electronic prescribin g in 2011, we propose that the professional must have and regularly use a "qualified" elec tronic prescribing system, as defined in the electronic prescribing measure specifications. If the professional do es not have general

### CMS-1503-P 566

access to an eRx system in the practice setting, as cited in the hardship exception as stated by the secretary, there is nothing to report. In addition, under section 1848(a)(5)(A) of the Act, a PFS payment adjustment applies beginning in 2012 to those who ar e not successful electronic prescribers. Specifically, for 2012, 2013, and 2014, if the EP is not a successful electronic prescriber for the reporting period for the year, the PFS amount for covered professional services furnished by such professionals during the year as referenced above shall be less than the PFS amount that would otherwise appl y over the next several years by:

● 1.0 percent for 2012.

● 1.5 percent for 2013.

● 2.0 percent for 2014. We believe that the criteria for determination of successful electronic prescriber proposed herein for the eRx incentive payment are not required to be identical to the criteria that will be used to determine the applicability of the payment adjustment that begins in 2012. Policy considerations underl ying the application of the incentive payment are not necessarily the same as those in applying a payment adjustment. In general, we believe that an incentive should be broadly available to encourage the widest possible adoption of eRx, even for low vol ume prescribers. On the other hand, we believe that a payment adjustment should be applied primarily to a ssure that those who have a large volume of prescribing do so electronically, without penalizing those for whom the adoption and use of an electronic pr escribing system may be impractical given the low volume of prescribing. The 2011 eRx incentive and the application of the payment adjustment for 2012 will be addressed separately below.

### CMS-1503-P 567

Under section 1848(m)(6)(A) of the Act, th e definition of "EP" for purposes of eligibility for the eRx Incentive Program is identical to the definition of "EP" for the PQRI under section 1848(k)(3)(B) of the Act. In other words, EPs include physicians, other practitioners as descri bed in section 1842(b)(18)(C) of the Act, physical and occupational therapists, qualified speech -language pathologists, and qualified audiologists. However, as we have noted in prior years, for purposes of the eRx Incentive Program, eligibility is further restricted by scope of practice to those professionals who have prescr ibing authority. Detailed in formation about the types of professionals that are eligible to participat e in the eRx Incentive Program is available on the Electronic Prescribing Incentive P rogram section of the CMS Web site at http://www.cms.gov/ERXIncentive

. As in the 2010 eRx Incentive Program, we propose in 2011 that the eRx Incentive Program continue to be an incentive program in which determination of whether an EP is a successful electronic prescriber will be made at the individual prof essional level, based on the NPI. Inasmuch as some individuals (i dentified by NPIs) may be associated with more than one practice or TIN, the determin ation of whether an EP is a successful electronic prescriber will be made to th e holder of each unique TIN/NPI combination. Then, as in previous years, payment will be made to the applicable holder of the TIN. For 2011, the determination of whether an EP is a successful electronic prescriber will continue to be made for each unique TIN/NPI combination. However, section 1848(m)(3)(C) of the Act required the Secretar y by January 1, 2010 to establish and have in place a process under which EPs in a group practice (as defined by the Secretary) would be treated as meeting the requirements for submitting data on electronic prescribing quality measures for covered profe ssional services for a reporting period (or,

### CMS-1503-P 568

for purposes of the payment adjustment under section 1848(a)(5) of the Act, for a reporting period for a year) if, in lieu of repo rting the electronic prescribing measure, the group practice reports measures determined appropriate by the Secretary, such as measures that target high-cost chronic c onditions and preventive care, in a form and manner, and at a time specified by the Secretary. Therefore, in addition to making incentive payments for 2011 to individual EPs based on separately analyzing whether the

individual EPs are successful el ectronic prescribers, we propose to also make incentive payments to group practices based on the de termination that the group practice, as a whole, is a successful electronic prescrib er in accordance with section 1848(m)(3)(C) of

the Act.

b. The 2011 eRx Incentive (1) The 2011 Reporting Period for the eRx Incentive Program Section 1848(m)(6)(C)(i)(II) of the Act defines "reporting period" for the 2011 eRx Incentive Program to be the entire year. Section 1848(m)(6)(C)(ii) of the Act, however, authorizes the Secretary to revise the reporting period if the Secretary

determines such revision is appropriate, produces valid results on meas ures reported, and is consistent with the goals of maximizing scientific validity and reducing administrative burden. We propose the 2011 eRx Incentive Pr ogram reporting period to be the entire calendar year (January 1, 2011 through De cember 31, 2011) based on the definition of "reporting period" specified under section 1848(m )(6)(C)(i)(II) of the Act. We believe that keeping the 2011 eRx Incentive Program reporting period consistent with 2009 and 2010 eRx Incentive Program reporting periods w ill help to further maintain program stability and be less confusing for EPs.

### CMS-1503-P 569

Accordingly, we propose that successful electronic prescribers would be eligible to receive an incentive payment equal to 1.0 percent of the to tal estimated allowed Medicare Part B charges (based on claims submitted by no later than February 28, 2012) for all covered professional services furnished January 1, 2011 through December 31,

2011. (2) Proposed Criteria for Dete rmination of Successful El ectronic Prescriber for EPs Under section 1848(m)(3)(B) of the Act, in order to qualify for the incentive payment, an EP must be a "successful electronic prescriber," which the Secretary is authorized to identify using 1 of 2 possi ble criteria. One criterion, under section 1848(m)(3)(B)(ii) of the Act, is based on the EP 's reporting, in at least 50 percent of the reportable cases, on any electronic prescribing quality measures that have been established under the physic ian reporting system, under s ubsection 1848(k) of the Act (which, as noted previously, we have named "PQRI" for ease of reference) and are applicable to services furnished by the EP during a reporting period. We applied this criterion in 2009. However, for years afte r 2009, section 1848(m)(3)(D) of the Act permits the Secretary in consultation with stak eholders and experts to revise the criteria for submitting data on electronic prescribing measures under section 1848(m)(3)(B)(ii) of

the Act. The second criterion, under section 1848(m)(3)( B)(iii) of the Act, is based on the electronic submission by the EP of a sufficient number (as determined by the Secretary) of prescriptions under Part D during the repor ting period. If the Secretary decides to use the latter standard, then, in accordance with section 1848(m)(3)(B)(iv) of the Act, the Secretary is authorized to use Part D drug claims data to assess whether a "sufficient" number of prescriptions have been sub mitted by EPs. However, under section

### CMS-1503-P 570

1848(m)(3)(B)(i) of the Act, if the standard based on a sufficient number (as determined by the Secretary) of electronic Part D prescr iptions is applied for a particular reporting period, then the standard based on the reportin g on electronic prescribing measures would no longer apply. For 2011, we propose to continue to re quire EPs to report on the electronic prescribing measure used in the 2009 and 2010 eRx Incentive Program to determine

whether an EP is a successful electronic prescriber, but we are proposing to again use modified measure specificati ons and to use modified reporting criteria based on the authority provided under section 1848(m)(3)(D) of Act, as discussed below. As we stated in prior years, we are still considering the use of a certain number of Part D prescribing events as the basis for th e incentive payment. We propose to continue to require EPs to report on the electronic prescribing measure used in the 2009 and 2010 eRx Incentive Program because we believe that the accuracy and completeness of the Part D data with respect to whether a prescription was submitted electronically is unknown. In 2010, information on whether a pr escription was submitted electronically by an individual EP began to be collected on the Part D claims and/or Prescription Drug Event (PDE) data. Also, since April 1, 2009, pr escription drug plan sponsors are required to send PDE data with an individual prescriber's NPI. We currently have limited information on the accuracy and completeness of NPI data that is submitted with the PDE

data. The NPI is needed in order for CMS to be able to link an EP's PDE data to his or

her Medicare Part B claims to calculate the incentive payment amount. During 2010, we continue to evaluate the adequacy of Part D data to determine the feasibility of its use for determining whether an EP qualifies as a successful electronic prescriber. The use of Part D data for correlation has not yet shown to be possible due to NPI and other issues.

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Part D data is supplied by the pharmacy and not the EP. We are in the process of writing and will publish an evaluation of the PQRI re porting experience. The experience report will include an evaluation of the eRx Incentive Program. (i) Reporting the Electronic Prescribing Measure For 2011, we propose to retain the 3 reportin g mechanisms available to individual EPs to report the electronic pr escribing measure in 2010 to maintain program stability. First, we propose to again retain the claims-b ased reporting mechanism that is used in the 2009 and 2010 eRx Incentive Program. In addition, similar to the PQRI, for the eRx Incentive Program, we propose to continue the registry-based reporting mechanism and, we also propose that the EHR-based reporting mechanism be available for the electronic prescribing measure for 2011. We propose that only registries qualified to submit quality measure results and

numerator and denominator da ta on quality measures on behalf of EPs for the 2011 PQRI would be qualified to submit measure results and numerator and denominator data on the electronic prescribing measure on behalf of EPs for the 2011 eRx Incentive Program. As in 2010, not all registries qualified to submit quality measures on behalf of EPs for the 2011 PQRI would be qualified to submit qua lity measures results and numerator and

denominator data on the eRx measure. The electronic prescribing measure is reportable by an EP any time he or she bills for one of the procedure codes for Part B services

included in the measure's denominator. Some registries who self-nominate to become a qualified registry for PQRI may not choose to self-nominate to become a qualified registry for submitting measures that require re porting at each eligible visit. Registries need to indicate their desire to qualify to submit measure results and numerator and denominator data on the electronic pres cribing measure for the 2011 eRx Incentive

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program at the time that they submit their self-nomination letter for the 2011 PQRI. In addition, we propose that registires that want to be qualified to submit measure results

and numerator and denominator data on the electronic prescribing measure for the 2011 eRx Incentive Program would be required to transmit 2011 eRx measure results and

numerator and denominator data on the elec tronic prescribing measure to CMS in two separate transmissions. In addition to submitting 2011 measure results and numerator data on the electronic prescribing measure in 2012 as described in section VI.F.1. above, such registries would need to sub mit 2011 measure results and numerator and denominator data on the electronic prescr ibing measure between July 1, 2011 and August 19, 2011 for purposes of the eRx penalty described in section VI.F.2.c. below. The self-nomination process a nd requirements for registries for the PQRI, which also would apply to the registries for the 2011 eRx Incentive Program, are discussed previously in section VI.F.1. of this proposed rule. We will post a final list of qualified registries for the 2011 eRx Incentive Progra m on the Electronic Prescribing Incentive Program section of the CMS Web site at http://www.cms.gov/ERXIncentive when we post the final list of qualified registries fo r the 2011 PQRI on the PQRI section of the

CMS Web site. Similarly, we continue to propose th at only EHR products "qualified" to potentially be able to submit clinical quality data extracted from the EHR to CMS for the 2011 PQRI would be considered "qualified" for the purpose of an EP potentially being able to submit data on the electronic pr escribing measure for the 2011 eRx Incentive Program. The self-nominati on process and requirements fo r EHR vendors for the PQRI, which would apply to the EHR vendors fo r the 2011 eRx Incentive Program were

discussed in the CY 2010 PFS final rule with comment period (74 FR 61801 through

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61802). EHR vendors were required to indicate thei r desire to have one or more of their EHR products qualified for the purpose of an EP potentially being ab le to submit data on the electronic prescribing m easure for the 2011 eRx Incentive Program at the time that they submitted their self-no mination letter for the 2011 PQRI . A list of qualified EHR vendors and their products (including the ve rsion that is qualified) for the 2011 eRx Incentive Program will be posted on the eRx Incentive Program section of the CMS Web

site at http://www.cms.gov/ERXIncentive when we post the list of qualified EHR products for the 2011 PQRI on the PQRI secti on of the CMS Web site. We propose that EPs who want to use a qualified EHR to submit the electronic prescribing measure for the 2011 eRx Incentive Program would be required to transmit 2011 eRx data to CMS in two separate transmissions. In addition to sub mitting 2011 data on the el ectronic prescribing measure in 2012, as described in section VI .F.1. above, such EPs would need to submit 2011 data on the electronic prescrib ing measure between July 1, 2011 and August 19, 2011 for purposes of the eRx penalty described in section VI.F.2.c. below. (ii) The Reporting Denominator for the Electronic Prescribing Measure The electronic prescribing measure, similar to the PQRI measures, has 2 basic elements, which include: (1) a reporting de nominator that defines the circumstances when the measure is reportable; and (2) a reporting numerator. The denominator for the electronic prescrib ing measure consists of specific billing codes for covered professional services. Th e measure becomes reportable when any one of these procedure codes is billed by an EP for Part B covered professional services. As initially required under section 1848(k)(2)(A)(ii) of the Act, and further established through rulemaking and under section 1848(m)(2 )(B) of the Act, we may modify the codes making up the denominator of the elec tronic prescribing measure. As such, we

### CMS-1503-P 574

expanded the scope of the denominator code s for 2010 to covered pr ofessional services outside the professional office and outpatient setting, such as professional services furnished in skilled nursing facilities or the home care setting. We propose to retain the following CP T codes in the denominator of the electronic prescribing measure for 2011: 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90862, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0101, G0108, G0109. In 2010, the expansion of the electronic prescribing measure denominator was expected to provide more EPs the opportunity to report the measure, and thus, provide more opportun ities for EPs to participate in the eRx Incentive Program. Thus far, our experience in the 2010 eRx In centive Program has been positive and we do not see a need to change the denominator codes for 2011. We invite comments on our proposal to retain the deno minator codes from the 2010 electronic prescribing measure

denominator. There are no diagnosis codes in the measure's denominator and there are no age/gender requirements in order for a pa tient to be included in the measure's denominator (that is, reporting of the electr onic prescribing measure is not further limited to certain ages or a specific gender). EPs ar e not required to report this measure in all cases in which the measure is reportable. EPs who do not bill for one of the procedure codes for Part B covered professional services included in the measure's denominator will have no occasion to report the el ectronic prescribing measure.

### CMS-1503-P 575

We further propose that by December 31, 2010, we will post the final specifications of the measure on the "eRx M easure" page of the eRx Incentive Program

section of the CMS Web site at http://www.cms.gov/ERXIncentive

. (iii) Qualified Electronic Prescribing System – Required Functionalities and Part D eRx

Standards To report the electronic prescribing meas ure in 2011, we again propose that the EP must report one of the measure's numerator "G" codes, as will be discussed below. However, when reporting any of the G-codes for purposes of qualifying for the incentive payment for electronic prescribing in 2011, we propose that the professional must have and regularly use a "qualified" electronic prescribing system, as defined in the electronic prescribing measure specifications. If the pr ofessional does not have general access to an eRx system in the practice setting, the EP does not have any data to report for purposes of the incentive payment. Required Functionalities for a "Qualified" Electronic Prescriber System

. For 2011, we propose to retain what constitutes a "qualified" electronic prescribing system as a system based upon ce rtain required functionalities that the system can perform. We propose that for 2011, a "q ualified" electronic prescribing system

would be one that can--

• Generate a complete active medication list incorporating electronic data received from applicable pharmacies and PBMs, if available.

• Allow EPs to select medications, pr int prescriptions, electronically transmit prescriptions, and conduct alerts (written or acoustic signals to warn the prescriber of possible undesirable or unsafe situations in cluding potentially inappropriate dose or route

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of administration of a drug, drug-drug inter actions, allergy concer ns, or warnings and cautions). This functionality must be enabled.

• Provide information related to lo wer cost, therapeutically appropriate alternatives (if any). The ability of an electronic prescribing system to receive tiered formulary information, if available, would again suffice for this requirement for 2011 and until this function is more widely available in the marketplace.

• Provide information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronica lly from the patient's drug plan (if available). Part D Electronic Prescribing Standards . Section 1848(m)(3)(B)(v) of the Act specifies that to the extent practicable, in determining whether an EP is a successful electronic prescriber, "the Secretary shall en sure that EPs utilize electronic prescribing systems in compliance with standards established for such systems pursuant to the Part D Electronic Prescribing Program under secti on 1860D-4(e)" of the Act. The Part D standards for electronic prescribing systems establish which electronic standards Part D sponsors, providers, and dispensers must use when they electronically transmit prescriptions and certain prescription related information for Part D covered drugs that are prescribed for Part D eligible individua ls. To be a qualified electronic prescribing system under the current eRx Incentive Prog ram, electronic systems must convey the information listed above under (a) through (d) us ing the standards currently in effect for the Part D electronic prescribing program. Additional Part D electronic prescribing standards were implemented April 1, 2009. Th ese latest Part D electronic prescribing standards, and those that had previously been adopted, can be found on the CMS Web

site at http://www.cms.gov/eprescribing

.

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To ensure that EPs utilize electronic prescribing systems that meet these requirements, the electronic prescribing measure requires that those functionalities required for a "qualified" electronic prescr ibing system utilize the adopted Part D electronic prescribing standards. The Part D electronic prescribing standards relevant to the four functionalities for a "qualified" syst em in the electronic prescribing measure

described above and listed as (a), (b), (c), and (d), currently are as follows: (a) Generate medication list – Use th e National Council for Prescription Drug Programs (NCPDP) Prescriber/Pharmacist In terface SCRIPT Standard, Implementation Guide, Version 8, Release 1, October 2 005 (hereinafter "NCPDP SCRIPT 8.1") Medication History Standard. (b) Transmit prescriptions electronica lly – Use the NCPDP SCRIPT 8.1 for the transactions listed at §423.160(b)(2). (c) Provide information on lower cost alternatives – Use the NCPDP Formulary and Benefits Standard, Implementation Gu ide, Version 1, Release 0 (Version 1.0), October 2005 (hereinafter "NCPDP Formulary and Benefits 1.0"). (d) Provide information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronica lly from the patient's drug plan – use-- (1) NCPDP Formulary and Benefits 1.0 for communicating formulary and

benefits information between prescribers and plans; (2) Accredited Standards Committee (ASC) X12N 270/271-Health Care Eligibility Benefit Inquiry and Response, Version 4010 , May 2000, Washington Publishing Company, 004010X092 and Addend a to Health Care Eligibility Benefit Inquiry and Response, Version 4010A1, October 2002, Washington Publishing

### CMS-1503-P 578

Company, 004010X092A1 for communicating eligibility information between the plan and prescribers; and (3) NCPDP Telecommunication Standard Specification, Version 5, Release 1 (Version 5.1), September 1999, and equiva lent NCPDP Batch Standard Batch Implementation Guide, Version 1, Re lease 1 (Version 1.1), January 2000 for communicating eligibility information between the plan and dispensers. However, there are Part D electronic prescribing standards that are in effect for functionalities that are not commonly utilized at this time. Such functionalities are not currently required for a "qualified" syst em under the eRx Incentive Program. One example is Rx Fill Notification, which is disc ussed in the Part D electronic prescribing final rule (73 FR 18918, 18926). For purpos es of the 2011 Electronic Prescribing Program, we again are not proposing to requi re that an electronic prescribing system

contain all functionalities for which there ar e available Part D electronic prescribing standards. For those required functi onalities described above , we propose that a "qualified" system must use the adopted Pa rt D electronic prescribing standards for electronic messaging. There are other aspects of the functionalitie s for a "qualified" system that are not dependent on electronic messaging and are pa rt of the software of the electronic prescribing system, for which Part D standard s for electronic prescribing do not pertain and are not required for purposes of the eR x Incentive Program. For example, the requirements in qualification (b) listed above that require the system to allow professionals to select medi cations, print prescriptions, a nd conduct alerts are functions included in the particular software, for whic h Part D standards for electronic messaging do not apply.

### CMS-1503-P 579

We are aware that there are significant numbers of EPs who are interested in participating in the eRx Incentive Program, but currently do not have an electronic prescribing system. The electronic prescribing measure does not require the use of any particular system or transmi ssion network; only that the system be a "qualified" system having the functiona lities described a bove based on Part D electronic prescribing standards. As in 2010, if th e professional does not have ge neral access to an electronic prescribing system in the practice setting, the EP does not have any data to report for purposes of the incentive payment and would not be able to participate in the 2011 eRx Incentive Program. If an EP does not par ticipate in the 2011 eRx Incentive Program he or she may be subject to the 2012 eRx penalt y discussed in section VI.F.2.c. of this proposed rule. (iv) The Reporting Numerator for the Electronic Prescribing Measure The proposed criteria for reporting for purposes of being a 2011 successful electronic prescriber are designed to reward those EPs who demonstrate that they have adopted a qualified electronic prescribing sy stem and actually used the system in a substantial way to electronically prescribe. In this context, the reporting of information in circumstances where a profe ssional did not electronically prescribe is not pertinent. Additionally, although it may be of intere st to measure the proportion of prescribing events that are electronic, we do not believe such detail at the individual or group practice

level is of sufficient value to warrant the hi gh burden of reporting such information. We do note that in the future the use of Part D claims data may allow this information to be collected without the necessity for professi onals to specifically report such details. Accordingly, for the 2011 electronic pres cribing measure, we propose to retain the following numerator G-code from th e 2010 electronic prescribing measure's

### CMS-1503-P 580

numerator: G8553 (At least 1 prescription cr eated during the encounter was generated and transmitted electronically using a qualified electronic prescribing system.) We propose to post the final 2011 electroni c prescribing measure specifications on the "eRx Measure" page of the eRx Incentiv e Program section of the CMS Web site at http://www.cms.gov/ERXIncentive . We propose to post the final 2011 electronic prescribing measure specifications by no later than December 31, 2010. Because the electronic prescribing quality measure will apply only when an EP furnishes services indicated by one of the codes included in the measure's denominator,for claims-based reporting, for example, it will not be necessary for an EP to report Gcodes for the electronic prescribing measur e on claims not containing one of the denominator codes. However, if reporting a G-code, the G-code data submission will only be considered valid if it appears on the same Medicare Part B claim containing one of the electronic prescribing quality measure's denominator codes. In addition, if the EP submits a Medicar e Part B claim containing one of the electronic prescribing measure's denominator c odes, he or she can report the numerator G-code only when the EP furnishes services indicated by the G-code included in the measure's numerator. That is, only when at least 1 prescription created during the encounter is generated and transmitted el ectronically using a qualified electronic prescribing system. (v) Criteria for Successful Reporting of the Electronic Prescribing Measure As discussed above, section 1848(m)(3)(D) of the Act authorizes the Secretary to revise the criteria for submitting data on the electronic prescribing measure from the criteria specified under section 1848(m)(3)(B)(ii) of the Act, which requires the measure to be reported in at least 50 percent of the ca ses in which the measure is reportable. In

### CMS-1503-P 581

2010, we revised the criteria for successful elect ronic prescriber such that an EP shall be treated as a successful electronic prescriber for a reporting period based on the EP's reporting of the electronic prescribing measur e by generating and reporting one or more prescriptions associated with a patient vis it electronically, a minimum of 25 unique visits per year in 2010 of applicable cases in th e denominator of the eRx measure. For 2011, we again propose to make the determination of whether an EP is a successful electronic prescriber based on a count of the number of times (minimum threshold of 25) an EP reports that at least one pres cription created during the encounter is generated using a qualified electronic prescribing system (that is, reports the G8553 code). As in 2010, we believe these criteria will bring us closer to our intention to transition to using a certain number of electr onic Part D prescribing events as the basis for the incentive payment in future years. In proposing these criteria again for 2011 eRx,

we continue to assume that on ce an EP has invested in an eRx system, integrated the use of the eRx system into the practice's work flow s, and has used the system to some extent, he or she is likely to continue to use the eR x system for most of the prescriptions he or she generates. For structural measures such as the electronic prescribing measure, once an EP has demonstrated that he or she has integrat ed use of an eRx system into his or her practice's work flow, we believe that requiring the EP to c ontinue to report the measure represents an administrative burden with little added benefit to the reliability and validity of the data being reporting. In contrast, for clinical quality measures, we believe that the reliability and validity of the performance rates depends on the adequacy of the sample. Therefore, we propose that an EP would be re quired to report that at least 1 prescription for a Medicare Part B FFS patient created during an encounter that is represented by 1 of

### CMS-1503-P 582

the codes in the denominator of the electronic prescribing measure was generated and transmitted electronically using a qualified eRx system for at least 25 times during the 2011 reporting period. The reporting threshold of 25 also takes in to consideration that prescriptions are not generated with every Medicare Part B FFS patient encounter, some prescriptions, such as narcotics, cannot be prescribed elec tronically, and that not all Medicare Part B FFS encounters are represented by the elec tronic prescribing measure's denominator

codes. As stated previously, we propose th at by December 31, 2010, we will post the final specifications of the measure on the "eRx Measure" page of the eRx Incentive Program section of the CMS Web site at http://www.cms.gov/ERXIncentive

. (3) Determination of the 2011 Incentive Payment Amount for Individual EPs Who Are

Successful Electronic Prescribers Section 1848(m)(2)(B) of the Act imposes a limitation on the electronic prescribing incentive payment. The Secretar y is authorized to choose 1 of 2 possible criteria for determining whether or not th e limitation applies to a successful electronic prescriber. The first criterion, under secti on 1848(m)(2)(B)(i) of the Act, is based upon whether the Medicare Part B allowed charges fo r covered professional services to which the electronic prescribing quality measure applies are less than 10 percent of the total Medicare Part B PFS allowed charges for all covered professional services furnished by the EP during the reporting period. The se cond criterion, under section 1848(m)(2)(B)(ii) of the Act, is based on whether the EP submits (both electronically and non-electronically) a sufficient number (as determ ined by the Secretary) of prescriptions under Part D (which can, again, be assessed us ing Part D drug claims data). If the

### CMS-1503-P 583

Secretary decides to use the latter criterion, then, in accordance with section 1848(m)(2)(B) of the Act, the criterion base d on the reporting on electronic prescribing measures would no longer apply. The statutory limitation also applies with regard to the application of the payment adjustment. Based on our proposal to make the dete rmination of whether an EP is a "successful electronic prescriber" based on submission of the electronic prescribing measure, we propose to again apply the cr iterion under section 1848(m)(2)(B)(i) of the Act for the limitation for the 2011 eRx Incentive Program. Since, as discussed above, we are reta ining for 2011 our proposal to make the

determination of whether an EP is a "s uccessful electronic prescriber" based on submission of the electronic prescribing meas ure, we also are proposing to retain the requirement to analyze the claims submitted by the EP at the TIN/NPI level to determine whether the 10 percent threshold is met in determining the receipt of an electronic prescribing incentive payment for 2011 by an EP . This calculation is expected to take place in the first quarter of 2012 and will be performed by dividing the EP's total 2011 Medicare Part B PFS allowed charges for all such covered professional services submitted for the measure's denominator codes by the EP's total Medicare Part B PFS allowed charges for all covered professional services (as asse ssed at the TIN/NPI level). If the result is 10 percent or more, then the statutory limitation will not apply and a successful electronic prescriber will qualify to earn the electronic prescribing incentive payment. If the result is less than 10 percent, then the statutory limitation will apply and the EP will not earn an electronic prescrib ing incentive payment even if he or she electronically prescribes and reports a G-code indicating that he or she generated and transmitted a prescription electronically at l east 25 times for those eligible cases that

### CMS-1503-P 584

occur during the 2011 reporting period. Although an individual EP may decide to

conduct his or her own assessmen t of how likely this statutory limitation is expected to apply to him or her before deciding whethe r or not to report the electronic prescribing measure, an individual EP may report the elec tronic prescribing measure without regard to the statutory limitation for the incentive payment. (4) Proposed Reporting Option for Satisfactor y Reporting of the Electronic Prescribing Measure by Group Practices In 2010 eRx Incentive Program, we were required by section 1848(m)(3)(C) of the Act to establish a process under which EP s in a group practice shall be treated as a successful electronic prescriber. In a ddition, section 1848(m)(3)(C)(iii) of the Act requires that payments to a group practice by reason of the process established under section 1848(m)(3)(C)(i) of the Act shall be in lieu of the payments that would otherwise

be made under this subsection to EPs in the group practice for being a successful electronic prescriber. In 2011, we propose to retain the requirements from 2010 eRx Incentive Program with respect to making in centive payments to group practices based on the determination that the group practice, as a whole, is a successful electronic prescriber

for 2011. An individual EP who is affiliated with a group practice participating in the group practice reporting option that successf ully meets the proposed requirements for group practices would not be eligible to ea rn a separate eRx incentive payment for 2011

on the basis of his or her su ccessfully reporting the electronic prescribing measure at the

individual level. (i) Definition of "Group Practice" Section 1848(m)(3)(C)(i) of the Act aut horizes the Secretary to define "group practice." For purposes of determining whether a group practice is a successful

### CMS-1503-P 585

electronic prescriber for 2011, we propose that consistent with the definition of group practice proposed for the PQRI group practic e reporting option (GPRO) discussed in section VI.F.1. of this proposed rule, a "gr oup practice" would be defined as a single Taxpayer Identification Number (TIN) with 2 or more EPs, as identified by their individual National Provider Identifier (NPI), who have reassigned their Medicare billing rights to the TIN. "Group practice" would also include group practices participating in Medicare demonstration projects approved by the Secretary, as described in section VI.F.1.g.(2) of this proposed rule. In addition, we propose to restrict pa rticipation in the 2011 eRx GPRO to group practices participating in the 2011 PQRI GPRO (either through GPRO I orGPRO II) or group practices that are deemed to be par ticipating in the 2011 PQRI GPRO (that is, group practices participating in a CMS-approved Medicare demonstration) that have indicated their desire to par ticipate in the 2011 eRx GPRO. Therefore, unlike individual EPs who are not required to participate in the PQRI, to be eligible to earn an electronic prescribing incentive in 2011, group practices that wish to participate in the electronic pres cribing group practice re porting option will be required to participate in the PQRI group pr actice reporting option or be deemed to be participating in the PQRI group practice reporting option based on the practice’s participation in an approved Medicare demonstration project . Participation in the eRx Incentive Program, including participation in the electronic prescribing group practice reporting option is, however, optional for group pr actices that are participating in PQRI under the group practice reporting option. If a gr oup practice wishes to participate in the 2011 eRx Incentive Program under the group pr actice reporting option, it must indicate its desire to do so at the time that the group practice self-nominates to participate in the

### CMS-1503-P 586

2011 PQRI group practice reporting option. There is no need for group practices to indicate their intent to participate in th e 2011 eRx Incentive Program as individual EPs when the group practice self-nominates to participate in the 2011 PQRI group practice reporting option. Group practices interested in participa ting in the 2011 PQRI through the group practice reporting option will be required to submit a self-nomination letter to CMS, requesting to participate in the 2011 PQRI group practice reporting option. Instructions for submitting the self-nomination letter will be posted on the PQRI section of the CMS Web site by November 15, 2010. A group practic e that wishes to participate in the eRx Incentive Program group practice reporting op tion will be notified of the selection decision to participate in the eRx Incentive Prog ram at the same time that it is notified of the selection decision for the PQRI group practice reporting option. In addition to meeting the proposed eligib ility requirements discussed in section VI.F.1.g. of this proposed rule, we propose that a group practice that wishes to participate in the 2011 eRx Incentive Program under the group practice reporting option will also have to indicate how it intends to report the el ectronic prescribing measure. That is, the group practice will need to indicate in its self-nomination le tter which reporting mechanism the group practice intends to use fo r purposes of participating in the 2011 eRx Incentive Program group practice reporting option. (2) Process for Group Practices to Partic ipate as Group Practices and Criteria for Successful Reporting of the Electronic Pr escribing Measure by Group Practices For group practices selected to particip ate in the electronic prescribing group practice reporting option for 2011, we pr opose the reporting period would be January 1, 2011, to December 31, 2011.

### CMS-1503-P 587

We propose that physician groups selected to participate in the 2011 eRx Incentive Program through the group practice reporting option would be able to choose to report the electronic prescribing measure through the claims-based, the registry-based, or, the EHR-based reporting mechanism. In order for a group practice participating in the PQRI GPRO I to be considered a successful electronic prescriber, we propose th at the group practice would have to report that at least 1 prescription during an encounter was generated and transmitted electronically using a qualified electronic prescribing system in at least 2,500 instances during the reporting period. In order for a group practice participating in the PQRI

GPRO II to be considered a successful elect ronic presciber, we propose that the group practice would have to report that at l east 1 prescription during an encounter was generated and transmitted electronically using a qualified electronic prescribing system for the number of instances specified in Tabl e 50 (see section VI.F.1.g.(3).(ii). of this proposed rule). In other words, a group of 2-10 NPIs would need to report the 2011 electronic prescribing measure for at least 75 denominator eligible patie nt encounters during 2011, 225 instances for groups of 11-25 NPIs, 475 instances for groups of 26-50 NPIs, 925 instances for groups of 51-100, and 1,875 instances for groups of 101-199. Section 1848(m)(2)(B) of the Act specif ies that the limitation on the applicability of the electronic prescribing incentive applie s to group practices as well as individual EPs. Therefore, in determining whethe r a group practice will receive an electronic prescribing incentive payment for 2011 by meeting the proposed reporting criteria described above, we would de termine whether the 10 percen t threshold is met based on the claims submitted by the group practice.

### CMS-1503-P 588

This calculation is expected to take plac e in the first quarter of 2012 and will be determined by dividing the group practic e's total 2011 Medicare Part B PFS allowed charges for all covered professional services submitted for the measure's denominator codes by the group practice's total Medicare Part B PFS allowed ch arges for all covered professional services. If the result is 10 percent or more, then the statutory limitation would not apply and a group practice that is determined to be a successful electronic prescriber would qualify to earn the electronic prescribing incentive payment. If the result is less than 10 percent, then the statutory limitation would apply and the group practice would not qualify to earn the electronic prescribing incentive payment. c. The 2012 eRx Penalty As stated previously, section 1848(a)(5) of the Act requires that beginning with respect to covered professional services furn ished by an EP in 2012, if the EP is not a successful electronic prescriber for the reporting period for the year, the fee schedule amount for such services furnishd by such professional during 2012 sh all be equal to 99 percent of the fee schedule amount that would otherwise apply to such PFS services. As noted previously, we do not believe that the criteria that will be used to determine the applicability of the payment adjustment, or penalty, for 2012 need to be identical to the criteria for determination of successful electronic prescriber. We note also that although earning an incentive payment under the EHR incentive payment program precludes an EP from earning an eRx incentive payment, it does not preclude the EP from being subject to the eRx penalty. In order to avoid the eRx penalty, an EP participating in the Medicare EHR in centive program still must meet the relevant eRx penalty criteria for being a successful electronic prescriber. (1) The eRx Penalty Reporting Period

### CMS-1503-P 589

For purposes of the 2012 eRx penalty, we propose to make a determination of whether an EP or a group practice is a su ccessful electronic prescriber based on the reporting period that begins January 1, 2011 through June 30, 2011. We are proposing a 6-month reporting period for the 2012 penalty ra ther than a 12-month reporting period so that we may be able to complete the analysis of 2011 data to deter mine whether an EP or group practice is a successful electronic prescriber prior to January 1, 2012. In order to apply the penalty in 2012 concurrently with claims submission, we will need to make a determination of whether the pe nalty applies sufficiently in advance of 2012. We believe that establishing a 6-month reporting period fo r the first year of the penalty will provide

administrative efficiencies and avoid the need to apply a retroactive penalty or to make retroactive payments based on a pplication of a penalty. For EPs and group practices using the claims-based reporting mechanism, we propose that all claims for services furn ished between January 1, 2011 and June 30, 2011 must be processed by no later than July 31, 2011 for the claim to be included in our data analysis. This is in contrast to the incentive, where we allow 2 months for claims to be processed. In order to be able to make a determination of whethe r the penalty applies sufficiently in advance of 2012, we will need to begin our analysis of the claims shortly after June 30, 2011. We invite comments on the proposed reporting period for the 2012 penalty and our proposal to requi re claims to be submitted by no later than 1 month after the reporting period. (2) Criteria for Determining Applicability of the 2012 eRx Penalty to Individual EPs Based on the authority under section 1848( m)(3)(D) of the Act, we propose that the 2012 eRx penalty would apply to an i ndividual EP unless one of the following

conditions is met:

### CMS-1503-P 590

• The EP is not a physician (incl udes MDs, DOs, and podiatrists), nurse practitioner, or physician assist ant as of June 30, 2011. We be lieve that it is appropriate to limit the application of the penalty to those professionals who generally have prescribing privileges nationwide. Other EPs not listed above ma y have prescribing privileges in some states but not others. Therefore, we propose to exempt EPs who do not generally have prescribing privileges from being subject to the penalty.

• The EP does not have at least 100 cases (that is, claims for patient services) containing an encounter code that falls w ithin the denominator of the eRx measure for

dates of service between Ja nuary 1, 2011 through June 30, 2011. We seek to apply the penalty only to EPs who have a sufficient number of cases between January 1, 2011 and June 30, 2011 to meet the criteria for successful electronic prescribing for purposes of the penalty. We believe that, on average, for every 10 eligible cases, there will be at least one electronic prescribing opportunity, which provides a sufficient number of cases to allow EPs to meet the criteria for being a suc cessful electronic prescriber. In addition, we seek to prevent EPs who are new to Medica re from being subject to the eRx penalty.

• The EP is a successful electronic pr escriber for the January 1, 2011 through June 30, 2011 reporting period. Specifically, we propose that the EP must report that at least 1 prescription for Medicare Part B FFS pa tients created during an encounter that is represented by 1 of the codes in the de nominator of the 2011 electronic prescribing measure was generated and transmitted electronically using a qualified eRx system at least 10 times during the 2012 eRx penalty re porting period (that is, January 1, 2011 through June 30, 2011). We propose reporting criteria that are lower for the 2012 eRx penalty than for the 2011 eRx incentive because EPs will only have 6 months to satisfy

### CMS-1503-P 591

the criteria for the 2012 penalty but have a full year to satisfy the criteria for the 2011

incentive. The limitation with respect to the electr onic prescribing measures required under section 1848(m)(2)(B)(i) of the Act also applie s to the penalty. Therefore, we propose that if less than 10 percent of the EP's estimated total allowed charges for the January 1, 2011 through June 30,2011 reporting pe riod are comprised of services which appear in the denominator of the 2011 electroni c prescribing measure, then the EP would not be subject to the eRx penalty. We invite comments on the proposed conditions under which we would prospectively apply the 1.0 percent reducti on in PFS charges for services furnished January 1, 2012 through December 31, 2012. We specifically invite comments on our proposals to exempt certain types of EPs a nd EPs who do not have a certain number of cases from the penalty as well as the proposed criteria for successful reporting of the electronic prescribing measure for individua l EPs with respect to the penalty. As with the 2011 incentive payment, we propose that the determination of whether an EP is subject to the penalty will be made at the individual professional level, based on the NPI and for each unique TIN/NPI combination. (3) Criteria for Determining Applicability of the 2012 eRx Penalty to Group Practices As required by section 1848(m)(3)(C) of th e Act, we are also required to establish and have in place a process under which EPs in a group practice shall be treated as a successful electronic prescriber for purposes of the eRx penalty. Thus, we propose that for purposes of the 2012 eRx penalty, a paymen t adjustment would not be applied to a a group practice participating in the 2011 eRx GP RO if the group practi ce is participating in either the 2011 PQRI GPRO I or the 2011 PQRI GPRO II and meets the proposed

### CMS-1503-P 592

2011 criteria for successful electronic prescrib ing described in sec tions VI.F.2.b.(4).(ii). (with respect to the eRx requirements for GPRO I participants who wish to participate in the 2011 eRx GPRO) and VI.F.1.g.(3).(ii). of the preamble to this proposed rule (with respect to the eRx requirements for GPRO II participants who wish to participate in the 2011 eRx GPRO) for the 2011 eRx incentive. For purposes of the 2012 eRx penalty, we propose that the proposed 2011 criteria for successful electronic prescribing woul d need to be satisfied during the 2012 eRx penalty reporting period of Ja nuary 1, 2011 through June 30, 2011 for the same operational reasons that we are proposing a 6-month reporting period for the penalty for individual EPs. Furthermore, we do not believe that group practices would be disadvantaged by having to satisfy the propos ed criteria for being a successful electronic prescriber for the 2011 incentive in 6 months rath er than 12 months to avoid the penalty. When compared to the criteria for indivi dual EPs, the proposed criteria for being a successful electronic prescriber for the 2011 eRx incentive payment for group practices enable group practices, on average, to earn the incentive by electronically prescribing a fewer number of prescriptions per EP than what individual EPs are required to do. For purposes of determining whether the eRx penalty applies to a group practice, we propose to conduct our anlaysis for each unique TIN/NPI combination so as not to disadvantage EPs who may have joined the group practice after January 1, 2011. In addition, in accordance with secti on 1848(m)(2)(B)(i) of the Act, we also propose that the 2012 eRx penalty would not appl y to an eRx GPRO in which less than 10 percent of the group practic e's estimated total allowed ch arges for the January 1, 2011 through June 30, 2011 reporting period are compri sed of services which appear in the denominator of the 2011 electronic prescribing me asure. To be consistent with how this

### CMS-1503-P 593

limitation is applied to group practices for pur poses of the incentive, we propose to determine whether this limitation applies to a group practice for the penalty at the TIN

level. For the same reasons that we are proposing a 6-month reporting period for the 2012 eRx penalty for group practices, we also propose that we will use only claims processed by July 31, 2011 in our analysis. This is consistent with our proposed approach for analyzing individual EP claims. Similarly, we propose that registries would

need to submit eRx data for services fu rnished January 1, 2011 through June 30, 2011 to CMS between July 1, 2011 and August 19, 2011 so that we may include registry data in our analysis. We propose also that group practices participating in the eRx group practice reporting option via EHR-based reporting would be required to submit eRx data for services furnished January 1, 2011 through June 30, 2011 to CMS between July 1, 2011 and August 19, 2011. We invite comments on the proposed crite ria for determining applicability of the 2012 eRx penalty to group practices, includi ng the proposed criteria for successful reporting of the electronic prescribing me asure for group practices, and our proposed analytical approach. (4) Significant Hardship Exemption Section 1848(a)(5)(B) of the Act pr ovides that the Secretary may, on a case-by-case basis, exempt an EP from the application of the payment adjustment, or penalty, if the Secretary determines, subject to annual renewal, that compliance with the requirement for being a successful electronic prescriber would result in a significant hardship, such in the case of an EP who practices in a rural area without sufficient Internet access. Therefore, we propose th at in addition to meeting the criteria for

### CMS-1503-P 594

successful electronic prescriber described in sections VI.F.2.(c).(2) and VI.F.2.(c).(3) of the preamble to this proposed rule, an EP or group practice may also be exempt from application of the 2012 eRx pena lty, if during the 2012 eRx pe nalty reporting period (that is, January 1, 2011 through June 30, 2011), one of the following circumstances applies to the EP or group practice:

• The EP or group practice practices in a rural area with limited high speed

internet access.

• The EP or group practice practices in an area with limited available pharmacies for electronic prescribing. We propose to add two additional "G" codes to the 2011 electronic prescribing measure's specifications describing these 2 circumstances. EPs or group practices to

whom one or more of these circumstance s apply would be required to report the appropriate G-code at leas t once between January 1, 2011 and June 30, 2011 using their selected 2011 eRx reporting mechanism. Repor ting of one of these two G-codes prior to June 30, 2011 will indicate to us that the EP or group practice would like to be considered for an exemption from the 2012 penalty under th e significant hardship exception. We invite comments on the proposed process for th e significant hardship exception as well as comments regarding other circumstances that shou ld be considered a significant hardship. d. The 2013 eRx Penalty Section 1848(a)(5) of the Act also re quires that with respect to covered professional services furnished by an EP in 2013, if the EP is not a successful electronic prescriber for the reporting period for the ye ar, the fee schedule amount for such services furnishd by such professional during 2013 sh all be equal to 98.5 percent of the fee schedule amount that would otherwise apply to such PFS services. Under section

### CMS-1503-P 595

1848(m)(3)(C) of the Act, we are also required to establish and have in place a process under which EPs in a group practi ce shall be treated as a succe ssful electronic prescriber for purposes of the eRx penalty. For purposes of the 2013 eRx penalty, we propose to use the proposed 2011 criteria for successful electronic prescriber to determine whether an EP or a group practice is a successful electr onic prescriber for purposes of the 2013 eRx penalty. In addition, we propose that the reporting peri od for the 2013 eRx penalty would be the 2011 eRx incentive reporting period of January 1, 2011 through December 31, 2011. We believe that matching the cr iteria that will be applied for the 2013 penalty with the criteria that will be applied for the incentive in an earlier year would be the most effective means of encouraging EPs and group practices to adopt and use electronic prescribing systems since anyone who does not qualify for an incentive in 2011 would be subject to a payment adjustment in 2013. We invite comments on this proposal. e. Public Reporting of Names of Successful Electronic Prescribers Section 1848(m)(5)(G) of the Act require s the Secretary to post on the CMS Web site, in an easily understandable format, a lis t of the names of EPs (or group practices) who satisfactorily submit data on quality measures for the PQRI and the names of the EPs (or group practices) who are successful el ectronic prescribers. As required by section 1848(m)(5)(G) of the Act, we are pr oposing to make public the names of EPs and group practices who are successful electr onic prescribers for the 2011 eRx Incentive Program on the Physician Compare Web site that we are required to establish by January 1, 2011 under section 10331 of the ACA. As stated under section VI.F.1.k. of this proposed rule, we plan to use the existing Ph ysician and Other Health Care Professionals directory as the foundation for the Physician Compare Web site.

### CMS-1503-P 596

We anticipate that the names of indi vidual EPs and group practices who are successful electronic prescribers for the 2011 eRx Incentive Program will be available in 2012 after the 2011 incentive payments are paid. To comply with section 1848(m)(5)(G) of the Act, we specifically propose to post

the names of individual EPs who report the electronic prescribing measure at least 25 times during the 2011 reporting period for patient encounters included in the measure's denominator, without regard to whether the limitation under section 1848(m)(2)(B) of the Act applies to the EP and without regard to whether the EP actually qualifies to earn an incentive payment. In addition, since the PQRI and the eRx Incentive Program are two separate incentive programs and individual EP s are not required to participate in both programs to earn an incentive under either progra m, we point out that it is possible for an EP who participates in both incentive programs to be listed both as an individual EP who satisfactorily submits data on quality measures for the PQRI and is a successful electronic prescriber under the eRx Incentive Program. Li kewise, an individual EP may be listed as an individual EP who satisfactorily submits data on quality measures for the PQRI but not as a successful electronic prescriber under the eRx Incentive Program (or vice versa) even if he or she participated in both incentive programs. Similarly, for purposes of publicly repor ting the names of group practices, on the Physician Compare Web site, we intend to post the names of group practices that report the electronic prescribing measure the required number of times during the 2011 reporting period for patient encounters include d in the measure's denominator without regard to whether the limitation under section 1848(m)(2)(B) of the Act applies to the group practice or whether the group practice actually qualifies to earn an incentive payment. Although any group practice partic ipating in the eRx Incentive Program under

### CMS-1503-P 597

the group practice reporting option would al so have to participate in a PQRI group practice reporting option, the criteria for sa tisfactory reporting of PQRI measures for group practices are different from the criteri a for successful reporting of the electronic prescribing measure by group practices. Theref ore, it is possible for a group practice to be listed as a group practice that satisfactor ily submits data on quality measures for the PQRI but not as a successful electronic prescriber under th e eRx Incentive Program, or

vice versa.

G. DMEPOS Provisions

1. Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) a. Legislative and Regulatory History of DMEPOS CBP Medicare pays for most DMEPOS furnis hed after January 1, 1989 pursuant to fee schedule methodologies set forth in section 1834 of the Act, as added by section 4062 of the Omnibus Budget Reconciliation Act of 1987 (OBRA ’87) (Pub. L. 100-203). Specifically, sections 1834(a)(1)(A) and (B), and 1834 (h)(1)(A) of the Act provide that Medicare payment for these items is equal to 80 percent of the lesser of the actual charge for the item or the fee schedule amount for the item. We implemented this payment methodology at 42 CFR Part 414, Subpart D of our regulations. Sections 1834(a)(2) through (a)(5) and 1834(a)(7) of the Act, and implementing regulations at §414.200 through §414.232 (with the exception of §414.228), se t forth separate payment categories of durable medical equipment (DME) and describe how the fee schedule for each of the following categories is established:

● Inexpensive or other routinely purch ased items (section 1834(a)(2) of the Act and §414.220 of the regulations);

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● Items requiring frequent and substan tial servicing (sections 1834(a)(3) of the Act and §414.222 of the regulations);

● Customized items (section 1834(a)(4) of the Act and §414.224 of the regulations);

● Oxygen and oxygen equipment (sec tion 1834(a)(5) of the Act and §414.226 of the regulations);

● Other items of DME (section 1834( a)(7) of the Act and §414.229 of the regulations). For a detailed discussion of payment fo r DMEPOS under fee schedules, see the final rule published in the April 10, 2007 Federal Register (72 FR 17992). Blood glucose testing strips or diabetic testing strips are covered under the

Medicare DME benefit in accordance with s ection 1861(n) of the Act. Other supplies that are necessary for the effective use of DME are also covered under the Medicare DME benefit in accordance with longstanding program instructions at section 110.3 of chapter 15 of the Medicar e Benefit Policy Manual. Section 1847 of the Act, as amended by section 302(b)(1) of the MMA, requires the Secretary to establish and implement a DMEPOS CBP. Under the DMEPOS CBP, Medicare sets payment amounts for selected DMEPOS items and services furnished to beneficiaries in competitive bidding areas (CBAs) based on bids submitted by qualified suppliers and accepted by Medicare. For competitively bid items, these new payment amounts, referred to as "single payment amounts (SPA)," replace the fee schedule payment methodology. Section 1847(b)(5) of the Act provides that Medicare payment for these competitively bid items and services is made on an assignment-related basis equal to 80 percent of the a pplicable SPA, unless any unmet Part B deductib le described

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in section 1833(b) of the Act. Section 1847(b)(2)(A)(iii) of the Act prohibits the awarding of contracts to any entity unless the total amounts to be paid to contractors in a CBA are expected to be less than the tota l amounts that would otherwise be paid under the fee schedule methodologies set forth in s ection 1834(a) of the Act. This requirement guarantees savings to both the Medicare prog ram and beneficiaries under the program. The fee schedule methodologies will c ontinue to set payment amounts for noncompetitively bid DMEPOS items and se rvices. The program also includes provisions to ensure beneficiary access to quality DMEPOS items and services. Section 1847 of the Act limits par ticipation in the program to supp liers who have met applicable quality and financial standards and requires the Secretary to maintain beneficiary access to multiple suppliers. When first enacted by the Congress, s ection 1847(a)(1)(B) of the Act required the Secretary to phase in the DMEPOS CBP in a manner so that the competition under the program occurred in 10 of the largest metr opolitan statistical areas (MSAs) in 2007. The program was to be expanded into 70 additi onal MSAs in 2009, and then into additional

areas after 2009. In the May 1, 2006 Federal Register (72 FR 25654), we issued a proposed rule that would implement the DMEPOS CBP for certain DMEPOS items and services and solicited public comment on our pr oposals. In the April 10, 2007 Federal Register (72 FR 17992), we issued a final rule addre ssing the comments on the proposed rule and establishing the regulatory framework for the DMEPOS CBP in accordance with section

1847 of the Act. Consistent with the requirements of section 1847 of the Act and the competitive bidding regulations, we began implementati on of the program by conducting the first

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round of competition in 10 of the largest MSAs in 2007. We limited competition during this first round of the program to DMEPOS items and services included in 10 selected product categories, including mail order diab etic supplies. The bidding window opened on May 15, 2007 and was extended to allow bidde rs adequate time to prepare and submit

their bids. We then evaluated each submissi on and awarded contracts consistent with the requirements of section 1847(b)(2) of the Act and §414.414. Following the bid evaluation process, we awarded over 329 contracts to qualified suppliers. The DMEPOS CBP was effective on July 1, 2008. Beginning on that date, Medicare coverage for competitively bid DMEP OS items and services furnished in the first 10 CBAs was limited to items and services furnished by contract and grandfathered suppliers of oxygen and oxygen equipment and rented DME, and payment to these suppliers was based on the SPA, as determined under the competitive bidding regulations. For further discussion of the DMEPOS CBP and the bid evaluation process, see the final rule published in the April 10, 2007 Federal Register (72 FR 17992). On July 15, 2008, the MIPPA was enacte d. Section 154 of the MIPPA amended

section 1847 of the Act to make certain limite d changes to the DMEPOS CBP. Section 154(a) of the MIPPA delayed competition under the program and amended section 1847(a)(1)(D)(i) of the Act to terminate th e competitive bidding contracts effective June 30, 2008 and prohibit payment based on the contracts. Section 154(a) of the MIPPA required the Secretary to conduct a second competition to select suppliers for Round 1 in 2009 ("Round 1 Rebid"). The Round 1

Rebid includes the "same items and services" and is to be conducted in the “same areas” as the 2007 Round 1 competition, with certain limited exceptions. Specifically, we were required to exclude the product category of negative pressure wound therapy (NPWT)

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items and services and the San Juan, Puer to Rico CBA from the Round 1 Rebid. In addition, section 154(a) of the MIPPA permanently excluded group 3 complex rehabilitative wheelchairs from the DMEPOS CBP by amending the definition of "items and services" in section 1847(a)(2) of the Ac t. Section 154(a) of the MIPPA delayed competition for Round 2 of the DMEPOS CBP from 2009 to 2011, and subsequent competitions under the program to after 2011. Finally, section 154(a) of the MIPPA specifically addresses the phase in of a competition for national mail order items and services by specifying that such co mpetitions may be pha sed in after 2010. b. Implementation of a National Mail Orde r DMEPOS Competitive Bidding Program (CBP) for Diabetic Testing Supplies We conducted competitions for mail order diabetic te sting supplies in the 10

CBAs selected for Round 1. In the Round 1 rebid we conducted competition for mail order diabetic testing supp lies in 9 of the 10 CBAs selected in Round 1. These competitions were limited to diabetic testing supplies furnished by mail order contract suppliers, as defined in the April 10, 2007 DMEPOS Competitive Bidding final rule (72 FR 17992) to individuals located in those CBAs. As defined in the final rule, a mail order contract supplier is “a contract supplier that furnishes items through the mail to beneficiaries who maintain a permanent reside nce in a CBA”. We clarified in program

instructions that “mail order” means items ordered remotely (that is, by phone, email, Internet, or mail) and delive red to a beneficiary’s residence by common carriers (for example, U.S. Postal Service, Federal Expre ss, United Parcel Service, or other shipping or courier service companies) but not items obtained by be neficiaries from local retail

storefronts.

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Due to the inclusion of mail order di abetic supplies as a product category in Round 1 of the program, Medicare beneficiar ies in a CBA who obtain diabetic testing supplies through mail order must purchase these supplies from a mail order contract supplier in order for Medicare to pay for these items. Payment for these items will be at the SPA determined consistent with the prog ram’s regulations. Beneficiaries who do not obtain their testing supplies through mail order may purchase these products from any enrolled Medicare supplier and Medicare paym ent for these items will be at the fee schedule amount. The home blood glucose monito r (diabetic testing equipment) itself is

not included in the Round 1 DMEPOS CBP for ma il order diabetic supp lies. This allows the beneficiary to go to any enrolled supplier to obtain the glucose monitor that the beneficiary and their clinician believes best meets their medi cal needs. The supplier of the glucose monitor is responsible for traini ng the beneficiary on how to use the monitor and for answering all follow up questions a nd providing all services required by the DMEPOS quality standards and supplier st andards , found in §424.57, related to the glucose monitoring system selected by the beneficiary and their clinician. The beneficiary then has the choice of obtaining the replacement diabetic testing supplies that work with their purchased monitoring system from any local, non-mail order supplier (typically a pharmacy) or from a mail order s upplier whose contract requires them to ship the replacement diabetic supplies directly to the beneficiary’s home. If the beneficiary wants to continue receiving their repla cement supplies from a local pharmacy because that is their preference or because they want to have face-to-face access to a local pharmacist who, in addition to the supplier of the glucose monitoring system, can answer questions about the use of their system in te sting their blood glucose levels, this choice is preserved. However, if they choose the conve nience and savings associated with having

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their replacement supplies shipped directly to their home, the beneficiary can decide to obtain their supplies from a mail order contract supplier. The SPA was on average 43 percent lower than the fee schedule amount for diabetic testing supplies during the Round 1 of DMEPOS CBP. This reduction in payment would have resulted in a reduction of the beneficiary’s co-insurance payment.

The contracts and SPAs for the Round 1 Rebid fo r mail order diabetic testing supplies are

scheduled to be effective for diabetic supplies furnished on a mail order basis to beneficiaries in the 9 CBAs from January 1, 2011, through December 31, 2012. (1) National Mail Order DMEPOS CBP As part of our rulemaki ng implementing the DMEPOS CBP, we established regulations to implement competitions on a regional or national level for certain items such as diabetic testing supplies that are fu rnished on a mail order basis. We explained our rationale for establishing a national DMEPOS CBP for items furnished on a mail order basis in the Federal Register in th e May 1, 2006 proposed rule (71 FR 25669) and April 10, 2007 final rule (72 FR 18018). A na tional mail order prog ram would generate immediate national savings at a magnitude that may not be possible with local competitions among suppliers that are not able to obtain the type of volume purchasing

discounts from manufacturers that are available to large, national mail order suppliers. In a September 2004 report (GAO-04-765), the Government Accountability Office (GAO) recommended that we consider using mail deliver y for items that can be provided directly to beneficiaries in the home as a way to implement a DMEPOS competitive bidding strategy. In the case of diabetic supplie s and other items furnished by local neighborhood pharmacies, establishing a competition for items furnished on a mail order basis would exempt local pharmacies from competing with national mail order suppliers while

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preserving the choice of the beneficiary to go to any local pharmacy to pick up their diabetic supplies. Manufacturer s and suppliers have stated to CMS at different meetings

on numerous occasions that the choice for be neficiaries to obtain diabetic supplies from local pharmacies with licensed pharmacists in house who can provide instructions and guidance to beneficiaries related to their testing needs is important and needs to be preserved. (2) DMEPOS CBP for National Mail Order Diabetic Supplies

In the January 16, 2009 Federal Register, we published an interim final rule (IFC) (74 FR 2873) implementing certain changes to the DMEPOS CBP. Specifically, the rule implemented certain MIPPA provisions that delayed implementati on of Round 1 of the program; required CMS to conduct a second Round 1 comp etition in 2009, and mandated certain changes for both the Round 1 Rebid and subsequent rounds of the program. In the January 16, 2009 IFC preamble, we indi cated that we would be considering alternatives for competition of diabetic testing supplies in future notice and comment rulemaking. We explained that we believe d it was consistent with section 1847(a) to employ competitive bidding for diabetic supp liers in both the mail order and traditional retail markets, in part due to concerns raised about the bifurcation of the method of delivery of diabetic supplies and the difficulty in defining what constitutes “mail order” for purposes of competition. (3) Overview of Proposed Rule As part of the phase in of the DMEPOS CBP, we are proposing to implement a

national mail order DMEPOS CBP for diabetic testing supplie s. Under the proposed mail order DMEPOS CBP, we would award contracts to suppliers to furnish these items across

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the nation to beneficiaries who elect to ha ve replacement diabetic testing supplies delivered to their residence. Suppliers wishing to furnish these items through mail order to Medicare beneficiaries would be required to submit bids to participate in any DMEPOS CBP implemented for the furnishing of mail order items. In accordance with the DMEPOS CBP final rule, payment for mail order diabetic supplie s would be based on the SPA determined from the bids submitted and accepted for the furnishing of diabetic testing supplies by mail order th roughout the national CBA. As part of our proposal to implement the national mail or der DMEPOS CBP, we are also proposing a revised definition in regu lation of “mail order” so that there would

be a clear distinction between mail order ite ms and non-mail order ite ms. This revised definition would apply to all future competitions for mail order items and services. We are also proposing to implement the special rule mandated by section 1847(b)(10)(A) of the Act for competitions for diabetic testing strips following the Round 1 Rebid. Section 1847(b)(10)(A) requires suppliers bidding in competitions to furnish diabetic testing strips after the Round 1 Rebid to demonstrate th at their bid covers at least 50 percent of all types of diabetic te sting strips furnished by suppliers. If the supplier is not able to satisfy this requirement, the Secretary must re ject that bid. Finally, we are proposing to

include an additional term in contracts of mail order suppliers of diabetic testing supplies following the Round 1 Rebid. The proposed term would prohibit suppliers from influencing or incentivizing beneficiaries to change their brand of glucose monitor and test strips. (4) Future Competitions for Diabetic Testing Supplies Section 1847(a)(1)(A) of the Act mandate s the establishment of DMEPOS CBP

for items described in secti on 1847(a)(2)(A) of the Act, including diabetic testing

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supplies. Section 1847(a)(1)(B)(ii) of the Act authorizes the phase in of items and services under these programs beginning with the highest cost and highest volume items

and services or those items and services that are determined to have the largest savings potential. Current Medicare claims data from fiscal year 2009 shows that over 62 percent of beneficiaries currently receive their re placement diabetic testing supplies from mail order suppliers. Mail order diabetic testing supplies acc ount for approximately one billion dollars in allowed charges per year and are therefore high volume items. We

believe that a national mail or der CBP for diabetic testing supplies would result in large savings as a result of competition between entities that would factor into their bids savings from volume discount purchasing of quantities of supplies needed on a national rather than local basis. Therefore, we believe that implementing a national mail order DMEPOS CBP for diabetic testing supplies is the best option for meeting the requirements of the statute re ferenced above as long as certain refinements discussed below are made to the program to address concerns about the ma il order/non-mail order

bifurcation. We have heard from industry groups and s uppliers that furnish diabetic testing supplies on a national mail order basis of their concerns th at national chain pharmacies that furnish diabetic testing supplies throug h both a national mail or der business and local retail pharmacies will encourage beneficiaries to obtain these items from local retail locations by inappropriately offering certain incentives to Medicare beneficiaries such as coupons for other store items. Based on our experience from Round 1, we believe DMEPOS CBP for mail order diabetic testing supplies would be subject to manipulation

without a clearer definition of what we mean by mail order. We agree with the industry groups and suppliers that have indicated that this practice will harm businesses that only

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furnish diabetic testing supplies on a mail order basis. In order to address these concerns, we are proposing to add to §414.402 a definition of “ National mail order DMEPOS

CBP. ” We propose to define that term as a pr ogram whereby contracts are awarded to suppliers for the furnishing of mail order items across the nation. We believe that implementing a national competitive bidding program for diabetic supplies would preserve beneficiary choice to purchase testing supplies in person from any local pharmacy that is an enrolled Medicare supplie r that furnishes diabetic supplies, while clarifying the definition of mail order w ill provide significant savings potential for beneficiaries and the program. Savings w ould be generated in the near future from national SPAs for supplies furnished on a mail order or home delivery basis and on a long

term basis for all diabetic s upplies as a result of the require ment of section 1834(a)(1)(F) of the Act to either competitively bid in all areas or adjust prices in all areas by January 1,

2016. We believe that more beneficiaries will elect to choose the mail order/home delivery option, thereby further increasing short term savings under the program. Even if this is not the case, and the percentage of beneficiaries choosing the mail order/home delivery option remains at the current rate of 62 percent, savings for the remaining 38 percent must be achieved by no later than January 1, 2016, as a result of the requirements of section 1834(a)(1)(F) of the Act.

We considered other alternatives for establishing DMEPOS CBP for diabetic testing supplies that would eliminate the mail order/non-mail orde r bifurcation and

associated concerns. These alternatives include:

● A national competition among all ty pes of suppliers for all replacement diabetic supplies. Under this alternative, all beneficiaries would receive their replacement diabetic supplies from contract s uppliers responsible for furnishing diabetic

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supplies throughout the nation using any method of delivery as long as the supplies are delivered on a timely basis.

● Competitions in regional CBAs among all types of suppliers for all replacement diabetic supplies. Under this alternative, all beneficiaries would receive their replacement diabetic supplies from cont ract suppliers responsible for furnishing diabetic supplies throughout a designated region of the country using any method of delivery to a beneficiary home as long as th e supplies are delivered on a timely basis.

● Competitions in local CBAs among a ll types of suppliers for all replacement diabetic supplies. Under this alternative, all beneficiaries would receive their replacement diabetic supplies from contract s uppliers responsible for furnishing diabetic supplies throughout the local area using any method of delivery to a beneficiary as long as the supplies are delivered on a timely basis. We believe that the first option to bid on a national basis for all diabetic supplies, would result in most beneficiaries using mail order and might generate more savings than a national competition for diabetic supplie s furnished on a mail order basis only. However, this first option would likely eliminate the beneficiary choice to obtain replacement diabetic supplies on a non-mail order basis from an y enrolled supplier that is a pharmacy or other local supplier storefront where a licensed pharmacist is on hand to offer guidance and consultation to the benefi ciary. We believe the other two options

would also diminish this choice. In add ition, the alternatives of regional or local competitions are not likely to result in savings at or above the level that can be generated from a national competition for ma il order supplies. Suppliers participating in a national program may be able to obtain volume purchas ing discounts for the quantities of supplies needed nationwide. Therefore, we are not proposing any of these alternatives at this

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time. However, we are specifically requesting public comments on these and other alternatives for establishing DMEPOS CBP for diabetic supplies. In §414.411, we are proposing to establis h a national mail order DMEPOS CBP with competitions taking place after 2010 for the purpose of awarding contracts to suppliers to furnish replacement diabetic testing supplies across the nation, with additional program refine ments described below. We note that the decision to proceed

with a national mail order co mpetition after 2010 does not prev ent us from phasing in competitions for non-mail orde r diabetic supplies or from conducting competitions for diabetic supplies in general in the future consistent with section 1847(a)(1) of the Act. (5) Definition of Mail Order Item We are proposing to define “mail or der item” in 42 CFR §414.402 to mean any item (for example, diabetic testing supplies) shipped or delivered to the beneficiary’s home, regardless of the method of deliver y. We are also proposing to define “ non-mail

order item ” as any item (for example, diabetic testing supplies) that a beneficiary or caregiver picks up in person at a local pharmac y or supplier storefront. Therefore, the only items excluded from the mail order definition and mail order competition would be those that a beneficiary or caregiver picks up in person at a local pharmacy or other local supplier storefront. These revised definiti ons of mail order item and non-mail order item are intended to clearly identify which items ar e truly mail order. In addition, we believe this definition will preserve the choice of the beneficiary to obtain replacement diabetic supplies in person from a local pharmacy and eliminate the circumvention of the mail order program. As discussed above, for Round 1 and th e Round 1 Rebid of the DMEPOS CBP, we defined mail order contract supplier in our regulations at §414.402 to mean a contract

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supplier that furnishes items through the mail. We further defined mail order in program

instructions to mean “items ordered remotely (that is, by telephone, e-mail, internet or mail) and delivered to beneficiary’s residence by common carriers (for example, U.S. Postal Service, Federal Express, United Pa rcel Service) and does not include items obtained by beneficiaries from local storefr onts.” The intent of the Round 1 definition was to distinguish between mail order supplies (supplies fu rnished directly to the beneficiary’s home) and non- mail order supplies (supplies picked up at a local pharmacy). Manufacturers and suppliers of bl ood glucose monitors and test strips have expressed on numerous occasions the importance of maintaining the patient option of obtaining diabetic testing supplies from a local pharmacy that provides full time access to a licensed pharmacist who can provide instructions and guidance to the beneficiary or caregiver related to the use of the diabetic supplies (the pharmacy pickup option). This is the “non-mail order” option we attempted to separate from th e mail order option with the

Round 1 definition of mail order. During implementation of Round 1 of the program, we discovered that suppliers that did not successfully compete and win a contract under the program tried to adopt certain approaches to circumvent the mail order definition. In the first round of competitive bidding, suppliers that lost their bid to be a contract supplier for mail order diabetic testing supplies consid ered ways to change their delivery methods to circumvent the mail order DMEPOS CBP. For example, some mail order suppliers considered purchasing a fleet of cars to deliver these items to the beneficiary’s home so as not to be considered a mail order supplier. Other suppliers attempted to enter into special “private” arrangements with well known delivery serv ices and claimed that because of such arrangements they should not be considered mail order suppliers. These alternative home

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delivery methods do not provide any benefits to the patient beyond what the traditional mail order home delivery method offers. They are simply ways to continue furnishing diabetic supplies on a home delivery basis after submitting a bid for mail order that does

not result in the award of a contract under the DMEPOS CBP. Without a clear

distinction between mail or der (home delivery option) and non-mail order (pharmacy pickup option), suppliers could c ontinue to attempt to make ar rangements as they did in the initial Round 1 competition to circumvent the DMEPOS CBP. We consider these practices to be inconsistent with the DMEP OS CBP statute and regulations currently in effect, and our proposal is intended to further clarify the existing definition of mail order. Such arrangements prevent beneficiaries and the Medicare program from realizing savings afforded by the mail order DMEPOS CBP and is unfair to winning suppliers who bid in good faith for a contract for furnishi ng supplies to the home delivery market. This proposed definition of mail orde r item would not apply to the Round 1 competition because of the specific requireme nt of MIPPA to rebid Round 1 in 2009 for

the same items and services included in the initial Round 1 competition.However, for a national competition, it is imperative that th e new definition of ma il order item be in place because of the implications such a program would have on the entire mail order delivery market in the United States. In these future competitions, we would continue to emphasize in our educational efforts the basic distinction between mail order (home delivery) and non-mail order (pharmacy pickup) . In addition, we w ill continue to take appropriate and necessa ry action against suppliers that do not comply with the revised

definition. As mentioned above, an a lternative DMEPOS CBP fo r replacement diabetic supplies would be to hold a national compe tition among all types of suppliers for all

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replacement diabetic supplies. One benefit to this approach is that it would eliminate the

need to differentiate between mail order a nd non-mail order supplie s; however, it would likely eliminate the pharmacy pickup choice si nce most local pharmacies would not be able to service the entire CBA if they did not also operate a nationa l mail order service. We invite comments on our proposed defin ition of “mail order” and its impact on future rounds of bidding. (6) Special Rule in Case of Competition for Diabetic Testing Strips Following Round 1 of the program, any co mpetition for diabetic testing strips, such as the national mail order program for diab etic testing supplies proposed in this rule, must include the special rule set forth in s ection 1847(b)(10)(A) of the Act. Under that section, a supplier must demonstrat e that their bid to furnish di abetic testing strips covers the furnishing of a sufficient number of diff erent types of diabetic testing strip products that, in the aggregate and taking into ac count volume for the different products, to account for at least 50 percent of all such types of products on the market. Section 1847(a)(10)(A) also specifies that the vol ume for the different products may be determined in accordance with data (which may include market based data) recognized by the Secretary. When a beneficiary needs to obtain replacement test strips, they must obtain the specific brand of test strips products that work with their brand and model of blood glucose monitor. The test strips are not manufactured in a way that allows use of different brands of test strips in differe nt brands of monitors. Therefore, when replacement test strips are fu rnished, the supplier must ensure that the specific brand and model of test strips that th e patient requires for use with their purchased monitor is

furnished.

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Section 1847(b)(10)(B) of the Act manda tes the Office of Inspector General (OIG) of the Department to conduct a study before 2011 to generate volume data for the various products that could be used for this purpose. Under the DMEPOS CBP, bidding suppliers are required to provide information on the products they plan to furnish if awarded a contract. We propose to use this

information and information on the market shar e (volume) of the various diabetic testing strip products to educate suppliers on meeting the requirements of this special rule. In addition, it may be necessary to obtain add itional information from suppliers such as invoices or purchase orders to ve rify that the requirements in the statute have been met. We are proposing that suppliers be require d to demonstrate that its bid covers the minimum 50 percent threshold provided in th e statute, but we invite comments on whether a higher threshold should be used. We have proposed the 50 percent threshold in part because we believe that all suppliers have an inherent incentive to furnish a wide variety of types of diabetic te sting products to generate a wi der customer referral base. The 50 percent threshold would ensure that beneficiaries have access to mail order delivery of the top-selling diabetic test strip products. In addition, as explained below, we are proposing an “anti-switching provision” that we believe should obviate the need to establish a threshold of greater than 50 percent for the purpose of implementing this special rule because the contr act suppliers would not be able to carry a limited variety of products and switch benefici aries to those products. For purposes of implementing the special rule in section 1847(b)(10)(A), we are proposing to define “diabetic testing strip pr oduct” as a specific brand and model of test strip, as that is the best way to distinguish among different products. Therefore, we plan to use market based data for specific brands and models of diabe tic test strips to

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determine the relative market share or volume of the various products on the market that

are available to Medicare beneficiaries. We plan to review a variety of data, including but not limited to data furnished in the OIG report, to determine the market share of the various products. The special rule mandat ed by section 1847(b)(10)(A) of the Act applies to all competitions for diabetic testing strips after the first round of the DMEPOS CBP. Therefore, we would apply this rule to non-mail order comp etitions and/or local competitions conducted for diabe tic testing strips after Round 1 of the DMEPOS CBP. (7) Anti-switching Rule in Case of Competition for Diabetic Test Strips We do not believe that we can effectively apply the 50 percent rule, as required by section 1847(b)(10)(A) of the Act, if we do not establish an anti-switching rule to prevent suppliers from influencing beneficiaries to switch monitors. We have heard concerns from beneficiary advocacy groups, as well as industry representatives ,that contract suppliers furnishing diabetic testing supplies in the first round encouraged beneficiaries to switch to a different brand of blood gluc ose monitor and testing supplies than they and/or their physician or clin ician previously selected. Suppliers attempted to switch beneficiaries to the less expensive monitor or the monitor that provided them with the most profit rather than the monitor that wa s most suitable for them. Without the antiswitching rule, suppliers may offer 50 percent of the brands on the market but continue to

switch beneficiaries to the least expensive brands so that the requirement to offer at least 50 percent of the brands on the market rather than a few specific brands becomes meaningless. We are proposing to prohibit suppliers aw arded contracts for diabetic testing supplies from influencing or incentivizing the beneficiary in any way to switch the brand of glucose monitor and testing supplies they are currently using. We would propose that

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contract suppliers continue to furnish the br and of testing supplies that work with the monitor currently in use by the beneficiary. In the case where the beneficiary is receiving

a monitor for the first time or a replacement monitor, the contract supplier would be subject to the requirements of §414.420 in orde r to protect beneficiaries from feeling forced or incentivized to use a particular type or brand of monitor We continue to believe the proper role of the contract supplier is to furnish diabetic testing strips and other supplies to beneficiaries, not to interfere with the beneficiar y’s selection of the type of monitor and supplies. This requires the supp lier to furnish the brand of testing supplies that work with the blood glucose monitor produ ct that the beneficiary and/or clinician, and not the supplier of the testing supplies, selects. If the beneficiary needs a blood glucose monitor for the first time, or need s to replace their existing blood glucose monitor, and neither the beneficiary nor thei r physician has deter mined which brand or type of monitor to obtain, the beneficiary may continue to ask for assistance from the supplier to select a monitor and the supplier should show them the full range of products. However, if the beneficiary has already selected a monitor and simply needs replacement diabetic testing supplies, the supplier must furnish the brands of testing supplies that

work with the brand monitor that the benefici ary has selected. We believe this proposal would preserve the integrity of the clinic al decision regarding choice of glucose monitoring system and would result in contr act suppliers offering a wide variety of diabetic testing supply products. We are proposing to amend §414.422 t o o add the anti-switching requirement to the terms of the contract for a supplier of diabe tic testing supplies. A supplier would be in breach of their contract and subject to the sanctions set forth under §414.423(g), including termination, if they violate this term. We welcome comments on this proposal.

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c. Off-the-Shelf (OTS) Orthotics Exemption In the April 10, 2007 final rule (72 FR 17992), we established §414.404(b)(1), which sets forth several exemptions to the DMEPOS CBP. These exceptions are applicable to providers, physicians, and treating practitioners that furnish certain

DMEPOS items under Medicare Part B. Th e exempted items are limited to crutches, canes, walkers, folding manual wheelchairs, blood glucose monitors, and infusion pumps that are DME. For an explanation as to why these items were exempt see the DMEPOS Competitive Bidding final rule (CMS-1270- F) published April 10, 2007, (72 FR 17992). For the exemptions to apply, the items must be furnished by a physician or treating practitioner to his or her own patients as part of his or her professional service. The items are to be billed under a billing number assigned to the physician, th e treating practitioner (if possible), or a group practice to which the physician or tr eating practitioner has reassigned the right to receive Medicare payment. The April 10, 2007 final rule also estab lished an exemption for a physical therapist in private practice (as defined in §410.60(c)) or an occupational therapist in private practice (as defined in §410.59(c)) to furnish competitively bid OTS orthotics without submitting a bid and being awar ded a contract under the DMEPOS CBP, provided that the items are furnished only to the therapist’s own patients as part of a physical or occupational therapy service. Section 154(d) of MIPPA amended sec tion 1847(a) of the Act by adding paragraph (7), which expands the exempti ons from the DMEPOS CBP for certain OTS orthotics to physicians or other practitioners (a s defined by the Secretary) if furnished to their own patients as part of their professiona l service. Section 1847(a)(7) of the Act, as added by MIPPA, also expanded the exemption from the program to hospitals for certain

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OTS orthotics, crutches, canes, walkers, folding manual wheelchairs, blood glucose monitors, and infusion pumps if these items are furnished to the hospital’s own patients during an admission or on the date of discharge.

The DMEPOS CBP Round 1 Rebid interim fi nal rule with comment period (IFC) included the expanded exemption for certain DMEPOS items as provided by MIPPA for hospitals. We noted in the IFC that we would address the expanded exemption of OTS orthotics for hospitals, physicians and othe r practitioners in future rulemaking. In this proposed rule, we are proposin g to revise current provisions at §414.404(b)(1)(i) to incorporate the provision of section 1847(a)(7)(A)(i) and (ii) of the Act that exempts from the program OTS ort hotics furnished by physicians and other practitioners to their own patients as part of their professional service or by hospitals to the hospital’s own patients during an admi ssion or on the date of discharge. d. Grandfathering Rules Resu lting in Additional Payments to Contract Suppliers under the DMEPOS Competitive Bidding Program (CBP) Section 1847(a)(4) of the Act requires that in the case of rented DME and oxygen and oxygen equipment, the Secretary shall es tablish a “grandfathering” process. This requirement was implemented through regula tions at §414.408(j) that were published in the April 10, 2007 Federal Register (72 FR 17992). The grandfathering process allows beneficiaries who were renting DME items or receiving oxygen and oxygen equipment prior to the start of a DMEPOS CBP from a supplier who did not win a contract to continue to rent the equipment from that nonc ontract supplier if that supplier chooses to become a grandfathered supplier. Under §414.40 8(i)(2), when the beneficiary decides to use a contract supplier instead of a grandfathered supplier to receive their oxygen equipment and supplies, the contract supplier receives a minimum of 10 monthly

### CMS-1503-P 618

payments for taking over the furnishing of oxygen and oxygen equipment. When a beneficiary decides to use a contract supp lier to furnish capped rental DME, section §414.408(h)(2) restarts the 13-month capped rental period. These rules were established, in part, based on advice from the Program Advisory and Oversight Committee (PAOC) and are intended to give bidding suppliers an assurance that they would be compensated

in these situations and would not have to factor into their bids the cost of receiving as few as one monthly payment for beneficiaries ne ar the end of the 13-month cap for capped rental items and 36-month cap for oxygen equipment. At the time these rules were developed, th e supplier was mandated by the statute to transfer title to the equipment to the beneficiary after the both the 13-month cap for capped rental items and the 36-month cap for oxygen equipment. Section 144(b) of the MIPPA repealed the transfer of title requirement for oxygen equipment, as established by

Deficit Reduction Act of 2005, replacing that requirement with the 36-month rental cap. Under the revised oxygen payment provisions , suppliers now get the equipment back when the beneficiary no longer needs it. Also, at the time these rules were developed, the beneficiary had the option to acquire st andard power wheelchairs on a lump sum purchase basis, an option which greater than 95% of the beneficiaries selected, based upon historic claims data. Therefore, those ite ms generally would not be affected by the grandfathering rules. However, as disc ussed in section 3136 of this proposed rule, section 3136 of the ACA eliminates the lump sum purchase option for standard power wheelchairs. This new policy applies to items furnished under the DMEPOS CBP beginning with Round 2 of the program. Over 200,000 beneficiaries received standard power wheelchairs nationwide in 2009, and the Medicare allowed charges for these wheelchairs was over $650 million, including both rental and purchase options.

### CMS-1503-P 619

Therefore, this large volume of capped rental items will be subject to the grandfathering

rules effective with Round 2 of the DMEPOS CBP, thus increasing the overall magnitude

of the effect these rules have on the program and beneficiaries. In some cases, the grandfathering rules described above place a financial burden

on beneficiaries who are near the end of th e 13 or 36-month rental cap periods. If a beneficiary’s existing supplier chooses not to be a grandfathered supplier, the beneficiary will be required to switch to a contract supplier in order for Medicare to continue to pay for the furnishing of the rental equipment. In such cases, the beneficiary will be responsible for additional co-insurance am ounts. Based on experience from the initial Round 1 competition in 2008, we believe that most suppliers will choose to grandfather and therefore these rules will have no impact on these situations. However, in those limited situations in which the beneficiary does not use a grandfathered supplier and the beneficiary is near the end of the 13 or 36-month rental cap period, the impact on the beneficiary could be significant. As men tioned above, our current grandfathering rules will result in a limited number of beneficiaries facing additional co-insurance payments. To illustrate the impact some beneficiaries may face as a result of these rules, a beneficiary who has already made 12 coinsu rance payments for a capped rental item could make as many as 12 additional copayments as a result of restarting the capped rental period when they transition from a noncont ract supplier to a contract supplier at the beginning of a DMEPOS CBP. In another ex ample, a beneficiary who has already made 35 coinsurance payments for oxygen and oxygen equipment could make as many as 9 additional copayments as a result of the rule that provides a minimum of 10 monthly payments when they transition from a noncontr act supplier to a contract supplier at the beginning of a DMEPOS CBP. As stated above, we expect that most noncontract

### CMS-1503-P 620

suppliers will choose to become grandfathe red suppliers, therefore limiting the number of instances where these rules would apply. Howe ver, in light of the beneficiary impact in the those extreme cases illustrated above, and in light of the recent legislative changes by the MIPPA and the ACA as explained above, we are reevaluating whether or not changes to these grandfathering rules are necessary . As discussed above, as a result of the MIPPA, suppliers of oxygen equipment no l onger lose title to the equipment after receiving the 36 th 

### payment and this may warrant r econsideration of the minimum number of payments they should receive as contract suppliers when a beneficiary transitions to them from a noncontract supplier at the beginning of a DMEP OS CBP. In addition, we believe it is important to reevaluate the po licy that restarts the 13-month capped rental period in situations where a beneficiary transitions from a noncontract supplier to a contract supplier at the beginning of a DM EPOS CBP. Therefore, we are soliciting public comments on whether or not the current rules should be changed to reduce the number of payments the contract supplier woul d receive in these situations above the 13

and 36-month limits set forth under the standard payment rules in section 1834(a) of the Act. We also plan to solicit advice from the PAOC on this subject at a future committee meeting. e. Appeals Process The DMEPOS CBP final rule issued on April 10, 2007 includes §414.422(g)(1), which states that “any deviation from contract requirements, including a failure to comply with governmental agency or licensing organization requirements, constitutes a

breach of contract.” In the event we de termine that a contract supplier’s actions constitute a breach of contract, §414.422(g)(2) aut horizes us to take one or more of the following actions:

### CMS-1503-P 621

● Require the contract supplier to submit a corrective action plan;

● Suspend the contract supplier’s contract;

● Terminate the contract;

● Preclude the contract supplier from participating in the DMEPOS CBP;

● Revoke the supplier number of the contract supplier; or

● Avail itself of other remedies allowed by the statute. Proposed Appeals Process We are proposing to add a new §414.423 to establish an appeals process for contracts terminated under section 1847(a) and (b) of the Act. Section §414.423, as proposed in this rule, would set forth policies and procedures relating to our

determinations of a breach of contract and the appeals proce ss for contract suppliers that

are considered to be in breach of contract . In addition, we are proposing to add new definitions to §414.402 that are used in the proposed §414.423. Given the impact that termination has on a contract supplier, we believe it is appropriate for contract supplie rs whose contract(s) may be terminated due to a breach of

contract to have access to an appeal process that will rec onsider that termination. In establishing this process we reviewed othe r appeals processes, such as the appeals process under Part D located at 42 CFR §423.641 through §423.668, Subpart N –

Medicare Contract Determinati ons and Appeals, to consider essential steps to ensure suppliers have access to an a ppropriate review of certain CMS decisions. We chose to propose a simplified process that would not result in disruption to the program by having suppliers going in and out of the program. For this reason, we propose a process for

review and reconsideration before the contra ct is actually terminated. This proposal would avoid the necessity to reinstate retroactively suppliers because the contracts would

### CMS-1503-P 622

generally not be terminated before the full review process has occurred. This would protect the supplier because we generally would not terminate a supplier until a final

decision is made. Another feature of this process that may be beneficial to some suppliers is allowing them to submit a co rrective action plan (CAP) depending upon the

nature of the breach. We be lieve our proposal would allow most suppliers to correct

identified deficiencies. (1) Purpose and Definitions: (§414.402) We are proposing to amend §414.402 to define the following terms:

● Affected party means a contract supplier that has been notified that their

DMEPOS CBP contract woul d be terminated for a breach of contract.

● Breach of contract means any deviation from contract requirements, including a failure to comply with a governmental agen cy or licensing organization requirements.

● Corrective Action Plan (CAP) means a contract supplier’s written document with supporting information that describes th e actions the contract supplier would take within a specified timeframe to remedy the breach of contract.

● Competitive Bidding Implementation C ontractor (CBIC) Hearing Officer (HO) means an individual, who was not involved with the CBIC recommendation to terminate a DMEPOS CBP contract, who is designated by CMS to review and make an unbiased and independent determin ation from the CBIC’s recommendation to terminate a

DMEPOS CBP contract.

● Parties to the Hearing means the DMEPOS contract supplier and CMS. (2) Applicability The appeals process proposed in this re gulation would allow contract suppliers the opportunity for a review of the following:

### CMS-1503-P 623

● A CMS determination under §414.422(g)(1) th at the contract supplier breached its contract entered into as pa rt of the DMEPOS CBP; and

● Certain agency actions taken under §414.422(g)(2). The proposed appeals process would not apply to any other actions made by CMS, nor would the existence of other appeal s processes preclude us from terminating a DMEPOS CBP contract. In other words, th e proposed appeals process would be in addition to – and would not replace – existing CMS regulations regarding other appeals mechanisms. For example, a contract may be terminated because a supplier’s National Supplier Clearinghouse (NSC) number has been re voked or inactivated. In this case, the supplier would not appeal the decision to inactive or revoke its number through this appeals process. Instead, the supplier woul d continue to appeal the inactivation or revocation of its supplier number through th e NSC’s appeals process, and we would postpone the termination decision until the supp lier completes the NSC appeals process. Under our proposal, when we issue a ter mination decision, it would be final and binding unless a postponement of the ter mination decision is allowed by proposed §414.423. We welcome comments on the scope of the proposed appeals process. (3) Contract Termination We are proposing that this appeals process applies in situations where the supplier has received a notice that we have determined that they are in breach of contract and that their contract is therefore subject to termin ation. A contract may be terminated for any

violation of the terms of the contract. Exam ples of violations include, but are not limited to, situations where the contract supplier --

### CMS-1503-P 624

● Has committed or participated in fa lse, fraudulent, or abusive activities affecting the Medicare program, including the submission of false or fraudulent data or claims;

● Experiences financial difficulties so that they are unable to effectively provide the necessary services to a Medicare beneficiary; or

● Fails to meet the non-discrimination policy and provides different items to beneficiaries located in a competitive bidding area (CBA) than it provides to its non-Medicare beneficiaries at §414.422(c). We welcome comments on our pr oposed termination process. (4) Notice of Termination Under the proposed rule, the CBIC would work with suppliers to informally resolve performance deficiencies under its DMEPOS CBP contract prior to sending a recommendation to CMS that the supplier’s cont ract be terminated. If the CBIC cannot informally resolve the supplier’s deficiencies and recommends that we terminate the contract, we would review the CBIC’s r ecommendation to terminate the supplier’s

contract. If we find that a breach occurr ed, we would begin the contract termination process by sending out a notice of termination to the supplier. We also propose requirements for the notice of termination so that suppliers are

informed of the basis for CMS’s action as well as their options to respond to this action. The notice would explain all actions we plan to take in response to the supplier's breach, such as the ability to submit a CAP or our determination to preclude a supplier from participating in future rounds of competitive bidding if found in breach of contract. If the supplier decides to appeal any of these decisions the supplier would submit an appeal in response to the notice to terminate. If we consider a supplier to be in breach of its

### CMS-1503-P 625

contract, either in part or in whole, we would notify the contract supplier of the termination by certified mail. The notice w ould indicate that the contract supplier has

been found to be in breach of contract and that the supplier’s contract would be terminated within 45 calendar days of the da te of the notification of termination. The notice would be sent by the CBIC using certif ied mail on the same date as the date on the

notification of termination. The date of the notifica tion of termination is the date that the notification is signed. The notification will be mailed on the date that it is signed. This

date will be indicated on the notification. The proposed rule requires the notice to include, at a minimum, the following

information:

● The reasons for the termination in sufficient detail to allow the contract supplier to understand the nature of its breach of contract;

● Depending on the nature of the breach, whether the supplier may be allowed to submit a CAP in lieu of requesting a hearing by the HO;

• The right to request a hearing by the HO;

● The address to which the written request for a hearing must be mailed;

● The address to which th e CAP must be mailed; and

● The effective date of the termination of the contract, if a CAP is not submitted or if a request for a hearing has not been filed timely.

We believe that this information would be sufficient to provide the supplier with the basis for CMS’s action, as well as their options in responding to our decision. We welcome comments on our proposal regard ing the contents of the notice. In addition, our proposed rule requires the notice to indicate any additional penalties that may result from the termination, such as, not being eligible to bid in future

### CMS-1503-P 626

rounds of competitive bidding. An appeal of the termination would include the appeal of any other results from the termination th at are permissible under § 414.423, such as preclusion from participation in future rounds of the DMEPOS CBP. We believe this information may help the supplier to decide wh ether to appeal the notice of termination. (5) Corrective Action Plan We are also proposing a process by whic h a contract supplier may be able to

submit a CAP to address the breach of contract . Depending on the nature of the breach of contract, we propose that the notice to the supplier would indicate whether a contract supplier would be allowed to provide the CBIC with a written CAP instead of submitting a request for a hearing by a HO. For exampl e, under this proposal we would not allow a CAP if the supplier has been excluded, debarred or convicted of a health care related crime. We may also not allow a CAP that w ould result in negative consequences to the beneficiaries or the program caused by delayi ng the termination of the contract. We are proposing timelines rela ted to the CAP. Under the proposed rule, if the supplier decides to submit a CAP, the CAP must be received by the CBIC within 30 calendar days from the date on the notice of termination. If the supplier decides not to submit a CAP, the supplier retains the right to request a review by a HO within 30 days

from the date of the notice for terminati on. While the CAP is being evaluated, the

termination determina tion would be postponed. We believe that 30 days is a sufficient amount of time for suppliers to prepare and s ubmit a CAP and this would also ensure that there are no unnecessary delays in the appeals process. Under the proposed rule, we would requi re the CAP to demonstrate that the contract supplier has a plan to remedy all of the deficiencies that were identified in its notice of termination and must specify the timeframes for correcting these deficiencies.

### CMS-1503-P 627

The CBIC would review the CAP to ensure that the contract supplier would be taking the appropriate measures in a timely manner to remedy the breach of contract. What constitutes a timely manner is dependent on the type of deficiency that is being corrected. Once the nature of the deficiency is iden tified the CBIC and CMS would make a case-bycase determination concerning what constitutes a timely manner for correcting the deficiency. However, we expect most deficienci es to be corrected within 90 days or less. Further guidance of what constitutes a timely manner would be communicated to the contract supplier by the CBIC as pa rt of the review process. As part of the review process, the CB IC would provide guidance, in accordance with CMS instructions, regarding the type of documentation that the CAP and the follow up report must provide to substan tiate that the deficiencies ha ve been corrected. To make

a determination if a CAP woul d be considered acceptable, we may discuss the CAP with the supplier, and as a result of these discussions, the CBIC will allow a supplier to make revisions to its CAP during the review proce ss. Suppliers may only revise their CAP one time during the review process. The timefram e for the review process would vary upon

the circumstances for each case. If the supplier does not submit an acceptable CAP during the review process, the supplier would receive a new notice that their CAP is not acceptable or has not been implemented c onsistent with the supplier’s original

submission and its contract w ould be terminated within 45 calendar days. Every supplier would have a one time opportunity to revise their CAP base d upon deficiencies identified by the CBIC. Failure to develop and imple ment an approved CAP would result in a new notice to the supplier of the termination of the DMEPOS CBP contract and provide notice that the supplier may request a hearing on th is termination. Under the proposed rule, once an acceptable CAP has been completed the contract supplier must provide a follow-

### CMS-1503-P 628

up report within 5 days of the agreed upon da te for the completion of the CAP to verify

that all of the deficiencies identified in the CAP have been corrected consistent with the timeframes specified in the CAP, as approved by the CMS. We believe that 5 days is a sufficient time for a supplier to submit a report to CBIC outlining all steps that have been completed to correct the identified deficiencies. We welcome comments on our proposals relating to the option for a CAP. (6) Right to Request a Hearing by the CBIC Hearing Officer (HO) We propose that a contract supplier that ha s received a notice that we consider the supplier in breach of contract has the right to request a hearing before a HO who was not involved with the original breach of contract determination. We cons ider this process to be a reconsideration of the original decisi on, and, consistent with other Medicare appeals provisions, we believe it is impor tant that an individual not involved in making the initial

recommendation conduct the r econsideration of the initia l decision. As mentioned previously, the HO would be an individual who is designated by CMS to review and to make an unbiased and independent reco mmendation of whether to terminate the supplier’s DMEPOS CBP contr act. The notice to the cont ract supplier would also identify the location to which a request for hearing must be sent. Under the proposed rule, a contract supplie r may appeal the notice of termination by submitting a written request to the CBIC for a hearing by a HO. The written request should include any evidence to support its a ppeal. The HO is not required to allow evidence submitted in addition to the evidence submitted along with the written request. The hearing request must be received by th e CBIC within 30 calendar days from the date of the termination letter. A request for a hearing must be sent to the address identified on the notice. Failure to request a hearing within the allotted 30 calendar days would result

### CMS-1503-P 629

in a termination of the supplier’s contract, as of the effective date of termination identified in the notice to the supplier. There would be no extensions to this 30-day

timeframe. We be lieve suppliers have suff icient time to decide wh ether or not to request a hearing and the deficiencies identified in the notice may pose a risk to the DMEPOS CBP. The date the request is received by the CBIC determines if the hearing request was timely filed. We would require that the request for hear ing be filed by a supplier’s authorized official, because an authorized official of the company signed the contract and this ensures the validity of the request. The author ized official must be an official of the company who is identified on the supplier’s CMS 855-S form as an authorized official of the supplier. A supplier may appoint someone ot her than the authorized official to be a representative for them at the hearing. However, the representative may not be an individual who has been disqua lified or suspended from acting as a representative by the Secretary or otherwise prohibited by law. Th e request for a hearing must be filed with

the CBIC at the address identified on the notice of termination. We welcome comments on our proposed pr ocess for requesting a hearing by a

HO. (7) Scheduling of the Hearing The proposed rule also addresses schedulin g the hearing. We propose that within 30 calendar days from the receipt of a supplier’s timely hearing request the HO would contact the parties to schedule a hearing. The request for a hearing would result in the postponement of the date of th e contract termination. The only exception to this rule is when a supplier has been excluded, debarred or convicted of a health care related crime; in that situation the supplier’s contract woul d be terminated immediately. In the hearing

### CMS-1503-P 630

request the contract supplier may ask for the hear ing to be held in person or by telephone. The HO would send a notice to the parties to the hearing indicating the time and place for the hearing at least 30 days before the date of the hearing. The HO may, on his or her own motion, or at the request of a party, change the time and place for the hearing, but must give the parties to the hearing a 30 day notice of the change. The proposed rule would require that th e HO’s notice scheduling the hearing must provide, at a minimum, the following information:

● Date, time, and location of the scheduled hearing;

● Description of the hearing procedure;

● Issues to be resolved;

● Requirement that the contract supplier bears the burden of proof to demonstrate that it is not in breach of contract; and

● Provide an opportunity for the supplier to submit evidence to support its appeal. We believe this information provi des the supplier with sufficient information regarding the hearing date, time, and matters that would be addressed at that time. We

welcome comments on the content of this no tice and the procedures for scheduling a hearing. (8) Burden of Proof We propose that the contract supplier w ould present to the HO the basis for its disagreement with the termination notice and would have the burden of proof to demonstrate to the HO with supporting evidence th at it is not in breach of its contract and

that the termination action is not appropriate. The supplie r’s supporting evidence must be submitted with its request for a hearing. The supporting evidence and the request for a hearing must be submitted together and received by the HO within 30 calendar days from

### CMS-1503-P 631

the date identified on the notice of termina tion. In the absence of good cause, the HO may not allow evidence to be submitted in addition to the evidence submitted along with the written request. We also have the oppor tunity to submit evidence to the HO within 30 days of receiving the notice announcing th e hearing. The HO will share all evidence submitted, both from the supplier and CMS, in preparation for the hearing with all affected parties within 15 days prior to the scheduled date of the hearing. We welcome comments on our proposal regarding the burden of proof. (9) Role of the Hearing Officer (HO) Our proposal requires that the HO conduct a thorough and independent review. Such a review requires the consideration of all information and docum entation relevant to the hearing and submitted consistent with this proposal. Consistent with this goal, we propose that the HO, is responsible for the all of following:

• Sharing all evidence submitted, both from supplier and CMS, in preparation for the hearing with all affected parties within 15 days prior to the scheduled date of the hearing.

● Conducting the hearing and deciding the order in which the evidence and the arguments of the parties would be presented.

● Determining the rules on admissibility of the evidence.

● Examining the witnesses, in additi on to the examinations conducted by CMS and the contract supplier.

● Determining the rules for requesting documents and other evidence from other parties.

● Ensuring a complete recording of the hearing is available and provided to all parties to the hearing and the CBIC.

### CMS-1503-P 632

● Preparing a file of the record of the hearing which includes all evidence submitted as well as any relevant documents identified by the HO and considered as part of the hearing.

● Complying with all applicable provisions of 42 USC Title 18 and related provisions of the Act, the applicable regula tions issued by the Secretary, and manual instructions issued by CMS.

The HO would make a recommendation base d on the information presented and submitted. The HO would issue a written recommendation to CMS within 30 days of the close of the hearing, unless the HO requests an extension from CMS and demonstrates to

CMS that he or she needs an extension due to complexity of the matter or heavy work

load. . The HO’s recommendation would include the rationale for his or her recommendation regarding the termination of the supplier’s contract and the HO would

submit this recommendation to CM S for its determination. We welcome comments on the role of the CBIC HO in our proposed rule. (10) CMS’s Final Determination Under the proposed rule, the HO’s recomme ndation is submitted to CMS, and the agency would make the final determination regarding whether the supplier’s contract

would be terminated. Our determination would be base d upon on the record of the hearing, evidence, and documents considered by the HO as part of the HO

recommendation. Information s ubmitted after the hearing woul d not be considered. Our decision would be made within 30 days of the receipt of the HO’s recommendation. If our decision is to terminate the contract, th e supplier would be notified of the effective date of termination by certified mail. Our decision regarding the termination of the contract is final and binding.

### CMS-1503-P 633

We welcome comments on our proposal rela ting to CMS’s final determination of a supplier’s contract termination. (11) Effective Date of the Contract Termination Under the proposed rule, suppliers who s ubmit a CAP or request a hearing would

have the termination date identified on the no tice delayed. The only exception to this rule is when a supplier has been excluded, debarred or convicted of a health care related crime; in that situation the contract would be terminated immediately. For terminations that do not meet these exceptions, the effec tive date of a final termination would be

determined as follows:

● The termination of a supplier’s DMEPOS CBP contract is effective on the date specified in the initial notice of termination, which will be 45 days from the date of the notice, unless the supplier request a hearing with the HO or the supplier submits an acceptable CAP.

● After reviewing the HO recommendation, if we terminate a supplier’s contract the effective date of the termination would be the date specified in the post-hearing notice sent to the supplier indicating CMS’s final determination to terminate the contract. We welcome comments on our proposals relate d to the effective date of contract

termination. (12) Effect of Contract Termination Under our proposal, once a supplier’s contract is terminated for breach of contract under the DMEPOS CBP, the contract supplie r is no longer a DMEPOS CBP contract supplier for any DMEPOS CBP product categor y for which it was awarded a contract. This termination applies to all areas and product categories because there is only one contract that encompasses all CBAs and pr oduct categories for which the supplier was

### CMS-1503-P 634

awarded a contract. We would not make pa yment and would reject claims for DMEPOS competitive bid items and services furnishe d by a supplier whose contract has been

terminated after the effective date of the te rmination for the remainder of the contract period. We recognize that a supplier’s termination would impact beneficiaries within the CBA. Therefore, we therefore propose th at terminated suppliers must notify all

beneficiaries within the CBA who are receivi ng rented competitively bid items of the

termination of their contract status so that the beneficiaries can make arrangements to receive equipment and suppliers through other contract suppliers. After we have made

our final determinati on and sent notification to the supplier, the supplier must notify beneficiaries within 5 days of receipt of the contract supplier’s final notice of termination.

This notice must inform beneficiaries that they would have to select a new contract supplier to furnish their DMEPOS items in order for Medicare to pay for these items. For beneficiary protection, we also propose that contract suppliers who fail to give proper notification to beneficiaries may be prevente d from participating in future rounds of DMEPOS CBP. We also propose that rent al items may not be picked up from the beneficiary’s home until after the last day of the rental month for which the supplier has already received payment. We are propos ing both of these policies to protect the beneficiary and to ensure that suppliers do not pick up equipment from a beneficiary for a time period for which they have already been paid to provide the service. 2. Changes to Payment Rules for Oxygen and Oxygen Equipment a. Background The general Medicare payment rules for DME are set forth in section 1834(a) of the Act and 42 CFR part 414, subpart D of our regulations. Section 1834(a)(1) of the Act

### CMS-1503-P 635

and §414.210(a) of our regulations establish the Medicare payment for a DME item as equal to 80 percent of either the lower of the actual charge or the fee schedule amount for the item. The beneficiary coinsurance is equal to 20 percent of either the lower of the actual charge or the fee schedule amount for the item once the deductible is met. The specific payment rules for oxygen and oxygen equipment under the existing

fee schedules are set forth in secti on 1834(a)(5) of the Act and §414.226 of our regulations. Suppliers are paid a monthl y payment amount for furnishing medically necessary oxygen contents (for both stationa ry and portable) and stationary oxygen equipment described under th e class described in §414.226(c)(1)(i). Equipment in the stationary class includes stationary oxygen concentrators, which concentrate oxygen from room air; stationary liquid oxygen systems, wh ich use oxygen stored as a very cold liquid in cylinders and tanks; and gaseous oxyg en systems, which administer compressed oxygen directly from cylinders. A monthly add-on payment is also made to suppliers furnishing medically necessary portable oxygen equipment falling under one of two classes described in §414.226(c)(1)(ii) and (iii). E quipment in these classes includes traditional portable equipment, that is, portable liquid oxygen systems and portable gaseous oxygen systems, and oxygen generating portable equipm ent (OGPE), that is, portable oxygen concentrators and oxygen transfilling equipment used to fill portable tanks or cylinders in the home. Both the liquid and gaseous oxyg en systems (for stationary and traditional portable systems) require on-goin g delivery of oxygen contents. Section 1834(a)(5)(F) of the Act, as am ended by section 144(b) of MIPPA, limits the monthly rental payments to suppliers for oxygen equipment to 36 months of continuous use, although monthly payments for furnishing gaseous or liquid oxygen

### CMS-1503-P 636

contents continue after the 36-month equipm ent rental cap is reached for gaseous or liquid systems. In the CY 2009 PFS fina l rule with comment period (73 FR 69875 through 69876), we discussed section 144(b) of MIPPA and included a detailed discussion of how section 5101(b) of the Deficit Reduction Act of 2005 (DRA) previously required suppliers to transfer title to oxygen equi pment to the beneficiary at the end of the 36-month rental period. Sec tion 144(b) of the MIPPA repealed this requirement to transfer title to the oxygen equipment to the beneficiary and allows suppliers to retain title to the oxygen equipment after 36 monthly rental payments are made for the equipment. Section 414.210 establishes the requireme nts for the replacement of DME, including oxygen equipment. Section 414.210(f)(1) states that if an item of DME, which includes oxygen equipment, has been in con tinuous use by the patient for the equipment’s reasonable useful lifetime or if the original equipment is lost, st olen, or irreparably damaged, the patient may elect to obtain a new piece of equipment. In such circumstances, §414.420(f)(2) authorizes paym ent for the new oxygen equipment in accordance with §414.226(a). Section 414.210(f)(1) states that the reasonable useful lifetime for DME, which includes oxygen equipment, is determined through program instructions. In the absence of CMS program instructions, the carrier may determine the reasonable useful lifetime for equipment, but in no case can it be less than 5 years. Computation is based on when the equipment is delivered to the beneficiary, not the age of the equipment. If the beneficiary elec ts to obtain new oxygen equipment after the reasonable useful lifetime, the payment is made for a new 36-month rental period in accordance with §414.226(a).

### CMS-1503-P 637

We are proposing to revise the payment rule for oxygen and oxygen equipment at §414.226(g)(1) to address situations where bene ficiaries relocate outside the service area of a supplier during the 36-month rental paym ent cap period for the oxygen equipment. Beneficiaries are experiencing great difficulties in finding suppliers willing to furnish oxygen equipment in situations where only a few months are left in the 36-month rental payment period at the time they relocate. For example, if a beneficiary is in the 30 th 

### rental month, the new supplier would be entitled to only 6 months of rental payments and

then would have to continue to furnish th e oxygen and oxygen equipment during any period of medical need for the remainder of the reasonable useful lifetime of the equipment. This creates a fi nancial disincentive for oxygen suppliers to furnish oxygen and oxygen equipment to benefi ciaries in these situations. The proposed changes to the payment rules for oxygen and oxygen equipment would apply to oxygen and oxygen equipm ent furnished under Part B and would also apply to oxygen and oxygen equipment fu rnished under programs implemented in accordance with section 1847(a) of the Act. b. Furnishing Oxygen Equipment af ter the 36-Month Rental Period (Cap)

In the CY 2010 PFS final rule with comment period (74 FR 61887 through 61890), we finalized §414.226(g)(1) which, in accordance with section 1834(a)(5)(F)(ii)(I) of the Act, requires the supplier that furnishes oxygen equipment during the 36-month rental period to continue furnishing the oxygen equipment after the 36-month rental period. The supplier is requi red to continue to furnish the equipment during any period of medical need for the remainder of the reasonable useful lifetime of the equipment. As we noted when finalizin g this rule, section 1834(a)(5)(F)(ii)(I) does not provide any exceptions to this requirement . If the beneficiary relocates outside the

### CMS-1503-P 638

supplier’s normal service area at some time af ter the 36-month rental period but before

the end of the reasonable usef ul lifetime of the equipmen t, the supplier must make arrangements for the beneficiary to continue receiving the equipment at his or her new place of residence. This responsibility for fu rnishing the equipment does not transfer to another supplier. We revised §414.226(f) to conform our regulations to this new MIPPA requirement. We deleted the transfer of ownership requirement and added the new requirement that the supplier must continue furnishing the oxygen equipment after the 36-month rental period during any period of medical need for the remainder of the reasonable useful lifetime of the equipm ent. It is important to note that §414.226(g)(1)(ii) does not apply this same requirement in situations where the beneficiary relocates outside of the supplie r’s normal service area during the 36-month rental period. c. Furnishing Oxygen Equipment dur ing the 36-Month Rental Period (Cap) Section §414.226(g)(1) contains the requireme nt that the supplier that furnishes oxygen and oxygen equipment for the first month of the 36 th 

### month of the rental cap period must continue to furnish the equi pment for the entire 36-month period of continuous use, with limited exceptions. One exception at §414.226(g)(1)(ii) applies when a beneficiary permanently relocates his or her residence during the 36-month rental period outside of the current supplier’s norma l service area. This exception was proposed in the “Home Health Prospective Payment System Rate Update for Calendar Year 2007

and Deficit Reducti on Act of 2005 Changes to Medicare Payment for Oxygen Equipment and Capped Rental Durable Me dical Equipment; Proposed Rule” published in the August 3, 2006 Federal Register (71 FR 44094) and was intended to reduce the burden on the

### CMS-1503-P 639

supplier in these situations. This approach is also consistent with the regulations addressing capped rental items described in §414.229. We a ddressed this issue in the capped rental context in the July 10, 1995 Federal Register (60 FR 35494) in response to

comments. The discussion states that sin ce the implementation of the capped rental payment methodology on January 1, 1989, we rece ived no reports of beneficiaries having difficulty obtaining access to capped rental DME after relocating outside the supplier’s service area. Since enactment of the capped rental DME payment category in section 4062 of the Omnibus Budget Reconcilia tion Act of 1987 (Pub. L. 100-203), representatives of the DME industry indicat ed that suppliers would be able to accommodate beneficiaries in these situations, and this has proven to be true for capped rental items. In fact, we have found this to be the case to this day. For this reason, we believed that bene ficiaries would not encounter problems obtaining access to oxygen and oxygen equipment in similar situations, that is, following the 36-month cap imposed by section 144(b) of MIPPA. However, since the changes to the payment rules for oxygen and oxygen equipment mandated by the DRA became effective in 2006 and the 36-month rental cap imposed by MIPPA was reached for the first time in January 2009, we have received many reports of beneficiaries relocating prior to the end of the 36-month rental paym ent cap period and having difficulty finding an oxygen supplier in the new location. We have learned that many suppliers are unwilling to provide services in situations wher e there are a few number of months left in the 36-month rental payment period.

We do not believe that bene ficiaries have encountered similar issues following the 36-month rental cap, which most likely is the result of different statutory requirements for these two periods (that is, during and afte r the 36-month rental period). Section

### CMS-1503-P 640

1834(a)(5)(F)(ii) of the Act requires the supp lier that furnishes the oxygen equipment during the 36-month rental payment period to c ontinue furnishing the equipment after the 36-month rental payment period. Consistent with this requireme nt, we established regulations at §414.226(f)(1) that require the s upplier to furnish the equipment or make arrangements for furnishing the equipment in situations where the beneficiary relocates outside the supplier’s normal service area. Sin ce no such requirement currently applies in situations where the beneficiary relocates prio r to the end of the 36-month rental payment period, and in fact current regulations at §414.226(g)(1)(ii) absolve the supplier of the obligation to continue furnishing oxygen equi pment in these situations, beneficiaries are experiencing difficulties finding suppliers of oxygen equipment in their new locations that are willing to accommodate them. As noted above, we have not seen this problem in the capped rental DME context. The requi rement at §414.226(g)(1) to furnish oxygen equipment for the entire 36 month rental cap period was established in the course of implementing section 5101(b) of the DRA in order to safeguard the beneficiary from situations where suppliers might discontinue service and pick up oxygen equipment prior to the end of the 36-month rental cap in order to avoid losing title to the equipment. As mentioned earlier, the transfer of title of oxygen and oxygen equipment after the 36 th 

### paid rental month was repealed. The excepti on to this rule at §414.226(g)(1)(ii) was established based on our experience that suppliers of capped rental DME have accommodated beneficiaries in these situations, which, unfortunately, has not been our experience in the context of oxygen equipment. In order to address this vulnerability facing beneficiaries as a result of regulations currently in effect, we are proposing to re vise the exception at §414.226(g)(1)(ii) to apply only to situations where the beneficiary relocates before the 18 th 

### paid rental month to an

### CMS-1503-P 641

area that is outside the normal service area of the supplier that initially furnished the equipment. We are proposing to revise the regulation to require the supplier that furnishes the oxygen equipment and receives payment for month 18 or later to either furnish the equipment for the remainder of th e 36-month rental payment period or, in the case where the beneficiary has relocated outside the service area of the supplier, make arrangements for furnishing the oxygen equipment with another supplier for the remainder of the 36-month rental payment period. The supplier that is required to furnish the equipment on the basis of this requirement must also furnish the equipment after the 36-month rental payment period in accordance with the requirements of section 1834(a)(5)(F)(ii) and §414.226(f). The proposed revision would mean that a supplier does not have to continue to furnish the oxygen equipment if the beneficiary relocates outside the normal service area

before the 18 th 

### paid rental month during a period of continuous use. Under the current rule, a supplier does not have to furnish the ox ygen equipment if the beneficiary relocated

before the 36 th 

### paid rental month during a period of continuous use. The current rule was established based on the long term, demonstrat ed ability of suppliers of capped rental DME to accommodate beneficiaries in situations where they relocate near the end of a capped rental payment period. With regard to oxygen equipment, suppliers in general have not demonstrated a willingness to accommodate beneficiaries in similar situations. Therefore, it is necessary to revisit this rule in order to protect beneficiaries in these situations. This proposal would allow eith er a new supplier in the beneficiary’s new service area or a supplier in the old service area to receive at least half of the 36 monthly payments allowed for under the current statut ory payment rule for oxygen equipment. We believe this approach woul d be fair to suppliers in either scenario since the same

### CMS-1503-P 642

minimum number of payments applies. Based on current 2010 Medicare allowed fee schedule amounts for stationary oxygen equi pment, total payments for 18 months is $3,117.06. We believe this new rule would provide greater financial incentive to suppliers in areas where beneficiaries relo cate to furnish oxygen equipment in these situations. We also believe that this pr oposal would not disadvantage suppliers required to continue furnishing oxygen equipment or make arrangements for furnishing oxygen equipment to beneficiaries that relocate outside their normal service area since these suppliers would receive 18 or more monthly paym ents. Most of the cases that have been reported regarding problems encountered by be neficiaries in obtaining access to oxygen equipment after relocating during the 36-month rental cap period have been situations where the beneficiary has relocated during the second half of the 36-month rental cap period. Therefore, we believe that this rule would largely address access problems associated with relocations during the 36-m onth rental cap period because the supplier that received payments during the first half of the 36-month rental cap period would be obligated to continuing furnishing the equi pment during the second half of the 36-month rental cap period. H. Provider and Supplier Enrollment Issue: Air Ambulance Provision The National Transportation Safety Boar d (NTSB) is an independent Federal agency charged by the Congress with investigating transportation accidents, determining their probable cause and making recommendations to prevent similar accidents from occurring. Based on information derived fr om testimony provided at the NSTB public hearing and investigations into recent Helicopter Emergency Medical Services (HEMS) accidents, the NTSB made several specific recommendations to the Secretary of Health and Human Services on September 24, 2009.

### CMS-1503-P 643

Specifically, the NTSB recommended that the Secretary develop minimum safety accreditation standards for HEMS operators that augment the operating standards of 14 CFR part 135 by including for all fights with medical personnel on board: (a) scenario-based pilot training; (b) implementation of preflight risk evaluation programs; and (c) the installation of F AA-approved terrain awareness warning systems, night vision imaging systems, flight data recording system s for monitoring and autopilots if a second pilot is not used. In response to the NTSB concerns, the S ecretary noted that the recommendations to CMS were similar to those being made to the Federal Aviation Administration (FAA). While we have expertise to re gulate health and safety re quirements that suppliers and providers of healthcare should meet, we do not have the expertise to determine aircraft safety requirements. The S ecretary stated that, "we belie ve the FAA should determine the minimum level of safety that HEMS ope rators should meet and CMS should adopt regulations that require any HEMS operator that enrolls in Medicare to meet those requirements." The Secretary also added that, "while we do not believe CMS should augment FAA regulations, we do believe that CMS’ regulations should ensure that only those HEMS operators that maintain the minimum level of requirements established by the FAA through its regulations are enrolled or maintain enrollment in the Medicare program." In the April 21, 2006 Federal Register , we published the "Requirements for Providers and Suppliers to Establish and Maintain Medicare Enrollment" final rule. This final rule implemented section 1866(j)(1)(A) of the Act. In this final rule, we required that all providers and suppliers (other than physicians or practitioners who have elected to "opt-out" of the Medicare program) must complete an enrollment form and submit

### CMS-1503-P 644

specific information to CMS in order to obtain Medicare billing privileges. Section 424.515 required that ambulance se rvice providers continue to resubmit enrollment information in accordance with §410.41(c)(2), which states, "Upon a carrier’s request, complete and return the ambulance supplie r form designated by CMS and provide Medicare carrier with documentation of comp liance with emergency vehicle and staff licensure and certification requirements in accordance with State and local laws." This final rule also established §424.510(d)(2)( iii) which states, "Submission of all documentation, including all applicable Fede ral and State licensure and regulatory requirements that apply to the specific provider or supplier type that related to providing health care services, required by CMS under this or other statutory or regulatory authority, or under the Pape rwork Reduction Act of 1995, to establish the provider or supplier’s eligibility to furnish Medicare covered items or services to beneficiaries in the Medicare program." While the Airline Deregulation Act (Pub. L. 95-504) preempts a State, political subdivision of a State, or political authority of at least 2 States from enacting or enforcing a law, regulation, or other provision having the force and effect of law related to a price, route, or service of an air carrier that may provide air trans portation, air ambulances remain subject to Federal laws and regu lations. In accordance with §424.516(a)(2), providers and suppliers must adhere to all Fede ral regulations and State laws and regulations, as required, based on the type of services or supplies the provider or supplier type will furnish and bill Medicare. In §424.510(d)(iii), we are proposing to clar ify that ambulance suppliers and other providers and suppliers include documentation regarding all a pplicable Federal and State certifications. Accordingly we are props ing to revise §424.510(d)(iii) from "Submission

### CMS-1503-P 645

of all documentation, including all applicable Federal and St ate licenses and regulatory requirements that apply to the specific provider or supplier type that relate to providing health care service, required by CMS under this or other statutory or regulatory authority, or under the Paperwork Reducti on Act of 1995, to establish the provider or supplier's eligibility to furnish Medicare covered items or services to beneficiaries in the Medicare program," to "Submission of all documentation, including a ll applicable Federal and State licenses,certifications (including, but not limited to Federal Aviation Administration and Clinical Laboratory Improve ment Act certifications),and regulatory requirements that apply to the specific provider or supplier type that relate to providing health care service, required by CMS under this or other statutor y or regulatory authority, or under the Paperwork Reduction Ac t of 1995, to establish the provide r or supplier's eligibility to

furnish Medicare covered items or services to beneficiaries in the Medicare program." We are also proposing to revise §424.516(e )(2) and add new paragraph (e)(3) to clarify that Medicare enrolled providers and suppliers must report a revocation or suspension of a Federal or State license or certification, including but not limited to FAA and Clinical Laboratory Improvement Act (CLIA) certifications. This revision will clarify that fixed-wing ambulance operators and HEMS operators are responsible for notifying the designated Medicare contractor for their State when FAA revokes or suspends any license or certification. Mo reover, fixed-wing ambulance operators and HEMS operators must mainta in all requirements as specified in 14 CFR part 135. We believe that requiring fixed-wing ambulance and HEMS operators to notify their Medicare contractor of a suspension or revocation of a license or certification will ensure that any action taken by the FAA or other regulating authority will have a direct linkage to the operator’s ability to maintain their Medicare enrollment. We believe that

### CMS-1503-P 646

such a policy will help improve aircraft safety for operators that are enrolled in Medicare and providing services to Medicare benefi ciaries. In addition, since the FAA is responsible for the issuance and enforcem ent of regulations and minimum standards covering manufacturing, operating, and maintaining aircraft, we will work with the FAA to confirm that fixed-wing ambulance op erators and HEMS operators remain in compliance with FAA safety regulations. (including, but not limited to Federal Aviati on Administration and certifications) to the Medicare contractor within 30 days of the revocation or suspension of the license or certification, the provider or s upplier is making the decision to voluntarily terminate its Medicare billing privileges because the provider or supplier is no longer in compliance with the applicable licensing or certifica tion requirements for their provider or supplier type. We believe that allowing providers and suppliers to self-report licensure or

certification revocations a nd suspensions within a 30 day period via the Medicare enrollment application (such as, the Internet-based Provider Enrollment Chain and Ownership System (PECOS) or the paper CMS-855) promotes compliance with the Medciare reporting requireme nts found in §424.516. In addition, by reporting a licensure

or certification revocation or suspension within 30 days, the provider or supplier avoids the Medicare contractor bringing an action to revoke its Medicare billing privileges and establishing and Medicare enrollment bar, s ee §424.535(c). Thus, by complying with the reporting responsibilities f ound in §424.516 and voluntarily terminating from the Medicare program, the air ambulance supplier can submit an initial application to enroll in the Medicare program as soon as the licensu re or certification revocation or suspension action is resolved with the applicable licensing or certification organization.

### CMS-1503-P 647

In §424.502, we are proposing to define the term, "voluntary termination" as it is currently used in the Medicare program and th roughout this regulation in the context of the provider enrollment requirements: We are proposing that the term, "voluntary termination" to mean an air ambulance supplier, that submits written confirmation to CMS of its decision to discontinue enrollment in the Medicare program. Futhermore, we belive that an air ambul ance supplier, can make the decision to voluntary terminate their business relationship with the Medicare program at any time, including when the provider or supplier makes the decision that they will no longer

furnish services to Medicare beneficiaries. In those situations, where an air ambulan ce supplier does not meet their reporting responsibilities and notify the Medicare progra m of a Federal or State licensure or certification revocation or susp ension within 30 days of the reportable event, we believe that it is appropriate to th at CMS or the Medicare cont ractor revoke the supplier’s Medicare billing privileges using §424.535(a)(1). We believe that this change will clarify that CMS or our Medicare contractor may revoke Medicare billing privileges when these types of suppliersdo not report a revocation or suspension of a Federal or State license or

certification.

I. Technical Corrections 1. Physical Therapy, Occupational Therapy and Speech-language Pathology We are proposing to revise §409.23(c) by ma king a minor technical correction to

remove an extraneous cross-reference wh ich was initially proposed in the CY 2008 PFS proposed rule (72 FR 38122, 72 FR 38193, and 72 FR 38221). This cross-reference refers the reader to "paragraph (c)(1)(ii) of this section," a paragraph also proposed in the CY 2008 PFS proposed rule, but never finalize d. In the CY 2008 PFS final rule with

### CMS-1503-P 648

comment period, we inadvertently neglected to remove the associated cross-reference from the regulations text. Accordingly, we now propose to rectify that oversight by making an appropriate correction in the regulations text, along with other minor formatting revisions. We are also proposing to make a minor clarification to the section heading and introductory text of §409.23 (al ong with a conforming revision to the corresponding regulations text at §409.20(a)(3)) by revising the existing phrase "speech therapy" to read "speech-language pathology services," so that it more accurately reflects the currently used terminology for this type of therapeutic treatment. In addition, we are also proposing to make a minor wording change in the provision at §409.17(d) (which is incorporated by reference in §409.23(c)(2)), in order to clarify that the former provision’s reference to "hospital" policie s and procedures can alternatively refer, depending on the particular context, to SNF policies and procedures. 2. Scope of Benefits In §410.3, we are proposing a technical correction to paragraph (b)(2). Currently, §410.3(b)(2) states that the specific rules on pa yment are set forth in subpart E of part 410. However, the specific payment rules are actually listed in subpart I of part 410. Therefore, we are proposing to correct §410.3(b)(2) in this proposed rule. VII. Collection of Information Requirements Under the Paperwork Reduc tion Act of 1995, we are required to provide 60-day

notice in the Federal Register and solicit public comment before a collection of information requirement is submitted to the Office of Management and Budget (OMB) for review and approval. In order to fairly evaluate whether an information collection should be approved by OMB, section 3506(c)(2 )(A) of the Paperwor k Reduction Act of 1995 requires that we solicit comment on the following issues:

### CMS-1503-P 649

● The need for the information collecti on and its usefulness in carrying out the proper functions of our agency.

● The accuracy of our estimate of the information collection burden.

● The quality, utility, and clarity of the information to be collected.

● Recommendations to minimize the information collection burden on the affected public, including auto mated collection techniques. We are soliciting public comment on each of these issues for the following

sections of this document that contain information collection requirements (ICRs): A. ICRs Regarding Diagnostic X-ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic Tests: Conditions (§410.32) Proposed §410.32(d)(2)(i) would require the physician or qualified nonphysician practitioner (as defined in §410.32(a)(2)) who orders the service must maintain documentation of medical necessity in the bene ficiary’s medical record. In addition, both the medical record and the laboratory requis ition (or order) would be required to be signed by the physician or qualified nonphysician practitione r (as defined in §410.32(a)(2) of this section) who orders the se rvice. The burden associated with these requirements would be the time and effort necessary for a physician or qualified nonphysician practitioner to sign the medical r ecord or laboratory requisition (or order). There would also be a recordkeeping requirement associated with maintaining the documentation of medical necessity in the beneficiary medical record. While these requirements are subject to the PRA, we believe the associated burden is exempt from the PRA in accordance with 5 CFR 1320.3(b)(2). We believe that th e time, effort, and financial resources necessary to comply w ith the aforementioned information collection

### CMS-1503-P 650

requirements would be incurred by persons in the normal course of their activities and

therefore considered to be usua l and customary business practices. B. ICRs Regarding General Exceptions to the Referral Prohibition Related to Both Ownership/Investment and Compensation (§411.355) Proposed §411.355(b)(7)(i) states that w ith respect to magnetic resonance imaging, computed tomography, and positron emission tomography, the referring physician shall provide written notice to the pa tient at the time of the referral that the patient may receive the same services fro m a person other than one described in §411.355(b)(1). The written notice shall include a list of other suppliers (as defined in §400.202 of this title) that provide the services fo r which the individual is being referred. The list shall include a minimum of 10 suppliers within a 25-mile radius of the referring physician’s office location at the time of the referral. The notice should be written in a manner sufficient to be reasonably understood by all patients and should include for each supplier on the list, at a minimum, the supp lier’s name, address, telephone number, and distance from the referring physician’s office. A record of the disclosure notification, signed by the patient, shall be maintained as a part of the patient’s medical record. Section 411.355(b)(7)(ii) proposes that if th e referring physician makes a referral within an area with fewer than 10 other suppliers within the 25-mile radius of the physician’s office location at the time of the referral, the physician shall list all of the other suppliers of the imaging service that are present within a 25-mile radius of the referring physician’s office location, includi ng up to 10 suppliers. Provision of the written list of alternate supplie rs will not be required if no other suppliers provide the services for which the individual is being referred within the 25-mile radius. These physicians must still disclose to the patient that the patient may receive these services

### CMS-1503-P 651

from a person other than one described in §411.355(b)(1) in a manner sufficient to reasonably be understood by all patients. A r ecord of the disclosure notification, signed by the patient and the referring physician, sha ll be maintained as a part of the patient’s

medical record. The burden associated with the requireme nts contained in this section would be the time and effort necessary for a physician to develop a standard disclosure. There would also be burden associated with the time and effort necessary for a physician to provide the disclosure to the patient, to obtai n the patient’s signature, and to record the paper as part of the patient’s medical record. We estimate that it would take 1 hour for a physician’s office to devel op a standard disclosure. We further estimate that 71,000 physicians will be required to comply with these requirements. The total burden associated with the development of the sta ndard disclosure is 71,000 hours at a cost of $1,042,280. Similarly, we estimate that it will take each physician 1 minute to provide the disclosure to the patient, to obt ain the patient’s signature, and to record the paper as part of the patient’s medical record. We believe that each provider will make approximately

106 disclosures. The total estimated annual for this requi rement is 125,433 hours at a cost of $10,536,400. C. ICRs Regarding Appeals Process for Termination of Competitive Bidding Contract (§414.423) Proposed §414.423(c)(1)(i) states that CM S has the option to allow a DMEPOS supplier to provide a written CAP to remedy the deficiencies identified in the notice, when CMS determines that the delay in the termination date caused by allowing a CAP

will not cause harm to beneficiaries. As stated in proposed §414.423(c)(2)(i) a CAP must be submitted within 30 calendar days from the date on the notification letter. If the

### CMS-1503-P 652

supplier decides not to submit a CAP the supp lier may within 30 days of the date on the termination letter request a hearing by a CBIC hearing officer. The burden associated with this requirement is the time and effort necessary for a supplier that has received a termination notice to develop and submit a CAP. We estimate that 10 suppliers will need to comply with this requirementannually. Similarly,

we estimate that it will take a supplier an average of 3 hour s to develop a CAP. The total

estimated annual burden associated with this requirement is 30 hours at a cost of $2,250. Proposed §414.423(e)(2) would require that if CMS accepts the CAP, including supplier’s designated timeframe for its comple tion, the supplier must provide a follow-up report within 5 days after the supplier has fully implemented the CAP that verifies that all

of the deficiencies identified in the CAP ha ve been corrected in accordance with the timeframes accepted by CMS. The burden associ ated with this requirement is the time and effort necessary for a supplier to develop and submit a follow-up report. While this requirement is subject to the PRA, we belie ve the associated burden is exempt under 5 CFR 1320.3(h)(6). In accordance with 5 CFR 1320.3(h)(6), a request for facts or opinions addressed to a single person is not defined as information collection requirements and is therefore exempt from the PRA. Proposed §414.423(f)(1) states that a supplie r who has received a notice that CMS considers them in breach of contract or that their CAP is not acceptable has the right to request a hearing before a CBIC HO who was not involved with the original determination. Section 414.423(f)(2) further pr oposes that a supplier who wishes to appeal the termination notice must s ubmit a written request to the CBIC. The request for a hearing must be received by the CBIC within 30 calendar days from the date of the

notice to terminate.

### CMS-1503-P 653

The burden associated with this section is the time and effort necessary for a supplier to develop and submit a written request for a hearing by a CBIC Hearing Officer.

We estimate that it will take a supplier 8 hours to develop and submit a request for a hearing. We believe 5 suppliers will be subject to this requirement on an annual basis. The total estimated annual burden associated with developing and submitting a written request for a hearing by a CBIC Hearing Officer is 40 hours at a cost of $3,000. Proposed §414.423 would require a contract suppliers whose contract has been terminated to notify all beneficiaries who ar e receiving rented competitive bid items or competitive bid items received on a recurring basi s, of the termination of their contract. The notice to the beneficiary from the supplier whose contract was terminated must be provided within 5 days of receipt of the no tice of termination. The notification to the beneficiaries must inform the beneficiaries that they are going to have to select a new contract supplier for these items. The burden associated with this section is the time and effort necessary for a supplier to develop and distri bute notification of its termination to all beneficiaries receiving rented competitive bid items or co mpetitive bid items received on a recurring

basis. We estimate that it w ill take a supplier 3 hours to de velop and distribute a notice announcing its termination to a ll of its beneficiaries receiving rented competitive bid items or competitive bid items received on a recu rring basis. We believe 2 suppliers will be subject to this requirement on an annua l basis. The total estimated annual burden associated with this requirement is 6 hours at a cost of $450. D. ICRs Regarding Additional Provider and Supplier Requirements for Enrolling and Maintaining Active Enrollment status in the Medicare Program (§424.516)

### CMS-1503-P 654

Proposed §424.516(e)(2) would require a provider or supplier to report a revocation or suspension to the applicable Medicare contractor within 30 days any revocation or suspension of a Federal or State license or certification. Similarly, proposed §424.516(e)(2) states that within 30 days of voluntary withdrawal or involuntary termination from the Medicare prog ram, the provider or supplier must report voluntary withdraw or involuntary termination to the applicable Medicare contractor. The burden associated with the requirement s in §424.516(e)(2) and (3) is the time and effort necessary for a provider or supplier to report the required information to the applicable Medicare contractor. While these requirements are subject to the PRA, each submission will be evaluated on a case by case basis. E. ICRs Regarding Additional Provider and Supplier Requirements for Enrolling and Maintaining Active Enrollment status in the Medicare Program (§424.516) Proposed §424.516(e)(2) would require a provider or supplier to report a revocation or suspension to the applicable Medicare contractor within 30 days any revocation or suspension of a Federal or State license or certification. Similarly, proposed §424.516(e)(2) states that within 30 days of voluntary withdrawal or involuntary termination from the Medicare prog ram, the provider or supplier must report voluntary withdraw or involuntary termination to the applicable Medicare contractor. The burden associated with the requirement s in §424.516(e)(2) and (3) is the time and effort necessary for a provider or supplier to report the required information to the applicable Medicare contractor. While these requirements are subject to the PRA, each submission will be evaluated on a case-by-case basis. Table 72: Estimated Annual Recordkeeping and Reporting Burden

Regulation Section(s) OMB Control

No. Respondents Responses Burden per Response Total Annual Burden Hourly Labor Cost of Total Labor Cost of Total Capital/Maintenance Costs (in $) Total Cost (in $)

### CMS-1503-P 655

(hours) (hours) Reporting (in $) Reporting (in $) §411.355 0938-New 71,000 71,000 1 71,000 14.68 1,042,280 0 1,042,280 71,000 7,454,760 0.0167 125,433 83.79 10,536,400 * 0 10,536,400 §414.423 0938-New 10 10 3 30 75.00 2,250 0 2,250 5 5 8 40 75.00 3000 3000 2 2 3 6 75.00 450 450 Total 71,017 7,525,777 196,509 11,584,380 * The annual cost burden for this provision was calculated by taking 106 disclosures per year per physician x $1.40 per disclosu re = $148.40 a year per physician x 71,000 physicians = $10,536,400.



### If you comment on these information coll ection and recordkeeping requirements, please do either of the following: 1. Submit your comments electronically as specified in the ADDRESSES section of this proposed rule; or 2. Submit your comments to the Office of Information and Regulatory Affairs, Office of Management and Budget, Attention: CMS Desk Officer, [CMS-1503-P] Fax: (202) 395-6974; or Email: OIRA_submission@omb.eop.gov

F. Additional Informatio n Collection Requirements This proposed rule imposes collection of information requirements as outlined in the regulation text and specified above. However, this proposed rule also makes

reference to several associated information collections that are not discussed in the regulation text contained in this document. The following is a discussion of these information collections, some of which have already received OMB approval. 1. Part B Drug Payment The discussion of average sales price (A SP) issues in section VI.A.1 of this proposed rule does not contain any new info rmation collection requirements with respect to payment for Medicare Part B drugs and biologicals under the ASP methodology. Drug

### CMS-1503-P 656

manufacturers are required to submit ASP data to us on a quarterly basis. The ASP reporting requirements are set forth in section 1927(b) of the Act. The burden associated with this requirement is the time and effort required by manufacturers of Medicare Part B drugs and biologicals to calculate, record, and submit the required data to CMS. While the burden associated with this requirement is subject to the PRA, it is currently approved

under OMB control number 0938–0921. 3. Physician Quality Reporting Initiative (PQRI) Section VI.F.1. of this proposed rule discusses the background of the PQRI, provides information about the proposed m easures and reporting mechanisms to be available to eligible professi onals (EPs) and group practices who choose to participate in the 2011 PQRI, and the proposed criteria for satisfactory reporting in 2011. With respect to satisfactory submission of data on quality measures by EPs, EPs include physicians, other practitioners as desc ribed in section 1842(b)(18)(c) of the Act, physical and occupational therapists, qua lified speech-language pathologists, and qualified audiologists. EPs may choose whethe r to participate and, to the extent they satisfactorily submit data on quality measures for covered professional services, they can qualify to receive an incentive payment. To qualify to receive an incentive payment for 2011, the EP (or group practice) must meet on e of the proposed criteria for satisfactory reporting described in sections VI.F.1.e. or VI.F.1.f. of this proposed rule (or section VI.F.1.g. for group practices). Because this is a voluntary program, it is difficult to accurately estimate how many EPs will opt to participate in the PQ RI in CY 2011. Information from the “PQRI 2007 Reporting Experience Report,” which is av ailable on the PQRI section of the CMS

Web site at http://www.cms.hhs.gov/PQRI , indicates that nearly 110,000 unique TIN/NPI

### CMS-1503-P 657

combinations attempted to s ubmit PQRI quality measures data via claims for the 2007 PQRI. Therefore, for purposes of conducting a burden analysis for the 2011 PQRI, we

will assume that all EPs who attempted to participate in the 2007 PQRI will also attempt to participate in the 2011 PQRI. Furthermore, we believe that the burden for EPs who are participating in the PQRI for the first time in 2011 will be considerably higher than the burden for EPs who have participated in PQRI in prior years. For individual EPs, the burden associated with the requirements of this reporting initiative is the time and effort associated with EPs identifying applicable PQRI quality measures for which they can report the ne cessary information, collecting the necessary information, and reporting the information need ed to report the EP’s or group practice’s measures. We believe it is difficult to accurately quantify the burden because EPs may have different processes for integrating the PQRI into their practice’s work flows. Moreover, the time needed for an EP to review the quality measures and other information, select measures a pplicable to his or her patient s and the services he or she furnishes to them, and incorporate the use of quality data codes into the office work flows is expected to vary along with the number of measures that are potentially applicable to a given professional’s practice. Since EPs are generally required to report on at least 3 measures to earn a PQRI incentive, we will assume that each EP who attempts to submit PQRI quality measures data is attempting to earn a PQRI incentive payment and reports on an average of 3 measures for this burden analysis. Because we anticipate even greater participation in the 2011 PQRI than in previous years, including partic ipation by EPs who are participating in PQRI for the first time in 2011, we will assign 5 hours as the amoun t of time needed for EPs to review the 2011 PQRI Measures List, review the vari ous reporting options, select the most

### CMS-1503-P 658

appropriate reporting opt ion, identify the applicable meas ures or measures groups for which they can report the necessary informa tion, review the measure specifications for the selected measures or measures groups, and incorporate reporting of the selected measures or measures groups into the office work flows. This estimate is based on our assumption that an EP will need up to 2 hour s to review the 2011 PQRI Measures List, review the reporting options, and select a reporting option and measures on which to report and 3 hours to review the measure specif ications for up to 3 selected measures or up to 1 selected measures group and to deve lop a mechanism for incorporating reporting

of the selected measures or measures group into the office work flows. Information from the Physician Voluntar y Reporting Program (PVRP), which was a predecessor to the PQRI, indicated an aver age labor cost of $50 per hour. To account for salary increases over time, we will use an average practice labor cost of $58 per hour in our estimates based on an assumption of an average annual increase of approximately 3 percent. Thus, we estimate the cost for EP associated with preparing to report PQRI quality measures would be approximate ly $290 per EP ($58 per hour x 5 hours). We continue to expect the ongoing costs associated with PQRI participation to decline based on an EP’s familiarity with and understanding of the PQRI, experience with participating in the PQRI, and increa sed efforts by CMS and stakeholders to

disseminate useful educational resour ces and best practices.

We believe the burden associated w ith actually reporting the PQRI quality measures will vary depending on the reporting mechanism selected by the EP. For claims-based reporting, EPs must gather the required information, se lect the appropriate quality data codes (QDCs), and include the appropriate QDCs on the claims they submit for payment. The PQRI will collect QDCs as additional (optional) line items on the

### CMS-1503-P 659

existing HIPAA transaction 837-P and/or CMS Form 1500 (OCN: 0938-0999). We do not anticipate any new forms and no modificati ons to the existing transaction or form. We also do not anticipate changes to the 837-P or CMS Form 1500 for CY 2011. Based on our experience with the PVRP, we continue to estimate that the time needed to perform all the steps necessary to report each measure (that is, reporting the relevant quality data code(s) for a meas ure) on claims ranges from 15 seconds (0.25 minutes) to over 12 minutes for complicated cases and/or measures, with the median time being 1.75 minutes. At an average labor cost of $58 per hour per practice, the cost associated with this burden ranges from $0.24 in labor to about $11.60 in labor time for more complicated cases and/or measures, w ith the cost for the median practice being $1.69. The total estimated annual burden for this requirement will also vary along with the volume of claims on which quality data is reported. In previous years, when we required reporting on 80 percent of eligible cases for claims-based reporting, we found that on average, the median number of reporting instances for each of the PQRI measures was 9. Since we propose to reduce the requi red reporting rate by over one-third to 50 percent, then for purposes of this burden analysis we will assume that an EP will need to report each selected measure for 6 reportin g instances. The actual number of cases on which an eligible professional would be required to report quality measures data will vary, however, with the EP’s patient populati on and the types of measures on which the EP chooses to report (each measure’s sp ecifications includes a required reporting frequency). Based on the assumptions disc ussed above, we estimate the total annual reporting burden per EP associated with claims-bas ed reporting to range from 4.5 minutes (0.25

### CMS-1503-P 660

minutes per measure X 3 meas ures X 6 cases per measure) to 180 minutes (12 minutes per measure X 3 measures X 6 cases per measur e), with the burden to the median practice being 31.5 minutes (1.75 minutes per measure X 3 measures X 6 cases). We estimate the total annual reporting cost per EP associated with claims-b ased reporting to range from $4.32 ($0.24 per measure X 3 measures X 6 cases per measure) to $208.80 ($11.60 per measure X 3 measures X 6 cases per measure), with the cost to the median practice being $30.42 per EP ($1.69 per measure X 3 meas ures X 6 cases per measure). For registry-based reporting, there would be no additional time burden for EP to report data to a registry as EP opting for re gistry-based reporting would more than likely already be reporting data to the registry for other purposes. Little, if any, additional data would need to be reported to the registry fo r purposes of participa tion in the 2011 PQRI. However, EPs would need to authorize or inst ruct the registry to submit quality measures

results and numerator and deno minator data on quality measur es to CMS on their behalf. We estimate that the time and effort associated with this would be approximately 5 minutes per EP. Registries interested in submitting quality measures results and numerator and denominator data on quality measures to CM S on their participants’ behalf in 2011 would need to complete a self-nomination process in order to be considered “qualified” to submit on behalf of EPs unless the registry was qualified to submit on behalf of EPs for prior years and did so successfully. We estimate that the self-nomination process for qualifying additional registries to submit on behalf of EPs for the 2011 PQRI involves approximately 1 hour per registry to draft the letter of intent for se lf-nomination. It is estimated that each self-nominated entity will also spend 2 hours for the interview with CMS officials and 2 hours calculating numerator s, denominators, and measure results for

### CMS-1503-P 661

each measure the registry wishes to report using a CMS-provided measure flow. However, the time it takes to complete the measure flow could vary depending on the registry’s experience and the number and type of measures for which the registry wishes

to submit on behalf of EPs. Additionally, part of the sel f-nomination process involves the completion of an XML submission by the registry, which is estimated to take approximately 5 hours, but ma y vary depending on the registry’s experience. We estimate that the registry staff involved in th e registry self-nomina tion process have an average labor cost of $50 per hour. Ther efore, assuming the total burden hours per registry associated with the registry self-nomination proce ss is 10 hours, we estimate the total cost to a registry associated with the registry self-nomination process to be approximately $500 ($50 per hour x 10 hours per registry). The burden associated with the registry -based reporting requirements of this voluntary reporting initiative is the time and effort associated with the registry calculating quality measure results from the data submitted to the registry by its participants and submitting the quality measures results and numerator and denominator data on quality measures to CMS on behalf of their participants. The time needed for a registry to review the quality measures and other information, calculate the measures results, and submit the measures results and numerator and denominator data on the quality measures on their participants behalf is expected to vary along with the number of EPs reporting data to the registry and the number of appli cable measures. However, we believe that registries already perform many of these ac tivities for their participants. The number of measures that the registry intends to report to CMS and how similar the registry’s measures are to CMS’ PQRI measures will determine the time burden to the registry.

### CMS-1503-P 662

For EHR-based reporting, the EP must ha ve an IACS account, which we believe

takes less than 1 hour to obtain. Once an EP has an IACS account, he or she must extract the necessary clinical data from his or her EHR, and submit the necessary data to the CMS-designated clinical data warehouse. With respect to our proposal to require an EP to submit a test file, we believe that doing so would take less than 1 hour. With respect to submitting the actual 2011 data f ile in 2012, we believe that this would take an EP no more than 2 hours, depending on the number of patients on which the EP is submitting. We believe that once the EHR is programmed by the vendor to allow data submission to CMS, the burden to the EP associated with submission of data on PQRI quality measures

should be minimal. Because this manner of reporting quality data to CMS was new to PQRI for 2010 and no EHR data submissions ha ve taken place yet, it is difficult to estimate how many EPs will opt to participate in the PQRI through the EHR mechanism

in CY 2011. An EHR vendor interested in having thei r product(s) be used by EPs to submit PQRI quality measures data to CMS were requi red to complete a se lf-nomination process in order for the vendor’s product(s) to be c onsidered “qualified” for 2011. It is difficult to accurately quantify the burden associated with the EHR self-nomination process as there is variation regarding the technical capabilities and experience among vendors. For purposes of this burden analysis, however, we estimate that the time required for an EHR vendor to complete the self- nomination process will be s imilar to the time required for registries to self-nominate that is approx imately 10 hours at $50 per hour for a total of $500 per EHR vendor ($50 per hour x 10 hours per EHR vendor).

The burden associated with the EHR ve ndor programming its EHR product(s) to extract the clinical data that the EP needs to submit to CMS for purposes of reporting

### CMS-1503-P 663

2010 PQRI quality measures will be dependen t on the EHR vendor’s familiarity with PQRI, the vendor’s system capabilities, as we ll as the vendor’s prog ramming capabilities. Some vendors already have these necessary capabilities a nd for such vendors, we

estimate the total burde n hours to be 40 hours at a rate of $50 per hour for a total burden estimate of $2,000 ($50 per hour x 40 hours per vendor). However, given the variability in the capabilities of the vendors, those ve ndors with minimal experience would have a burden of approximately 200 hours at $50 per hour, for a total estimate of $10,000 per vendor ($50 per hour x 200 hours per EHR vendor). With respect to the process for group prac tices to be treated as satisfactorily submitting quality measures data under the 2011 PQRI discussed in section VI.F.1. of this proposed rule, group practices interested in participating in the 2011 PQRI through one of the proposed group practice reportin g options would need to complete a self-nomination process similar to the self-nomination process required of registries and EHR vendors. Therefore, assuming 2 hours for a group practice to decide whether to participate as a group or individually, appr oximately 2 hours per group practice to draft

the letter of intent for self- nomination, gather the requested information, and provide this requested information, and an additional 2 hours undergoing the vetting process with CMS officials, we estimate a total of 6 hours a ssociated with the self-nomination process. Assuming that the group practice staff involve d in the group practice self-nomination process have the same average practice labor cost as the average practice labor cost estimates we used for individual EPs of $58 per hour, we estimate the total cost to a group practice associated with the group pr actice self-nomination process to be approximately $348 ($58 per hour x 6 hours per group practice).

### CMS-1503-P 664

The burden associated with the group pr actice reporting requirements of this voluntary reporting initiative is the time and effort associated with the group practice submitting the quality measures data. For practices participa ting under the proposed GPRO I process, this would be the time associated with the physician group completing

the data collection tool. The information co llection components of this data collection tool have been reviewed by OMB and are currently approved under OMB control number 0938-0941, with an expiration date of Decembe r 31, 2011, for use in the Physician Group Practice, Medicare Care Management Perfor mance (MCMP), and EHR demonstrations.

Based on burden estimates for the PGP dem onstration, which uses the same data submission methods, we estimate the burde n associated with a physician group completing the data collection tool woul d be approximately 79 hours per physician group. Based on an average labor cost of $58 per physician group, we estimate the cost of data submission per physician group associ ated with participating in the proposed PQRI GPRO I would be $4,582 ($58 per hour x 79 hours per group practice). For group practices participating under th e proposed GPRO II process, the burden associated with submitting the PQRI quality measures data would be the time associated with the group practice submitting the required data to CMS via claims or a registry. We would expect that data submission under GPRO II would take no more time than the time

it would take an individual EP to submit via cl aims or registry. We believe it would be appropriate to multiply the appropriate bur den estimates for each reporting mechanism for individual EPs by the number of EPs in a group to obtain the burden estimates for data submission under GPRO II. For exampl e, based on our estimate of 15.75 minutes per EP under claims-based reporting, we woul d expect that a 2-person group would have

a burden of 31.50 minutes for claims-bas ed submission under GPRO II.

### CMS-1503-P 665

We invite comments on this burden analysis, including the underlying assumptions used in developing our burden estimates. 3. Electronic Prescribing (eRx) Incentive Program We believe it is difficult to accurately estimate how many EPs will opt to participate in the eRx Incentive Program in CY 2011. Final partic ipation numbers from the first year of the eRx Incentive Program (2009) are not available. Information from the “PQRI 2007 Reporting Experience Report,” wh ich is available on the PQRI section of

the CMS Web site at http://www.cms.hhs.gov/PQRI , however, indicates that nearly 110,000 unique TIN/NPI combinations attempted to submit PQRI quality measures data via claims for the 2007 PQRI. Therefore, for purposes of conducting a burden analysis for the 2011 eRx Incentive Program, we will assu me that as many EP s who attempted to participate in the 2007 PQRI will attempt to participate in the 2011 eRx Incentive Program. As such, we can estimate that nearly 110,000 unique TIN/NPI combinations will participate in the 2011 eRx Incentive Program. Section VI.F.2 of this proposed rule discusses the background of the eRx Incentive Program. Section VI.F.2.b.(2) of this proposed rule provides information on how we propose EPs and group practices can qu alify to be considered a successful electronic prescriber in 2011 in order to ea rn an incentive payment. For 2011, EPs and group practices may choose whether to partic ipate and, to the extent they meet-- (1) certain thresholds with respect to the volume of covered professional services furnished; and (2) the criteria to be considered a successful electronic prescriber described in section VI.F.2.b.(2) of this proposed ru le, they can qualify to receive an incentive payment for 2011 and/or avoid being subject to a pe nalty that goes into effect in 2012.

### CMS-1503-P 666

For the 2011 eRx Incentive Program, as discussed in section VI.F.2. of this proposed rule, we propose that each EP would ne ed to report the G-code indicating that at least one prescription generated during an encounter was electronically submitted at least 25 instances during the reporting period. We ex pect the ongoing costs associated with participation in the eRx Incentive Program to decline based on an EP’s familiarity with and understanding of the eRx Incentive Program, experience with participating in the eRx Incentive Program, and increased efforts by CMS and stakeholders to disseminate useful

educational resources and best practices. Similar to PQRI, one factor in the burden to individual EPs would be the time and effort associated with individual EPs reviewing the electronic prescribing measure to determine whether it is applicable to them, reviewing the available reporting options (we propose this measure would be reportable thro ugh claims-based reporting, registry-based reporting, or through EHRs) and selecting one, gathering the required information, and incorporating reporting of the measure into their office work flows. Since the eRx Incentive Program consists of only 1 measur e to report, we estimate 2 hours as the

amount of time needed for individual EPs to prepare for participation in the eRx Incentive Program. At an average cost of approximately $58 per hour per practice, we estimate the total preparation costs to indi vidual EPs to be appr oximately $116 (2 hours X $58 per hour).

Another factor that influences the burden to EPs is how they choose to report the electronic prescribing measure. For EPs who choose to do so via claims, we estimate that the burden associated with the requirements of this incentive program is the time and effort associated with gathering the requi red information, selecting the appropriate quality data codes (QDCs), a nd including the appropriate QDCs on the claims they

### CMS-1503-P 667

submit for payment. For claims-based reporting, the QDCs will be collected as additional (optional) line items on the ex isting HIPAA transaction 837-P and/or CMS Form 1500. We do not anticipate any new fo rms and no modifications to the existing

transaction or form. We also do not antic ipate changes to the 837-P or CMS Form 1500

for CY 201.

Based on the information from the PVRP described above for the amount of time it takes a median practice to report one measure one time on claims (1.75 minutes) and our proposal to require EPs to report th e measure 25 times, we estimate the burden

associated with claims-based data submi ssion to be 43.75 minutes (1.75 minutes per case X 1 measure X 25 cases per measure). This equates to a cost of approximately $42.29 (1.75 minutes per case X 1 measure X 25 cases per measure X $58 per hour) per

individual EP. Because registry-based reporting of the electronic prescribing measure to CMS was added to the eRx Incentive Program for 2010 and EPs are not required to indicate to us how they plan to report the electronic prescribing measure each year, it is difficult to accurately estimate how many EPs will opt to participate in the eRx Incentive Program through the registry-based reporting mechanism in CY 2011. We do not anticipate, however, any additional burden for EPs to repo rt data to a registry as EPs opting for registry-based reporting would more than likel y already be reporting data to the registry for other purposes. Little, if any, additional data would need to be reported to the registry for purposes of participation in the 2011 eRx Incentive Program. However, EPs would need to authorize or instruct the registry to submit quality measures results and numerator and denominator data on the electronic prescr ibing measure to CMS on their behalf. We estimate that the time and effort associated with this would be approximately 5 minutes

### CMS-1503-P 668

for each EP that wishes to authorize or in struct the registry to submit quality measures

results and numerator and de nominator data on the electronic prescribing measure to

CMS on their behalf. Based on our proposal to consider only re gistries qualified to submit PQRI quality

measures results and numerator and denomin ator data on quality measures to CMS on their participants’ behalf for the 2010 PQRI to be qualified to submit results and

numerator and denominator data on the elec tronic prescribing measure for the 2010 eRx Incentive Program, there would be no need fo r a registry to undergo a separate selfnomination process for the eRx Incentive Pr ogram and therefore, no additional burden associated with the registry self-nomination process. There would also be a burden to the registry associated with the registry calculating results for the electronic prescribing measure from the data submitted to the registry by its participants and submitting the quality measures results and numerator and denominator data on the electronic prescribing quality measure to CMS on behalf of their participants. The time needed for a registry to review the electronic prescribing measure and other information, calculate the measure’ s results, and submit the measure’s results

and numerator and denominator data on the measure on thei r participants behalf is expected to vary along with the number of EPs reporting data to whom the measure applies. However, we believe that registries already perform many of these activities for their participants. Since the E-Prescribin g Incentive Program consists of only one measure, we believe that the burden associated with the registry reporting the measure’s

results and numerator and denominator to CMS on behalf of their pa rticipants would be

minimal.

### CMS-1503-P 669

For EHR-based reporting, the EP must extract the necessary clinical data from his or her EHR and submit the necessary data to the CMS-designated clinical data warehouse. Because this manner of reporting qua lity data to CMS was first added to the eRx Incentive Program in 2010 and EPs are not re quired to indicate to us how they intend to report the electronic prescribing measure, it is difficult to estimate how many EPs will opt to participate in the eRx Incentive Program through the EHR-based reporting mechanism in CY 2011. We believe that once an EP’s EHR is programmed by the

vendor to allow data submi ssion to CMS, the burden to the EP associated with submission of data on the electronic pr escribing measure should be minimal. Since we are considering only EHR produ cts qualified for the 2010 PQRI to be qualified for the 2011 eRx Incentive Program, there would be no need for EHR vendors to undergo a separate self- nomination process for the 2011 eRx Incentive Program and therefore, no additional burden associated with the self-nomination process.

There would also be a burden to the EH R vendor associated with the EHR vendor programming its EHR product(s) to extract the cl inical data that the EP needs to submit to CMS for purposes of reporting the proposed 2011 electronic prescribing measure. The

time needed for an EHR vendor to review the measure and other information and program each qualified EHR produc t to enable EPs to submit data on the measure to the CMS-designated clinical data warehous e will be dependent on the EHR vendor’s familiarity with the electronic prescribing me asure, the vendor’s system capabilities, as well as the vendor’s programmin g capabilities. Since only EHR products qualified for the 2011 PQRI would be qualified for th e 2011 eRx Incentive Program and the eRx Incentive Program consists of only one measur e, we believe that any burden associated with the EHR vendor to progr am its product(s) to enable EPs to submit data on the

### CMS-1503-P 670

electronic prescribing measure to the CMS-designated clinical data warehouse would be

minimal. Finally, with respect to the process for group practices to be treated as successful electronic prescribers under the 2011 eRx Incen tive Program discusse d in section VI.F.2. of this proposed rule, we propose that group practices would have the same options as

individual EPs in terms of the form and ma nner for reporting the electronic prescribing measure (that is, group practices would have the option of reporting the measure through claims, a qualified registry, or a qualified EHR product). There are only 2 differences between the proposed requirements for an indi vidual EP and a group practice: (1) the fact that a group practice would have to self- nominate; and( 2) the number of times that a group practice would be required to report the electronic prescribing measure. We do not anticipate any additional burde n associated with the group practice self-nomination practice since we propose to limit the group practices to those selected to participate in the 2011 PQRI GPRO I or PQRI GPRO II. The practice only would needto indicate their desire to participate in the eRx GPRO at the same time they selfnominate for either PQRI GPRO I or PQRI GPRO II and indicate how they intend to report the electronic prescribing measure. In terms of the burden to group practices associated with submission of the electronic prescribing measure, we believe that this would be similar to the burden to individual EPs for submitting the electronic pres cribing measure. In fact, overall, there

could be less burden associated with a practice participating as a group rather than as individual EPs because the total number of reporting instances required by the group

could be less than the total num ber of reporting instances that would be required if each member of the group separately reported the electronic prescribing measure. Thus, we

### CMS-1503-P 671

believe that the burden to a group practice associated with reporting the electronic prescribing measure could range from almost no burden (for groups who choose to do so through a qualified EHR or registry) to 72.92 hours (1.75 minutes per measure x 1 measure x 2500 cases per meas ure) for a GPRO I group who chooses to report the electronic prescribing measures through cl aims submission. Consequently, the total estimated cost per group practice to report the electronic prescribing measure could be as high as $4,225 ($1.69 per measure x 1 m easure x 2500 cases per measure). As with individual EPs, we believe that group practices that choose to participate in the 2011 eRx GPRO through registry-based reporting of the electronic prescribing measure would more than likely already be reporting data to the registry. Little, if any,

additional data would need to be reported to the registry for purposes of participation in the 2011 eRx Incentive Program beyond authorizin g or instructing the registry to submit quality measures results and numerator and denominator data on the electronic prescribing measure to CMS on their behalf. We estimate that the time and effort

associated with this would be approximately 5 minutes for each group practice that wishes to authorize or instruct the regi stry to submit quality measures results and

numerator and denominator data on the elec tronic prescribing measure to CMS on their

behalf. For group practices that choose to participate in the 2011 eRx Incentive Program through EHR-based reporting of the electr onic prescribing measure, once the EHR is programmed by the vendor to allow data submission to CMS, the burden to the group practice associated with submission of data on the electronic prescribing measure should

be minimal.

### CMS-1503-P 672

We invite comments on this burden analysis, including the underlying assumptions used in developing our burden estimates. VIII. Response to Comments Because of the large number of pub lic comments we normally receive on Federal Register documents, we are not able to acknowle dge or respond to them individually. We will consider all comments we receive by the date and time specified in the "DATES" section of this preamble, and, when we pr oceed with a subsequent document, we will respond to the comments in the preamble to that document. IX. Regulatory Impact Analysis We have examined the impacts of this rule as required by Executive Order 12866 on Regulatory Planning and Re view (September 30, 1993), the Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L. 96-354), sect ion 1102(b) of the Social Security Act,

section 202 of the Unfunded Mandates Re form Act of 1995 (Pub. L. 104-4), Executive Order 13132 on Federalism (August 4, 1999), and the Congressional Review Act (5 U.S.C. 804(2)). Executive Order 12866 directs agencies to assess all costs and benefits of available regulatory alterna tives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (i ncluding potential econo mic, environmental, public health and safety effects, distributiv e impacts, and equity). A regulatory impact analysis (RIA) must be prepared for major rules with economically significant effects ($100 million or more in any 1 year). We es timate, as discussed be low in this section, that the PFS provisions included in this proposed rule will redistribute more than $100 million in 1 year. Therefore, we estimate that this rulemaking is “economically significant” as measured by the $100 million th reshold, and hence also a major rule under

### CMS-1503-P 673

the Congressional Review Act. Accordingly, we have prepared a Regulatory Impact Analysis that to the best of our ability presen ts the costs and benefits of the rulemaking. The RFA requires agencies to analyze options for regulatory relief of small businesses, if a rule has a significant impact on a substantial number of small entities. For purposes of the RFA, we estimate that most hospitals and most other providers are

small entities as that term is used in th e RFA (including sma ll businesses, nonprofit organizations, and small governme ntal jurisdictions). The great majority of hospitals and most other health care providers and suppliers are small entities, eith er by being nonprofit organizations or by meeting the SBA defin ition of a small busine ss (having revenues of less than $34.5 million in any 1 year) (for details see the SBA’s Web site at http://sba.gov/idc/groups/public/documen ts/sba_homepage/serv_sstd_tablepdf.pdf (refer to the 620000 series)

. Individuals and States are not incl uded in the definition of a small entity. The RFA requires that we analyze regulatory options for small businesses and other entities. We prepare a regulatory flexibility analysis unless we certify that a rule would not have a significant economic impact on a substantial number of small entities. The analysis must include a justification c oncerning the reason action is being taken, the

kinds and number of small entities the rule affe cts, and an explanation of any meaningful options that achieve the objectives with less significant adverse economic impact on the

small entities. For purposes of the RFA, physicians, N PPs, and suppliers including IDTFs are considered small businesses if they gene rate revenues of $10 million or less based on SBA size standards. Approximately 95 percent of physicians are considered to be small entities. There are over 1 million physicians, other practitioners, a nd medical suppliers that receive Medicare payment under the PFS.

### CMS-1503-P 674

For purposes of the RFA approximately 85 percent of suppliers of durable medical equipment, prosthetic s, orthotics, and supplies (D MEPOS) are considered small businesses according to the SBA size standards. Our most recent claims information includes 47,000 entities billing Medicare for DMEP OS each year. Total annual estimated Medicare expenditures for DMEPOS supplie rs are approximately $10.1 billion in CY 2009, for which $8.1 billion was fee-for-servi ce (FFS) and $2 billion was for managed

care. For purposes of the RFA, approximate ly 80 percent of clinical diagnostic laboratories are considered small businesses according to the SBA size standards. Ambulance providers and suppliers for purpos es of the RFA are also considered

to be small entities. In addition, most ESRD fac ilities are considered small entities for purposes of the RFA, either based on nonprofit status or by having revenues of $34.5 million or less in any year. We note that a considerable number of ESRD facilities are owned and operated by large dialysis organizations (LDOs) or regional chains, which would have total revenues more than $34.5 million in any ye ar if revenues from all locations are combined. However, the claims data we use to estimate payments for this RFA and RIA does not identify which dialysis facilities are parts of an LDO, regional chain, or other type of ownership. Each individual dialysis facility has its own provider number and bills Medicare using this number. Therefore, we consider each ESRD facility to be a small entity for purposes of the RFA. We consider a substantial number of entities to be significantly affected if th e proposed rule has an annual average impact on small entities of 3 to 5 percent or more. The majority of ESRD facilities will experience impacts of approximately 2 percent of total revenues. There are 954 nonprofit ESRD facilities with

### CMS-1503-P 675

a combined increase of 2.1 percent in overall payments relative to current overall payments. We note that although the overall effect of the wage index changes is budget neutral, there are increases and decreases based on the location of individual facilities. The analysis and discussion provided in this section and elsewhere in this proposed rule complies with the RFA requirements. Because we acknowledge that many of th e affected entities are small entities, the analysis discussed throughout the preambl e of this proposed rule constitutes our regulatory flexibility analysis for the remaining provisions and addresses comments

received on these issues. In addition, section 1102(b) of the Act requi res us to prepare a regulatory impact analysis, if a rule may have a significant imp act on the operations of a substantial number of small rural hospitals. Any such regulatory impact analysis must conform to the provisions of section 603 of the RFA. For purposes of section 1102(b) of the Act, we define a small rural hospital as a hospital that is located outside of a metropolitan

statistical area and has fewer than 100 beds. We do not believe th is proposed rule has impact on significant operations of a substantial number of small rural hospitals because most dialysis facilities are freestanding. While there are 184 rural hospital-based dialysis facilities, we do not know how ma ny of them are based at hos pitals with fewer than 100 beds. However, overall, the 184 rural hospita l-based dialysis facilities will experience an estimated 2.1 percent increase in payments. As a result, this rule will not have a significant impact on small rural hospitals. Th erefore, the Secretary has determined that this proposed rule will not have a signifi cant impact on the operati ons of a substantial number of small rural hospitals.

Section 202 of the Unfunded Mandate s Reform Act of 1995 (UMRA) also

### CMS-1503-P 676

requires that agencies assess anticipated costs and benefits before issuing any rule whose mandates require spending in any 1 year of $100 million in 1995 dollars, updated annually for inflation. In 2010, that thre shold is approximately $135 million. This proposed rule will not mandate an y requirements for State, local , or tribal governments in the aggregate, or by the private sector , of $135 million. Medicare beneficiaries are considered to be part of the private sector and as a result a more detailed discussion is presented on the Impact of Beneficiaries in section IX.G. of this regulatory impact analysis. Executive Order 13132 establishes certain requi rements that an agency must meet when it promulgates a proposed rule (and subseq uent final rule) that imposes substantial direct requirement costs on Stat e and local governments, preem pts State law, or otherwise has Federalism implications. We have examined this proposed rule in accordance with

Executive Order 13132 and have determined th at this regulation would not have any substantial direct effect on State or local g overnments, preempt States, or otherwise have a Federalism implication. We have prepared the following analysis, which together with the information provided in the rest of this preamble, meet s all assessment requirements. The analysis explains the rationale for and purposes of this proposed rule; details the costs and benefits of the rule; analyzes alternatives; and presen ts the measures we will use to minimize the burden on small entities. As indicated elsewhere in this rule, we are implementing a variety of changes to our regulations, paymen ts, or payment policies to ensure that our payment systems reflect changes in medical practice and the relative value of services. We provide information for each of the policy changes in the relevant sections of this proposed rule. We are unaware of any releva nt Federal rules that duplicate, overlap, or

### CMS-1503-P 677

conflict with this proposed rule. The relevant sections of this rule contain a description of significant alternatives if applicable. A. RVU Impacts 1. Resource-Based Work, PE , and Malpractice RVUs Section 1848(c)(2)(B)(ii) of the Act require s that increases or decreases in RVUs may not cause the amount of expenditures for the year to differ by more than $20 million from what expenditures would have been in the absence of these changes. If this threshold is exceeded, we make adjustme nts to preserve budget neutrality. Our estimates of changes in Medicare revenues for PFS services compare payment rates for CY 2010 with proposed payment rates for CY 2011 using CY 2009 Medicare utilization for all years. To the extent that there are year-to-year changes in the volume and mix of services provided by ph ysicians, the actual impact on total Medicare

revenues will be different than those shown in Table 73. The payment impacts reflect averages for each specialty based on Medicare utilization. The payment impact for an individual physician would be different from the average, based on the mix of services the physician furnishes. The average change in total revenues woul d be less than the impact displayed here because physicians furnish services to both Medicare and non-Medicare patients and specialties may re ceive substantial Medicare revenues for services that are not paid under the PFS. For instance, independent laboratories receive approximately 85 percent of th eir Medicare revenues from clinical laboratory services that are not paid under the PFS. Table 73 shows only the payment impact on PFS services. We note that these impacts do not include the effect of the cu rrent law -6.1 percent CY 2011 PFS update. The following is an explanation of the information represented in Table 73:

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● Column A (Specialty) : The Medicare specialty code as reflected in our physician/supplier enrollment files.

● Column B (Allowed Charges) : The aggregate estimated PFS allowed charges for the specialty based on CY 2009 utilizati on and CY 2010 rates. That is, allowed charges are the PFS amounts for covered services and include coinsurance and deductibles (which are the fi nancial responsibility of the beneficiary). These amounts

have been summed across all services furnishe d by physicians, prac titioners, or suppliers within a specialty to arrive at the total allowed charges for the specialty.

● Column C (Impact of Work a nd Malpractice (MP) RVU Changes) : This column shows the estimated CY 2011 impact on to tal allowed charges of the changes in the work and malpractice RVUs.

● Column D (Impact of PE RVU and Multiple Procedure Payment Reduction Changes - Full) : This column shows the estima ted CY 2011 impact on total allowed charges of the changes in the PE RVUs if there were no remaining transition to the full

use of the new PPIS data. This column also includes the impact of the various MPPR and imaging equipment utilization polices.

● Column E (Impact of PE RVU and MPPR Changes - Tran) : This column shows the estimated CY 2011 impact on total allo wed charges of the changes in the PE RVUs under the second year of the 4-year trans ition to the full use of the new PPIS data. This column also includes the impact of the various MPPR and imaging equipment utilization policies.

● Column F (Impact of MEI Rebasing) : This column shows the estimated CY 2011 impact on total allowed charges of the pr oposed CY 2011 rescaling of the RVUs so

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that the proportions of total payments ba sed on the work, PE, and malpractice RVUs match the proportions proposed in the rebased CY 2006 MEI.

● Column G (Combined Impact - Full) : This column shows the estimated CY 2011 combined impact on total allowed charge s of all the changes in the previous columns if there were no remaining transition to the new PE RVUs using the PPIS data.

● Column H (Combined Impact - Tran) : This column shows the estimated CY 2011 combined impact on total allowed charge s of all the changes in the previous columns under the second year of the 4-year transition to the new PE RVUs using the

PPIS data. TABLE 73: CY 2011 PFS Proposed Rule Total Allowed Charge Estimated Impact for RVU, MPPR , and MEI Rebasing Changes*

(A) (B) (C) (D) (E) (F) (G) (H) Impact of PE RVU and MPPR Changes Combined Impact Specialty Allowed Charges

(mil) Impact of Work and MP RVU Changes Full Tran Impact of MEI Rebasing Full Tran TOTAL $79,731 0% 0% 0% 0% 0% 0% 01-ALLERGY/IMMUNOLOGY $176 0% 0% 0% 4% 4% 4% 02-ANESTHESIOLOGY $1,729 0% 3% 1% -3% 0% -2% 03-CARDIAC SURGERY $373 0% -1% 0% 0% -1% 0% 04-CARDIOLOGY $6,801 0% -5% -2% 0% -5% -2% 05-COLON AND RECTAL SURGERY $134 0% 4% 1% 0% 4% 1% 06-CRITICAL CARE $233 0% 2% 1% -2% 0% -1% 07-DERMATOLOGY $2,678 0% 1% 1% 2% 3% 3% 08-EMERGENCY MEDICINE $2,527 0% 1% 1% -3% -2% -2% 09-ENDOCRINOLOGY $382 0% 3% 1% -1% 2% 0% 10-FAMILY PRACTICE $5,351 0% 3% 1% 0% 3% 1% 11-GASTROENTEROLOGY $1,752 0% 2% 1% -1% 1% 0% 12-GENERAL PRACTICE $704 0% 2% 1% 0% 2% 1% 13-GENERAL SURGERY $2,221 0% 3% 1% 0% 3% 1% 14-GERIATRICS $182 0% 5% 2% -2% 3% 0% 15-HAND SURGERY $100 0% 3% 1% 2% 5% 3% 16-HEMATOLOGY/ONCOLOGY $1,870 0% -5% -2% 1% -4% -1% 17-INFECTIOUS DISEASE $567 0% 4% 2% -2% 2% 0% 18-INTERNAL MEDICINE $10,381 0% 3% 1% -1% 2% 0%

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(A) (B) (C) (D) (E) (F) (G) (H) Impact of PE RVU and MPPR Changes Combined Impact Specialty Allowed Charges

(mil) Impact of Work and MP RVU Changes Full Tran Impact of MEI Rebasing Full Tran 19-INTERVENTIONAL PAIN MGMT $379 0% 4% 2% 1% 5% 3% 20-INTERVENTIONAL RADIOLOGY $222 0% -9% -4% 0% -9% -4% 21-MULTISPECIALTY CLINIC/OTHER $44 0% -5% -4% 1% -4% -3% 22-NEPHROLOGY $1,891 0% 0% 0% -1% -1% -1% 23-NEUROLOGY $1,415 0% 4% 1% 0% 4% 1% 24-NEUROSURGERY $622 0% 2% 1% 1% 3% 2% 25-NUCLEAR MEDICINE $57 0% -7% -4% 1% -6% -3% 27-OBSTETRICS/GYNECOLOGY $649 0% 1% 0% 1% 2% 1% 28-OPHTHALMOLOGY $5,154 0% 7% 3% 1% 8% 4% 29-ORTHOPEDIC SURGERY $3,339 0% 2% 1% 1% 3% 2% 30-OTOLARNGOLOGY $915 0% 3% 1% 1% 4% 2% 31-PATHOLOGY $1,040 0% -1% 0% -1% -2% -1% 32-PEDIATRICS $65 0% 2% 1% 0% 2% 1% 33-PHYSICAL MEDICINE $868 0% 4% 1% -1% 3% 0% 34-PLASTIC SURGERY $306 0% 4% 2% 1% 5% 3% 35-PSYCHIATRY $1,105 0% 1% 1% -3% -2% -2% 36-PULMONARY DISEASE $1,736 0% 2% 1% -1% 1% 0% 37-RADIATION ONCOLOGY $1,889 0% -5% -2% 4% -1% 2% 38-RADIOLOGY $4,975 0% -12% -6% 0% -12% -6% 39-RHEUMATOLOGY $496 0% 0% 0% 1% 1% 1% 40-THORACIC SURGERY $388 0% -1% 0% 0% -1% 0% 41-UROLOGY $1,909 0% -6% -2% 1% -5% -1% 42-VASCULAR SURGERY $702 0% -2% -1% 2% 0% 1% 43-AUDIOLOGIST $52 0% -7% -2% 1% -6% -1% 44-CHIROPRACTOR $732 0% 3% 1% -2% 1% -1% 45-CLINICAL PSYCHOLOGIST $557 0% -6% -2% -5% -11% -7% 46-CLINICAL SOCIAL WORKER $376 0% -5% -2% -5% -10% -7% 47-DIAGNOSTIC TESTING FACILITY $851 0% -26% -13% 6% -20% -7% 48-INDEPENDENT LABORATORY $1,009 0% -6% -2% 4% -2% 2% 49-NURSE ANES / ANES ASST $706 0% 2% 2% -3% -1% -1% 50-NURSE PRACTITIONER $1,175 0% 4% 1% -1% 3% 0% 51-OPTOMETRY $937 0% 7% 3% 1% 8% 4% 52-ORAL/MAXILLOFACIAL SURGERY $38 0% 3% 2% 2% 5% 4% 53-PHYSICAL/OCCUPATIONAL THERA $2,138 0% -7% -11% -1% -8% -12% 54-PHYSICIAN ASSISTANT $868 0% 3% 1% 0% 3% 1% 55-PODIATRY $1,738 0% 4% 2% 1% 5% 3%

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(A) (B) (C) (D) (E) (F) (G) (H) Impact of PE RVU and MPPR Changes Combined Impact Specialty Allowed Charges

(mil) Impact of Work and MP RVU Changes Full Tran Impact of MEI Rebasing Full Tran 56-PORTABLE X-RAY SUPPLIER $91 0% 3% 2% 6% 9% 8% 57-RADIATION THERAPY CENTERS $69 0% -9% -3% 8% -1% 5% OTHER $67 0% 2% 1% -1% 2% 2% * Does not include the impact of the current law -6.1 percent CY 2011 update.



### 2. CY 2011 PFS Impact Discussion a. Changes in RVUs The most widespread specialty impacts of the RVU changes are generally related to two factors. First, as discussed in secti on II.A.2. of this proposed rule, we are currently implementing the second year of the 4-year transition to new PE RVUs using the new PPIS data that were adopted in the CY 2010 PFS final rule with comment period (74 FR 61751). The impacts of using the new PPIS da ta are generally consistent with the impacts discussed in the CY 2010 PFS fina l rule with comment period (74 FR 61983 through 61984). The second general factor contributing to the CY 2011 impacts shown in Table 73 is the proposed CY 2011 rescaling of the RVUs so that in the aggregate they match the proposed work, PE, and malprac tice proportions in the rebased CY 2006 MEI. That is, as discussed in section II.E.1. of this proposed rule, the proposed rebased MEI has a greater proportion attributable to ma lpractice and PE and, corres pondingly, a lesser proportion

attributable to work. Specialties that have a high proportion of total RVUs attributable to work, such as anesthesiology, are estimated to experience a decrease in aggregate payments as a result of this rescaling, while specialties that have a high proportion attributable to PE, such as radiation oncology, are estimated to experience an increase in aggregate payments. Malpractice generall y represents a small proportion of total

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payments and the rescaling of the malpracti ce RVUs is not the primary driver of the specialty impacts. As discussed in secti on II.E.1. of this proposed rule, the proposed rescaling of the RVUs to match the propos ed rebased MEI is budget neutral overall. Table 73 also includes the impacts resulting from our proposed regulatory change to apply the current 50 percent MPPR policy to therapy services. Under the PFS, we estimate that this change would primarily reduce payments to the specialties of physical therapy and occupational therapy. In orde r to maintain budget neutrality, we are proposing to redistribute the PFS savings back into other services paid under the PFS by increasing all PE RVUs by approximately 1 percent. Because providers in settings outside of the PFS, such as outpatient hospital departments, are also paid using the PFS pa yment rates and policies for physical therapy services, we estimate that this proposal would reduce (not redistribute) payments in those settings for therapy services by a pproximately 13 percent in CY 2011. In addition, Table 73 includes the impacts resulting from the proposed regulatory change to the scope of the current contiguous body area MPPR policy for imaging services from contiguous body areas to in clude noncontiguous body areas. We estimate that this change would primarily reduce payments to the specialties of IDTF and radiology. In order to main tain budget neutrality, we are proposing to redistribute these savings back into other services paid under the PFS by increasing all PE RVUs by approximately 0.1 percent. Table 73 also reflects the impacts resulting from certain ACA provisions, including section 3135 that amends section 1848(b)(4) of the Act to reduce the payment for expensive diagnostic imaging equipment, and, effective July 1, 2010, increases the level of the MPPR for contiguous body areas from 25 percent to 50 percent. The

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proposed expansion of the MPPR policy is fu rther discussed in section II.C.4. of this proposed rule, while the discussions of th e provisions of section 3135 of the ACA are

found in sections V.M. and II.A.3.a. of this proposed rule. As required by sections 1848(c)(2)(B)(v)(V) and (VI) of the Act (as added by sections 3135(a) and (b) of the ACA), these changes are not budget neutral a nd result in program savings. See section

IX.D below for a discussion of the budget impacts of the ACA provisions. We note that the payment impact for an individual physician may be different from the average, based on the mix of services the physician furnishes. b. Combined Impact Column H of Table 73 displays the es timated CY 2011 combined impact on total allowed charges by specialty of a ll the proposed RVU and MPPR changes. These impacts range from an increase of 8 percent for portable x-ray suppliers, to a decrease of 12 percent for physical/occupational therapy. There is generally a slightly positive net effect of our proposals on primary care sp ecialties, such as family practice, internal medicine, and geriatrics. Again, these impacts are estimated prior to the application of the negative CY 2011 CF update speci fied under the current statute. Table 74 shows the estimated impact on tota l payments for selected high-volume procedures of all of the cha nges discussed previously, including the effect of the CY 2011 negative PFS CF update. We selected th ese procedures because they are the most commonly furnished by a broad spectrum of physician specialties. There are separate columns that show the change in the fac ility rates and the nonfacility rates. For an explanation of facility and nonfacility PE, we refer readers to Addendum A of this proposed rule.CMS-1503-P 684TABLE 74:Impact of Proposed Rule and Estimated PhysicianUpdate on CY 2011 Payment for Selected ProceduresFacility NonfacilityCPT1/HCPCSCodeMOD Short DescriptorCT 20102CY 20113PercentChangeCY 20102CY 20113PercentChange11721 Debride nail, 6 or more $ 20.72$ 18.41-11% $ 31.23$ 29.71-5%17000 Destruct premalg lesion $ 40.88$ 39.04-4% $ 57.91$ 55.98-3%27130 Total hip arthroplasty $ 1,084.09$ 1,005.16-7% NA NANA27244 Treat thigh fracture $ 918.31$ 854.90-7% NA NANA27447 Total knee arthroplasty $ 1,159.32$ 1,074.64-7% NA NANA33533 CABG, arterial, single $ 1,536.01$ 1,374.42-11% NA NANA35301 Rechanneling of artery $ 869.49$ 783.95-10% NA NANA43239 Upper GI endoscopy, biopsy $ 133.42$ 122.76-8% $ 256.05$ 243.80-5%66821 After cataract laser surgery $ 216.59$ 210.41-3% $ 228.80$ 222.69-3%66984 Cataract surg w/iol, 1 stage $ 549.57$ 524.43-5% NA NANA67210 Treatment of retinal lesion $ 479.17$ 457.89-4% $ 494.21$ 473.12-4%71010 Chest x-ray NANANA $ 18.17$ 16.94-7%71010 26 Chest x-ray $ 7.10$ 6.38-10% $ 7.10$ 6.38-10%77056 Mammogram, both breasts NANANA $ 82.61$ 78.08-5%77056 26 Mammogram, both breasts $ 34.63$ 30.69-11% $ 34.63$ 30.69-11%77057 Mammogram, screening NANANA $ 61.60$ 57.45-7%77057 26 Mammogram, screening $ 27.82$ 24.80-11% $ 27.82$ 24.80-11%77427 Radiation tx management, x5 $ 153.00$ 141.17-8% $ 153.00$ 141.17-8%88305 26 Tissue exam by pathologist $ 28.67$ 26.03-9% $ 28.67$ 26.03-9%90801 Psy dx interview $ 100.21$ 88.14-12% $ 120.93$ 109.75-9%90862 Medication management $ 35.77$ 32.16-10% $ 44.28$ 41.00-7%90935 Hemodialysis, one evaluation $ 53.08$ 48.37-9% NA NANA92012 Eye exam established pat $ 38.32$ 36.09-6% $ 58.48$ 56.96-3%92014 Eye exam & treatment $ 58.48$ 55.00-6% $ 85.44$ 82.74-3%92980 Insert intracoronary stent $ 689.80$ 608.64-12% NA NANA93000 Electrocardiogram, complete NANANA $ 15.61$ 14.24-9%93010 Electrocardiogram report $ 7.10$ 6.38-10% $ 7.10$ 6.38-10%CMS-1503-P 685Facility NonfacilityCPT1/HCPCSCodeMOD Short DescriptorCT 20102CY 20113PercentChangeCY 20102CY 20113PercentChange93015 Cardiovascular stress test NANANA $ 72.67$ 66.29-9%93307 26 Echo exam of heart $ 38.32$ 34.13-11% $ 38.32$ 34.13-11%93510 26 Left heart catheterization $ 198.71$ 174.81-12% $ 198.71$ 174.81-12%98941 Chiropractic manipulation $ 24.13$ 21.85-9% $ 27.25$ 25.29-7%99203 Office/outpatient visit, new $ 57.34$ 52.79-8% $ 76.93$ 72.67-6%99213 Office/outpatient visit, est $ 38.04$ 35.11-8% $ 51.38$ 48.86-5%99214 Office/outpatient visit, est $ 58.48$ 53.77-8% $ 76.93$ 72.43-6%99222 Initial hospital care $ 101.62$ 93.54-8% NA NANA99223 Initial hospital care $ 149.60$ 137.25-8% NA NANA99231 Subsequent hospital care $ 29.81$ 27.25-9% NA NANA99232 Subsequent hospital care $ 53.93$ 49.35-9% NA NANA99233 Subsequent hospital care $ 77.50$ 70.96-8% NA NANA99236 Observ/hosp same date $ 166.06$ 151.73-9% NA NANA99239 Hospital discharge day $ 77.78$ 71.94-8% NA NANA99283 Emergency dept visit $ 48.26$ 43.21-10% NA NANA99284 Emergency dept visit $ 91.41$ 81.76-11% NA NANA99291 Critical care, first hour $ 170.04$ 153.94-9% $ 203.25$ 187.33-8%99292 Critical care, addÏl 30 min $ 85.16$ 77.09-9% $ 91.97$ 83.97-9%99348 Home visit, est patient NANANA $ 63.59$ 58.19-8%99350 Home visit, est patient NANANA $ 130.58$ 120.30-8%G0008 Admin influenza virus vac NANANA $ 16.75$ 16.45-2%1CPT codes and descriptions are copyright 2010 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.2Payments based upon corrected CY 2010 conversion factor of $28.3868 under the statute as of October 30, 2009 that would be ineffect on December 31, 2010 under current law.3Payments based upon the projected CY 2011 conversion factor of $26.6574 adjusted by the proposed MEI rescaling factor of 0.921.

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B. Geographic Practice Cost Indices (GPCIs) As discussed in section II.D. of this pr oposed rule, we are required to update the GPCI values at least every 3 years and phase in the adjustment over 2 years (if there has not been an adjustment in the past year). For CY 2011, we are proposing new GPCIs for each Medicare locality. The updated GPCIs reflect the first year of the 2-year phase in. The new GPCIs rely upon the 2010 HUD datafor determining the relative cost

differences in the office rent component of the PE GPCIs, as well as the 2006 through 2007 professional malpractice pre mium data for determining the malpractice GPCIs. The 2006 through 2008 Bureau of Labor and Sta tistics (BLS) Occupational Employment Statistics (OES) data were us ed as a replacement for 2000 Ce nsus data for determining the physician work GPCIs and the employee compensation component of the PE GPCIs. As discussed in section II.D. of this proposed rule, the cost share weights for each GPCI value, that is, work, PE, and malpractice, re flect the same proportions determined for the proposed 2006-based MEI. Additionally, the proposed GPCIs reflect se veral provisions required by the ACA. Section 1848(e)(1)(H) of the Act (as added by section 3102(b) of the ACA) specifies that for CY 2010 and CY 2011, the employee wage an d rent portions of the PE GPCIs reflect only one-half of the relative cost differences for each locality compared to the national average and includes a “hold harmless” provision for any PFS locality that would receive a reduction to its PE GPCI resulting from the limited recognition of cost differences. Section 1848(e)(1)(E) of the Act (as amended by section 3102(a) of the ACA) extends the 1.000 work GPCI floor only through December 31, 2010. Therefore, the proposed

CY 2011 GPCIs reflect the sunset of the 1.000 work GPCI floor. Section 1848(e)(1)(G) of the Act (as amended by section 134(b) of the MIPPA) established a permanent 1.500

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work GPCI floor in Alaska, beginning January 1, 2009 and, therefore, the 1.500 work GPCI floor in Alaska will remain in pl ace for CY 2011. Moreover, section 1848(e)(1)(I) of the Act (as added by section 10324(c) of the ACA) establishes a 1.000 PE GPCI floor

for services furnished in fr ontier states effective January 1, 2011. OACT estimates the combined impact of these provisions on a fis cal year cash basis as $580 million for FY

2011. As required by the statute, the updated GPCIs would be phased in over a 2-year period. Addendum D to this proposed rule shows the estimated effects of the revised GPCIs on locality GAFs for the transitional ye ar (CY 2011) in descending order. The GAFs reflect the use of updated underlying GP CI data, updated cost share weights, and the ACA provisions. The GAFs are a weighted composite of each area’s work, PE, and malpractice GPCIs using the national GPCI cost share weights. While we do not actually use the GAFs in computing the PFS payment fo r a specific service, they are useful in comparing the estimated overall costs and payments for different localities. The actual effect on payment for any specific servi ce would deviate from the estimated payment based on the GAF to the extent that the propor tions of work, PE, and malpractice expense RVUs for the specific service differ from those of the GAF. The most significant changes would occur in 12 payment localities, where the GAF increases by more than 1 percent or decreases by more than 2 percent. The cumulative effects of all of the GPCI revisions, including the updated underlying GP CI data, updated cost share weights, and provisions of the ACA, are refl ected in the CY 2012 GPCI values that are displayed in Addendum E to this proposed rule. C. Rebasing and Revising of the MEI

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As discussed in section II.E.1. of this proposed rule, we are proposing to rebase and revise the MEI for the CY 2011 PFS. Substituting the proposed 2006 MEI weights in place of the 2000 weights and implementing the proposed revisions to the MEI has no impact on the projected MEI increase for CY 2011. The projected MEI update for CY 2011 is 0.3 percent under both the 2000-based and 2006-based MEI. After CY 2011, the MEI updates are slightly higher (0.1 percentage point) in the early part of the forecast, unchanged in the medium term, and slightly lower in the long term (between 0.1 to 0.2 percentage points).

D. The Affordable Care Act Provisions 1. Section 3103: Extension of Exceptions Process for Medicare Therapy Caps This provision extends the exceptions process for therapy caps through December 31, 2010. Therapy caps are discussed in detail in section III.A.1. of this proposed rule. OACT estimates the impact on a fiscal year cash basis as $1.16 billion for

FY 2011. 2. Section 3104: Extension of Payment for Technical Component of Certain Physician Pathology Services

As discussed in section V.E. of this proposed rule, this provision continues payment to independent laboratories for the TC of physician pathology services for feefor-service Medicare beneficiaries who are inpa tients or outpatients of a covered hospital through CY 2010. OACT estimates the impact on a fiscal year cash basis as $80 million

for FY 2011.

3. Sections 3105 and 10311: Extension of Ambulance Add-Ons

As discussed in section V.F. of this proposed rule, these provisions require the extension of certain add-on payments for ground ambulance services, and the extension

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of certain rural area designations for purpos es of air ambulance payment. As further discussed in section V.F., we are amending the Medicare program regulations to conform the regulations to these provisions of the ACA. These statutory provisions are essentially prescriptive and do not allow for discretionary a lternatives on the part of the Secretary. As discussed in the July 1, 2004 interim final rule (69 FR 40288), in determining the super-rural bonus amount under section 1834(l)( 12) of Act, we followed the statutory guidance of using the data from the Comptroller General (GAO) of the U.S. We obtained

the same data as the data that were used in the GA O’s September 2003 Report titled “Ambulance Services: Medicare Payments Can Be Better Targeted to Trips in Less Densely Populated Rural Areas” (GAO repo rt number GAO-03-986) and used the same general methodology in a regression analysis as was used in that report. The result was that the average cost per trip in the lowe st quartile of rural county populations was 22.6 percent higher than the average cost per trip in the highest quartile. As required by section 1834(l)(12) of the Act, this percent in crease is applied to the base rate for ground ambulance transports that originate in qualif ied rural areas, which were identified using the methodology set forth in the statute. Payments for ambulance services under Medicare are determined by the point of pick -up (by zip code area) where the beneficiary

is loaded on board the ambulance. We de termined that ground ambulance transports originating in 7,842 zip code areas (which we re determined to be in “qualified rural areas”) out of 42,879 zip code areas, according to the July 2010 zip code file, will realize increased base rate payments under this provision; however, the number and level of services that might occur in these areas for CY 2011 is unknown at this time. While many elements may factor into the final impact of sections 3105(a), (b), and (c) and 10311(a), (b), and (c) of the ACA, our Of fice of the Actuary (OACT) estimates the

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impact of all these provisions to be $10 million for FY 2011. 4. Section 3107: Extension of Physicia n Fee Schedule Mental Health Add-On

As discussed in section V.G. of this proposed rule, this provision extends the period of time for the five percent increase in Medicare payment for specified mental health services through CY 2010. OACT estimate s the impact on a fiscal year cash basis as $20 million for FY 2011. 5. Section 3111: Payment for Bone Density Tests As discussed in section V.I. of this pr oposed rule, this provision restores payment for dual-energy x-ray absorptiometry (DXA) services furnished during CYs 2010 and 2011 to 70 percent of the Medicare rate pa id in CY 2006. OACT estimates the impact on a fiscal year cash basis as $60 million for FY 2011.

6. Section 3122: Extension of Medicare Reas onable Costs Payments for Certain Clinical Diagnostic Laboratory Tests Furnished to Hospital Patients in Certain Rural Areas

As discussed in section V.K. of this proposed rule, this provision reinstitutes reasonable cost payment for clinical diagnostic laboratory tests performed by hospitals with fewer than 50 beds that are located in qua lified rural areas as part of their outpatient services for cost reporting periods beginning on or after July 1, 2010 through June 30, 2011. For some hospitals with cost reports that begin as late as June 30, 2011, this reinstitution of reasonable cost payment could affect services performed as late as June 29, 2012, because this is the date those cost reports will close.

7. Section 3135: Modificati on of Equipment Utilization Factor For Advanced Imaging

Services As discussed in section V.M. of this pr oposed rule, for services furnished on or after July 1, 2010, section 1848(b)(4)(D) of the Act (as added by section 3135(b) of the

### CMS-1503-P 691

ACA) adjusts the technical component MPPR for multiple imaging studies provided in a single imaging session on contiguous body part s within families of c odes from 25 percent to 50 percent as of July 1, 2010. For services furnished on or after January 1, 2011, section 1848(b)(4)(C) of the Act (as added by section 3135(a) of the ACA) increases the equipment utilization rate to 75 percent fo r expensive diagnostic imaging equipment, changing the CY 2011 transitional utilization ra te adopted in the CY 2010 PFS final rule with comment period to the 75 percent rate. Both of these provisions are not budget neutral. OACT estimates the impact on a fiscal year cash basis to be savings to the Medicare program of $160 million for FY 2011. 8. Section 3136: Revisions in Payments for Power Wheelchairs

As discussed in section V.N. of this proposed rule, this provision requires the Secretary to revise the ca pped rental fee schedule amount s for all power wheelchairs effective for power wheelchairs furnishe d on or after January 1, 2011. Under the monthly capped rental payment structure, the fee schedule will pay 15 percent (instead of 10 percent) of the purchase price for the firs t three months and 6 percent (instead of 7.5 percent) for the remaining rental months not to exceed 13 months. In addition, the lump sum (up front) purchase payment will be eliminated for standard power-driven wheelchairs. For complex rehabilitative power-driven wheelchairs, the provision permits payment to be made on a lump sum purchase method or a monthly rental method. These changes are prescriptive in the statute and does not allow for discretionary alternatives. We expect the changes mandated by section 3136 of the ACA as a whole to achieve program savings as a result of tota l payments per standard power wheelchair being less than 100 percent of the purchas e fee schedule amount. This decrease in expenditures is expected for two reasons. Primarily, the provision will eliminate the

### CMS-1503-P 692

lump sum payment method for standard power-driven wheelchairs and instead payment

will be made under the monthl y rental method resulting in lower aggregate payments because many beneficiaries who use standard power wheelchairs do not use them for as long as 13 months. In addition, we note that currently a significantly lower volume of power-driven wheelchairs are paid under the monthly payment method. The payment impact of increasing monthly rental payments in the initial 3 months will be offset both by the savings achieved from eliminating th e lump sum payment method for standard power-driven wheelchairs and by decreasing paym ents for the remaining months of rental from 7.5 percent to 6 percent of the purchase price for all power-driven wheelchairs. We compared the estimates of current payments for power-driven wheelchairs to estimates of payments resulting from the changes which showed an estimated payment impact of a decrease in expenditures of approximately $780 million over a 5-year period. The FY 2011 cash savings was $120 million.

9. Section 3401: Revisions of Certain Mark et Basket Updates and Incorporation of Productivity Adjustments

As discussed in section V.P. of this proposed rule, section 3401 of the ACA incorporates a productivity adjustment into the update factors for certain payment systems. Specifically, section 3401 requires that in CY 2011 (and in subsequent years), update factors under the ambulatory surgical center payment system, the ambulance fee schedule, and the clinical laboratory fee schedule be adjusted by the productivity adjustment. OACT estimates the impact to be savings to the Medicare program of $20 million, $30 million, and $50 million for the ambulatory surgical center payment system, the ambulance fee schedule, and the clinical laboratory fee schedule, respectively, for FY 2011. Furthermore section 3401 changed the 201 1 ESRD composite rate Market Basket

### CMS-1503-P 693

minus one increase to a Market Basket increas e. This provision would be a cost to the Medicare program of $40 million (does not include coinsurance). 10. Section 4103: Medicare Coverage of Annual Wellness Visit Providing a

Personalized Prevention Plan As discussed in section V.Q. of this pr oposed rule, for services furnished on or after January 1, 2011, section 1861(s)(2)(FF) of the Act (as added by section 4103 of the ACA) provides Medicare cove rage, with no coinsurance or deductible, for an annual

wellness visit. The annual wellness visit en tails the creation of a personalized prevention plan for an individual that includes a hea lth risk assessment and may include other elements, such as updating the family history, identifying providers that regularly provide medical care to the individual, body ma ss index measurement, development of a screening service schedule, and identification of risk factors. OACT estimates the impact on a fiscal year cash basis to be $110 million for FY 2011.

11. Section 4104: Removal of Barriers to Preventive Services in Medicare As discussed in section V.R. of this pr oposed rule, for services furnished on or after January 1, 2011, sections 1833(a)(1) and 183 3(b)of the Act (as amended by section 4104 of the ACA) waive the deductible a nd coinsurance requirements for most preventive services, and waive the deductible for colorectal cancer screening tests that are reported with other codes. Services to which no coinsura nce or deductible would be applied are the annual wellness visit, the initial preventive physical examination, and any covered preventive service if it is recommended with a grade of A or B by the United

States Preventive Services Task Force. We estimate that this new benefit will result in an increase in Medicare payments. OACT estimates the impact on a fiscal year cash basis to be $110 million for FY 2011.

### CMS-1503-P 694

12. Section 5501: Expanding Access to Prima ry Care Services and General Surgery

Services As discussed in section V.S. of this pr oposed rule, for services furnished on or after January 1, 2011 and before January 1, 2016, sections 1833(x) and (y) of the Act (as added by section 5501 of the ACA) provide pr imary care practitioners, as well as general surgeons practicing in geographic health pr ofessional shortage areas, with 10 percent incentive payments based on their provision of primary care or major surgical services, respectively. OACT estimates the impact on a fiscal year cash basis to be $170 million

for FY 2011.

13. Section 6003: Disclosure Requirements for In-office Ancillary Services Exception to the Prohibition of Physician Self-re ferral for Certain Imaging Services In section V.T of the preamble of this proposed rule, we propose to amend §411.355(b)(2) to include a new disclosure re quirement created by section 6003 of the ACA and related to the in-office ancillary serv ices exception to the physician self-referral prohibition. Specifically, the st atute requires that, with resp ect to magnetic resonance imaging, computed tomography, and positron emission tomography the referring physician must inform the patient in writing at the time of the referral that the patient may obtain the same imaging services from anothe r supplier. In addition, the statute requires physicians to provide a writte n list of other suppliers who furnish the same imaging services in the area in which the patient resides. We propose that the written notice shall incl ude a list of at least 10 other suppliers who provide the services for which the indivi dual is being referred and which are located within a 25-mile radius of the referring phys ician’s office location. If there are fewer than 10 other suppliers located within a 25-mile radius of the physician’s office location,

### CMS-1503-P 695

the physician shall list all of the other suppliers of the imaging service that are present within a 25-mile radius of the referring ph ysician’s office location, including up to 10 suppliers. Provision of the written list of a lternate suppliers will not be required if no other suppliers provide the services for whic h the individual is being referred within a 25-mile radius. We also propose that the no tice should be written in a manner sufficient to be reasonably understood by all patients and should include for each supplier on the list, at a minimum, the supplier’s name, addr ess, telephone number, and distance from the referring physician’s office location. A record of the disclosure notification, signed by the patient, shall be maintained as a part of the patient’s medical record. Our proposal minimizes the administrative burden for physician by requiring the development of only one list of alternative suppliers for each office location, rather than multiple lists targeting the various areas in which the physician’s patients reside. We do not anticipate that our proposals in section V.T. of the preamble of this proposed rule would have a significant economic impact on a substantial number of physicians, other health care providers a nd suppliers, or the Medicare or Medicaid programs and their beneficiaries. Specifically, we believe that this proposed rule would affect only those physicians who provide MRI, CT, PET services under the in-office ancillary services exception and beneficiaries receiving those services. We are uncertain of the number of physicians who will have to comply with this disclosure requirement. Using data from the 2009 CMS Statistic s booklet, we propose an estimate of 71,000 Medicare enrolled physicians would have to comply with this new requirement. This figure represents 20 percent of primary care and medical specialty physicians enrolled in Medicare Part B. In order to ensure accuracy of the effect of this provision on physician practices, we are soliciting comments regarding the appropriateness of this estimate. The

### CMS-1503-P 696

burden associated with disclosing the inform ation, receiving the patient’s signature on the form and maintaining a record of such disclosure will be de minimis for the individual physician. Our proposed criteria for the new disc losure requirement would present a negligible economic impact on the physicia n or group practice required to create the disclosure notice. The physician or gr oup practice would incur only a one-time cost associated with developing a disclosure notice that informs patients that they may receive the same imaging services from another supp lier and also lists other suppliers located within a 25-mile radius of the physician’s offi ce location at the time of the referral. We

believe it would take an individual 1 hour to create the notice informing patients that they may receive imaging services from another supplier as well as to compile the list of 10 other suppliers. In addition, we believe it would require a negligible amount of time to provide the notice and list of suppliers to the patient and to maintain a copy of the notice in the patient’s medical record.

We believe that be neficiaries would be impacted pos itively by this new provision. The disclosure that the patient may receive the referred imaging services from another supplier contributes to inform ed decision-making about the availability of such imaging services from other suppliers. We also belie ve that furnishing a list of other suppliers who provide the same services in the vicinity of the referring physician serves patient convenience. The proposed regulation makes no significant changes that would impede patient access to health care services, and it will likely improve patients’ awareness of options in deciding where to receive imaging services.

14. Section 6404: Maximum Period for Submis sion of Medicare Claims Reduced to Not

More Than 12 Months

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As discussed in section V.U. of this proposed rule, section 6404 of the ACA reduces the maximum time period for filing Medicare claims to no more than 12 months

after the date of service. Under the new la w, claims for services furnished on or after January 1, 2010, must be filed within 1 calenda r year after the date of service. In addition, section 6404 of the ACA provides that claims for services furnished before January 1, 2010, must be filed no la ter than December 31, 2010. Section 6404 of the ACA also permits the S ecretary to make certain exceptions to the 1-year filing deadline. This proposed rule would create two new exceptions to the 1- year filing deadline. The first exception would permit the time limits for filing claims to be extended where a beneficiary becomes retroactively entitled to Medicare benefits, but was not

entitled to Medicare benefits at the time the services were furnished. Under this exception, the time to file a claim would be extended through the last day of the sixth month following the month in which the beneficiary received notification of the

retroactive Medicare entitlement to the date of the furnished service. The second exception would permit the time limits for filing claims to be extended where: (1) at the time the service was furnished, the beneficiary was not entitled to Medicare; (2) subsequently, the beneficiary received notification of Medicare entitlement, retroactively effective to the date of the furnished service; and (3) subsequently the State Medicaid agency recovered the Medicaid payment for the furnished service from a provider or supplier 11 months or more after date the service was furnished. Under this exception, the time to file a claim would be extended through the last day of the sixth month following the month in which the State recovered the Medicaid payment from the provider or supplier

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The budgetary impact related to this provisi on is significant as future payment of claims for services incurred will now be made at an earlier date, relative to the 12-month submission expiration. This is reflected by the Part A and Part B payment amounts of $60 and $50 million for FY 2011. However, for purposes of the Regulatory Impact Analysis, the economic impact of this provisi on is non-economically significant, as to the interest lost on money now required to pa y claims prior to the 12-month submission expiration is minimal. Providers and suppliers have established billing practices for the submission of claims for payment to the Medicare program. Although this proposed rule would require providers and suppliers to submit Medicare fee-for-service claims within 12 months from the date of service, we belie ve providers and suppliers w ould easily revise their billing practices on a one-time basis, and suffer no economic impact. In fact, analysis of

Medicare claims data shows that more than 99 percent of Part A a nd Part B claims are filed in 12 months or less. In addition, some providers and s uppliers will receive payment and interest on claims that are filed at an earlier date. Lastly, providers, suppliers, or the small number of beneficiaries that occasionally submit claims may benefit from the availab ility of the two proposed new exceptions to the timely filing rule; however, we believe the impact on program costs would be negligible. E. Other Provisions of the Proposed Regulation 1. Part B Drug Payment: ASP Issues Application of our proposed policies for “Carry Over ASP” and “Partial Quarter ASP Data,” as discu ssed in section VI.A. of this proposed rule, are dependent on the status and quality of quarterly manufacturer data submissions, so we cannot quantify

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associated savings. Furthermore, we do not expect that our proposed policy for determining the payment amount for drugs and biologicals whic h include intentional overfill, as discussed in section VI.A of this proposed rule, will impact payments made by the Medicare

program. Finally, as discussed in section VI.A of this proposed rule, we are proposing to provide for appropriate price substitutions that account for market-rel ated pricing changes and would allow Medicare to pay based off lower market prices for those drugs and biologicals that consistently exceed the applicable threshold percentage. We believe that this proposal will generate some savings fo r the Medicare program and its beneficiaries since any substituted prices would be for am ounts less than the calculated 106 percent of

the ASP. 2. Ambulance Fee Schedule: Proposed Po licy for Reporting Units when Billing for Ambulance Fractional Mileage

As discussed in section VI.B. of th is proposed rule, we are proposing to implement fractional mileage billing for all providers and suppliers of ambulance services. For all claims for mileage totalin g up to 100 covered miles, we are proposing to require all providers and supp liers of ambulance services to bill mileage rounded up to the nearest tenth of a mile rather than the nearest whole mile and are proposing to pay based on that amount. By requiring that pr oviders and suppliers round up to the nearest

tenth of a mile rather than the nearest w hole mile, providers and suppliers would be submitting claims for anywhere between 0.1 and 0.9 of a mile less per claim and Medicare would pay based on that amount. We anticipate that requiri ng greater accuracy in billing for ambulance mileage will generate modest cost savings for the Medicare

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program. Based on our rough estimates usin g CY 2008 claims data , Medicare could potentially save at least $45 million per year in payments for base mileage billed by suppliers, and perhaps as much as $80 million pe r year when considering other types of ambulance mileage payments such as those for rural mileage and those made to institutional providers. 3. Chiropractic Serv ices Demonstration

As discussed in section VI.D. of this proposed rule, we are continuing the recoupment of the $50 million in expenditures from this demonstration in order to satisfy the budget neutrality requirement in section 651(f)(1)(b) of the MMA. We initiated this recoupment in CY 2010 and this will be the s econd year. As discussed in the CY 2010

PFS final rule with commen t period, we finalized a policy to recoup $10 million each year through adjustments to the PFS for all chiropractors in CYs 2010 through 2014. To implement this required budget neutrality ad justment, we are recouping $10 million in CY 2011 by reducing the payment amount under the PFS for the chiropractic CPT codes (that is, CPT codes 98940, 98941, and 98942) by approximately 2 percent. 4. Renal Dialysis Services Furnished by ESRD Facilities The ESRD related provisions are discussed in sections V.P. and VI.E. of this proposed rule. To understand the impact of th e changes affecting payments to different categories of ESRD facilities, it is necessa ry to compare estimated payments under the current year (CY 2010 payments) to estimate d payments under the revisions to the composite rate payment system (CY 2011 payments ) as discussed in section VI.E. of this proposed rule. To estimate the impact among various classes of ES RD facilities, it is imperative that the estimates of current pa yments and estimates of proposed payments contain similar inputs. Therefore, we simu lated payments only for those ESRD facilities

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for which we are able to calculate both current CY 2010 payments and proposed CY 2011 payments. Also, as explained in the ESRD PPS proposed rule (74 FR 50019), section 1881(b)(14)(E)(i) of the Act requires a 4-year transition (phase-in) from the current composite payment system to the ESRD PP S, and section 1881(b)(14)(E)(ii) allows

ESRD facilities to make a one-time election to be excl uded from the transition. As of January 1, 2011, ESRD facilities that elect to go through the transition would be paid a

blended amount that will consis t of 75 percent of the basic case-mix adjusted composite payment system and the remaining 25 percent would be based on the ESRD PPS payment. Therefore, these proposed rates lis ted in the impact table below reflect only the composite rate portion of the blended paym ent amounts for facilities going through the first year of the 4-year transition under the new ESRD PPS. A full analysis of the projected impact of the ESRD PPS will be addressed in the ESRD PPS final rule which will be published in the summer. ESRD providers were grouped into th e categories based on characteristics provided in the Online Survey and Certifi cation and Reporting (OSCAR) file and the most recent cost report data from the Healthcare Cost Report Information System (HCRIS). We also used the December 2009 update of CY 2009 National Claims History file as a basis for Medicare dialysis treatments and separately billable drugs and biologicals. Since the December 2009 update of the CY 2009 National Claims History File is incomplete, we update d the data. The description of the updates for the separately billable drugs is described in section IV.E. of this proposed rule. To update the treatment

counts we used the ratio of the June 2009 to the December 2008 updates of the CY 2008 National Claims History File fi gure for treatments. This was an increase of 12.4 percent.

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Due to data limitations, we are unable to es timate current and proposed payments for 32

of the 5318 ESRD facilities that bill fo r ESRD dialysis treatments. Table 75 shows the impact of this year’s proposed changes to CY 2011 payments to hospital-based and independent ESRD facilities. The first column of Table 75 identifies the type of ESRD provider, the se cond column indicates the number of ESRD facilities for each type, and the third column indicates the number of dialysis treatments.

The fourth column shows the effect of all proposed changes to the ESRD wage index for CY 2011 as it affects the composite rate paymen ts to ESRD facilities. The fourth column compares aggregate ESRD wage-adjusted composite rate payments in CY 2011 to aggregate ESRD wage-adjusted composite rate payments in CY 2010. In CY 2010, ESRD facilities receive 100 percent of the CBSA wage-adjusted composite rate. The overall effect to all ESRD providers in ag gregate is zero because the CY 2011 ESRD wage index has been multiplied by a budget neutrality adjustment factor to comply with the statutory requirement that any wage inde x revisions be done in a manner that results in the same aggregate amount of expenditure s as would have been made without any changes in the wage index. The fifth column shows the effect of proposed changes to the ESRD wage index in CY 2011 and the effect of section 3401(h) of the ACA, which amends section 1881(b)(14)(F) of the Act to revise the ESRD market basket increase factor. Effective January 1, 2011, there is a full ESRD bundled market basket update to the composite rate component of the ble nded payment amount under the payment system. We anticipate an estimated ESRD market bask et increase factor of 2.5 percent for those facilities electing to go through the ESRD PPS transition. The sixth column shows the overall effect of the proposed changes in co mposite rate payments to ESRD providers, including the drug add-on. The overall effect is measured as the difference between the

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proposed CY 2011 payment with all changes as proposed in this rule and current CY 2010 payment. This payment amount is computed by multiplying the wage-adjusted composite rate with the drug add-on for each provider times the number of dialysis

treatments from the CY 2009 claims. The CY 2011 proposed payment is the composite rate for each provider (with the proposed 14.7 percent drug add on) times dialysis

treatments from CY 2009 claims. The CY 2010 cu rrent payment is the composite rate for each provider (with the current 15.0 percent dr ug add on) times dialysis treatments from

CY 2009 claims. The overall impact to ESRD providers in aggregate is 2.2 percent as shown in

Table 75. Most ESRD facilities will see an in crease in payments as a result of the ACA provision. While section 3401(h) of the ACA modifies the ESRD bundled market basket, which we anticipate will be a 2.5 percent incr ease to the ESRD composite rate portion of the blended payment amount, this 2.5 percent increase does not apply to the drug add-on to the composite rate. For this reason, the impact of all changes in this proposed rule is a 2.2 percent increase for all ESRD providers. Overall, payments to independent ESRD facilities will increase by 2.2 pe rcent and payments to hosp ital-based ESRD facilities will increase by 2.1 percent. TABLE 75: Impact of CY 2012 Changes in Payments to Hospital-Based and Independent ESRD Facilities [Percent change in composite rate payments to ESRD facilities]

1 2 3 4 5 6 Number of facilities Number of Dialysis Treatments (in millions) Effect of Changes in Wage Index 1/ Effect of Changes in Wage Index and of Affordable

Care Act provision/ 2 Overall Effect of Wage Index Affordable

Care Act & Drug Add-on 3 /

All Providers 5,286 38.8 0.0% 2.5% 2.2% Independent 4,715 35.1 0.0% 2.5% 2.2% Hospital Based 571 3.7 -0.1% 2.4% 2.1%

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1 2 3 4 5 6 Number of facilities Number of Dialysis Treatments (in millions) Effect of Changes in Wage Index 1/ Effect of Changes in Wage Index and of Affordable

Care Act provision/ 2 Overall Effect of Wage Index Affordable

Care Act & Drug Add-on 3 / By Facility Size Less than 5000 treatments 1,973 5.6 0.1% 2.6% 2.3% 5000 to 9999 treatments 2,042 14.8 0.1% 2.6% 2.3% Greater than 9999 treatments 1,271 18.3 -0.1% 2.4% 2.1% Type of Ownership Profit 4,332 32.1 0.0% 2.5% 2.3% Nonprofit 954 6.7 -0.1% 2.4% 2.1% By Geographic Location Rural 1,167 6.3 0.2% 2.7% 2.4% Urban 4,119 32.5 0.0% 2.5% 2.2% By Region New England 163 1.3 -0.6% 1.9% 1.6% Middle Atlantic 591 4.8 -0.4% 2.1% 1.8% East North Central 869 6.0 0.2% 2.7% 2.4% West North Central 397 2.1 -0.1% 2.4% 2.2% South Atlantic 1,188 8.8 0.0% 2.5% 2.2% East South Central 415 2.9 0.0% 2.5% 2.3% West South Central 712 5.6 0.4% 2.9% 2.7% Mountain 310 1.8 0.2% 2.7% 2.4% Pacific 603 5.1 0.0% 2.5% 2.3% Puerto Rico & Virgin Islands 38 0.4 -2.4% 0.0% -0.2% Notes: Payments have been adjusted to reflect budget neutrality. 2010 includes the MIPPA 1 percent increase and site neutral rates. 2010 & 2011 are 100 percent new CBSA wage adjusted compsite rate.

1 This column shows the overall effect of wage index changes on ESRD providers. Composite rate payments are computed using the proposed CY 2011 wage indexes which are compared to composite rate payments using the current CY 2010 wage indexes. 2 This column shows the effect of the changes in the Wage Indexes and the ACA provision which includes an ESRD Bundled Market Basket (anticipated 2.5 percent) increas e to the composite rate. Th is provision is effective January 1, 2011. 3 This column shows the percent change between CY 2011 and CY 2010 composite rate payments to ESRD facilities. 4 The CY 2011 payments include the CY 2011 wage adjusted composite rate, an anticipated 2.5 percent increase due to the ACA effective January 1, 2011, and the drug add-on of 14.7 percent. The CY 2010 payments include the CY 2010 wage adjusted composite rate, a 1 percent increase and site neutral rates effective January 1, 2009, and the drug add-on of 15.0 percent. This column shows the effect of wage index, ACA, and drug add-on changes. Although as a result of the ACA provision we anticipate a 2.5 percent increase to the composite rate in CY 2011, this increase does not apply to the drug add-on to the composite rate. For this reason, the impact of all changes in this proposed rule is a 2.2 percent increase for all ESRD providers.



### 5. Section 131(b) of the MIPPA: Physic ian Payment, Efficiency, and Quality Improvements - Physician Quality Reporting Initiative (PQRI)

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As discussed in section VI.F.1 of this proposed rule, we propose several different reporting options for EPs who wish to partic ipate in the 2011 PQRI. Although there may be some cost incurred in the PQRI and thei r associated code sets, and for expanding an existing clinical data warehouse to acco mmodate registry-based reporting and EHRbased reporting for the PQRI, we do not anticipate a significant cost impact on the Medicare program. Participation in the CY 2011 PQRI by i ndividual EPs is voluntary and individual EPs and group practices may have different proc esses for integrating the PQRI into their practice’s work flows. Given this variability and the multiple reporting options that we propose to provide, it is difficult to accurate ly estimate the impact of the PQRI on providers. Furthermore, we be lieve that costs for EPs who are participating in the PQRI for the first time in 2011 will be considerably higher than the cost for EPs who participated in PQRI in prior years. In add ition, for many EPs, the co st of participating in the PQRI is offset by the incentive payment received. With respect to the potential incentive payment that will be made for the 2011 PQRI, we estimate this amount to be a pproximately $100 million. This estimate is derived from looking at our 2008 incentive payment of more than $93 million and then accounting for the fact that the 2008 incentive payment was 1.5 percent of an EP’s total estimated Medicare Part B PFS allowed charges for all covered professional services furnished during the 2008 reporting period. For 2011, the incentive payment is 1.0 percent of an EP’s total estimated Medicare Part B PFS allowed charges for all covered professional services furnis hed during the 2011 reporting period. Although we expect that the lower incentive payment amount for 2011 would reduce the total outlay by

### CMS-1503-P 706

approximately one-third, we also expect more EPs to participate in the 2011 PQRI as

there are more methods of data submission a nd additional alternativ e reporting periods.

One factor that influences the cost to individual EPs is the time and effort associated with individual EPs identifying applicable PQRI quality measures and reviewing and selecting a repor ting option. This burden will vary with each individual EP by the number of applicable measures, th e EP’s familiarity and understanding of the PQRI, experience with PQRI participation, a nd the method(s) selected by the EP for reporting of the measures, and incorporating th e reporting of the measures into the office

work flows. Information obtained from the Physician Voluntary Reporting Program (PVRP), which was a predecessor to the PQRI and was the first step for the reporting of physician quality of care through certain qualit y metrics, indicated an average labor cost per practice of approximately $50 per hour. To account for salary increases over time, we will use an average practice labor cost of $58 per hour for our estimates, based on an assumption of an average annual increase of approximately 3 percent. Therefore, assuming that it takes an indi vidual EP approximately 5 hours to review the PQRI quality measures, review the various reporting opti ons, select the most appropriate reporting option, identify the applicable measures for which they can report the necessary information, and incorporate reporting of the selected measures in to their office work flows, we estimate that the cost to EPs associated with preparing to report PQRI quality measures would be approximately $290 pe r individual EP ($58 per hour X 5 hours).

Another factor that influen ces the cost to individual EPs is how they choose to report the PQRI measures (that is, whether they select the claims-based, registry-based or EHR-based reporting mechanism). For claims -based PQRI reporting, estimates from the PVRP indicate the time needed to perform all the steps necessary to report quality data

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codes (QDCs) for 1 measure on a claim ra nges from 15 seconds (0.25 minutes) to 12 minutes for complicated cases or measures. In previous years, when we required reporting on 80 percent of eligible cases for claims-based reporting, we found that on average, the median number of reporting instances for each of the PQRI measures was 9. Since we propose to reduce the required reportin g rate by over one-third to 50 percent, then for purposes of this impact analysis we will assume that an EP will need to report each selected measure for 6 reporting instances, or 6 cases. Assuming that an EP, on average, will report 3 measures and that an EP reports on an average of 6 reporting instances per measure, we estimate that the cost to an individual EP associated with claims-based reporting of PQRI measures would range from a pproximately $4.35 (0.25 min per reporting instance x 6 reporting inst ances per measure x 3 measures x $58 per hour) to $208.80 (12 min per reporting instance x 6 reporting instances per measure x 3 measures x $58 per hour). If an EP satisfa ctorily reports, these costs will more than likely be negated by the incentive earned. For the 2007 PQRI, which had a 1.5 percent incentive for a 6-month reporting period, th e mean incentive amount was close to $700

for an individual EP and the median in centive payment amount was over $300. For registry-based reporting, individual EPs must generally incur a cost to submit data to registries. Estimated fees for using a qualified registry range from no charge, or a nominal charge, for an individual EP to use a registry to several thousand dollars, with a majority of registries charging fees ranging from $500-$1000. However, our impact analysis should be limited to the incremental co sts associated with PQRI reporting, which we believe are minimal. Many EPs who sel ect registry-based reporting were already utilizing the registry for other purposes and would not need to report additional data to

### CMS-1503-P 708

the registry specifically for PQRI. The regi stries also often provide the EP services above and beyond what is required for PQRI. For EHR-based reporting, an individual EP generally would incur a cost associated with purchasing an EHR product. Although we do not believe that the majority of EPs would purchase an EHR solely for the purpose of participating in PQRI,

we estimate that an individual EP who chooses to do so would have to spend anywhere from $25,000-$54,000 to purchase and implement a certified EHR and $10,000 annually for ongoing maintenance. Although we believe that the majority of EPs attempting to qualify for the additional 0.5 percent incentive payment aut horized by section 1848(m)(7) of the Act would be those who are already required by their Boards to participate in an MOCP, individual EPs who wish to qualify for the additional 0.5 percent incentive payment and are not currently participating in an MOCP would also have to incur a cost for participating in an MOCP. The manner in which fees are charged for participating in an MOCP vary by specialty. Some Boards charge a single fee for participation in the full cycle of MOC. Such fees appear to range anywhere from over $1,100 to nearly $1,800 per cycle. Some Boards have annual fees that are paid by their diplomates. On average, ABMS diplomates pay approximately $200.00 per year for participating in MOC. Some

Boards have an additional fee for the MOC Pa rt III secure examination, but most Boards do not have additional charge s for participation in the Part IV practice/quality improvement activities. With respect to the proposed process for group practices to be treated as satisfactorily submitting quality measures da ta for the CY 2011 PQRI discussed in section VI.F.1 of this proposed rule, group prac tices interested in participating in the CY

### CMS-1503-P 709

2011 PQRI through the group practice reporting option (GPRO) I or GPRO II may also incur a cost. However, for groups that sa tisfactorily report fo r 2011 PQRI, we believe these costs would be completely offset by the incentive payment earned since the group practice would be eligible for an incentive payment equal to 1 percent of the entire group’s total estimated Medicare Part B PFS allowed charges for covered professional services furnished during the reporting period. One factor in the cost to group practices would be the costs associated with the self-nomination process. Similar to our estimates fo r staff involved with the claims-based reporting option for individual EP s, we also estimate that the group practice staff involved in the group practice self-nomin ation process has an average labor cost of $58 per hour. Therefore, assuming 2 hours fo r a group practice to decide whether to participate individually or as a group and 4 hours for the self-nomination process, we estimate the total cost to a group practice associated with the group practice selfnomination process to be approximately $348 ($58 per hour X 6 hours per group practice). For groups participating under the proposed GP RO I process, another factor in the cost to the group would be the time and ef fort associated with the group practice completing and submitting the proposed data collection tool. The information collection components of this data coll ection tool have been reviewed by OMB and are currently approved under OMB control number 0938- 0941, with an expiration date of December 31, 2011. Based on the Physician Group Practice (PGP) demonstration’s estimate that it takes approx imately 79 hours for a group prac tice to complete the data collection tool, which uses the same data s ubmission methods as t hose we have proposed,

### CMS-1503-P 710

we estimate the cost associated with a phys ician group completing the data collection tool would be approximately $4,582 ($58 per hour X 79 hours per group practice). For group practices participating under th e proposed GPRO II process, the costs associated with submitting the PQRI quality measures data would be the time associated with the group practice submitting the required data to CMS via claims or a registry. The costs for a group practice reporting to a registry should be similar to the costs associated with registry reporting for an individual EP, as the process is the same with the exception that more patients and more measures must be reported in GPRO II compared to an individual EP. For similar reasons, the cost s for a group practice reporting via claims

should also be similar to the costs associ ated with claims-based reporting for an individual EP. Overall, there is significan tly less burden associated with a group practice participating in PQRI via GPRO II than doing so as individual EPs. Participation in GPRO II requires the group practice as a whol e to report a fewer number of measures on a fewer number of people since EPs within a group who share patients would not be required to separately report measures for thos e shared patients. Therefore, assuming that an average group practice would spend 20 hour s for data submission, we estimate the

cost of data submission under GPRO II would be approximately $1,160 (20 hours for data submission x $58 per hour). Smaller gr oups may need less time for data submission as they would be required to report fewer measures and presumably have a smaller patient population while larger groups may need more time for data submission since they would be required to report more measur es and presumably have a larger patient population. In addition to costs incurred by EPs and group practices, registries and EHR vendors may also incur some costs related to the PQRI. Registries interested in

### CMS-1503-P 711

becoming “qualified” to submit on behalf of individual EPs would also have to incur a cost associated with the vetting process and with calculating quality measures results from the data submitted to the registry by its participants and submitting the quality

measures results and numerator and denomin ator data on quality measures to CMS on behalf of their participants. We estimate th e registry self-nomination process would cost approximately $500 per registry ($50 per hour X 10 hours per registry). This cost estimate includes the cost of submitting the self-nomination letter to CMS and completing the CMS vetting process. Our estima te of $50 per hour average labor cost for registries is based on the assumption that re gistry staff include IT professionals whose average hourly rates range from $36 to $84 per hour depending on experience, with an average rate of nearly $50 per hour for a mid-level programmer. However, the 2010 qualified registries would not incur any costs associated with the self-nomination process unless they are unsuccessful at submitting 2010 PQ RI results, they wish to be qualified to

submit additional measures or for additiona l methods, or we fina lize new requirements for 2011. We do not believe that there are any additional costs for re gistries associated with a registry calculating quality measures results from the data submitted to the registry by its participants and submitting the quality measures results and numerator and denominator data on quality measures to CMS on behalf of their partic ipants. We believe that the majority of registries already pe rform these functions for their participants. An EHR vendor interested in having its product(s) be used by individual EPs to submit PQRI measures to CMS for 2012 would have to complete a vetting process during 2011 and program its EHR product(s) to extract the clinical da ta that the EP needs to submit to CMS for purposes of reporting 2012 qu ality measures as well. We propose that previously qualified vendors would need to only update their electronic measure

### CMS-1503-P 712

specifications and data trans mission schema to incorporat e any new EHR measures to maintain their qualification for the 2012 PQRI. Therefore, for EHR vendors that were not previously qualified, the cost associated with completing the self-nomination process, including the vetting process with CMS offici als, is estimated to be $500 ($50 per hour X 10 hours per EHR vendor). Our estimate of a $50 per hour average labor cost for EHR vendors is based on the assumption that vendor staff include IT professionals whose average hourly rates range from $36 to $84 per hour depending on experience, with an average rate of nearly $50 per hour for a mid-l evel programmer. We believe that the cost

associated with the time and effort needed for an EHR vendor to review the quality measures and other information and program the EHR product to enable individual EPs to submit PQRI quality measures data to th e CMS-designated clinical warehouse will be dependent on the EHR vendor’s familiarity with PQRI, the vendor’s system’s capabilities, as well as the vendor’s progra mming capabilities. Some vendors already have the necessary capabilities and for such vendors, we estimate the total cost to be approximately $2,000 ($50 per hour X 40 hours per vendor). However, given the variability in the capabilities of the vendors, we believe an estimate for those vendors with minimal experience would be appr oximately $10,000 per ve ndor ($50 per hour X 200 hours per EHR vendor).

6. Section 132 of the MIPPA: Incentives fo r Electronic Prescribing (eRx)- The eRx Incentive Program Section VI.F.2. of this proposed rule describes the proposed 2011 Electronic Prescribing (eRx) Incentive Program. To be considered a successful electronic prescriber in CY 2011, an individual EP would need to meet the requirements proposed in section VI.F.2. of this proposed rule.

### CMS-1503-P 713

We anticipate that the cost impact of the eRx Incentive Program on the Medicare program would be the cost incurred for maintaining the electronic prescribing measure and its associated code set, and for mainta ining the existing clinical data warehouse to accommodate registry-based reporting and EHR-based reporting for the electronic prescribing measure. However, we do not anticipate a significant cost impact on the Medicare program since much of this infrastructure has already been established for the PQRI program. Individual EPs and group practices may ha ve different processes for integrating the eRx Incentive Program into their practices’ work flows. Given this variability and the multiple reporting options that we propose to pr ovide, it is difficult to accurately estimate the impact of the eRx Incentive Program on pr oviders. Furthermore, we believe that costs for EPs who are participating in the eRx Incentive Program for the first time in 2011 will be considerably higher than the co st for EPs who participated in the eRx Incentive Program in prior years. In addition, for many EPs (especially those who participated in the eRx Incentive Program in pr ior years), the cost of participating in the eRx Incentive Program will be offset by the incentive payment received. At this time, no eRx incentive payments have been made yet. We are currently analyzing 2009 eRx data, which was the first ye ar of the program, and anticipate making the 2009 incentive payments later this year. We estimate that the incentive payments for the 2011 eRx Incentive Program (which will be paid in 2012) will be approximately $81

million. This estimate is base d on preliminary participation numbers from the early part of 2010 and incentive payments that have been made for PQRI. We anticipate that despite a decrease in the incentive payment amount from 2 percent in 2010 to 1 percent

of total estimated Medicare Part B allowed ch arges for covered professional services in

### CMS-1503-P 714

2011, more EPs (and groups) will choose to participate in the 2011 eRx Incentive Program to avoid a prospective 1 percent pa yment penalty in 2012 for not demonstrating that they are successful electronic prescr ibers. Even though the incentive payment amount for the 2011 eRx Incentive Program is equal to the incentive payment amount for the 2011 PQRI, we believe that the total in centive amount that will be paid for the 2011 eRx Incentive Program will be less than the total incentive payment amount that will be paid for the PQRI discussed above. The eRx Incentive Program does not apply to all EPs. For example, EPs who do not have prescribing privileges or EPs who do not practice in a particular care setting would not be able to participate in the eRx Incentive Program even though they can participate in PQRI. Any EP who wishes to participate in the eRx Incentive Program must have a qualified electronic prescribing system in orde r to participate. Therefore, a one-time potential cost to some individual EPs would be the cost of purchasing and using an eRx system, which varies by the commercial software package selected, the level at which the professional currently employs information t echnology in his or her practice and the training needed. One study indicated that a midrange complete electronic medical record with electronic prescribing functionality cost s $2,500 per license with an annual fee of $90 per license for quarterly updates of the drug database after setup costs while standalone prescribing, messaging, a nd problem list system may cost $1,200 per physician per year after setup costs. Hardwa re costs and setup fees substantially add to the final cost of any software package. (Cor ley, S.T. (2003). “Electronic prescribing: a review of costs and benefits.” Topics in Health Information Management 24(1):29-38.). These are the estimates that we propose to use for our impact analysis.

### CMS-1503-P 715

Similar to PQRI, one factor in the cost to individual EPs is the time and effort associated with individual EPs reviewing the electronic prescribing measure to determine whether it is applicable to them, reviewing the available reporting options and selecting one, gathering the required information, and in corporating reporting of the measure into

their office work flows. Since the eRx In centive Program consists of only 1 quality measure, we propose to estimate 2 hours as th e amount of time needed for individual EPs to prepare for participation in the eRx Incentive Program. Information obtained from the Physician Voluntary Reporting Program (PVR P), which was a predecessor to the PQRI and was the first step for the reporting of ph ysician quality of care through certain quality metrics, indicated an average labor cost pe r practice of approximately $50 per hour. To account for salary incr eases over time, we will use an av erage practice labor cost of $58 per hour for our estimates, ba sed on an assumption of an average annual increase of approximately 3 percent. At an average co st of approximately $58 per hour, we estimate the total preparation costs to individual EP s to be approximately $116 ($58 per hour x 2 hours).

Another factor that influences the cost to individual EPs is how they choose to report the electronic prescribing measure (that is, whether they select the claims-based, registry-based or EHR-based reporting mechanism). For claims-based reporting, there would be a cost associated with reportin g the appropriate QDC on the claims an individual EP submits for payment. Based on the information from the PVRP described

above for the amount of time it takes a median practice to report one measure one time (1.75 min) and the proposed requirement to re port 25 electronic prescribing events during 2011, we estimate the annual estima ted cost per individual EP to report the electronic prescribing measure via cl aims-submission to be $42.29 (1.75 min per case X 1 measure

### CMS-1503-P 716

X 25 cases per measure X $58 per hour). Assuming that the mean and median incentive payment amounts per individual EP would be co mparable to those for the PQRI since the incentive payments are calculated in the same manner, we believe that for most successful electronic prescribers who earn an incentive, these costs would be negated by the incentive payment received. For EPs who select the registry-based reporting mechanism, we do not anticipate any additional cost for individual EPs to report data to a registry, as individual EPs opting for registry-based reporting are more than likely already reporting data to the registry. Little if any, additional data would need to be reported to the registry for purposes of participation in the CY 2011 eRx Incentive Prog ram. Individual EPs using registries for PQRI will likely experience minimal, if any, increased costs charged by the registry to report this 1 additional measure. For EHR-based reporting, the EP must extract the necessary clinical data from his or her EHR, and submit the necessary data to the CMS-designated clinical data warehouse. Once the EHR is programmed by the vendor to allow data submission to CMS, the cost to the individual EP associated with the time and effort to submit data on the electronic prescribing measure should be minimal. With respect to the proposed process for group practices to be treated as successful electronic prescribers under the CY 2011 eRx Incentive Program discussed in section VI.F.2 of this proposed rule, group pr actices have the same option as individual eligible professionals in terms of the form and manner for reporting the eRx measure (that is, group practices have the option of reporting the measure through claims, a qualified registry, or a qualif ied EHR product). There are only 2 differences between the requirements for an individual EP and a group practice: (1) the fact that a group practice

### CMS-1503-P 717

would have to self-nominate; and (2) th e number of times a group practice would be required to report the eRx measure. Overall, there could be less cost associated with a practice participating in the eRx Incentive Pr ogram as a group rather than the individual members of the group separately participating. We do not anticipate any additional costs associated with the group practice self-no mination process since we propose to limit the group practices to those selected to particip ate in the 2011 PQRI GPRO I or PQRI GPRO II. The practices only would need to indicate their desire to participate in the eRx GPRO at the time they self-nominate for either PQRI GPRO I or PQRI GPRO II. The costs for a group practice reporting to an EHR or registry should be similar to the costs associated with registry and EHR reporting for an individual EP, as the process is the same with the exception that more electronic prescribing events must be reported by the group. For similar reasons, the costs for a group practice reporting via claims

should also be similar to the costs associ ated with claims-based reporting for an individual EP. Therefore, we estimate that the costs for group practices who are selected to participate in the CY 2011 eRx Incentive Program as a group would range from $126.88 (1.75 min per case X 1 measure X 75 cases per measure X $58 per hour) for the smallest groups participating under GP RO II to $4,229.17 (1.75 min per case x 2500 cases per measure x $58 per hour) for the gr oups participating under GPRO I.

We believe that the costs to individual EPs and group practices associated with avoiding the eRx penalty that goes into effe ct in 2012 would be similar to the costs of an EP or group practice reporting the electroni c prescribing measure for purposes of the 2011 eRx incentive. The proposed requireme nts for avoiding the 2012 eRx penalty, including the reporting period, essentially ove rlaps with the proposed requirements for

the 2011 eRx incentive.

### CMS-1503-P 718

Based on our proposal to consider onl y registries qualified to submit quality

measures results and numerator and denomin ator data on quality measures to CMS on their participant’s behalf for the 2011 PQRI to be qualified to submit results and

numerator and denominator data on the eRx measure for the CY 2011 eRx Incentive Program, we do not anticipate any cost to the registry associated with becoming a registry qualified to submit the eRx measure for CY 2011. The cost for the registry would be the time and effort associated with the registry calculating results for the eRx measure from the data submitted to the registry by its participants and submitting the quality measur es results and numerator and denominator data on the eRx quality measure to CMS on behalf of their participants . We believe such costs would be minimal as registries would al ready be required to perform these activities for PQRI. Likewise, based on our proposal to cons ider only EHR products qualified for the CY 2011 PQRI to be qualified to submit results and numerat or and denominator data on the electronic prescribing measure for the CY 2011 eRx Incentive Program, there would be no need for EHR vendors to undergo a sepa rate self-nomination process for the eRxIncentive Program. Therefore, there would be no additional cost associated with the selfnomination process.

The cost to the EHR vendor asso ciated with the EHR-based reporting requirements of this reporting initiative is the time and effort associated with the EHR vendor programming its EHR product( s) to extract the clinical data that the individual EP needs to submit to CMS for purposed of repo rting the CY 2011 eRx measure. Since we propose that only EHR products qualified for the 2011 PQRI would be qualified for the CY 2011 eRx Incentive Program, and the eRx Incentive Program consists of only one

### CMS-1503-P 719

measure, we believe that any burden asso ciated with the EHR vendor to program its product(s) to enable individual EPs to submit data on the eRx measure to the CMS-designated clinical data warehouse would be minimal. 7. Durable Medical Equipment-Related Issues a. Off-the-Shelf (OTS) Orthotics Exemption In section VI.G. of this proposed rule, we are proposing to expand the exemptions from the Competitive Bidding Program (CBP) for certain OTS orthotics to physicians or other practitioners (as defined by the Secretary) if furnished to their own patients as part of their professional service. The proposed exemption is a self-imple menting mandate required by section 154(d) of MIPPA, which added section 1847(a)(7) of the Act. Section 1847(a)(7)(A) of the Act expanded the exemptions from the CBP for certain OTS orthotics to physicians or other practitioners (as defined by the Secretary) if furnished to their own patients as part of their professional service. Section 1847(a)(7)(B) of th e Act, as added by section 154(d) of MIPPA, also expanded the exemp tion from CBP for certain OTS DME items (crutches, canes, walkers, folding manua l wheelchairs, blood glucose monitors, and infusion pumps) when furnished by hospitals to the hospital’s own patients during an admission or on the date of discharge. We believe this exemption would have a negligible impact on physicians and other providers. The exemption will allow physicians to continue to provide these items to their own patients without submitting a bid and becoming a contract supplier. This will also allow continued access to OTS items for beneficiaries while being seen in their physician’s office. b. Changes to Payment for Oxygen Equipment

### CMS-1503-P 720

The revisions pertaining to oxygen and ox ygen equipment in section VI.G. of this proposed rule reflect changes made by section 144(b) of MI PPA and regulations implementing that provision. In §414.226(g), ex ceptions are listed to the requirement that the supplier that furnishes oxygen equi pment in the 1st month of the 36-month period

must continue to furnish it until medical n ecessity ends or the 36-month of continuous use ends. Section VI.G. changes one excep tion (§414.226(g)(1)(ii)) to read that if a beneficiary relocates to an area that is outside the normal service area of the supplier before the 18th month, then the supplier does not have to continue to furnish the item or make arrangements. We expect that revising §414.226(g)(1)(ii) so that only suppliers that have received at least 18 months of rental payments must continue to furnish the oxygen equipment until medical necessity ends or the end of the reasonable useful lifetime should have a minor impact on the supplie r, but should provide protection to beneficiaries. The reason that we expect the revised exception will have little impact has foremost to do with the fact that it applies in cases that are the exception to the normal circumstances. Only 38 percent of the beneficiaries are still renting by the 18 th 

### month of the rental period; only suppliers furnishing oxygen equipment to this subgroup of

beneficiaries will be affected by this proposed change. Further, relocation between the 18th to the 36th month is not a common occurrence. Such relocation happens with less than 0.5 percent of the benefi ciaries using oxygen equipment. In addition, between the 32nd and 35th month, relocation ha ppens with the beneficiarie s in about 0.06 percent of the time on average. c. Diabetic Testing Supplies

### CMS-1503-P 721

We are establishing requirements fo r conducting a national competition for furnishing diabetic supplies on a mail order ba sis. Specifically this proposed rule will establish 3 requirements: a new definition for what constitutes mail order; a rule that requires contract suppliers to provide at a minimum 50 percen t of all of the different types of diabetic testing products on the market by br and and model name; and a prohibition against influencing and incentivizin g beneficiaries to switch their brand of monitor and testing suppliers. Currently based on claims data from fiscal year 2009 over 62 percent of beneficiaries receive their replacement diabetic testing s upplies from mail order suppliers. This definition will not impact these beneficiaries because they can continue to obtain their items through mail order. The remaining 38 percent of beneficiaries may

continue to obtain these items from a local storef ront. We do not expect this rule to have any adverse affects on beneficiaries because th e new definition of mail order is reflective of the way that beneficiaries currently get their testing supplies. However, we believethat by clarifying this definition we will protect beneficiaries from paying higher copayment amounts and we anticipate program sa vings that would have been eroded by suppliers circumventing our defi nition to continue to provide items, even if not awarded a contract under competitive bidding and to obtain the higher fee schedule payment amount. This definition is also consistent with the way that suppliers currently do business by either providing items through mail order or at a local storefront. For these reasons we believe this new definition will have minimal impact. Also, we considered the option to not bifurcate bidding based on delivery method and to bid for diabetic testing suppliers rega rdless of how the items were obtained. We rejected this approach because it would for ce companies with different business models

### CMS-1503-P 722

to compete against each other, by requiring local pharmacies to compete with national mail order suppliers in order to win a contract to be able to furnish testing supplies. In order to implement a na tional mail order competition fo r diabetic supplies, we are also proposing to implement the special “50 percent rule” mandated by MIPPA. This rule requires a bidder to demonstrate that its bid “covers types of diabetic testing strip products that, in the aggregate and taking in to account volume for the different products, cover 50 percent (or such higher percentage as the Secretary may specify) of all such types of products.” The 50 percent threshold would ensure that beneficiaries have access to mail order delivery of the top-selling diabe tic test strip products from every contract supplier. We plan to use the information th at bidding suppliers provide on their bidding Form B where suppliers list the products they plan to furnish. We believe this requirement will have a minima l impact on suppliers because most suppliers currently provide a wide range of the brands and models in order to gain market share. The statute states that suppliers are required to carry at le ast 50 percent of all brands on the market. However, the Secretary can establish suppliers to carry a higher percentage of brands. We have adopted 50 percent criteria because we believe this is reflective of what suppliers are currently doing and ensures appropriate access for beneficiaries. In addition to the 50 percent rule, we are also proposing to establish an antiswitching requirement. This provision would prevent contract suppliers from switching

beneficiaries from their current brand to a br and provided by the s upplier. We believe this requirement will protect the beneficiary and physician choice of glucose monitoring systems. The decision concerning the type of monitor and testing supplies that a beneficiary chooses should not be made by the supplier but ra ther by the beneficiary and their physician. We believe that this pr ovision will have a minimal impact on suppliers

### CMS-1503-P 723

because suppliers currently offer a variet y of products and generally do require beneficiaries to switch from the brands they are familiar with and customarily use. d. Metropolitan Statistical Areas We believe that the provisi ons pertaining to subdividing metropolitan statistical areas (MSAs) with populations of at l east 8,000,000 for the purpose of establishing competitive bidding areas (CBAs) under R ound 2 of the DMEPOS Competitive Bidding Program will have a positive impact on most s uppliers, particularly small suppliers. The authority provided by section 1847(a)(1)(D)(ii )(II) of the Act would be used to create CBAs that are smaller than the highly and densely populated MSAs of: ChicagoNaperville-Joliet, IL-IN-WI; Los Angeles-Long Beach-Santa Ana, CA; and New YorkNorthern New Jersey-Long Island, NY-NJ-PA. This should result in more manageable service areas for suppliers to navigate wh en furnishing items. More importantly, it should ensure more timely de livery of items and services to beneficiaries located throughout each of the MSAs. It should also benefit small suppliers because they would have smaller geographic areas to cover as contract suppliers than the large MSAs, which in some cases, might prevent them from be ing considered for participation under the program. The larger suppliers would still have the opportunity to bid in all of the CBAs within each MSA. We expect that subdividing the large MSAs of Chicago, Los Angeles, and New York would not have a negative impact on program savings, as long as each CBA is large enough to be attractiv e to suppliers for bidding purposes. Table 76 considers FY cash impact on th e entire Medicare program, including Medicare Advantage for FYs 2011 thru 2015 of the provisions of this proposed rule

related to the establishment of CBAs dur ing Round 2 and prior to calendar year 2015. The FY–CY distinction is an important one wh en comparing savings. For example, the

### CMS-1503-P 724

savings for the Medicare DMEPOS Competitive Bidding Program will be for 9 months of FY 2013, but for 12 months of CY 2013. Table 76 considers the impact on program expenditures, and does not incl ude beneficiary coinsurance. Finally, the estimates in Table 76 incorporate spillover effects from the competitive acquisition program onto the Medicare Advantage program. The expectati on is that the 21 additional MSAs added to the Medicare DMEPOS Competitive Bidding Program would lower prices for DME products in FFS would lead to lower prices in the Medicare Advantage market. The table below considers FY cash impact of the above provisions on the entire Medicare program, including Medicare Advantage for the FY. Table 76: Fiscal Year Costs to the Medicare Program FY Cost (in $millions) 2011 0 2012 0 2013 -40 2014 -70 2015 -110

Subdividing the large MSAs of Chicago, Los Angeles, and New York is considered to have little to no fiscal impact. The exceptions to the Medicare DMEPOS Competitive Bidding program involving rural areas, MSAs with populations less than 250,000, and low population density areas in selected MSAs before 2015 are consid ered to have little to no impact because the baseline never consid ered these areas as subject to competitive bidding prices.

8. Air Ambulance In section VI.G. of this proposed rule , we present our proposals regarding air ambulance and provider and supplier enrollment . We note that this proposal is an administrative initiative that may result in Medicare program savings but at this time

### CMS-1503-P 725

those savings are inestimable. We believe the probable costs providers or suppliers will incur as a result of this rule to be negligible.

F. Alternatives Considered This proposed rule contains a range of policies, including so me provisions related to specific MIPPA and ACA provisions. The preceding preamble provides descriptions of the statutory provisions that are addre ssed, identifies those policies when discretion has been exercised, presents rationale for our proposals and, where relevant, alternatives

that were considered. G. Impact on Beneficiaries There are a number of changes in this propos ed rule that would have an effect on beneficiaries. In general, we believe that many of the proposed changes, including the refinements of the PQRI with its focus on measuring, submitting, and analyzing quality data, the expansion of the list of Medicare- approved telehealth services, the incentive payments for primary care services furnished by primary care practitioners in any location and major surgical procedures furn ished by general surgeons in HPSAs, the waiver of beneficiary cost-sharing for most preventive services, and the annual wellness visit proposals, will have a positive impact a nd improve the quality and value of care provided to Medicare beneficiaries. The regulatory provisions may affect beneficiary liab ility in some cases. For example, the waiver of the deductible and co insurance for the annual wellness visit, the IPPE, and preventive services with a grade of A or B from the USPSTF would reduce beneficiary liability for these services. Most changes in aggregate beneficiary liability due to a particular provision would be a f unction of the coinsurance (20 percent if applicable for the particular provision after the beneficiary has met the deductible). To

### CMS-1503-P 726

illustrate this point, as shown in Table 74, the CY 2010 national payment amount in the nonfacility setting for CPT code 99203 (Office /outpatient visit, new) under the

conversion factor that was consistent with the statute as of October 30, 2009 and that would be in effect on December 31, 2010 under current law, is $76.93 which means that in CY 2010 a beneficiary would be responsib le for 20 percent of this amount, or $15.39. Based on this proposed rule, the CY 2011 national payment amount in the nonfacility setting for CPT code 99203, as shown in Ta ble 74, is $72.67, which means that, in CY 2011, the beneficiary coinsurance for this service would be $14.53. Additionally, beneficiary liability would also be impacted by the effect of the aggregate cost (savings) of the provisions on the standard calculation of the Medicare Part B premium rate (generally 25 percent of the provision's cost or savings). Most policies discussed in this rule that impact payment rates, such as the expansion of the MPPR to therapy services and the increased discount on the TC of multiple imaging procedures from 25 percent to 50 percent, would similarly impact

beneficiaries’ coinsurance.

### CMS-1503-P 727

H. Accounting Statement As required by OMB Circular A-4 (available at http://www.whitehouse.gov/omb/circ ulars/a004/a-4.pdf), in Table 77, we have prepared an accounting statement showing the estimated expenditures associated with this proposed rule. This estimate include s the estimated FY 2011 cash benefit impact associated with certain ACA and MIPPA pr ovisions, and the CY 2011 incurred benefit impact associated with the estimated CY 2011 PFS conversion factor update based on the FY 2011 President’s Budget baseline. TABLE 77: Accounting Statement: Classification of Estimated Expenditures CATEGORY TRANSFERS CY 2011 Annualized Monetized Transfers Estimated decrease in ex penditures of $5.7 billion for PFS conversion factor update From Whom To Whom? Federal Government to physicians, other practitioners and provide rs and suppliers who receive payment under Medicare. FY 2011 Annualized Monetized Transfers E stimated increase in expenditures of $2 billion fo r Affordable Care Act provisions From Whom To Whom? Federal Government to providers In accordance with the provisions of Executive Order 12866, this proposed rule was reviewed by the Office of Management and Budget.

### CMS-1503-P 728

List of Subjects

42 CFR Part 405 Administrative practice and procedure, Health facilities, Health professions, Kidney diseases, Medical devices, Medicare, Reporting and recordk eeping requirements, Rural areas, X-rays.

42 CFR Part 409 Health facilities, Medicare.

42 CFR Part 410 Health facilities, Health professions, Ki dney diseases, Laboratories, Medicare, Reporting and recordkeeping requi rements, Rural areas, X-rays.

42 CFR Part 411 Kidney diseases, Medicare, Physician Referral, Reporting and record keeping requirements.

42 CFR Part 413 Health facilities, Kidney diseases, Medicare Reporting and recordkeeping requirements.

42 CFR Part 414 Administrative practice and procedure, Health facilities, Health professions, Kidney diseases, Medicare, Reporting and recordkeeping.

42 CFR Part 415 Health facilities, Health professions, Medicare, Reporting and recordkeeping requirements.

42 CFR Part 424

### CMS-1503-P 729

Emergency medical services, Health f acilities, Health professions, Medicare, Reporting and recordk eeping requirements.

### CMS-1503-P 730

For the reasons set forth in the preamble, the Centers for Medicare & Medicaid Services proposes to amend 42 CFR chapter IV as set forth below:

PART 405--FEDERAL HEALTH INSURANCE FOR THE AGED AND

DISABLED 1. The authority citation for part 405 continues to read as follows: Authority : Secs. 1102, 1861, 1862(a), 1871, 1874, 1881, and 1886(k) of the Social Security Act (42 U.S.C. 1302, 1395x, 1395y(a), 1395hh, 1395kk, 1395rr and 1395ww(k)), and sec. 353 of the Public Health Service Act (42 U.S.C.263a).

Subpart X—Rural Health Clinic and Federally Qualified Health Center Services 2. A new §405.2449 is added to read as follows §405.2449 Preventive services.

For services furnished on or after Janua ry 1, 2011, preventive services covered under the Medicare Federally qua lified health center benefit are those preventive services defined in section 1861(ddd)(3) of the Act, a nd § 410.2 of this chapter. Specifically, these include the following: (a) The specific services currently listed in section 1861(ww)(2) of the Act, with the explicit exclusion of electrocardiograms; (b) The Initial Preventive Physical Examination (IPPE) (as specified by section 1861(ww)(1) of the Act as added by secti on 611 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (Pub. L. 108-173) and §410.16 of this chapter); and (c) The Personalized Prevention Plan Services (PPPS), also known as the “Annual Wellness Visit” (as specified by section 1861( hhh) of the Act as added by section 4103 of

### CMS-1503-P 731

the Affordable Care Act (Pub. L. 111-148) and part 410, subpart B, §410.15 of this chapter). 3. Section 405.2470 is amended by adding a new paragraph (d) to read as

follows: § 405.2470 Reports and maintenance of records.

* * * * * (d) Collection of additional claims data

. Beginning January 1, 2011, a Medicare FQHC must report on its Medicare claims such information as the Secretary determines is needed to develop and implement a pros pective payment system for FQHCs including, but not limited to all pertinent HCPCS (Healthcare Common Procedure Coding System) code(s) corresponding to the service(s) pr ovided for each Medicare FQHC visit ( as defined in §405.2463).

PART 409--HOSPITAL INSURANCE BENEFITS 4. The authority citation for part 409 continues to read as follows: Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh). Subpart B--Inpatient Hospital Services and Inpatient Critical Access Hospital

Services §409.17 [Amended] 5. Amend §409.17(d) by removing the phra se “hospital policies and procedures” and adding in its place the phrase “the provider’s policies and procedures.” Subpart C--Posthospital SNF Care 6. Section 409.20 is amended by revising paragraph (a)(3) to read as follows: §409.20 Coverage of services.

### CMS-1503-P 732

(a) * * * (3) Physical therapy, occupational therapy, and speech-language pathology

services.

* * * * *

7. Section 409.23 is revised to read as follows: §409.23 Physical therapy, occupational therapy, and speech-language pathology

services. Medicare pays for physical therapy, occupational therapy, or speech-language pathology services as posthospital SNF care if they are furnished-- (a) By (or under arrangements made by) the facility and billed by (or through) the facility; (b) By qualified physical therapists, physical therapist assistants, occupational therapists, occupational therapy assistants, or speech-language pathologists as defined in part 484 of this chapter; and (c) In accordance with a plan that m eets the requirements of §409.17(b) through (d) of this part.

PART 410--SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS 8. The authority citation for part 410 continues to read as follows: Authority : Secs. 1102, 1834, 1871, and 1893 of the Social Security Act (42 U.S.C. 1302, 1395m, 1395hh, and 1395ddd). Subpart A--General Provisions 9. Section 410.2 is amended by adding the definition of “Preventive services” in alphabetical order to read as follows: §410.2 Definitions.

### CMS-1503-P 733

* * * * *

Preventive services means all of the following: (1) The specific services listed in s ection 1861(ww)(2) of the Act, with the explicit exclusion of electrocardiograms; (2) The Initial Preventive Physical Examination (IPPE) (as specified by section 1861(ww)(1) of the Act); and (3) The Personalized Prevention Plan Services (PPPS), also known as the “Annual Wellness Visit” (as specified by section 1861(hhh) of the Act) §410.3 [Amended] 10. Amend §410.3(b)(2) by removing the reference “subpart E” and adding in its place the reference “subpart I.” Subpart B--Medical and Other Health Services

11. Section 410.15 is added to read as follows: §410.15 Annual wellness visits providing Personalized Prevention Plan Services: Conditions for and limitations on coverage. (a) Definitions

. Detection of any cognitive impairment , for the purpose of this section, means assessment of an individual’s cognitive f unction by direct observation, with due consideration of information obtained by way of patient report, concerns raised by family members, friends, caretakers or others. Eligible beneficiary for purposes of this section means an individual who is no longer within 12 months after the effective date of his or her first Medicare Part B coverage period and who has not received either an initial preventive physical

### CMS-1503-P 734

examination or an annual welln ess visit providing a personalized prevention plan within the past 12 months. Establishment of, or an update to th e individual’s medical and family history for purposes of this section means, at a minimu m, the collection and documentation of the following: (i) Past medical and surgical history, including experiences with illnesses, hospital stays, operations, allergies, injuries and treatments. (ii) Use or exposure to medications and supplements, including calcium and

vitamins. (iii) Medical events in the beneficiary’s parents and any siblings and children, including diseases that may be hereditary or place the individual at increased risk. First annual wellness visit providing pe rsonalized prevention plan services for purposes of this section means the following se rvices furnished an eligible beneficiary by a health professional as those term s are defined in this section: (i) Establishment of an individual’s me dical and family history. (ii) Establishment of a list of current pr oviders and suppliers that are regularly involved in providing medical care to the individual. (iii) Measurement of an individual’s height, weight, body-mass index (or waist circumference, if appropriate), blood pre ssure, and other routine measurements as deemed appropriate, based on the benefi ciary’s medical and family history. (iv) Detection of any cognitive impairment that the individual may have, as that

term is defined in this section. (v) Review of the individual’s potential (risk factors) for depression, including current or past experiences with depression or other mood disorders, based on the use of

### CMS-1503-P 735

an appropriate screening instrument for persons without a current diagnosis of depression, which the health pr ofessional may select from vari ous available standardized screening tests designed for this purpose and recognized by nationa l medical professional organizations. (vi) Review of the individual’s functional ability and level of safety, based on direct observation or the use of appropri ate screening questions or a screening questionnaire, which the health professional as defined in this section may select from various available screening questions or st andardized questionnaires designed for this purpose and recognized by national professional medical organizations. (vii) Establishment of the following: (A) A written screening schedule for the individual such as a checklist for the next 5 to 10 years, as appropriate, based on reco mmendations of the United States Preventive Services Task Force and the Advisory Committee on Immunization Practices, and the individual’s health status, screening histor y, and age-appropriate preventive services covered by Medicare. (B) A list of risk factors and conditions for which primary, secondary or tertiary

interventions are recommended or are underwa y for the individual, including any mental health conditions or any such risk factors or conditions that have been identified through an initial preventive physical examination (as described under §410.16 of this subpart), and a list of treatment op tions and their associated risks and benefits. (viii) Furnishing of personalized health advice and a referral, as appropriate, to health education or preven tive counseling services or programs aimed at reducing identified risk factors and improving self management, or community-based lifestyle

### CMS-1503-P 736

interventions to reduce health risks a nd promote self-management and wellness, including weight loss, physical activity, smoking cessation, fall pr evention and nutrition. (ix) Any other element determined appr opriate through the National Coverage Determination process. Health professional for purposes of this section means: (i) A physician who is a doctor of medici ne or osteopathy (as defined in section 1861(r)(1) of the Social Security Act); or (ii) A physician assistant, nurse practiti oner, or clinical nurse specialist (as defined in section 1861(aa)(5) of the Act; or (iii) A medical professional (including a health educator, registered dietitian or nutritionist) or a team of medi cal professionals, who are work ing under the supervision of a physician as defined in paragraph (i) of this definition. Review of the individual’s functional ability and level of safety for purposes of this section includes, at minimum, assessment of the following topics: (i) Hearing impairment, (ii) Ability to successfully perform activities of daily living, (iii) Fall risk and (iv) Home safety. Subsequent annual we llness visit providing personalized prevention plan services means the following services furnished an eligible beneficiary by a health professional as

those terms are defined in this section: (i) An update of the individual’ s medical and family history.

### CMS-1503-P 737

(ii) An update of the list of current pr oviders and suppliers that are regularly involved in providing medical care to the i ndividual as that list was developed for the first annual wellness visit providing pe rsonalized prevention plan services. (iii) Measurement of an individual’s we ight (or waist circumference), blood pressure and other routine measurements as deemed appropriate, based on the individual’s medical and family history. (iv) Detection of any cognitive impairment that the individual may have, as that

term is defined in this section. (v) An update to the following: (A) The written screening schedule for the individual as that schedule is defined in paragraph (a) of this section for the fi rst annual wellness visit providing personalized prevention plan services. (B) The list of risk factors and conditions for which primary, secondary or tertiary

interventions are recommended or are under way for the individual as that list was developed at the first annual wellness vi sit providing personalized prevention plan

services. (vi) Furnishing of personalized health advice to the individual and a referral, as appropriate, to health educati on or preventive counseling services or programs as that

advice and related services are defined in paragraph (a) of this section. (vii) Any other element determined appr opriate through the National Coverage Determination process. (b) Conditions for coverage of annual wellness visits providing personalized prevention plan services . Medicare Part B pays for firs t and subsequent annual wellness visits providing personalized prevention plan se rvices that are furnished to an eligible

### CMS-1503-P 738

beneficiary, as described in this section, if they are furnished by a heath professional, as

defined in this section. (c) Limitations on coverage of an annual wellness visit providing personalized prevention plan services

. (1) Payment may not be made for either a first or a subsequent annual wellness visit providing personalized prevention plan se rvices that is performed for an individual who is not an eligible beneficiar y as described in this section. (2) Payment may not be made for either a first or a subsequent annual wellness visit providing personalized prevention plan se rvices that is performed for an individual who is an eligible beneficiary as described in this section and who has had either an initial preventive physical examination as sp ecified in section 410.16 of this subpart or either a first or a subsequent annual wellne ss visit providing personalized prevention plan services performed within the past 12 months. (d) Effective date . Coverage for an annual welln ess visit providing personalized prevention plan services is effective for se rvices furnished on or after January 1, 2011. 12. Section 410.32 is amended by adding paragraph (b)(2)(vii) to read as follows: §410.32 Diagnostic x-ray tests, diagnostic laboratory test s, and other diagnostic

tests: Conditions.

* * * * * (b) * * * (2) * * * (vii) Diagnostic tests performed by a certified nurse-midwife authorized to perform the tests under applicable State laws.

* * * * *

### CMS-1503-P 739

13. Section 410.78 is amended by revising the introductory text of paragraph (b)

to read as follows: §410.78 Telehealth services.

* * * * * (b) General rule . Medicare Part B pays for o ffice or other outpatient visits, subsequent hospital care services (with the limitation of one telehealth visit every 3 days), subsequent nursing facility care services ( not including the Federally-mandated periodic visits under §483.40(c) of this chapter and with the limitation of one te lehealth visit every 30 days), professional consultations, psyc hiatric diagnostic interview examination,

neurobehavioral status ex am, individual psychotherapy , pharmacologic management, end-stage renal disease-related services included in the monthly capitation payment (except for one “hands on” visit per month to examine the access site), individual and group medical nutrition therapy services, individual and gr oup kidney disease education services, individual and group diabetes self -management (DSMT) training services (except for one hour of in-person services to be furnished in the year following the initial DSMT service to ensure effective injection training), and individua l and group health and

behavior assessment and in tervention services furnished by an interactive telecommunications system if th e following conditions are met:

* * * * * Subpart I--Payment for SMI Benefits 14. Section 410.150 is amended by adding pa ragraph (a)(20) to read as follows: §410.150 To whom payment is made

. (a) * * *

### CMS-1503-P 740

(20) To a certified nurse-midwife for professional services furnished by the

certified nurse-midwife in all se ttings and for services and supplies furnished incident to those services. Payment is made only if no f acility or other provider charges or is paid any amount for the furnishing of the professiona l services of the certified nurse-midwife. 15. Section 410.152 is amended by revising paragraph (l) to read as follows: §410.152 Amounts of payment.

* * * * * (l) Amount of payment: Preventive services . Medicare Part B pays 100 percent of the Medicare payment amount establishe d under the applicable payment methodology for the service setting for providers and supplie rs for the following preventive services: (1) Pneumococcal (as specified in paragra ph (h) of this section), influenza, and hepatitis B vaccine and administration. (2) Screening mammography. (3) Screening pap tests and screening pelvic exam. (4) Prostate cancer screening tests (exc luding digital rectal examinations). (5) Colorectal cancer screening tests (excluding barium enemas). (6) Bone mass measurement. (7) Medical nutrition th erapy (MNT) services. (8) Cardiovascular screening blood tests. (9) Diabetes screening tests. (10) Ultrasound screening for abdominal aortic aneurysm (AAA). (11) Additional preventive services iden tified for coverage through the national coverage determina tion (NCD) process. (12) Initial Preventive Physical Examination (IPPE).

### CMS-1503-P 741

(13) Personalized Prevention Plan Services (PPPS). 16. Section 410.160 is amended by-- A. Revising paragraph (b)(2). B. Adding paragraphs (b )(10), (11), (12), and (13).

The revisions and additions read as follows: §410.160 Part B annual deductible.

* * * * * (b) * * * (2) Pneumococcal, influenza, and hepa titis b vaccines and their administration.

* * * * * (10) Bone mass measurement. (11) Medical nutrition therapy (MNT) services. (12) Personalized prevention plan services (PPPS). (13) Additional preventive services iden tified for coverage through the national coverage determina tion (NCD) process.

* * * * *

PART 411—EXCLUSIONS FROM ME DICARE AND LIMITATIONS ON

MEDICARE PAYMENT 17. The authority citation for part 411 continues to read as follows: Authority : Secs. 1102, 1860D-1 through 1860D-42, 1871, and 1877 of the Social Security Act (42 U.S.C. 1302, 1395w-101 through 1395w-152, 1395hh, and 1395nn). Subpart A--General Exclusions and Exclusion of Particular Services 18. Section 411.15 is amended by--

### CMS-1503-P 742

A. Republishing the introductory text. B. Revising paragraph (a)(1). C. Adding new paragraph (k)(16).

The revision and addition read as follows: §411.15 Particular services excluded from coverage. The following services are excluded from coverage. (a) * * * (1) Examinations performed for a purpose ot her than treatment or diagnosis of a specific illness, symptoms, complaint, or injury, except for screening mammography, colorectal cancer screening tests, screening pelvic exams, prostate cancer screening tests, glaucoma screening exams, ultrasound screen ing for abdominal aortic screening for abdominal aortic aneurysms (AAA), cardiovasc ular disease screenin g tests, diabetes screening tests, a screening electrocardiogram, initial preventive physical examinations that meet the criteria specified in paragra phs (k)(6) through (k)(15) of this section, additional preventive services that meet the criteria in §410.64 of this chapter, or annual wellness visits providing persona lized prevention plan services

* * * * * (k) * * * (16) In the case of an annual wellne ss visit providing a personalized prevention plan, subject to the conditions and limitati ons specified in §410.15 of this chapter.

* * * * * Subpart J--Financial Relati onships Between Physicians and Entities Furnishing Designated Heal th Services 19. Section 411.355 is amended by adding pa ragraph (b)(7) to read as follows:

### CMS-1503-P 743

§411.355 General exceptions to the refer ral prohibition related to both ownership/investment and compensation.

* * * * * (b) * * * (7) Disclosure requirement for certain imaging services

. (i) With respect to magnetic resona nce imaging, computed tomography, and positron emission tomography, the referring physician shall provide written notice to the patient at the time of the referral that the patient may receive the same services from a person other than one described in paragraph (b )(1) of this section. Except as set forth in paragraph (b)(7)(ii) of this section, the wr itten notice shall include a list of at least 10 other suppliers (as defined in §400.202 of this chapter) that provide the services for which the individual is being referred and wh ich are located within a 25-mile radius of the referring physician’s office location at th e time of the referral. The notice should be

written in a manner sufficient to be reasona bly understood by all patients and should include for each supplier on the list, at a minimum, the supplier’s name, address, telephone number, and distance from the referring physician’s office location. A record of the disclosure notification, signed by the pa tient, shall be maintain ed as a part of the patient’s medical record. (ii) If there are fewer than 10 other suppliers located within a 25- mile radius of the physician’s office location at the time of the referral, the physician shall list all of the other suppliers of the imaging service that are present within a 25-mile radius of the referring physician’s office location, includi ng up to 10 suppliers. Provision of the written list of alternate supplie rs will not be required if no other suppliers provide the services for which the individual is being referred within the 25-mile radius.

### CMS-1503-P 744

* * * * *

PART 413--PRINCIPLES OF REASO NABLE COST REIMBURSEMENT; PAYMENT FOR END–STAGE RENAL DISEASE SERVICES; OPTIONAL

PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED

NURSING FACILITIES 20. The authority citation for part 413 continues to read as follows: Authority: Secs. 1102, 1812(d), 1814(b), 1815, 1833( a), (i), and (n), 1861(v), 1871, 1881, 1883, and 1886 of the Social Security Act (42 U.S.C. 1302, 1395d(d), 1395f(b), 1395g, 1395l(a), (i), and (n), 1395x(v), 1395hh, 1395rr, 1395tt, and 1395ww); and sec. 124 of Public Law 106–133 (113 Stat. 1501A–332). Subpart E--Payments to Providers 21. Section 413.70 is amended by adding a sentence at the end of paragraph (b)(3)(ii)(B) to read as follows: §413.70 Payment for services of a CAH.

* * * * * (b) * * * (3) * * * (ii) * * * (B) * * * Effective for primary care services furnished by primary care practitioners (as defined in §414.80(a)) and major surgical procedures furnished by general surgeons in health professional shor tage areas (as defined in §414.2) furnished on or after January 1, 2011 and before January 1, 2016, incentive payments specified under §414.80 and §414.67(b), respectively, of this chapte r shall not be incl uded in determining payment made under this paragraph.

### CMS-1503-P 745

* * * * *

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

SERVICES 22. The authority citation for part 414 continues to read as follows: Authority: Secs. 1102, 1871, and 1881(b)(l) of th e Social Security Act (42 U.S.C. 1302, 1395hh, and 1395rr(b)(l)). Subpart A--General Provisions 23. Section 414.2 is amended by adding th e definitions of “H ealth Professional Shortage Area” and “Major surgical procedure” in alphabetical order to read as follows: §414.2 Definitions.

* * * * *

Health Professiona l Shortage Area (HPSA) means an area designated under section 332(a)(1)(A) of the Public Health Serv ice Act as identified by the Secretary prior to the beginning of such year. Major surgical procedure means a surgical procedure for which a 10-day or 90-day global period is used for payment unde r the PFS and section 1848(b) of the Act.

* * * * * 24. Section 414.26 is amended by-- A. Redesignating paragraph (c) as paragraph (d). B. Adding a new paragraph (c).

The addition reads as follows: §414.26 Determining the GAF.

* * * * *

### CMS-1503-P 746

(c) Adjusting the practice expense index to account for the Frontier State floor. (1) General criteria

. Effective on or after January 1, 2011, CMS will adjust the practice expense index for physicians' services furnis hed in qualifying States to recognize the practice expense index floor established for Fr ontier States. A qualifying State must meet the following criteria: (i) At least 50 percent of counties located within the State have a population density less than 6 persons per square mile. (ii) The State does not receive a non-labor re lated share adjustment determined by the Secretary to take into account the unique ci rcumstances of hospitals located in Alaska

and Hawaii. (2) Amount of adjustment

. The practice expense value applied for physicians' services furnished in a qualifying State will be not less than 1.00. (3) Process for determining adjustment. (i) CMS will use the most recent Population Estimate data published by the U.S. Census Bureau to determine county definitions and population density. This analys is will be periodically revised, such as for updates to the decennial census data. (ii) CMS will publish annually a listing of qualifying Frontier States receiving a practice expense index floor a ttributable to this provision.

* * * * * Subpart B--Physicians and Other Practitioners

25. Section 414.54 is revised to read as follows: §414.54 Payment for certified nurse-midwives’ services. (a) For services furnished after December 31, 1991, allowed amounts under the fee schedule established under section 1833(a )(1)(K) of the Act for the payment of

### CMS-1503-P 747

certified nurse-midwife services may not exceed 65 percent of the physician fee schedule

amount for the service. (b) For certified nurse midwife services furnished on or after January 1, 2011, allowed amounts may not exceed 100 percent of the physician fee schedule amount for

the services. 26. Section 414.65 is amended by revising the introductory text of paragraph (a)(1) to read as follows: §414.65 Payment for tele health services. (a) * * * (1) The Medicare payment amount for office or other outpatient visits, subsequent hospital care services (with the limitation of one telehealth subsequent hospital care service every 3 days), subsequent nursing facility care services (not including the Federally-mandated periodic visits unde r §483.40(c) and with the limitation of one telehealth nursing facility care service ev ery 30 days), professional consultations, psychiatric diagnostic interview examinati on, neurobehavioral stat us exam, individual psychotherapy, pharmacologic management, end-stage renal disease-related services included in the monthly capitation payment (ex cept for one “hands on” visit per month to examine the access site), individual and group medical nutrition therapy services, individual and group kidney disease educati on services, individual and group diabetes self-management training (DSMT) services (except for 1 hour of in-person DSMT services to be furnished in the year following the initial DSMT service to ensure effective injection training), and individual and group health and beha vior assessment and intervention furnished via an interactive telecommunications system is equal to the current fee schedule amount app licable for the service of the physician or practitioner.

### CMS-1503-P 748

* * * * *

27. Section 414.67 is revised to read as follows: §414.67 Incentive payments for services furnished in Health Professional Shortage

Areas. (a) Health Professiona l Shortage Area (HPSA) physician bonus program . A HPSA physician incentive payment will be made subject to the following: (1) HPSA bonuses are payable for services furnished by physicians as defined in section 1861(r) of the Act in areas designated as of December 31 of the prior year as geographic primary medical care HPSAs as de fined in section 332(a)(1)(A) of the Public

Health Service Act. (2) HPSA bonuses are payable for services furnished by psychiatrists in areas designated as of December 31 of the prior ye ar as geographic mental health HPSAs if the services are not already eligible for the bonus based on being in a geographic primary

care HPSA. (3) Physicians eligible for the HPSA physician bonus are entitled to a 10 percent incentive payment above the amount paid fo r their professional services under the physician fee schedule. (4) Physicians furnishing services in areas that are designated as geographic HPSAs prior to the beginning of the year but not included on the published list of zip codes for which automated HPSA bonus paymen ts are made should use the AQ modifier to receive the HPSA physician bonus payment. (b) HPSA surgical incentive payment program . A HPSA surgical incentive payment will be made subject to the following:

### CMS-1503-P 749

(1) A major surgical procedure as defined in §414.2 of this part is furnished by a general surgeon on or after January 1, 2011 and before January 1, 2016 in an area recognized for the HPSA physician bonus pr ogram under paragraph (a)(1) of this

section. (2) Payment will be made on a quarterly ba sis in an amount equal to 10 percent of the Part B payment amount for major surgi cal procedures furnished as described in paragraph (1), in addition to the amount the physician would otherwise be paid. (3) Physicians furnishing services in areas that are designated as geographic HPSAs eligible for the HPSA physician bonus program under paragraph (a)(1) of this section prior to the beginning of the year but not included on the published list of zip codes for which automated HPSA surgical bonus payments are made should report a specified HCPCS code modifier to rece ive the HPSA surgical bonus payment. (4) The payment described in paragraph (b )(2) of this section is made to the surgeon or, where the surgeon has reassigned his or her benefits to a critical access hospital (CAH) paid under the optional me thod, to the CAH based on an institutional

claim. 28. Section 414.80 is added to subpart B to read as follows: §414.80 Incentive paym ent for primary care services. (a) Definitions . As defined in this section-- Eligible primary care practitioner means one of the following: (i) A physician (as defined in section 1861(r)(1)) who meets all of the following

criteria: (A) Enrolled in Medicare with a prima ry specialty designation of 08-family practice, 11-internal medicine, 37- pediatrics, or 38-geriatrics.

### CMS-1503-P 750

(B) At least 60 percent of the physician’s allowed charges during a reference period specified by the Secretary are for primary care services. (ii) A nurse practitioner, clinical nurse specialist, or physician assistant (as defined in section 1861(aa)(5)) who m eets all of the following criteria: (A) Enrolled in Medicare with a primary specialty designation of 50-nurse practitioner, 89-certified clinical nurse, or 97-physician assistant. (B) At least 60 percent of the practitione r’s allowed charges during a reference period specified by the Secretary are for primary care services. Primary care services means new and established patie nt office or other outpatient evaluation and management (E/M) visits; initial, subsequent, discharge, and other nursing facility E/M services; new and established patient domiciliary, rest home (eg, boarding home), or custodial care E/M services; domiciliary, rest home (eg, assisted living facility), or home care plan oversight services; and new and established patient home

E/M visits. (b) Payment. (1) For primary care services furnished by an eligible primary care practitioner on or after January 1, 2011 and before January 1, 2016, payment is made on a quarterly basis in an amount equal to 10 percent of the pa yment amount for the primary care services under Part B, in addition to the amount the primary care practitione r would otherwise be paid for the primary care services under Part B. (2) The payment described in paragraph (b )(1) of this section is made to the eligible primary care practitioner or, where the physician has reassigned his or her

benefits to a critical access hospital (CAH) paid under the optional method, to the CAH

based on an institutional claim.

### CMS-1503-P 751

29. A new §414.90 is added to subpart B to read as follows: § 414.90 Physician quality repor ting initiative (PQRI) (a) Basis and Scope . This part implements the following provisions of the

Act: (1) 1848(a)-Payment Based on Fee Schedule. (2) 1848(k)-Quality Reporting System. (3) 1848(m)-Incentive Payments for Quality Reporting. (b) Definitions . As used in this secti on, unless otherwise indicated— Covered professional services means services for which payment is made under, or is based on, the Medicare physician fee schedule as pr ovided under section 1848(k)(3)

of the Act and which are furnishe d by an eligible professional. Eligible professional (EP) means any of the following: (i) A physician. (ii) A practitioner described in section 1842(b)(18)(C) of the Act. (iii) A physical or occupational ther apist or a qualified speech-language pathologist. (iv) A qualified audiologis t (as defined in section 1861(ll)(3)(B) of the Act). Group practice means a single Taxpayer Identification Number (TIN) with 2 or more eligible professionals, as identified by their individual National Provider Identifier (NPI), who have reassigned their Medicare billing rights to the TIN. This term also includes group practices partic ipating in Medicare demonstr ation projects approved by the Secretary. Maintenance of certification program means a continuous assessment program, such as qualified American Board of Medical Specialties Maintenance of Certification

### CMS-1503-P 752

Program or an equivalent progr am (as determined by the Secretary), that advances quality and the lifelong learning and self-assessment of board cer tified specialty physicians by focusing on the competencies of patient care, medical knowledge, practice-based learning, interpersonal and communication skills and professionalism. Such a program must include the following: (i) The program requires the physician to maintain a valid unrestricted license in

the United States. (ii) The program requires a physician to participate in educational and selfassessment programs that require an assessment of what was learned. (iii) The program requires a physician to demonstrate, through a formalized secure examination, that the physician ha s the fundamental diagnostic skills, medical knowledge, and clinical judgment to provide quality care in their respective specialty. (iv) The program requires successful co mpletion of a qualified Maintenance of Certification Program practice assessment. Maintenance of certification program practice assessment means an assessment of a physician’s practice that – (i) Includes an initial assessment of an eligible professional’s practice that is designed to demonstrate the physician’s use of evidence-based medicine; (ii) Includes a survey of patie nt experience with care; and (iii) Requires a physician to implement a quality improvement intervention to address a practice weakness identified in th e initial assessment unde r paragraph (i) and then to remeasure to assess performance improvement after such intervention. Measures group means a subset of four or more PQRI measures that have a particular clinical condition or focus in common. The deno minator definition and coding

### CMS-1503-P 753

of the measures group identifies the condition or focus that is shared across the measures within a particular measures group.

Performance rate means the percentage of a defined population who receives a particular process of care or achieve a particular outcome for a particular quality measure. Physician quality reporting initiative (PQRI) means the physician reporting system under section 1848(k) of the Act for the reporting by eligible pr ofessionals of data on quality measures and the incentive payment associated with this physician reporting

system. Qualified electronic health record (EHR) means an EHR vendor’s product and version that, with respect to a particul ar program year, has self-nominated and successfully completed a vetting process (as specified by CMS) to demonstrate the product’s compliance with the PQRI qualification requirements specified by CMS for a

program year. Qualified registry means a medical registry or a Maintenance of Certification Program operated by a specialty body of the American Board of Medical Specialties that, with respect to a particular program year, ha s self-nominated and successfully completed a vetting process (as specified by CMS) to demonstrate its compliance with the PQRI qualification requirements specified by CMS for that program year. The registry may act as a data submission vendor, wh ich has the requisite legal aut hority to provide PQRI data (as specified by CMS) on behalf of an eligible professional to CMS. Quality reporting period means with respect to a year, a period specified by the Secretary. Reporting rate means the percentage of patients that the eligible professional indicated a quality action was or was not pe rformed divided by the total number of

### CMS-1503-P 754

patients in the denominator of the measure. (c) Incentive payments . With respect to covered pr ofessional services furnished during a reporting period by an eligible professional, if -- (1) There are any quality measures that ha ve been established under the PQRI that are applicable to any such services furnished by such professional (or in the case of a group practice under paragraph (h) of this sec tion, such group practice) for such reporting period; and (2) The eligible professional (or in th e case of a group practice under paragraph (h) of this section, the group practice) sa tisfactorily submits (as determined under paragraph (g) of this section for eligible pr ofessionals and paragraph (h) of this section for group practices) to the Secretary data on su ch quality measures in accordance with the PQRI for such reporting period, in addition to the amount otherwise paid under section 1848 of the Act, there also shall be paid to th e eligible professional (o r to an employer or facility in the cases described in section 1842(b)(6)(A) of the Act or, in the case of a group practice) under paragraph (h) of this section, to the group practice, from the Federal Supplementary Medical Insurance Trust Fund established under section 1841 an amount equal to the applicable quality percent (as specified in paragraph (c)(3) of this section) of the eligible prof essional’s (or, in the case of a group practice under paragraph (h) of this section, the group practice’s) tota l estimated allowed ch arges for all covered professional services furnished by the eligible professional (or, in the case of a group practice under paragraph (h) of this section, by the group practice) during the applicable reporting period. For purposes of this paragraph, (i) The eligible professional’s (or, in the case of a group practice under paragraph (h) of this section, the group practice’s) to tal estimated allowed charges for covered

### CMS-1503-P 755

professional services furnishe d during a reporting period are determined based on claims processed in the National Claims History (NCH) no later than 2 months after the end of the applicable reporting period; (ii) In the case of an eligible prof essional who furnishes covered professional services in more than one practice, incentive payments are separately determined for each practice based on claims submitted for the eligible professional for each practice; (iii) Incentive payments earned by an eligible professional (or in the case of a group practice under paragraph (h) of this sec tion, by a group practice) for a particular program year will be paid as a single consolidated payment to the TIN holder of record. (3) Applicable quality percent . The applicable quality percent is as follows: (i) For 2011, 1.0 percent; and (ii) For 2012, 2013, and 2014, 0.5 percent; (d) Additional incentive payment . (1) Through 2014, if an eligible professional meets the requirements described in paragra ph (d)(2) of this section, the applicable percent for such year, as described in paragraphs (c)(3)(i) and (ii) of this section, must be increased by 0.5 percentage points. (2) In order to qualify for the additional incentive payment described in paragraph (d)(1) of this section, an eligible professi onal shall meet the following requirements: (i) The eligible professional must-- (A) Satisfactorily submit data on quality measures for purposes of this section for a year; and (B) Have such data submitted on their behalf through a Maintenance of Certification program (as defi ned in paragraph (b) of this section) that meets: (1 ) The criteria for a registry (as specified by CMS)); or

### CMS-1503-P 756

(2 ) An alternative form and manner deter mined appropriate by the Secretary. (ii) The eligible professional, more fre quently than is required to qualify for or

maintain board certification status-- (A) Participates in such a Maintenance of Certification Program for a year; and (B) Sucessfully completes a qualified Ma intenance of Certification Program practice assessment (as define d in paragraph (b) of this section) for such year. (iii) A Maintenance of Certification prog ram submits to the Secretary, on behalf of the eligible profe ssional, information – (A) In a form and manner specified by the Secretary, that the eligible professional has successfully met the requirements of paragraph (d)(2)(ii) of this section which may be in the form of a structural measure); (B) If requested by the Secretary, on the survey of patient experience with care (as described in paragraph (b) of this section); and (C) As the Secretary may require, on the methods, measures, and data used under

the Maintenance of Certifica tion Program and the qualified Ma intenance of Certification Program practice assessment. (e) Incentive payment adjustment

. (1) With respect to covered professional services furnished by an eligible professi onal during 2015 or any subsequent year, if the eligible professional does not satisfactorily submit data on quality measures for covered professional services for the quality reportin g period for the year (as determined under paragraph (g) for eligible professionals a nd paragraph (h) of this section for group practices), the fee schedule amount for such services furnished by such professional during the year (including the fee sche dule amount for purposes of determining a payment based on such amount) must be equa l to the applicable percent of the fee

### CMS-1503-P 757

schedule amount that would otherwise apply to such services under section 1848(m) of

the Act. (2) Applicable percent . For purposes of paragraph (1) of this section, the term ‘applicable percent’ means – (i) For 2015, 98.5 percent; and (ii) For 2016 and each subsequent year, 98 percent. (f) Use of consensus-based quality measures . For each program year, CMS will publish the final list of measures and the final detailed measure specifications for all quality measures selected for inclusion in the PQRI quality measure set for a given program year on a CMS website by no later than December 31 of the prior year. (1) Subject to paragraph (f)(2) of this section, for purposes of reporting data on quality measures for covered professional serv ices furnished during a year, subject to paragraph (g) of this section, the quality meas ures specified under this paragraph must be such measures selected by the Secretary from measures that have been endorsed by the entity with a contract with the Secr etary under section 1890(a) of the Act. (2) Exception . In the case of a specified area or medical topic determined appropriate by the Secretary for which a feasible and practical measure has not been endorsed by the entity with a contract under section 1890(a) of the Act, the Secretary may specify a measure that is not so endorsed as long as due consideration is given to measures that have been endorsed or adopted by a consensus organization identified by the Secretary, such as the AQA alliance. (3) Opportunity to provide input on measures . For each quality measure adopted by the Secretary under this paragraph, the Secretary shall ensure that eligible professionals have the opportunity to provide input during the development,

### CMS-1503-P 758

endorsement, or selec tion of quality measures applicable to services they furnish. (g) Requirements for individual eligible professionals to qualify to receive an incentive payment . In order to qualify to earn a PQRI incentive payment for a particular program year, an individual eligible prof essional, as identified by a unique TIN/NPI combination, must meet the criteria for satis factory reporting specified by CMS for such year by reporting on either individual PQRI quality measures or PQRI measures groups identified by CMS during a reporting period speci fied in paragraph (g)(1) of this section and using one of the reporting mechanisms speci fied in paragraph (g)(2) of this section. Although an eligible professi onal may attempt to qualify for the PQRI incentive payment by reporting on both individual PQRI quality me asures and measures groups, using more than one reporting mechanism (as specified in paragraph (g)(2) of this section), or reporting for more than one reporting period, he or she will receive only one PQRI incentive payment per TIN/NPI combination for a program year. (1) Reporting periods

. For purposes of this paragraph, the reporting period with

respect to a program year are-- (i) The 12-month period from January 1 through December 31 of each program

year; or (ii) The 6-month period from July 1 through December 31 of each program year. (iii) Exceptions

. The 6-month reporting period is not available for EHR-based reporting of individual PQRI qu ality measures or for reporting by group practices under the process described in paragraph (h) of this section. (2) Reporting mechanisms . For each program year, an eligible pr ofessional who wishes to participate in the PQRI must re port information on the individual PQRI quality measures or PQRI measures groups iden tified by CMS in the following manner:

### CMS-1503-P 759

(i) Reporting the individual PQRI quality measures or PQRI measures groups to CMS, by no later than 2 months after the end of the applicable reporting period, on the eligible professional’s Medicare Part B claims for covered professional services furnished during the applicable reporting period; (ii) Reporting the individual PQRI quality measures or PQRI measures groups to a qualified registry (as specified in paragraph (b) of this section) in the form and manner and by the deadline specified by the qualified registry selected by the eligible professional. The selected registry will submit information, as required by CMS, for covered professional services furnished by the eligible professional during the applicable reporting period to CMS on the eligib le professional ’s behalf; or (iii) Reporting the individual PQRI qua lity measures to CMS by extracting clinical data using a secure data sub mission method, as required by CMS, from a qualified EHR product (as defined in paragraph (b) of this section) by the deadline specified by CMS for covered professional serv ices furnished by the eligible professional during the applicable reporting period. Prio r to actual data submission for a given program year and by a date specified by CMS, the eligible professional must submit a test file containing real or dummy clinical quality data extracted from the qualified EHR product selected by the eligible professiona l using a secure data submission method, as required by CMS. (h) Requirements for group practices to qualify to receive an incentive payment

. A group practice (as defined in paragraph (b) of this s ection) will be treated as satisfactorily submitting data on quality measures under PQRI for covered professional services for a reporting period (or for purposes of paragraph (e) of this section, for a quality reporting period for the year), if, in lieu of reporting PQRI measures, the group

### CMS-1503-P 760

practice-- (1) Meets the participation requirement s specified by CMS for the PQRI group practice reporting option (GPRO); (2) Is selected by CMS to participate in the PQRI GPRO; (3) Reports measures specified by CMS in the form and manner, and at a time specified by CMS; and (4) Meets the criteria for satisfactory reporting specified by CMS. (5) No double payments . Payments to a group practice under this paragraph must be in lieu of the payments that would othe rwise be made under the PQRI to eligible professionals in the group practice for meeting the criteria for satisfactory reporting for individual eligible professionals. (i) If an eligible professional, as iden tified by an individua l NPI, has reassigned his or her Medicare billing rights to a TIN selected to participate in the PQRI GPRO for a program year, then for that program year the eligible professional must participate in the PQRI via the GPRO. For any program year in which the TIN is selected to participate in the PQRI GPRO, the eligible professiona l cannot individually qualify for a PQRI incentive payment by meeting the requirements sp ecified in paragraph (g) of this section. (ii) If, for the program year, the eligib le professional participates in the PQRI under another TIN that is not selected to par ticipate in the PQRI GPRO for that program year, then the eligible professional may individually qualify for a PQRI incentive by meeting the requirements specified in paragra ph (g) of this section under that TIN. (i) Limitations on review

. (1) Except as specified in paragraph (h)(2) of this section, there is no administrative or judi cial review under section 1869, section 1879, or

otherwise of--

### CMS-1503-P 761

(i) The determination of measures applicab le to services furnished by eligible professionals under PQRI; (ii) The determination of the payment limitation; and (iii) The determination of any PQRI incentive payment and the PQRI payment adjustment. (j) Informal review . Except as specified in paragr aph (i) of this section eligible professionals (or in the case of reportin g under paragraph (h) of this section, group practices ) may seek a review of the determination that an eligible professional (or in the case of reporting under paragraph (h) of this section, group practices ) did not satisfactorily submit data on quality measures under the PQRI. (1) To request an informal review, an eligible professional (or in the case of reporting under paragraph (h) of this sec tion, group practices) must submit a written request to CMS within 90 days of the releas e of the feedback reports. The request must summarize the concern(s) and reasons for re questing an informal review and may also

include information to assist in the review. (2) CMS will provide a written response w ithin 60 days of the receipt of the original request. All decisions based on the informal review will be final. There will be no further review or appeal. (k) Public reporting of an eligible pr ofessional’s or group practice’s PQRI data

. For each program year, CMS will post on a publ ic website, in an ea sily understandable format, a list of the names of eligible prof essionals (or in the case of reporting under paragraph (h), group practices) who satisfa ctorily submitted PQRI quality measures. 30. A new §414.92 is added to subpart B to read as follows: § 414.92 Electronic prescribi ng incentive program

### CMS-1503-P 762

(a) Basis and scope . This part implements the fo llowing provisions of the Act: (1) Section1848(a)-Payment Based on Fee Schedule. (2) Section 1848(m)-Incentive Payments for Quality Reporting. (b) Definitions . As used in the part, unless otherwise indicated— Covered professional services means services for which payment is made under, or is based on, the Medicare physician fee schedule as pr ovided under section 1848(k)(3)

of the Act and which are furnishe d by an eligible professional. Electronic prescribing (eRx) incentive program means the incentive payment program established under s ection 1848(m) of the Act for the adoption and use of electronic prescribing technology by eligible professionals. Eligible professional means any of the following healthcare professionals who have prescribing authority: (i) A physician. (ii) A practitioner described in section 1842(b)(18)(C) of the Act. (iii) A physical or occupational ther apist or a qualified speech-language pathologist. (iv) A qualified audiologis t (as defined in section 1861(ll)(3)(B) of the Act). Group practice means a group practice, as defined at §414.90(b), that-- (i) Is or is deemed to be participating in the Physician Quality Reporting Intiative (PQRI) group practice reporting option (GPRO) under § 414.90; and (ii) Has indicated its desire to participate in the eRx GPRO. Qualified electronic health record (EHR) means an EHR product and version that, with respect to a particular program year, is designated by CMS as a qualified EHR for the purpose of the PQRI (as described in §414.90) and the product’s vendor has indicated

### CMS-1503-P 763

a desire to have the produc t qualified for purposes of the product’s users to submit

information related to the eRx measure. Qualified registry means a medical registry or a Maintenance of Certification Program operated by a specialty body of the American Board of Medical Specialties that, with respect to a particular program year, is designated by CMS as a qualified registry for the purpose of the PQRI (as described in §414.90) and that has indicated its desire to be qualified to submit the eRx measure on behalf of eligible professionals for the purposes of the eRx Incentive Program. (c) Incentive payments

. (1) Subject to paragraph (c)(3) of this section, with respect to covered professional services furnis hed during a reporting period by an eligible professional, if the eligible professional is a successful el ectronic prescriber for such reporting period, in addition to the amount ot herwise paid under section 1848 of the Act, there also shall be paid to the eligible professional (or to an employer or facility in the cases described in paragraph (A) of section 1842(b)(6)) or, in the case of a group practice under paragraph (e) of this section, to the gr oup practice, from the Federal Supplementary

Medical Insurance Trust Fund established unde r section 1841 of the Act an amount equal to the applicable eRx percent (as specified in paragraph (c)(1)(ii) of this section) of the eligible professional’s (or, in the case of a group practice under paragraph (e) of this section, the group practice’s) to tal estimated allowed charges for all covere d professional services furnished by the eligible professi onal (or, in the case of a group practice under paragraph (e) of this section, by the gr oup practice) during the applicable reporting period. (i) For purposes of this paragraph, (A) The eligible professional’s (or, in th e case of a group practice under paragraph

### CMS-1503-P 764

(e) of this section, the group practice’s) total es timated allowed charges for covered professional services furnishe d during a reporting period are determined based on claims processed in the National Claims History (NCH) no later than 2 months after the end of the applicable reporting period; (B) In the case of an eligible profe ssional who furnishes covered professional services in more than one practice, incentive payments are separately determined for each practice based on claims submitted for the eligible professional for each practice; (C) Incentive payments earned by an eligible professional (or in the case of a group practice under paragraph (e) of this sec tion, by a group practice) for a particular program year will be paid as a single consolidated payment to the TIN holder of record. (ii) Applicable eRx percent . The applicable eRx percent is as follows: (A) For the 2011 and 2012 program years, 1.0 percent; and; (B) For the 2013 program year, 0.5 percent. (iii) Limitation with respect to electronic health record (EHR) incentive payments

. The provisions of this paragraph do not apply to an eligible professional (or, in the case of a group practice under paragraph (e) of this section, a group practice) if, for the EHR reporting period the eligible professional (or group prac tice) receives an incentive payment under section 1848(o)(1)(A) of th e Act with respect to a certified EHR technology (as defined in section 1848(o)(4) of th e Act) that has the capability of eRx. (2) Incentive payment adjustment . Subject to paragraph (c)(1)(ii) and paragraph (c)(3) of this section, with respect to cove red professional services furnished by an eligible professiona l during 2012, 2013, or 2014, if the elig ible professional (or in the case of a group practice under paragraph (e) of this section, the group practice) is not a successful electronic prescriber (as specified by CMS for purposes of the payment

### CMS-1503-P 765

adjustment) for an applicable reporting pe riod (as specified by CMS) the fee schedule amount for such services furnished by such professional (or group practice) during the program year (including the fee schedule am ount for purposes of determining a payment based on such amount) is equal to the appli cable percent (as specified in paragraph (c)(2)(i) of this section) of the fee schedul e amount that would otherwise apply to such

services under section 1848 of the Act. (i) Applicable percent . The applicable percent is as follows: (A) For 2012, 99 percent; (B) For 2013, 98.5 percent; and (C) For 2014, 98 percent. (ii) Significant hardship exception . An eligible professiona l (or in the case of a group practice under paragraph (e) of this se ction, a group practice) may be exempt from the application of the payment adjustment under this paragraph if, subject to annual renewal, CMS determines that compliance with the requirement for being a successful electronic prescriber (as specified by CMS for purposes of the payment adjustment) would result in a significant hardship. Fo r purposes of this paragraph, any of the following circumstances constitute a “significant hardship:” (A) An eligible professional (or group prac tice) who practices in a rural area with limited high speed internet access. (B) An eligible professional (or group practice) who practices in an area with limited available pharmacies for electronic prescribing. (C) Other circumstances identified by CMS. (3) Limitation with respect to electronic prescribing quality measures . The provisions of paragraphs (c)(1) and (c)(2) of this section do not apply to an eligible

### CMS-1503-P 766

professional (or, in the case of a group prac tice under paragraph (e) of this section, a group practice) if for the reporting period th e allowed charges under section 1848 of the Act for all covered professional services furn ished by the eligible professional (or group, as applicable) for the codes to which the el ectronic prescribing measure (as identified by CMS) applies are less than 10 percent of the total of the allowed charges under section

1848 of the Act for all such c overed professional services furnished by the eligible professional (or the group practice, as applicable). (d) Requirements for individual eligible professionals to qualify to receive an incentive payment . In order to be considered a successful electronic prescriber and qualify to earn an eRx an incentive payment (s ubject to paragraph (c)(3) of this section), an individual eligible profe ssional, as identified by a unique TIN/NPI combination, must meet the criteria for successful electronic prescriber specified by CMS during the reporting period specified in paragraph (d)(1) of this section and using one of the reporting mechanisms specified in paragraph (d )(2) of this section. Although an eligible professional may attempt to qualify for the eRx incentive payment using more than one reporting mechanism (as specified in paragraph (d)(2) of this section), he or she will receive only one eRx incentive payment per TIN/NPI combination for a program year. (1) Reporting period . For purposes of this paragraph, the reporting period with respect to a program year is the entire calendar year. (2) Reporting mechanisms . An eligible professional who wishes to participate in the eRx Incentive Program must report information on the eRx measure identified by

CMS to-- (i) CMS, by no later than 2 months af ter the end of the applicable reporting period, on the eligible professi onal’s Medicare Part B cla ims for covered professional

### CMS-1503-P 767

services furnished by the eligible profe ssional during the reporting period specified in paragraph (d)(1) of this section; (ii) A qualified registry (a s defined in paragraph (b)) in the form and manner and by the deadline specified by the qualified registry selected by the eligible professional. The selected registry will submit inform ation, as required by CMS, for covered professional services furnishe d by the eligible professional during the reporting period specified in paragraph (d)(1) of this section to CMS on the eligible professional’s behalf;

or (iii) CMS by extracting c linical data using a secure data submission method, as required by CMS, from a qualif ied EHR product (as defined in paragraph (b) of this section) by the deadline specified by CMS fo r covered professional services furnished by the eligible professional during the reporting period specified in paragraph (d)(1) of this

section. Prior to actual data submission for a given program year and by a date specified by CMS, the eligible professional must submit a test file containing real or dummy clinical quality data extracted from the qua lified EHR product select ed by the eligible professional using a secure data submission method, as required by CMS. (e) Requirements for group practices to qualify to receive an incentive payment

. (1) A group practice (as defined in paragraph (b) of this section) will be treated as a successful electronic prescriber for covered professional services for a reporting period if the group practice meets the criteria for succ essful electronic pres criber specified by CMS in the form and manner and at the time specified by CMS. (2) No double payments . Payments to a group practice under this paragraph must be in lieu of the payments that would otherwise be made under the eRx Incentive Program to eligible professionals in the gr oup practice for being a successful electronic

### CMS-1503-P 768

prescriber. (i) If an eligible professional, as iden tified by an individua l NPI, has reassigned his or her Medicare billing rights to a TIN selected to participate in the eRx GPRO for a program year, then for that program year the eligible professional must participate in the eRx Incentive Program via the GPRO. For any program year in which the TIN is selected to participate in the eRx Incentiv e Program GPRO, the eligible professional cannot individually qualify for an eRx incen tive payment by meeting the requirements specified in paragraph (d) of this section. (ii) If, for the program year, the eligib le professional participates in the eRx Incentive Program under another TIN that is not selected to participate in the eRx Incentive Program GPRO for that program ye ar, then the eligible professional may individually qualify for an eRx incentive by meeting the requirements specified in paragraph (d) of this section under that TIN. (f) Public reporting of an eligible pr ofessional’s or group practice’s erx incentive program data

. For each program year, CMS will post on a public website, in an easily understandable format, a list of the names of eligible profe ssionals (or in the case of reporting under paragraph (e) of this sec tion, group practices) who are successful electronic prescribers. Subpart D--Payment for Durable Medical Equipment and Prosthetic and Orthotic

Devices 31. Section 414.202 is amended by adding a definition of “complex rehabilitative power-driven wheelchair” in alphabeti cal order to read as follows: §414.202 Definitions.

* * * * *

### CMS-1503-P 769

Complex rehabilitative power-driven wheelchair means a power-driven

wheelchair that is classified as- (1) Group 2 power wheelchair with pow er options that can accommodate rehabilitative features (for example, tilt in space); or (2) Group 3 power wheelchair.

* * * * * 32. Section 414.226 is amended by revising paragraph (g)(1) to read as follows: §414.226 Oxygen and oxygen equipment.

* * * * * (g) * * * (1) The supplier that furnishes oxygen equipment for the first month during which payment is made under this section must continue to furnish the equipment until medical necessity ends, or the 36-month pe riod of continuous use ends, whichever is earlier, unless-- (i) The item becomes subject to a competitive acquisition program implemented in accordance with section 1847(a) of the Act; (ii) Before the 18 th 

### month of continuous use, the be neficiary relocates to an area

that is outside the normal service area of the supplier that initially furnished the equipment; (iii) The beneficiary elects to obtain oxygen equipment from a different supplier prior to the expiration of th e 36-month rental period; or (iv) CMS or the carrier determines that an exception should apply in an individual

case based on the circumstances.

* * * * *

### CMS-1503-P 770

33. Section 414.229 is amended by-- A. Revising paragraphs (a)(3), (d)(1), and (h). B. Adding paragraphs (a)(4), (a)(5), and (b)(3).

The revisions and additions read as follows: §414.229 Other durable medical equi pment-capped rental items.

( 

### a) * * * (3) For power-driven wheelch airs furnished on or after January 1, 2006 through December 31, 2010, payment is made in accordance with the rules set forth in paragraphs (f) or (h) of this section. (4) For power-driven wheelchairs that are not classified as complex rehabilitative power-driven wheelchairs, furnished on or after January 1, 2011, payment is made in

accordance with the rules set forth in paragraph (f) of this section.(5) For power-driven wheelchairs classified as complex rehabilitative powerdriven wheelchairs, furnished on or after January 1, 2011, payment is made in accordance with the rules set forth in paragr aphs (f) or (h) of this section. (b) * * * (3) For power-driven wheel chairs furnished on or after January 1, 2011, the monthly fee schedule amount fo r rental equipment equals 15 percent of the purchase price recognized as determined under paragraph (c) of this section for each of the first 3 months and 6 percent of the purchase pr ice for each of the remaining months.

* * * * * (d) * * * (1) Suppliers must offer beneficiarie s the option of purchasing power-driven

wheelchairs at the time the s upplier first furnishes the item. On or after January 1, 2011,

### CMS-1503-P 771

this option is available only for complex rehabilitative power-driven wheelchairs. Payment must be on a lump-sum fee schedule purchase basis if the beneficiary chooses the purchase option. The purchase fee is the am ount established in paragraph (c) of this

section.

* * * * * (h) Purchase of power-driven wheelchairs furnished on or after January 1, 2006

. (1) Suppliers must offer beneficiarie s the option to purchase power-driven wheelchairs at the time the equipment is initially furnished. (2) Payment is made on a lump-sum purchas e basis if the beneficiary chooses this option. (3) On or after January 1, 2011, this option is available only for complex rehabilitative power-driven wheelchairs. Subpart F--Competitive Bidding for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) 34. Section 414.402 is amended by adding the definitions of “Affected party,” “Breach of contract,” “Corrective Action Plan,” “Hearing Officer,” “Mail order item,” “National mail order competitive bidding pr ogram,” “Nonmail order item” and “Parties to the hearing” in alphabetical order to read as follows: §414.402 Definitions. Affected party means a contract supplier that has been notified that their

DMEPOS CBP contract will be ter minated for a breach of contract.

* * * * *

### CMS-1503-P 772

Breach of contract means any deviation from contr act requirements, including a failure to comply with a governmental agen cy or licensing organization requirements,

constitutes a breach of contract.

* * * * * Corrective action plan (CAP) means a contract supplier’s written document with supporting information that describes the actions the contract supplier will take within a specified timeframe to remedy a breach of contract.

* * * * * Hearing Officer (HO) means an individual, who was not involved with the CBIC recommendation to terminate a DMEPOS Competitive Bidding Program contract, who is designated by CMS to review and make an unbiased and indepe ndent determination following the Competitive Bidding Implementation Contractor’s (CBIC’s) recommendation to terminate a DMEPOS Competitive Bidding Program contract.

* * * * *

Mail order item means any item (for example, diabetic testing supplies) shipped or delivered to the beneficiary’s home, regardless of the method of delivery.

* * * * * National mail order competitive bidding program means a program and competition resulting in the award of contract s to suppliers for furnishing mail order items throughout the nation.

* * * * *

Nonmail order item means any item (for example, diabetic testing supplies) that a beneficiary or caregiver picks up in person at a local pharmacy or supplier storefront. Parties to the hearing means the DMEPOS contract supplier and CMS.

### CMS-1503-P 773

* * * * * 35. Section 414.404 is amended by revising paragraph (b)(1)(i) to read as

follows: §414.404 Scope and applicability

* * * * * (b) * * * (1) * * * (i) The items furnished are limited to crutches, canes, walkers, folding manual wheelchairs, blood glucose monitors, and infu sion pumps that are DME, and, in addition, off-the-shelf (OTS) orthotics.

* * * * * 36. Section 414.408 is amended by-– A. Revising paragraph (f)(1). B. Redesignating paragraphs (h)(2) through (h)(7) as paragraphs (h)(3) through (h)(8) respectively. C. Adding new paragraph (h)(2). D. In newly designated paragraphs (h)( 3)(i) and (ii), remove the phrase “(h)(2)” and add in its place the phrase “(h)(3).”

The revision and addition reads as follows: § 414.408 Payment rules.

* * * * *

( 

### f) * * * (1) The single payment amounts for new purchased durable medical equipment, including power wheelchairs that are purchased when the equipment is initially furnished,

### CMS-1503-P 774

and enteral nutrition equipment are calculated based on the bids submitted and accepted

for these items. For contracts entered into beginning on or after January 1, 2011, payment on a lump sum purchase basis is only available for power wheelchairs classified as complex rehabilitative power wheelchairs.

* * * * * (h) * * * (2) For contracts entered into beginning on or after January 1, 2011, the monthly fee schedule amount for rental of power whee lchairs equals 15 per cent of the single payment amounts calculated for new durable medical equipment under paragraph (f)(1)

of this section for each of the first 3 mont hs, and 6 percent of the single payment amounts calculated for these items for each of the remaining months 4 through 13.

* * * * *

37. Section 414.410 is amended as follows: A. Revising paragraphs (a)(2) and (a)(3). B. Adding a new paragraph (a)(4).

The revisions and addition read as follows: §414.410 Phase-in implementation of competitive bidding programs. (a) * * * (2) In CY 2011, in an additional 91 MSAs (the additional 70 MSAs selected by CMS as of June 1, 2008, and the next 21 la rgest MSAs by total population based on 2009 population estimates, and not al ready phased in as of June 1, 2008). CMS may subdivide any of the 91 MSAs with a population of greater than 8,000,000 into separate CBAs, thereby resulting in more than 91 CBAs. (3) After CY 2011, additional CBAs (or, in the case of national mail order for

### CMS-1503-P 775

items and services, after CY 2010). (4) For competitions (other than for national mail order items and services) after CY 2011 and prior to CY 2015, the following areas are excluded: (i) Rural areas. (ii) MSAs not selected under paragraphs (a)(1) or (a)(2) of this section with a population of less than 250,000. (iii) An area with low population density within an MSA not selected under paragraphs (a)(1) or (a)(2) of this section.

* * * * *

38. Section 414.411 is added to read as follows: §414.411 Special rule in case of competitions for diabetic testing strips conducted on or after January 1, 2011. (a) National mail order competitions

. A supplier must demonstrate that their bid submitted as part of a national mail order competition for diabetic testing strips covers the furnishing of a sufficient number of different types of diabetic tes ting strip products that, in the aggregate, and taking into account volume for the different products, includes at least 50 percent of all the different types of products on the market. A type of diabetic testing strip means a specific brand and model of testing strips. (b) Other competitions

. CMS may apply this special rule to non-mail order or local competitions for diabetic testing strips. 39. Section 414.422 is amended by adding pa ragraph (e)(3) to read as follows: §414.422 Term of contracts.

* * * * * (e) * * *

### CMS-1503-P 776

(3) Contract suppliers for diabetic te sting supplies must furnish the brand of diabetic testing supplies that work with th e home blood glucose monitor selected by the beneficiary. The contract supplier is prohi bited from influencing or incentivizing the beneficiary by persuading, pressuring, or advising them to switch from their current brand or for new beneficiaries from their pref erred brand of glucose monitor and testing supplies. The contract supplier may not furn ish information about a lternative brands to the beneficiary unless the beneficiar y requests such information.

* * * * *

40. Section 414.423 is added to read as follows: §414.423 Appeals process for te rmination of competitive bidding contract. This section implements an appeals process for suppliers that CMS has

determined are in breach of their Medi care DMEPOS Competitive Bidding Program contracts and where CMS has taken action to terminate the supplier’s contract. Except as specified in this regulation termination deci sions made under this section are final and binding. (a) Terminations for breach of contract

. CMS may terminate a supplier’s DMEPOS Competitive Bidding Program contract when it determines that the supplier has violated any of the terms of its contract. (b) Notice of termination

. (1) CMS notification

. If CMS determines a supplier to be in breach of its contract either in part or in whole, it will no tify the Medicare DMEP OS supplier of the termination by certified mail. (2) Content of the notice . The CMS notice sent by the CBIC will include the following:

### CMS-1503-P 777

(i) The reasons for the termination. (ii) The right to request a hearing by a CBIC Hearing Officer, and depending on the nature of the breach, the supplier may also be allowed to submit a CAP in lieu of requesting a hearing by a CBIC Hearing Officer, as specified in paragraph (c)(1)(i) of this

section. (iii) The address to which the written request for a hearing must be mailed. (iv) The address to which the CAP must be mailed, if applicable. (v) Penalties that will accompany the termina tion, such as not being eligible to bid in future rounds of competitive bidding. (vi) The effective date of termination is 45 days from the date of the notification letter unless a timely hearing request has been filed or a Correctiv e Action Plan (CAP) has been submitted within 30 days of the date on the notification letter. (c) Corrective action plan

. (1) Option for Corrective action plan (CAP)

. (i) CMS has the option to allow a DMEPOS supplier to provide a written Corrective Action Plan (CAP) to remedy the deficiencies identified in the notice, when CMS determines that the delay in the termin ation date caused by allowing a CAP will not cause harm to beneficiaries, for example, we would not allow a CAP if the supplier has been excluded, debarred, or convicted of a healthcare related crime. (ii) If a supplier chooses not to sub mit a CAP or if CMS determines that a supplier's CAP is insufficient, the supplie r may request a hearing on the termination. (2) Submission of a CAP

. (i) A corrective action plan must be submitted within 30 calendar days from the date on the notification letter. If the supplier decides not to submit a corrective action

### CMS-1503-P 778

plan the supplier may within 30 days of the date on the termination letter may request a hearing by a CBIC hearing officer. (ii) Suppliers will only have the opportunity to submit a CAP when they are first notified that they have been determined to be in breach of contract. If the CAP is not acceptable or properly implemented, supplie rs will receive a termination notice.. (d) The purpose of the corrective action plan

. (1) For the supplier to eliminate all of the deficiencies that were identified in the

CBIC notice to terminate its contract to avoid contract termination. (2) To identify the timeframes by which the supplier will implement each of the components of the CAP. (e) Review of the CAP

. (1) The CBIC will review the CAP and submit a recommendation to CMS concerning whether the CAP includes the steps necessary to remedy the contract

deficiencies as identified in the notice. (2) If CMS accepts the CAP, including supplier’s designated timeframe for its completion; the supplier must provide a follow- up report within 5 days after the supplier has fully implemented the CAP that verifies that all of the deficiencies identified in the CAP have been corrected in accordance with the timeframes accepted by CMS. (3) If the supplier does not implement an acceptable CAP the supplier will receive a new notice that their contract will be terminated within 45 calendar days of the date on

the notice to terminate. (f) Right to request a hearing by the CBIC hearing officer (HO)

.

### CMS-1503-P 779

(1) A supplier who has received a notice that CMS considers the supplier in breach of contract or that the supplier's CAP is not acceptable has the right to request a hearing before a HO who was not involve d with the original determination. (2) A supplier who wishes to appeal the termination notice must s ubmit a written request to the CBIC. The request for a hearin g must be received by the CBIC within 30 calendar days from the date of the notice to terminate. (3) A request for hearing must be in writing and submitted by an authorized official of the supplier. (4) The appeals process for the Medicare DMEPOS Competitive Bidding Program is not to br used in place of other existing appeals processes that apply to other parts of the Medicare. (5) In the absence of submitting a CAP when the supplier is offered the opportunity to submit a CAP within 30 days of the notice in accord ance with paragraph (c)(1) of this section, a supplier's failure to timely request a hearing will result in a termination of the supplier's DMEPOS Competitive Bidding Program contract effective 45 days from the date on the notice to terminate. (g) The CBIC Hearing Officer schedules and conducts the hearing. (1) Within 30 calendar days from the receipt of the supplier's timely request for a hearing the hearing officer will contact the parties to schedule the hearing. (2) The hearing may be held in person or by telephone at the supplier’s request. (3) The scheduling notice to the parties must indicate the time and place for the hearing and must be sent to the supplier 30 days before the date of the hearing.

### CMS-1503-P 780

(4) The HO may, on his or her own motion, or at the request of a party, change the time and place for the hearing, but must gi ve the parties to the hearing 30 day notice of the change. (5) The HO’s scheduling notice must provi de the parties to the hearing and the CBIC the following information: (i) Description of the hearing procedure. (ii) The general and specific issues to be resolved. (iii) The supplier has the bur den to prove it is not in violation of the contract. (iv) The opportunity for parties to the he aring to submit evidence to support their positions. (v) All evidence submitted, both from the supplier and CMS, in preparation for the hearing with all affected parties within 15 days prior to the scheduled dated of the hearing. (h) Burden of proof

. (1) The burden of proof is on the Competitive Bidding Program contract supplier to demonstrate to the HO with convincing eviden ce that it has not breached its contract or

that termination is not appropriate. (2) The supplier’s supporting evidence must be submitted with its request for a hearing. (3) If the Medicare DMEPOS supplier fails to submit this evidence at the time of its submission, the Medicare DMEPOS s upplier is precluded from introducing new evidence later during the hearing process, unless permitted by the hearing officer. (4) The CBIC and CMS also have the opportunity to submit evidence to the HO within 10 days of receiving a notice announcing the hearing.

### CMS-1503-P 781

(5) The HO will share all evidence submitted, both from the supplier and/or CMS, in preparation for the hearing with all affe cted parties within 15 days prior to the scheduled date of the hearing. (i) Role of the Hearing Officer

. The HO will conduct a thor ough and independent review of the evidence including the information and documentation submitted for the hearing and other information that the HO considers pertinent for the hearing. The role of the HO includes, at a minimum, the following: (1) Conducts the hearing and decides th e order in which the evidence and the arguments of the parties are presented; (2) Determine the rules on admissibility of the evidence; (3) Examines the witnesses, in addition to the examinations conducted by CMS, CBIC and the contract supplier; (4) The CBIC may assist CMS in the appeals process including being present at the hearing, testifying as a witness, or performing other, related ministerial duties. (5) Determines the rules for requesting documents and other evidence from other parties; (6) Ensures a complete record of the hearing is made available to all parties to the hearing; (7) Prepares a file of the record of the hearing which includes all evidence submitted as well as any relevant documents identified by the HO and considered as part of the hearing; and (8) Complies with all applicable provisions of 42 USC Title 18 and related provisions of the Act, the applicable regula tions issued by the Secretary, and manual instructions issued by CMS.

### CMS-1503-P 782

(j) Hearing Officer recommendation

. (1) The HO will issue a written recommendation to CMS within 30 days of the close of the hearing or as soon as practical after the hearing. (2) The recommendation will explain the basis and the rationale for the HO’s

recommendation. (3) The hearing officer must include the record of the hearing, along with evidence and documents produced during the hearing along with its recommendation. (k) CMS' consideration of a HO’s recommendation. (1) CMS’ review of the HO recommendati on will not allow the supplier to submit

new information. (2) After reviewing the HO recommendati on, CMS’ decision will be made within 30 days from the date of recei pt of the HO’s recommendation. (3) A CMS decision to terminate will indicate the effective date of the

termination. (4) This decision is final and binding. (l) Effect of contract termination

. (1) A contract supplier whose contract ha s been terminated may no longer furnish competitive bid items to beneficiaries within a CBA and be reimbursed by Medicare for

these items after the effective date of the termination. (2) A contract supplier whose contract has been terminated must notify all beneficiaries who are receiving rented co mpetitive bid items or competitive bid items received on a recurring basis, of the termination of their contract. The notice to the beneficiary from the supplier whose contract was terminated must be provided within 5 days of receipt of the final notice of termin ation. The notification to the beneficiaries

### CMS-1503-P 783

must inform the beneficiaries that they are go ing to have to select a new contract supplier to furnish these items in order for Medicare to pay these items. (m) Effective date of the contract termination

. (1) A supplier’s DMEPOS CBP contract is terminated effective on the termination date specified in the CBIC notice to the supplier, unless the supplier timely requests a hearing with the HO or the supp lier has submitted a CAP under paragraph (x)

of this section. (2) If a supplier requests an HO review of the CMS decision to terminate its contract, and CMS based upon on the HO re commendation terminates the supplier’s contract, the effective date of the termina tion will be the date specified in the CBIC notice to the supplier. (3) For violations of the terms of the supplier’s DMEPOS CBP contract that may harm beneficiaries, such as a supplier providing an inferior product that causes harm to the beneficiary, no delays of the effective date of the termination will be allowed. Subpart H – Fee Schedule for Ambulance Services 39. Section 414.610 is amended by revising paragraphs (c)(1)(i),(c)(5)(ii), (f), and (h) to read as follows: §414.610 Basis of payments.

* * * * * (c) * * * (1) Ground ambulance service levels

. (i) The CF is multiplied by the applicable RVUs for each level of service to produce a service-level base rate. For services furnished during the period July 1, 2004 through December 31, 2006, ambulance services originating in urban areas (both base rate and mileage) are paid based on a

### CMS-1503-P 784

rate that is one percent higher than othe rwise is applicable under this section, and ambulance services originating in rural areas (both base rate and mileage) are paid based on a rate that is two percent higher than otherwise is applicable under this section. For services furnished during the period July 1, 2008 through December 21, 2010, ambulance services originating in urban areas (both base rate and mileage) are paid based on a rate that is two percent higher than otherw ise is applicable under this section, and ambulance services originatin g in rural areas (both base rate and mileage) are paid based on a rate that is three percent higher than otherwise is applicable under this section.

* * * * * (5) * * * (ii) For services furnished during the period July 1, 2004 through December 31, 2010, the payment amount for the ground ambulance base rate is increased by 22.6 percent where the point of pickup is in a ru ral area determined to be in the lowest 25 percent of rural population arrayed by popul ation density. The amount of this

increase is based on CMS’s estimate of the ra tio of the average cost per trip for the rural areas in the lowest quartile of populati on compared to the average cost per trip for the rural areas in the highest quartile of population. In making this estimate, CMS may use data provided by the GAO.

* * * * * (f) Updates

. The CF, the air ambulance base rates, and the mileage rates are updated annually by an inflati on factor established by law. The inflation factor is based on the consumer price index for a ll urban consumers (CPI-U) (U.S. city average) for the 12-month period ending with June of the previous year and, as of

### CMS-1503-P 785

January 1, 2011, is reduced by the 10-year moving average of changes in annual economy-wide private nonfarm busine ss multi-factor productivity (MFP) (as projected by the Secretary for the 10-year period ending with the applicable fiscal year, year, cost reporting pe riod, or other annual period.)

* * * * * (h) Treatment of certain areas for payment for air ambulance services

. Any area that was designated as a rural area for purposes of making payments under the ambulance fee

schedule for air ambulance serv ices furnished on December 31, 2006, must be treated as a rural area for purposes of making payments under the ambulance fee schedule for air ambulance services furnished during the period July 1, 2008 through December 31, 2010.

40. Section 414.620 is revised to read as follows: §414.620 Publication of the ambulance fee schedule. (a) Changes in payment rates resulting from incorporation of the annual inflation factor and the multi-factor productivity ad justment as described in §414.610(f) will be announced by CMS by instruction and on the CMS website. (b) CMS will follow applicable rulemaking procedures in publishing revisions to the fee schedule for ambulance services that result from any factors other than those described in §414.610(f). Subpart J--Submission of Manufact urer’s Average Sales Price Data 41. Section 414.804 is amended by-- A. Redesignating paragr aph (a)(6) as (a)(7). B. Adding new paragraph (a)(6).

The addition reads as follows: §414.804 Basis of payment.

### CMS-1503-P 786

(a) * * * (6) The manufacturer’s average sales price must be calculated based on the amount of product in a vial or other contai ner as conspicuously reflected on the FDA approved label as defined by section 201(k) of the Food Drug and Cosmetic Act.

* * * * * Subpart K—Payment for Drugs and Biologicals Under Part B 42. Section 414.902 is amended by addi ng the definitions of “Biosimilar biological product” and “Reference biological product” in alphabetical order to read as

follows: §414.902 Definitions.

* * * * * Biosimilar biological product means a biological product approved under an abbreviated application for a license of a biol ogical product that relie s in part on data or information in an application for another biological product licensed under section 351 of

the Public Health Service Ac t (PHSA) as defined at sec tion 1847A(c)(6)(H) of the Act.

* * * * * Reference biological product means the biological product licensed under such

section 351 of the PHSA that is referred to in the application of th e biosimilar biological product as defined at secti on 1847A(c)(6)(I) of the Act.

* * * * * 43. Section 414.904 is amended by-- A. Adding paragraphs (a)(3), (i), and (j). B. Revising paragraph (d)(3).

The revisions and additions read as follows:

### CMS-1503-P 787

§414.904 Average sales price as the basis for payment. (a) * * * (3) For purposes of this section-- (i) CMS calculates an average sales pr ice payment limit based on the amount of product included in a vial or other container as reflected on the FDA-approved label. (ii) Additional product contai ned in the vial or other container does not represent a cost to providers and is not incorporated into the ASP payment limit. (iii) No payment shall be made for amounts of product in excess of that reflected on the FDA-approved label.

* * * * * (d) * * * (3) Widely available market price and average manufacturer price

. If the Inspector General finds that the average sales price exceeds the widely available market price or the average manufacturer price by the applicable threshold percentage specified in paragraph (d)(3)(iii) of this section, the In spector General is responsible for informing the Secretary (at such times as specified by the Secreatry) and the payment amount for the drug or biological will be substituted by the lesser of the widely available market price or 103 percent of the average manufact urer price as subject to the following adjustments: (i) The payment amount substitution will be applied at the next ASP payment amount calculation period after the Inspector General informs the Secretary (at such times specified by the Secretary) about drug s or biologicals that have exceeded the applicable threshold percentage, and will remain in effect for one quarter after publication.

### CMS-1503-P 788

(ii) Payment at 103 percent of the average manufa cturer price for a billing code will be applied at such times when: (A) The threshold for making price substituti ons, as defined in section (iii) is met; and, (B) When 103 percent of the AMP is less than the 106 percent of the ASP during the quarter in which the average ma nufacturer price would be applied. (iii) The applicable threshold for AMP comparisons for calendar years 2005, 2006, 2007, 2008, 2009, 2010, is 5 percent. For CY 2011, the threshold for ASP comparisons is reached when: (A) The ASP for the billing code has exceeded the AMP for the billing code by 5 percent or more in two consecutive quarters, or three of the last four quarters; immediately preceding the quarter to which the price substitution recommendation would apply; and, (B) The average manufacturer price for the billing code is calculated using the same set of NDCs used for the average sales price calculation as per this section for the billing code; (iv) The applicable threshold for WA MP comparisons for calendar years 2005 through 2011 is 5 percent. (v) No payment amount substitutions will occur before the preliminary injunction issued on December 19, 2007, by the United Stat es District of Columbia in National Association of Chain Drug Stores et al. v. Health and Human Serv ices, Civil Action No. 1:07-cv-02017 (RCL), is vacated.

* * * * *

### CMS-1503-P 789

(i) If manufacturer ASP data is not ava ilable prior to the publication deadline for quarterly payment limits, the payment limit is calculated by carrying over the most recent available manufacturer ASP price from a previous quarter for an NDC, adjusted by the weighted average of the change in the manufacturer ASPs for the NDCs that were reported during both the most recently available quarter and the current quarter. (j) Biosimilar biological products

. Effective July 1, 2010, the payment amount for a biosimilar biological drug product (a s defined in §414.902 of this subpart) is the sum of the average sales price of all NDCs assigned to the biosimilar biological product as determined under section 1847A(b)(6) of the Act and 6 percent of the amount determined under section 1847A (b)(4) of th e Act for the reference drug product (as defined in §414.902 of this subpart). PART 415--SERVICES FURNISHED BY PHYSICIANS IN PROVIDERS,

SUPERVISING PHYSICIANS IN TEACH ING SETTINGS, AND RESIDENTS IN

CERTAIN SETTINGS 44. The authority citation for part 415 continues to read as follows: Authority: Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh). Subpart C--Part B Carrier Payments for Physician Services to Beneficiaries in

Providers 45. Section 415.130 is amended by revising paragraph (d) to read as follows: §415.130 Conditions for payment: Ph ysician pathology services.

* * * * * (d) Physician pathology services furn ished by an independent laboratory.

### CMS-1503-P 790

(1) The technical component of physicia n pathology services furnished by an independent laboratory to a hospital i npatient or outpatie nt on or before December 31, 2010, may be paid to the laborator y by the contractor under the physician fee schedule if the Medicare beneficiary is a patient of a covered hos pital as defined in paragraph (a)(1) of this section. (2) For services furnished after Decemb er 31, 2010, an independent laboratory may not bill the Medicare cont ractor for the technical com ponent of physician pathology services furnished to a hospita l inpatient or outpatient. (3) For services furnished on or after January 1, 2008, the date of service policy in §414.510 of this chapter applies to the TC of specimens for physician pathology services.

PART 424--CONDITIONS FOR MEDICARE PAYMENT 46. The authority citation for part 424 continues to read as follows: Authority : Secs. 1102 and 1871 of the Social Security Act (42 U.S.C. 1302 and 1395hh). Subpart B--Certification and Plan of Treatment Requirements 47. Section 424.20 is amended by revising paragraph (e)(2) to read as follows: §424.20 Requirements for posthospital SNF care.

* * * * * (e) * * * (2) A physician extender (that is, a nurse pr actitioner, a clinical nurse specialist, or a physician assistant as those terms are de fined in section 1861(aa)(5) of the Act) who does not have a direct or indirect employme nt relationship with the facility but who is working in collaboration with a physicia n. For purposes of this section-- (i) Collaboration.

### CMS-1503-P 791

(A) Collaboration means a process whereby a physician extender works with a doctor of medicine or osteopathy to deliver health care services. (B) The services are delivered within the scope of the physician extender’s professional expertise, with me dical direction and appropriate supervis ion as provided for in guidelines jointly developed by the ph ysician extender and the physician or other mechanisms defined by Federal regulations and the law of the State in which the services are performed. (ii) Types of employment relationships

. (A) Direct employment relationship . A direct employment relationship with the facility is one in which the physician extender meets the common law definition of the facility’s “employee,” as specified in 20 CFR 404.1005, 404.1007, and 404.1009. When a physician extender meets this definition with respect to an entity other than the facility itself, and that entity has an agreement with the facility for the provision of nursing services under § 409.21 of this subchapter, the fa cility is considered to have an indirect employment relationship with the physician extender. (B) Indirect employment relationship . (1 ) When a physician extender meets the definition of a direct employme nt relationship in paragraph (e)(2)(ii)(A) of this section with respect to an entity other than the facility itself, and that entity has an agreement with the facility for the provision of nursing services under § 409.21 of this subchapter, the facility is considered to have an indirect employment relationship with the physician

extender. (2 ) An indirect employment relationship does not exist if the agreement between the entity and the facility involves only the performance of delegated physician tasks under §483.40(e) of this chapter.

### CMS-1503-P 792

* * * * * Subpart C--Claims for Payment 48. Section 424.44 is amended by revising para graphs (a), (b), and (e) to read as

follows: §424.44 Time limits for filing claims. (a) Time limits

. (1) For services furnished on or after January 1, 2010, except as provided in paragraphs (b) and (e) of this section, the cla im must be filed no later than the close of the period ending 1 calendar year after the date of service. (2) For services furnished before January 1, 2010, except as provided in paragraphs (b) and (e) of this section, the claim must be filed on or before December 31 of the following year for services that we re furnished during the first 9 months of a calendar year, and on or before December 31 st 

### of the second following year for services that were furnished during the last 3 months of the calendar year, except that for services furnished during the last 3 months of 2009 all claims must be filed no later than December 31, 2010. (b) Exceptions to time limits . Exceptions to the time limits for filing claims include the following: (1) The time for filing a claim will be exte nded if CMS or one of its contractors determines that a failure to meet the deadline in paragraph (a) of this section was caused by error or misrepresentation of an employee , Medicare contractor (including Medicare Administrative Contractor, intermediary, or carrier), or agent of the Department that was performing Medicare functions and acting within the scope of its authority. (2) The time for filing a claim will be exte nded if CMS or one of its contractors

### CMS-1503-P 793

determines that a failure to meet the deadline in paragraph (a) of this section is caused by all of the following conditions: (i) At the time the service was furnished the beneficiary was not entitled to

Medicare. (ii) The beneficiary subsequently rece ived notification of Medicare entitlement effective retroactively to or before the date of the furnished service. (3) The time for filing a claim will be exte nded if CMS or one of its contractors determines that a failure to meet the deadline in paragraph (a) of this section is caused by all of the following conditions: (i) At the time the service was furnished the beneficiary was not entitled to

Medicare. (ii) The beneficiary subsequently rece ived notification of Medicare entitlement effective retroactively to or before the date of the furnished service. (iii) A State Medicaid agency recovered the Medicaid payment for the furnished service from a provider or supplier 11 months or more after the service was furnished. (4) Extension of time . (i) The time to file a claim will be extended through the last day of the 6th calendar month follo wing the month in which the error or misrepresentation referenced in paragraph (b)(1 ) of this section, is corrected. However, no extension of time will be granted for paragraph (b)(1) when the request for that exception is made to CMS or one of its contractors more than 4 years after the date of

service. (ii) If CMS or one of its contractors determines that both of the conditions are met in paragraph (b)(2) of this section but th at all of the conditions in paragraph (b)(3) are not satisfied, the time to file a claim will be extended through the last day of the 6 th

### CMS-1503-P 794

calendar month following the month in whic h the beneficiary received notification of Medicare entitlement effective retroactively to or before the date of the furnished service. (iii) If CMS or one of its contractors determines that all of the conditions are met in paragraph (b)(3) of this section, the time to file a claim will be extended through the last day of the 6 th 

### calendar month following the m onth in which the State Medicaid agency recovered the Medicaid payment for the furnished service from the provider or supplier.

* * * * * (e) As specified in §§ 424.520 and 424.521 of this subpart, there are restrictions on the ability of the following newly-enrolled suppliers to submit claims for items or services furnished prior to the effective date of their Medicare billing privileges: (1) Physician or non-physicia n practitioner organizations. (2) Physicians. (3) Nonphysician practitioners. (4) Independent diagnostic testing facilities.

* * * * * Subpart P--Requirements for Establishi ng and Maintaining Medicare Billing Privileges 49. Section 424.502 is amended by a dding a definition of "Voluntary termination" in alphabetical order to read as follows: §424.502 Definitions.

* * * * *

### CMS-1503-P 795

Voluntary termination means that a provider or supplier, including an individual physician or non-physician pr actitioner, submits written c onfirmation to CMS of its decision to discontinue enrollment in the Medicare program. 50. Section 424.510 is amended by revising paragraph (d)(1)(iii) to read as

follows: §424.510 Requirements for enrolling in the Medicare program.

* * * * * (d) * * * (1) * * * (iii) Submission of all docu mentation, including all app licable Federal and State licenses,certifications (including, but not limited to Federal Aviation Administration and Clinical Laboratory Improvement Act certifi cations),and regulatory requirements that apply to the specific provider or supplier type that relate to providing health care service, required by CMS under this or other statutor y or regulatory authority, or under the Paperwork Reduction Ac t of 1995, to establish the provide r or supplier’s eligibility to

furnish Medicare covered items or services to beneficiaries in the Medicare program.

* * * * * 51. Section 424.516 is amended by adding pa ragraph (e)(3) to read as follows: §424.516 Additional provider and suppli er requirements for enrolling and maintaining active enrollment status in the Medicare program.

* * * * * (e) * * * (3) Within 30 days any revocation or susp ension of a Federal or State license or certification (including Fe deral Aviation Administration and Clinical Laboratory

### CMS-1503-P 796

Improvement Act certifications), an air ambul ance supplier must report a revocation or suspension of its license or certification to the applicable Medicare contractor.

* * * * *

### CMS-1503-P

Authority: (Catalog of Federal Domestic A ssistance Program No. 93.773, Medicare-- Hospital Insurance; and Program N o. 93.774, Medicare--Supplementary Medical Insurance Program)

Dated: June 18, 2010.

_______________________________ Marilyn Tavenner, Acting Administrator and Chief Operating Officer

Centers for Medicare & Medicaid Services.

Approved: June 24, 2010.

__________________________________ Kathleen Sebelius, Secretary.

### CMS-1503-P 798

ADDENDUM A: Explanation and Use of Addendum B The Addenda on the following pages provi de various data pertaining to the Medicare fee schedule for physicians’ serv ices furnished in CY 2011. Addendum B contains the RVUs for work, nonfacility PE, f acility PE, and malpr actice expense, and

other information for all services included in the PFS. In previous years, we have listed many services in Addendum B that are not paid under the PFS. To avoid publishing as many pages of codes for these services, we are not including clinical laboratory codes or the alpha-numeric codes (Healthcare Common Procedure Coding System (HCPCS) codes not included in CPT) not paid under the PFS

in Addendum B. Addendum B contains the following info rmation for each CPT code and alphanumeric HCPCS code, except for: alpha-numer ic codes beginning with B (enteral and parenteral therapy); “E” (durable medical equipment); “K” (temporary codes for nonphysicians’ services or items); or “L” (o rthotics); and codes for anesthesiology. Please also note the following:

• An “NA” in the “Nonfacility PE RVUs” column of Addendum B means that CMS has not developed PE RVUs in the nonf acility setting for the service because it is typically performed in the hospital (for exam ple, an open heart surgery is generally performed in the hospital setting and not a physician’s office). If there is an “NA” in the nonfacility PE RVU column, and the contractor determines that this service can be performed in the nonfacility setting, the service will be paid at the facility PE RVU rate.

• Services that have an “NA” in the “Facility PE RVUs” column of Addendum B are typically not paid under the PFS when provided in a facility setting. These services (which include “incident to” services and th e technical portion of diagnostic tests) are

### CMS-1503-P 799

generally paid under either the hospital outpatient prospective payment system or bundled into the hospital inpatient prospective payment system payment. In some cases, these services may be paid in a facility setting at the PFS rate (for example, therapy services), but there would be no payment made to the practitioner under the PFS in these

situations.

1. CPT/HCPCS code . This is the CPT or alpha -numeric HCPCS number for the service. Alpha-numeric HCPCS codes are included at the end of this Addendum. 2. Modifier . A modifier is shown if there is a technical compone nt (modifier TC) and a professional component (PC) (modifier-26) for the service. If there is a PC and a TC for the service, Addendum B contains thre e entries for the code, specifically a code for: the global values (both professional and technical); modi fier -26 (PC); and modifier -TC. The global service is not designated by a modifier, and physicians must bill using the code without a modifier if the physicia n furnishes both the PC and the TC of the

service. Modifier-53 is shown for a discon tinued procedure, for example a colonoscopy that is not completed. There will be RVUs for a code with this modifier.

3. Status indicator . This indicator shows whether the CPT/HCPCS code is included

in the PFS and whether it is separately payable if the service is covered.

A = Active code . These codes are separately pa yable under the PFS if covered. There will be RVUs for codes with this status. The presence of an “A” indicator does not

mean that Medicare has made a national coverage determina tion regarding the service. Contractors remain responsible for coverage decisions in the absence of a national Medicare policy.

B = Bundled code . Payments for covered services are always bundled into payment for other services not specified. If RVUs are shown, they are not used for

### CMS-1503-P 800

Medicare payment. If these services are co vered, payment for them is subsumed by the payment for the services to which they are incident (an example is a telephone call from a hospital nurse regarding care of a patient). C = Contractors price the code . Contractors establish RVUs and payment amounts for these services, generally on an i ndividual case basis following review of documentation, such as an operative report. E = Excluded from the PFS by regulation . These codes are for items and services that CMS chose to exclude from the PFS by regulation. No RVUs are shown, and no payment may be made under the PFS for thes e codes. Payment for them, when covered, continues under reasonable charge procedures. I = Not valid for Medicare purposes . Medicare uses another code for the reporting of, and the payment for these servi ces. (Codes not subject to a 90-day grace period.) M = Measurement codes, used for reporting purposes only . There are no RVUs and no payment amounts for these codes. CM S uses them to aid with performance measurement. No separate payment is made . These codes should be billed with a zero (($0.00) charge and are denied) on the MPFSDB.

N = Noncovered service . These codes are noncovered services. Medicare payment may not be made for these codes. If RVUs are shown, they are not used for Medicare payment. R = Restricted coverage . Special coverage instructions apply. If the service is

covered and no RVUs are show n, it is contractor-priced. T = There are RVUs for these services, but they are only paid if there are no other services payable under the PFS billed on the same date by the same provider . If

### CMS-1503-P 801

any other services payable under the PFS ar e billed on the same date by the same provider, these services are bundled into th e service(s) for which payment is made. X = Statutory exclusion . These codes represent an item or service that is not within the statutory definition of “physician s’ services” for PFS payment purposes. No RVUs are shown for these codes, and no payment may be made under the PFS. (Examples are ambulance services and clin ical diagnostic laboratory services.) 4. Description of code . This is an abbreviated vers ion of the narrative description

of the code. 5. Physician work RVUs . These are the RVUs for the physician work in CY

2011. 6. Fully implemented nonfacility PE RVUs . These are the fully implemented

resource-based PE RVUs for nonfacility settings. 7. CY 2011 transitional nonfacility PE RVUs . These are the CY 2011 resourcebased PE RVUs for nonfacility settings. 8. Fully implemented facility PE RVUs . These are the fully implemented resource-based PE RVUs for facility settings. 9. CY 2011 Transitional facility PE RVUs . These are the CY 2011 resourcebased PE RVUs for facility settings. 10. Malpractice expense RVUs . These are the RVUs for the malpractice expense

for CY 2011.

Note: The BN reduction resulting from the chiropractic demonstration is not reflected in the RVUs for CPT codes 98940, 98941 and 98942. The required reduction will only be reflected in the files used for Medicare payment.

11. Global period . This indicator shows the number of days in the global period

### CMS-1503-P 802

for the code (0, 10, or 90 days). An explanation of the alpha codes follows:

MMM = Code describes a service furnishe d in uncomplicated maternity cases, including antepartum care, delivery, and pos tpartum care. The usual global surgical concept does not apply. See the Physicians’ Current Procedural Terminology for specific

definitions. XXX = The global concept does not apply. YYY = The global period is to be set by the contractor (for example, unlisted surgery codes).

ZZZ = Code related to another service that is always included in the global period of the other service. (Note: Physician work and PE are associated with intra-service time and, in some instances, with the post-service time.)CMS-1503-P803ADDENDUM B: Proposed RelativeValue Units and Related Information Usedin Determining Medicare Payments for CY 2011**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**0016T C Thermotx choroid vasc lesion 0.00 0.00 0.00 0.00 0.00 0.00 XXX0017T C Photocoagulat macular drusen 0.00 0.00 0.00 0.00 0.00 0.00 XXX0019T C Extracorp shock wv tx,ms nos 0.00 0.00 0.00 0.00 0.00 0.00 XXX0030T C Antiprothrombin antibody 0.00 0.00 0.00 0.00 0.00 0.00 XXX0042T C Ct perfusion w/contrast, cbf 0.00 0.00 0.00 0.00 0.00 0.00 XXX0048T C Implant ventricular device 0.00 0.00 0.00 0.00 0.00 0.00 XXX0050T C Removal circulation assist 0.00 0.00 0.00 0.00 0.00 0.00 XXX0051T C Implant total heart system 0.00 0.00 0.00 0.00 0.00 0.00 XXX0052T C Replace component heart syst 0.00 0.00 0.00 0.00 0.00 0.00 XXX0053T C Replace component heart syst 0.00 0.00 0.00 0.00 0.00 0.00 XXX0054T C Bone surgery using computer 0.00 0.00 0.00 0.00 0.00 0.00 XXX0055T C Bone surgery using computer 0.00 0.00 0.00 0.00 0.00 0.00 XXX0071T C U/s leiomyomata ablate<200 0.00 0.00 0.00 0.00 0.00 0.00 XXX0072T C U/s leiomyomata ablate>200 0.00 0.00 0.00 0.00 0.00 0.00 XXX0073T A Delivery, comp imrt 0.00 13.68 15.38 NA NA 0.01 XXX0075T C Perq stent/chest vert art 0.00 0.00 0.00 NA NA 0.00 XXX0075T TC C Perq stent/chest vert art 0.00 0.00 0.00 NA NA 0.00 XXX0075T 26 C Perq stent/chest vert art 0.00 0.00 0.00 0.00 0.00 0.00 XXX0076T C S&i stent/chest vert art 0.00 0.00 0.00 NA NA 0.00 XXX0076T TC C S&i stent/chest vert art 0.00 0.00 0.00 NA NA 0.00 XXX0076T 26 C S&i stent/chest vert art 0.00 0.00 0.00 0.00 0.00 0.00 XXX0078T C Endovasc aort repr w/device 0.00 0.00 0.00 0.00 0.00 0.00 XXX0079T C Endovasc visc extnsn repr 0.00 0.00 0.00 0.00 0.00 0.00 XXX0080T C Endovasc aort repr rad s&i 0.00 0.00 0.00 0.00 0.00 0.00 XXXCMS-1503-P804**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**0081T C Endovasc visc extnsn s&i 0.00 0.00 0.00 0.00 0.00 0.00 XXX0085T N Breath test heart reject 0.00 0.00 0.00 0.00 0.00 0.00 XXX0092T C Artific disc addl0.00 0.00 0.00 0.00 0.00 0.00 XXX0095T C Artific diskectomy addl0.00 0.00 0.00 0.00 0.00 0.00 XXX0098T C Rev artific disc addl0.00 0.00 0.00 0.00 0.00 0.00 XXX0099T C Implant corneal ring 0.00 0.00 0.00 0.00 0.00 0.00 XXX0100T C Prosth retina receive&gen 0.00 0.00 0.00 0.00 0.00 0.00 XXX0101T C Extracorp shockwv tx,hi enrg 0.00 0.00 0.00 0.00 0.00 0.00 XXX0102T C Extracorp shockwv tx,anesth 0.00 0.00 0.00 0.00 0.00 0.00 XXX0103T C Holotranscobalamin 0.00 0.00 0.00 0.00 0.00 0.00 XXX0104T C At rest cardio gas rebreathe 0.00 0.00 0.00 0.00 0.00 0.00 XXX0105T C Exerc cardio gas rebreathe 0.00 0.00 0.00 0.00 0.00 0.00 XXX0106T C Touch quant sensory test 0.00 0.00 0.00 0.00 0.00 0.00 XXX0107T C Vibrate quant sensory test 0.00 0.00 0.00 0.00 0.00 0.00 XXX0108T C Cool quant sensory test 0.00 0.00 0.00 0.00 0.00 0.00 XXX0109T C Heat quant sensory test 0.00 0.00 0.00 0.00 0.00 0.00 XXX0110T C Nos quant sensory test 0.00 0.00 0.00 0.00 0.00 0.00 XXX0111T C Rbc membranes fatty acids 0.00 0.00 0.00 0.00 0.00 0.00 XXX0123T C Scleral fistulization 0.00 0.00 0.00 0.00 0.00 0.00 XXX0124T C Conjunctival drug placement 0.00 0.00 0.00 0.00 0.00 0.00 XXX0126T C Chd risk imt study 0.00 0.00 0.00 0.00 0.00 0.00 XXX0130T C Chron care drug investigatn 0.00 0.00 0.00 0.00 0.00 0.00 XXX0140T C Exhaled breath condensate ph 0.00 0.00 0.00 0.00 0.00 0.00 XXX0141T I Perq islet transplant 0.00 0.00 0.00 0.00 0.00 0.00 XXX0142T I Open islet transplant 0.00 0.00 0.00 0.00 0.00 0.00 XXX0143T I Laparoscopic islet transplnt 0.00 0.00 0.00 0.00 0.00 0.00 XXXCMS-1503-P805**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**0155T C Lap impl gast curve electrd 0.00 0.00 0.00 0.00 0.00 0.00 XXX0156T C Lap remv gast curve electrd 0.00 0.00 0.00 0.00 0.00 0.00 XXX0157T C Open impl gast curve electrd 0.00 0.00 0.00 0.00 0.00 0.00 XXX0158T C Open remv gast curve electrd 0.00 0.00 0.00 0.00 0.00 0.00 XXX0159T C Cad breast mri 0.00 0.00 0.00 NA NA 0.00 ZZZ0159T TC C Cad breast mri 0.00 0.00 0.00 NA NA 0.00 ZZZ0159T 26 C Cad breast mri 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ0160T C Tcranial magn stim txplan 0.00 0.00 0.00 0.00 0.00 0.00 XXX0161T C Tcranial magn stim tx deliv 0.00 0.00 0.00 0.00 0.00 0.00 XXX0163T C Lumb artif diskectomy addl 0.00 0.00 0.00 0.00 0.00 0.00 YYY0164T C Remove lumb artif discaddl 0.00 0.00 0.00 0.00 0.00 0.00 YYY0165T C Revise lumb artif discaddl 0.00 0.00 0.00 0.00 0.00 0.00 YYY0166T C Tcath vsd close w/o bypass 0.00 0.00 0.00 0.00 0.00 0.00 XXX0167T C Tcath vsd close w bypass 0.00 0.00 0.00 0.00 0.00 0.00 XXX0168T C Rhinophototx light app bilat 0.00 0.00 0.00 0.00 0.00 0.00 XXX0169T C Place stereo cath brain 0.00 0.00 0.00 0.00 0.00 0.00 XXX0171T C Lumbar spine proces distract 0.00 0.00 0.00 0.00 0.00 0.00 XXX0172T C Lumbar spine process addl 0.00 0.00 0.00 0.00 0.00 0.00 XXX0173T C Iop monit io pressure 0.00 0.00 0.00 0.00 0.00 0.00 XXX0174T C Cad cxr with interp 0.00 0.00 0.00 0.00 0.00 0.00 XXX0175T C Cad cxr remote 0.00 0.00 0.00 0.00 0.00 0.00 XXX0176T C Aqu canal dilat w/o retent 0.00 0.00 0.00 0.00 0.00 0.00 XXX0177T C Aqu canal dilat w retent 0.00 0.00 0.00 0.00 0.00 0.00 XXX0178T C 64 lead ecg w i&r 0.00 0.00 0.00 0.00 0.00 0.00 XXX0179T C 64 lead ecg w tracing 0.00 0.00 0.00 0.00 0.00 0.00 XXX0180T C 64 lead ecg w i&r only 0.00 0.00 0.00 0.00 0.00 0.00 XXXCMS-1503-P806**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**0181T C Corneal hysteresis 0.00 0.00 0.00 0.00 0.00 0.00 XXX0182T C Hdr elect brachytherapy 0.00 0.00 0.00 NA NA 0.00 XXX0182T TC C Hdr elect brachytherapy 0.00 0.00 0.00 NA NA 0.00 XXX0182T 26 C Hdr elect brachytherapy0.00 0.00 0.00 0.00 0.00 0.00 XXX0183T C Wound ultrasound 0.00 0.00 0.00 0.00 0.00 0.00 XXX0184T C Exc rectal tumor endoscopic 0.00 0.00 0.00 0.00 0.00 0.00 XXX0185T C Comptr probability analysis 0.00 0.00 0.00 0.00 0.00 0.00 XXX0186T C Suprachoroidal drug delivery 0.00 0.00 0.00 0.00 0.00 0.00 XXX0187T C Ophthalmic dx image anterior 0.00 0.00 0.00 0.00 0.00 0.00 XXX0188T N Videoconf crit care 74 min 0.00 0.00 0.00 0.00 0.00 0.00 XXX0189T N Videoconf crit care addl30 0.00 0.00 0.00 0.00 0.00 0.00 XXX0190T C Place intraoc radiation src 0.00 0.00 0.00 0.00 0.00 0.00 XXX0191T C Insert ant segment drain int 0.00 0.00 0.00 0.00 0.00 0.00 XXX0192T C Insert ant segment drain ext 0.00 0.00 0.00 0.00 0.00 0.00 XXX0193T C Rf bladder neck microremodel 0.00 0.00 0.00 0.00 0.00 0.00 XXX0195T C Arthrod presac interbody 0.00 0.00 0.00 0.00 0.00 0.00 XXX0196T C Arthrod presac interbody eac 0.00 0.00 0.00 0.00 0.00 0.00 XXX0197T C Intrafraction track motion 0.00 0.00 0.00 0.00 0.00 0.00 XXX0198T C Ocular blood flow measure 0.00 0.00 0.00 0.00 0.00 0.00 XXX0199T C Physiologic tremor record 0.00 0.00 0.00 0.00 0.00 0.00 XXX0200T C Perq sacral augmt unilat inj 0.00 0.00 0.00 0.00 0.00 0.00 XXX0201T C Perq sacral augmt bilat inj 0.00 0.00 0.00 0.00 0.00 0.00 XXX0202T C Post vert arthrplst 1 lumbar 0.00 0.00 0.00 0.00 0.00 0.00 XXX0203T C Unattend sleep study w/time 0.00 0.00 0.00 NA NA 0.00 XXX0203T TC C Unattend sleep study w/time 0.00 0.00 0.00 NA NA 0.00 XXX0203T 26 C Unattend sleep study w/time 0.00 0.00 0.00 0.00 0.00 0.00 XXXCMS-1503-P807**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**0204T C Unattended sleep study 0.00 0.00 0.00 NA NA 0.00 XXX0204T TC C Unattended sleep study 0.00 0.00 0.00 NA NA 0.00 XXX0204T 26 C Unattended sleep study 0.00 0.00 0.00 0.00 0.00 0.00 XXX0205T C Inirs each vessel add-on 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ0206T C Remote algorithm analys ecg 0.00 0.00 0.00 0.00 0.00 0.00 XXX0207T C Clear eyelid gland w/heat 0.00 0.00 0.00 0.00 0.00 0.00 XXX0208T C Automated audiometryair 0.00 0.00 0.00 0.00 0.00 0.00 XXX0209T C Auto audiometry air/bone 0.00 0.00 0.00 0.00 0.00 0.00 XXX0210T C Auto audiometry sp thresh 0.00 0.00 0.00 0.00 0.00 0.00 XXX0211T C Auto audiometry sp thresh 0.00 0.00 0.00 0.00 0.00 0.00 XXX0212T C Comprehen auto audiometry 0.00 0.00 0.00 0.00 0.00 0.00 XXX0213T C Us facet jt inj cerv/t 1 lev 0.00 0.00 0.00 0.00 0.00 0.00 XXX0214T C Us facet jt inj cerv/t 2 lev 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ0215T C Us facet jt inj cerv/t 3 lev 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ0216T C Us facet jt inj ls 1 level 0.00 0.00 0.00 0.00 0.00 0.00 XXX0217T C Us facet jt inj ls 2 level 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ0218T C Us facet jt inj ls 3 level 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ0219T C Fuse spine facet jt cerv 0.00 0.00 0.00 0.00 0.00 0.00 XXX0220T C Fuse spine facet jt thor 0.00 0.00 0.00 0.00 0.00 0.00 XXX0221T C Fuse spine facet jt lumbar 0.00 0.00 0.00 0.00 0.00 0.00 XXX0222T C Fuse spine facet jt add seg 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ0528F I Rcmnd flw-up 10 yrs docd 0.00 0.00 0.00 0.00 0.00 0.00 XXX0535F I Dyspnea mngmnt plan docd 0.00 0.00 0.00 0.00 0.00 0.00 XXX0545F I Follow up care plan mdd docd 0.00 0.00 0.00 0.00 0.00 0.00 XXX10021 A Fna w/o image 1.27 2.70 2.64 0.62 0.57 0.23 XXX10022 A Fna w/image 1.27 2.37 2.54 0.49 0.51 0.14 XXXCMS-1503-P808**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**10040 A Acne surgery 1.21 1.60 1.56 1.25 1.20 0.18 01010060 A Drainage of skin abscess 1.22 1.96 1.83 1.43 1.34 0.13 01010061 A Drainage of skin abscess 2.45 2.69 2.55 1.99 1.90 0.31 01010080 A Drainage of pilonidal cyst 1.22 3.52 3.41 1.54 1.43 0.21 01010081 A Drainage of pilonidal cyst 2.50 4.66 4.52 2.09 1.94 0.47 01010120 A Remove foreign body 1.25 2.60 2.49 1.31 1.23 0.17 01010121 A Remove foreign body 2.74 4.71 4.44 2.32 2.18 0.42 01010140 A Drainage of hematoma/fluid 1.58 2.87 2.70 1.66 1.60 0.21 01010160 A Puncture drainage of lesion 1.25 2.31 2.21 1.37 1.33 0.17 01010180 A Complex drainage, wound 2.30 4.26 4.04 2.45 2.34 0.49 01011000 A Debride infected skin 0.60 0.91 0.86 0.21 0.21 0.06 00011001 A Debride infected skin add-on 0.30 0.29 0.28 0.10 0.11 0.03 ZZZ11004 A Debride genitalia & perineum 10.80 NA NA 4.67 4.48 1.96 00011005 A Debride abdom wall 14.24 NA NA 6.23 5.79 3.08 00011006 A Debride genit/per/abdom wall 13.10 NA NA 5.77 5.50 2.43 00011008 A Remove mesh from abd wall 5.00 NA NA 2.18 2.03 1.09 ZZZ11010 A Debride skin, fx 4.19 9.20 8.73 3.41 3.21 0.79 01011011 A Debride skin/muscle, fx 4.94 9.39 9.12 3.05 2.86 1.02 00011012 A Debride skin/muscle/bone, fx 6.87 12.17 12.00 4.57 4.36 1.36 00011040 A Debride skin, partial 0.50 0.84 0.79 0.20 0.20 0.04 00011041 A Debride skin, full 0.60 0.90 0.87 0.24 0.25 0.06 00011042 A Debride skin/tissue 0.80 1.25 1.20 0.35 0.35 0.10 00011043 A Debride tissue/muscle 3.14 4.72 4.44 3.57 3.35 0.52 01011044 A Debride tissue/muscle/bone 4.26 6.53 6.13 4.92 4.66 0.76 01011055 R Trim skin lesion 0.43 0.99 0.93 0.13 0.14 0.03 00011056 R Trim skin lesions, 2 to 4 0.61 1.07 1.02 0.18 0.20 0.04 000CMS-1503-P809**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**11057 R Trim skin lesions, over 4 0.79 1.21 1.15 0.23 0.26 0.06 00011100 A Biopsy, skin lesion 0.81 2.04 2.05 0.57 0.53 0.11 00011101 A Biopsy, skin add-on 0.41 0.50 0.49 0.29 0.27 0.06 ZZZ11200 A Removal of skin tags 0.82 1.57 1.50 1.19 1.12 0.11 01011201 A Remove skin tags add-on 0.29 0.23 0.21 0.18 0.16 0.04 ZZZ11300 A Shave skin lesion 0.51 1.41 1.38 0.33 0.30 0.07 00011301 A Shave skin lesion 0.85 1.73 1.71 0.58 0.53 0.11 00011302 A Shave skin lesion 1.05 2.02 2.00 0.73 0.66 0.14 00011303 A Shave skin lesion 1.24 2.38 2.34 0.85 0.77 0.18 00011305 A Shave skin lesion 0.67 1.30 1.25 0.26 0.27 0.06 00011306 A Shave skin lesion 0.99 1.67 1.63 0.51 0.50 0.11 00011307 A Shave skin lesion 1.14 1.99 1.96 0.67 0.64 0.14 00011308 A Shave skin lesion 1.41 2.10 2.03 0.69 0.67 0.14 00011310 A Shave skin lesion 0.73 1.62 1.60 0.48 0.44 0.10 00011311 A Shave skin lesion 1.05 1.90 1.88 0.72 0.67 0.14 00011312 A Shave skin lesion 1.20 2.21 2.18 0.84 0.78 0.18 00011313 A Shave skin lesion 1.62 2.62 2.57 1.12 1.02 0.25 00011400 A Exc tr-ext b9+marg 0.5 < cm 0.90 2.44 2.37 1.29 1.20 0.13 01011401 A Exc tr-ext b9+marg 0.6-1 cm 1.28 2.76 2.68 1.57 1.47 0.21 01011402 A Exc tr-ext b9+marg 1.1-2 cm 1.45 3.03 2.94 1.66 1.56 0.25 01011403 A Exc tr-ext b9+marg 2.1-3 cm 1.84 3.32 3.18 2.15 1.99 0.32 01011404 A Exc tr-ext b9+marg 3.1-4 cm 2.11 3.73 3.58 2.27 2.11 0.38 01011406 A Exc tr-ext b9+marg > 4.0 cm 3.52 4.80 4.47 3.04 2.75 0.69 01011420 A Exc h-f-nk-sp b9+marg 0.5 < 1.03 2.33 2.24 1.23 1.18 0.13 01011421 A Exc h-f-nk-sp b9+marg 0.6-1 1.47 2.82 2.72 1.58 1.49 0.23 01011422 A Exc h-f-nk-sp b9+marg 1.1-2 1.68 3.09 2.97 2.04 1.92 0.27 010CMS-1503-P810**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**11423 A Exc h-f-nk-sp b9+marg 2.1-3 2.06 3.43 3.31 2.25 2.10 0.34 01011424 A Exc h-f-nk-sp b9+marg 3.1-4 2.48 3.81 3.66 2.40 2.25 0.42 01011426 A Exc h-f-nk-sp b9+marg > 4 cm 4.09 4.85 4.59 3.31 3.05 0.73 01011440 A Exc face-mm b9+marg 0.5 < cm 1.05 2.61 2.54 1.78 1.69 0.17 01011441 A Exc face-mm b9+marg 0.6-1 cm 1.53 3.05 2.95 2.09 1.98 0.25 01011442 A Exc face-mm b9+marg 1.1-2 cm 1.77 3.36 3.26 2.24 2.12 0.30 01011443 A Exc face-mm b9+marg 2.1-3 cm 2.34 3.77 3.63 2.57 2.41 0.40 01011444 A Exc face-mm b9+marg 3.1-4 cm 3.19 4.47 4.27 3.05 2.84 0.54 01011446 A Exc face-mm b9+marg > 4 cm 4.80 5.82 5.40 4.12 3.74 0.83 01011450 A Removal, sweat gland lesion 3.22 6.91 6.52 3.46 3.15 0.68 09011451 A Removal, sweat gland lesion 4.43 8.27 7.96 4.10 3.76 0.93 09011462 A Removal, sweat gland lesion 3.00 6.90 6.60 3.42 3.13 0.62 09011463 A Removal, sweat gland lesion 4.43 8.47 8.25 4.24 3.92 0.92 09011470 A Removal, sweat gland lesion 3.74 7.38 6.91 3.84 3.47 0.73 09011471 A Removal, sweat gland lesion 4.89 8.73 8.26 4.42 4.01 0.95 0901150F I Doc pt rsk death w/in 1yr 0.00 0.00 0.00 0.00 0.00 0.00 XXX1151F I Doc no pt rsk death w/in 1yr 0.00 0.00 0.00 0.00 0.00 0.00 XXX1152F I Doc advncd dis comfort 1st 0.00 0.00 0.00 0.00 0.00 0.00 XXX1153F I Doc advncd dis cmfrt not 1st 0.00 0.00 0.00 0.00 0.00 0.00 XXX1157F I Advnc care plan in rcrd 0.00 0.00 0.00 0.00 0.00 0.00 XXX1158F I Advnc care plan tlk docd 0.00 0.00 0.00 0.00 0.00 0.00 XXX1159F I Med list docd in rcrd 0.00 0.00 0.00 0.00 0.00 0.00 XXX11600 A Exc tr-ext mlg+marg 0.5 < cm 1.63 3.56 3.40 1.64 1.49 0.27 01011601 A Exc tr-ext mlg+marg 0.6-1 cm 2.07 4.18 4.05 2.07 1.92 0.32 01011602 A Exc tr-ext mlg+marg 1.1-2 cm 2.27 4.54 4.43 2.29 2.13 0.35 01011603 A Exc tr-ext mlg+marg 2.1-3 cm 2.82 4.94 4.77 2.62 2.39 0.44 010CMS-1503-P811**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**11604 A Exc tr-ext mlg+marg 3.1-4 cm 3.17 5.40 5.19 2.76 2.51 0.54 01011606 A Exc tr-ext mlg+marg > 4 cm 5.02 7.15 6.69 3.69 3.28 0.92 0101160F I Rvw meds by rx/dr in rcrd 0.00 0.00 0.00 0.00 0.00 0.00 XXX11620 A Exc h-f-nk-sp mlg+marg 0.5 < 1.64 3.62 3.49 1.69 1.54 0.27 01011621 A Exc h-f-nk-sp mlg+marg 0.6-1 2.08 4.22 4.10 2.10 1.95 0.32 01011622 A Exc h-f-nk-sp mlg+marg 1.1-2 2.41 4.63 4.53 2.38 2.22 0.38 01011623 A Exc h-f-nk-sp mlg+marg 2.1-3 3.11 5.14 4.95 2.79 2.56 0.51 01011624 A Exc h-f-nk-sp mlg+marg 3.1-4 3.62 5.63 5.40 3.02 2.76 0.62 01011626 A Exc h-f-nk-sp mlg+mar > 4 cm 4.61 6.51 6.22 3.48 3.20 0.83 01011640 A Exc face-mm malig+marg 0.5 < 1.67 3.80 3.67 1.80 1.66 0.27 01011641 A Exc face-mm malig+marg 0.6-1 2.17 4.37 4.27 2.20 2.08 0.34 01011642 A Exc face-mm malig+marg 1.1-2 2.62 4.85 4.76 2.53 2.38 0.41 01011643 A Exc face-mm malig+marg 2.1-3 3.42 5.38 5.20 3.01 2.79 0.57 01011644 A Exc face-mm malig+marg 3.1-4 4.34 6.49 6.25 3.59 3.32 0.73 01011646 A Exc face-mm mlg+marg > 4 cm 6.26 7.87 7.50 4.72 4.36 1.09 01011719 R Trim nail(s) 0.17 0.46 0.44 0.05 0.06 0.01 00011720 A Debride nail, 1-5 0.32 0.57 0.54 0.09 0.10 0.03 00011721 A Debride nail, 6 or more 0.54 0.66 0.64 0.16 0.18 0.04 00011730 A Removal of nail plate 1.10 1.63 1.56 0.33 0.36 0.08 00011732 A Remove nail plate, add-on 0.57 0.67 0.64 0.17 0.19 0.04 ZZZ11740 A Drain blood from under nail 0.37 0.99 0.92 0.53 0.51 0.03 00011750 A Removal of nail bed 2.50 3.68 3.47 2.34 2.27 0.23 01011752 A Remove nail bed/finger tip 3.63 5.27 4.90 3.63 3.52 0.41 01011755 A Biopsy, nail unit 1.31 2.44 2.35 0.92 0.92 0.11 00011760 A Repair of nail bed1.63 4.60 4.22 1.99 1.91 0.27 01011762 A Reconstruction of nail bed 2.94 4.79 4.47 2.19 2.21 0.32 010CMS-1503-P812**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**11765 A Excision of nail fold, toe 0.74 3.31 3.09 1.25 1.18 0.06 01011770 A Removal of pilonidal lesion 2.66 4.68 4.42 2.22 2.03 0.54 01011771 A Removal of pilonidal lesion 6.09 9.10 8.44 5.37 4.91 1.29 09011772 A Removal of pilonidal lesion 7.35 10.71 10.09 7.68 7.13 1.53 0901180F I Thromboemb risk assessed 0.00 0.00 0.00 0.00 0.00 0.00 XXX11900 A Injection into skin lesions 0.52 1.03 1.03 0.37 0.34 0.07 00011901 A Added skin lesions injection 0.80 1.17 1.15 0.58 0.53 0.11 00011920 R Correct skin color defects 1.61 3.06 3.15 1.56 1.45 0.32 00011921 R Correct skin color defects 1.93 3.52 3.54 1.81 1.68 0.38 00011922 R Correct skin color defects 0.49 1.20 1.18 0.34 0.31 0.08 ZZZ11950 R Therapy for contour defects 0.84 1.02 1.10 0.47 0.48 0.10 00011951 R Therapy for contour defects 1.19 1.47 1.47 0.73 0.68 0.25 00011952 R Therapy for contour defects 1.69 1.58 1.81 0.79 0.86 0.25 00011954 R Therapy for contour defects 1.85 2.52 2.45 1.36 1.21 0.37 00011960 A Insert tissue expander(s) 11.49 NA NA 12.79 12.82 1.91 09011970 A Replace tissue expander 8.01 NA NA 8.88 8.20 1.62 09011971 A Remove tissue expander(s) 3.41 9.31 9.29 5.27 5.00 0.66 09011975 N Insert contraceptive cap 1.48 2.09 2.08 0.64 0.63 0.10 XXX11976 R Removal of contraceptive cap 1.78 2.07 2.11 0.80 0.73 0.31 00011977 N Removal/reinsert contra cap 3.30 2.91 2.91 1.43 1.41 0.25 XXX11980 A Implant hormone pellet(s) 1.48 1.34 1.31 0.72 0.67 0.24 00011981 A Insert drug implant device 1.48 2.13 2.18 0.70 0.73 0.25 XXX11982 A Remove drug implant device 1.78 2.20 2.32 0.83 0.89 0.25 XXX11983 A Remove/insert drug implant 3.30 2.53 2.83 1.36 1.54 0.37 XXX12001 A Repair superficial wound(s) 1.75 2.39 2.26 1.08 0.99 0.30 01012002 A Repair superficial wound(s) 1.91 2.48 2.35 1.22 1.12 0.32 010CMS-1503-P813**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**12004 A Repair superficial wound(s) 2.29 2.85 2.70 1.33 1.23 0.40 01012005 A Repair superficial wound(s) 2.91 3.44 3.26 1.54 1.43 0.51 01012006 A Repair superficial wound(s) 3.71 4.11 3.90 1.87 1.74 0.66 01012007 A Repair superficial wound(s) 4.16 4.51 4.34 2.00 1.95 0.75 0101200F I Seizure type(s)+ frqdocd 0.00 0.00 0.00 0.00 0.00 0.00 XXX12011 A Repair superficial wound(s) 1.81 2.58 2.45 1.08 1.00 0.32 01012013 A Repair superficial wound(s) 2.04 2.79 2.65 1.25 1.16 0.35 01012014 A Repair superficial wound(s) 2.51 3.12 2.97 1.39 1.30 0.44 01012015 A Repair superficial wound(s) 3.24 3.76 3.59 1.57 1.48 0.57 01012016 A Repair superficial wound(s) 3.97 4.36 4.14 1.85 1.75 0.71 01012017 A Repair superficial wound(s) 4.75 NA NA 1.78 1.84 0.86 01012018 A Repair superficial wound(s) 5.57 NA NA 1.93 2.31 1.03 01012020 A Closure of split wound 2.67 4.82 4.63 2.42 2.30 0.44 01012021 A Closure of split wound 1.89 2.58 2.40 1.91 1.77 0.32 01012031 A Intmd wnd repair s/tr/ext 2.20 4.63 4.42 2.35 2.15 0.37 01012032 A Intmd wnd repair s/tr/ext 2.52 5.90 5.87 2.90 2.78 0.40 01012034 A Intmd wnd repair s/tr/ext 2.97 5.51 5.30 2.65 2.47 0.52 01012035 A Intmd wnd repair s/tr/ext 3.47 6.74 6.53 2.92 2.76 0.66 01012036 A Intmd wnd repair s/tr/ext 4.09 7.07 6.77 3.19 3.00 0.81 01012037 A Intmd wnd repair s/tr/ext 4.71 7.71 7.43 3.70 3.51 0.93 01012041 A Intmd wnd repair n-hf/genit 2.42 4.73 4.49 2.41 2.20 0.38 01012042 A Intmd wnd repair n-hg/genit 2.79 5.24 5.14 2.79 2.60 0.42 01012044 A Intmd wnd repair n-hg/genit 3.19 6.55 6.17 2.65 2.47 0.54 01012045 A Intmd wnd repair n-hg/genit 3.68 6.45 6.29 2.86 2.73 0.65 01012046 A Intmd wnd repair n-hg/genit 4.29 7.59 7.44 3.38 3.23 0.88 01012047 A Intmd wnd repair n-hg/genit 4.69 8.43 8.08 3.46 3.41 0.95 010CMS-1503-P814**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**12051 A Intmd wnd repair face/mm 2.52 4.91 4.79 2.56 2.39 0.41 01012052 A Intmd wnd repair face/mm 2.87 5.64 5.50 3.27 3.03 0.44 01012053 A Intmd wnd repair face/mm 3.17 6.28 6.04 2.82 2.63 0.52 01012054 A Intmd wnd repair, face/mm 3.50 6.53 6.22 2.70 2.54 0.61 01012055 A Intmd wnd repair face/mm 4.47 7.63 7.18 2.92 2.74 0.76 01012056 A Intmd wnd repair face/mm 5.28 9.78 8.84 4.79 4.06 0.69 01012057 A Intmd wnd repair face/mm 6.00 11.35 10.07 4.67 4.31 0.79 0101205F I EPI etiol synd rvwd and docd 0.00 0.00 0.00 0.00 0.00 0.00 XXX13100 A Repair of wound or lesion 3.17 5.38 5.34 3.29 3.17 0.52 01013101 A Repair of wound or lesion 3.96 6.95 6.87 3.94 3.77 0.64 01013102 A Repair wound/lesion add-on 1.24 1.73 1.65 0.82 0.75 0.24 ZZZ13120 A Repair of wound or lesion 3.35 5.56 5.50 3.45 3.29 0.54 01013121 A Repair of wound or lesion 4.42 7.79 7.67 4.71 4.47 0.69 01013122 A Repair wound/lesion add-on 1.44 1.80 1.75 0.92 0.83 0.27 ZZZ13131 A Repair of wound or lesion 3.83 6.01 5.94 3.82 3.66 0.61 01013132 A Repair of wound or lesion 6.58 9.45 9.22 6.54 6.22 1.02 01013133 A Repair wound/lesion add-on 2.19 2.44 2.34 1.50 1.38 0.35 ZZZ13150 A Repair of wound or lesion 3.85 5.95 5.84 3.77 3.57 0.64 01013151 A Repair of wound or lesion 4.49 6.68 6.57 4.33 4.15 0.69 01013152 A Repair of wound or lesion 6.37 9.10 8.90 5.44 5.19 0.99 01013153 A Repair wound/lesion add-on 2.38 2.73 2.60 1.60 1.46 0.40 ZZZ13160 A Late closure of wound 12.04 NA NA 9.85 9.26 2.32 09014000 A Skin tissue rearrangement 6.37 10.75 10.46 7.58 7.25 1.17 09014001 A Skin tissue rearrangement 8.78 13.25 12.88 9.41 9.06 1.60 09014020 A Skin tissue rearrangement 7.22 12.04 11.72 8.66 8.34 1.26 09014021 A Skin tissue rearrangement 9.72 14.44 14.06 10.47 10.15 1.61 090CMS-1503-P815**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**14040 A Skin tissue rearrangement 8.60 12.65 12.30 9.26 8.96 1.37 09014041 A Skin tissue rearrangement 10.83 15.45 15.10 11.15 10.81 1.68 09014060 A Skin tissue rearrangement 9.23 12.39 11.96 9.74 9.33 1.47 09014061 A Skin tissue rearrangement 11.48 16.75 16.37 12.00 11.64 1.78 09014301 A Skin tissue rearrangement 12.65 16.91 16.91 11.82 11.82 2.22 09014302 A Skin tissue rearrange add-on 3.73 2.49 2.49 2.49 2.49 0.65 ZZZ14350 A Skin tissue rearrangement 11.05 NA NA 8.56 8.46 1.61 09015002 A Wound prep, trk/arm/leg 3.65 5.74 5.39 2.56 2.32 0.68 00015003 A Wound prep, addl 100 cm 0.80 1.21 1.15 0.42 0.38 0.17 ZZZ15004 A Wound prep, f/n/hf/g 4.58 6.39 6.15 2.95 2.76 0.69 00015005 A Wnd prep, f/n/hf/g, addl cm 1.60 1.70 1.59 0.84 0.75 0.32 ZZZ15040 A Harvest cultured skin graft 2.00 4.94 4.91 1.44 1.35 0.38 00015050 A Skin pinch graft 5.57 10.28 9.61 6.98 6.53 0.93 09015100 A Skin splt grft, trnk/arm/leg 9.90 13.40 13.03 9.63 9.08 2.02 09015101 A Skin splt grft t/a/l, add-on 1.72 3.27 3.31 1.26 1.20 0.35 ZZZ15110 A Epidrm autogrft trnk/arm/leg 10.97 11.93 11.43 8.93 8.33 2.23 09015111 A Epidrm autogrft t/a/l add-on 1.85 1.20 1.21 0.89 0.87 0.40 ZZZ15115 A Epidrm a-grft face/nck/hf/g 11.28 12.63 11.81 9.67 8.98 1.92 09015116 A Epidrm a-grft f/n/hf/g addl 2.50 2.20 1.95 1.78 1.52 0.51 ZZZ15120 A Skn splt a-grft fac/nck/hf/g 11.16 15.26 14.38 10.70 9.95 2.01 09015121 A Skn splt a-grft f/n/hf/g add 2.67 4.61 4.50 1.98 1.85 0.52 ZZZ15130 A Derm autograft, trnk/arm/leg 7.53 10.82 10.45 7.88 7.41 1.54 09015131 A Derm autograft t/a/l add-on 1.50 1.29 1.15 1.07 0.89 0.32 ZZZ15135 A Derm autograft face/nck/hf/g 11.03 13.03 12.19 10.10 9.42 1.95 09015136 A Derm autograft, f/n/hf/g add 1.50 1.16 0.97 0.98 0.78 0.10 ZZZ15150 A Cult epiderm grft t/arm/leg 9.39 8.81 8.68 7.19 7.04 2.06 090CMS-1503-P816**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**15151 A Cult epiderm grft t/a/l addl 2.00 1.11 1.16 0.86 0.89 0.44 ZZZ15152 A Cult epiderm graft t/a/l +% 2.50 1.35 1.54 1.10 1.24 0.51 ZZZ15155 A Cult epiderm graft, f/n/hf/g 10.14 6.82 7.80 5.49 6.44 0.79 09015156 A Cult epidrm grft f/n/hfg add 2.75 1.44 1.59 1.18 1.33 0.61 ZZZ15157 A Cult epiderm grft f/n/hfg +% 3.00 1.19 1.58 0.89 1.23 0.23 ZZZ15170 A Acell graft trunk/arms/legs 5.99 6.00 5.48 4.22 3.75 1.13 09015171 A Acell graft t/arm/leg add-on 1.55 0.97 0.89 0.81 0.74 0.32 ZZZ15175 A Acellular graft, f/n/hf/g 7.99 6.12 5.94 4.46 4.31 1.09 09015176 A Acell graft, f/n/hf/g add-on 2.45 1.55 1.44 1.24 1.16 0.41 ZZZ15200 A Skin full graft, trunk 9.15 13.59 12.81 9.41 8.66 1.71 09015201 A Skin full graft trunk add-on 1.32 2.75 2.69 0.89 0.79 0.27 ZZZ15220 A Skin full graft sclp/arm/leg 8.09 13.20 12.72 9.08 8.64 1.44 09015221 A Skin full graft add-on 1.19 2.56 2.54 0.78 0.72 0.24 ZZZ15240 A Skin full grft face/genit/hf 10.41 15.45 14.74 12.02 11.32 1.77 09015241 A Skin full graft add-on 1.86 3.26 3.14 1.28 1.16 0.34 ZZZ15260 A Skin full graft een & lips 11.64 16.43 15.71 12.59 11.93 1.84 09015261 A Skin full graft add-on 2.23 3.76 3.62 1.74 1.63 0.38 ZZZ15300 A Apply skinallogrft, t/arm/lg 4.65 4.96 4.55 3.31 3.01 0.89 09015301 A Apply sknallogrft t/a/l addl 1.00 0.67 0.63 0.50 0.47 0.21 ZZZ15320 A Apply skin allogrft f/n/hf/g 5.36 4.89 4.69 3.13 3.02 0.76 09015321 A Aply sknallogrft f/n/hfg add 1.50 1.02 0.94 0.80 0.74 0.31 ZZZ15330 A Aply acell alogrft t/arm/leg 3.99 5.02 4.60 3.32 3.01 0.79 09015331 A Aply acell grft t/a/l add-on 1.00 0.74 0.66 0.58 0.52 0.21 ZZZ15335 A Apply acell graft, f/n/hf/g 4.50 4.38 4.19 2.76 2.66 0.52 09015336 A Aply acell grft f/n/hf/gadd 1.43 1.31 1.04 1.02 0.79 0.10 ZZZ15340 A Apply cult skin substitute 3.82 4.83 4.68 3.51 3.36 0.54 010CMS-1503-P817**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**15341 A Apply cult skin sub add-on 0.50 0.81 0.78 0.19 0.19 0.07 ZZZ15360 A Apply cult derm sub,t/a/l 4.02 5.76 5.66 4.27 4.15 0.62 09015361 A Aply cult derm sub t/a/l add 1.15 0.51 0.57 0.36 0.40 0.21 ZZZ15365 A Apply cult derm sub f/n/hf/g 4.30 5.23 5.12 3.85 3.74 0.42 09015366 A Apply cult derm f/hf/g add 1.45 0.74 0.74 0.51 0.53 0.17 ZZZ15400 A Apply skin xenograft, t/a/l 4.47 6.96 6.47 5.41 5.13 0.72 09015401 A Apply skn xenogrft t/a/l add 1.00 1.34 1.41 0.50 0.47 0.23 ZZZ15420 A Apply skin xgraft, f/n/hf/g 4.98 7.14 6.97 5.66 5.50 0.69 09015421 A Apply skn xgrft f/n/hf/g add 1.50 1.65 1.55 0.80 0.72 0.31 ZZZ15430 A Apply acellular xenograft 6.20 8.86 8.32 8.16 7.69 1.09 09015431 C Apply acellular xgraft add 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ15570 A Form skin pedicle flap 10.21 14.16 13.50 9.49 8.83 2.15 09015572 A Form skin pedicle flap 10.12 14.10 13.18 10.43 9.52 1.89 09015574 A Form skin pedicle flap 10.70 14.55 13.75 10.68 9.91 1.89 09015576 A Form skin pedicle flap 9.37 13.05 12.42 9.49 8.83 1.60 09015600 A Skin graft 2.01 6.84 6.93 3.71 3.55 0.40 09015610 A Skin graft 2.52 7.22 6.81 4.16 3.98 0.47 09015620 A Skin graft 3.75 8.32 8.23 5.29 5.00 0.64 09015630 A Skin graft 4.08 8.68 8.57 5.64 5.41 0.68 09015650 A Transfer skin pedicle flap 4.77 9.17 9.15 5.93 5.75 0.81 09015731 A Forehead flap w/vasc pedicle 14.38 17.26 16.34 14.14 13.21 2.50 09015732 A Muscle-skin graft, head/neck 19.90 21.63 20.28 17.35 15.72 3.67 09015734 A Muscle-skin graft, trunk 19.86 21.30 20.53 16.59 15.64 4.14 09015736 A Muscle-skin graft, arm 17.04 19.32 18.64 14.65 13.60 3.49 09015738 A Muscle-skin graft, leg 19.04 19.43 18.76 15.01 14.05 3.96 09015740 A Island pedicle flap graft 11.80 16.68 16.09 12.49 11.89 1.84 090CMS-1503-P818**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**15750 A Neurovascular pedicle graft 12.96 NA NA 12.28 11.53 2.37 09015756 A Free myo/skin flap microvasc 36.94 NA NA 28.48 26.11 6.60 09015757 A Free skin flap, microvasc 37.15 NA NA 27.91 25.63 6.15 09015758 A Free fascial flap, microvasc 36.90 NA NA 27.69 25.56 6.15 09015760 A Composite skin graft 9.86 13.91 13.21 10.09 9.41 1.64 09015770 A Derma-fat-fascia graft 8.96 NA NA 9.62 8.89 1.70 09015775 R Hair transplant punch grafts 3.95 4.74 4.59 2.51 2.22 0.30 00015776 R Hair transplant punch grafts 5.53 6.48 6.28 3.30 3.10 0.40 00015780 A Abrasion treatment of skin 8.73 13.81 13.76 8.40 8.45 1.24 09015781 A Abrasion treatment of skin 5.02 10.19 9.86 7.02 6.77 0.79 09015782 A Abrasion treatment of skin 4.44 10.52 10.82 6.22 6.45 0.65 09015783 A Abrasion treatment of skin 4.41 9.07 8.97 6.14 5.86 0.65 09015786 A Abrasion, lesion, single 2.08 4.59 4.53 1.71 1.64 0.34 01015787 A Abrasion, lesions, add-on 0.33 0.98 1.00 0.16 0.15 0.04 ZZZ15788 R Chemical peel, face, epiderm 2.09 10.87 10.39 4.96 4.69 0.37 09015789 R Chemical peel, face, dermal 4.91 10.45 10.53 6.94 6.77 0.71 09015792 R Chemical peel, nonfacial 1.86 10.33 10.15 5.50 5.44 0.31 09015793 A Chemical peel, nonfacial 3.96 9.70 9.42 6.33 6.05 0.58 09015819 A Plastic surgery, neck 10.65 NA NA 7.46 8.01 2.18 09015820 A Revision of lower eyelid 6.27 9.44 8.74 8.00 7.28 1.29 09015821 A Revision of lower eyelid 6.84 9.99 9.15 8.36 7.52 1.38 09015822 A Revision of upper eyelid 4.62 7.70 7.14 6.28 5.72 0.85 09015823 A Revision of upper eyelid 8.32 11.43 10.34 9.83 8.76 1.61 09015824 R Removal of forehead wrinkles 0.00 0.00 0.00 0.00 0.00 0.00 00015825 R Removal of neck wrinkles 0.00 0.00 0.00 0.00 0.00 0.00 00015826 R Removal of brow wrinkles 0.00 0.00 0.00 0.00 0.00 0.00 000CMS-1503-P819**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**15828 R Removal of face wrinkles 0.00 0.00 0.00 0.00 0.00 0.00 00015829 R Removal of skin wrinkles 0.00 0.00 0.00 0.00 0.00 0.00 00015830 R Exc skin abd 17.11 NA NA 14.87 13.55 3.52 09015832 A Excise excessive skin tissue 12.85 NA NA 13.05 11.52 2.67 09015833 A Excise excessive skin tissue 11.90 NA NA 11.37 10.57 2.42 09015834 A Excise excessive skin tissue 12.17 NA NA 12.57 10.90 2.49 09015835 A Excise excessive skin tissue 12.99 NA NA 13.12 11.40 2.66 09015836 A Excise excessive skin tissue 10.61 NA NA 8.39 8.37 2.16 09015837 A Excise excessive skin tissue 9.55 14.13 12.35 9.79 8.73 2.09 09015838 A Excise excessive skin tissue 8.25 NA NA 7.99 7.47 1.10 09015839 A Excise excessive skin tissue 10.50 13.21 12.50 9.34 8.73 2.01 09015840 A Graft for face nerve palsy 14.99 NA NA 13.60 12.49 2.49 09015841 A Graft for face nerve palsy 25.99 NA NA 22.37 19.96 3.49 09015842 A Flap for face nerve palsy 41.01 NA NA 28.66 27.73 5.48 09015845 A Skin and muscle repair, face 14.32 NA NA 14.18 12.48 1.91 09015847 C Exc skin abd add-on 0.00 0.00 0.00 0.00 0.00 0.00 YYY15850 B Removal of sutures 0.78 1.58 1.65 0.34 0.33 0.06 XXX15851 A Removal of sutures 0.86 1.80 1.74 0.41 0.36 0.13 00015852 A Dressing change not for burn 0.86 NA NA 0.41 0.38 0.14 00015860 A Test for blood flow in graft 1.95 NA NA 0.89 0.88 0.40 00015876 R Suction assisted lipectomy 0.00 0.00 0.00 0.00 0.00 0.00 00015877 R Suction assisted lipectomy 0.00 0.00 0.00 0.00 0.00 0.00 00015878 R Suction assisted lipectomy 0.00 0.00 0.00 0.00 0.00 0.00 00015879 R Suction assisted lipectomy 0.00 0.00 0.00 0.00 0.00 0.00 00015920 A Removal of tail bone ulcer 8.29 NA NA 8.05 7.41 1.78 09015922 A Removal of tail bone ulcer 10.38 NA NA 11.36 10.02 2.11 090CMS-1503-P820**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**15931 A Remove sacrum pressure sore 10.07 NA NA 7.92 7.37 2.15 09015933 A Remove sacrum pressure sore 11.77 NA NA 10.75 9.99 2.50 09015934 A Remove sacrum pressure sore 13.68 NA NA 11.35 10.41 2.88 09015935 A Remove sacrum pressure sore 15.78 NA NA 13.78 12.86 3.31 09015936 A Remove sacrum pressure sore 13.16 NA NA 10.95 10.10 2.77 09015937 A Remove sacrum pressure sore 15.14 NA NA 13.17 12.15 3.18 09015940 A Remove hip pressure sore 10.20 NA NA 8.51 7.83 2.15 09015941 A Remove hip pressure sore 12.41 NA NA 11.91 11.17 2.57 09015944 A Remove hip pressure sore 12.44 NA NA 11.96 10.98 2.60 09015945 A Remove hip pressure sore 13.75 NA NA 13.44 12.31 2.84 09015946 A Remove hip pressure sore 24.12 NA NA 20.59 18.92 5.00 09015950 A Remove thigh pressure sore 8.03 NA NA 7.26 6.90 1.65 09015951 A Remove thigh pressure sore 11.58 NA NA 12.86 11.02 2.36 09015952 A Remove thigh pressure sore 12.31 NA NA 9.39 9.40 2.73 09015953 A Remove thigh pressure sore 13.57 NA NA 10.31 10.47 2.77 09015956 A Remove thigh pressure sore 16.79 NA NA 14.67 13.43 3.55 09015958 A Remove thigh pressure sore 16.75 NA NA 15.43 14.17 3.52 09015999 C Removal of pressure sore 0.00 0.00 0.00 0.00 0.00 0.00 YYY16000 A Initial treatment of burn(s) 0.89 1.00 0.95 0.38 0.33 0.13 00016020 A Dress/debrid p-thick burn, s 0.80 1.53 1.45 0.80 0.74 0.11 00016025 A Dress/debrid p-thick burn, m 1.85 2.21 2.09 1.30 1.20 0.32 00016030 A Dress/debrid p-thick burn, l 2.08 2.81 2.66 1.50 1.38 0.38 00016035 A Incision of burn scab, initi 3.74 NA NA 1.56 1.60 0.65 00016036 A Escharotomy; addl incision 1.50 NA NA 0.66 0.64 0.28 ZZZ17000 A Destruct premalg lesion 0.65 1.59 1.57 0.92 0.88 0.08 01017003 A Destruct premalg les, 2-14 0.07 0.12 0.13 0.05 0.05 0.01 ZZZCMS-1503-P821**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**17004 A Destroy premlg lesions 15+ 1.85 2.85 2.88 1.81 1.79 0.28 01017106 A Destruction of skin lesions 3.69 5.72 5.65 3.93 3.84 0.55 09017107 A Destruction of skin lesions 4.79 7.22 7.30 4.85 4.89 0.76 09017108 A Destruction of skin lesions 7.49 9.88 9.53 6.73 6.54 1.36 09017110 A Destruct b9 lesion, 1-14 0.70 2.35 2.37 1.25 1.21 0.08 01017111 A Destruct lesion, 15 or more 0.97 2.65 2.66 1.43 1.38 0.13 01017250 A Chemical cautery, tissue 0.50 1.65 1.60 0.50 0.48 0.07 00017260 A Destruction of skin lesions 0.96 1.65 1.65 0.95 0.90 0.13 01017261 A Destruction of skin lesions 1.22 2.73 2.72 1.35 1.30 0.18 01017262 A Destruction of skin lesions 1.63 3.15 3.13 1.65 1.57 0.24 01017263 A Destruction of skin lesions 1.84 3.42 3.40 1.79 1.70 0.27 01017264 A Destruction of skin lesions 1.99 3.64 3.61 1.87 1.77 0.30 01017266 A Destruction of skin lesions 2.39 4.00 3.96 2.12 1.99 0.35 01017270 A Destruction of skin lesions 1.37 2.76 2.72 1.43 1.35 0.21 01017271 A Destruction of skin lesions 1.54 2.97 2.95 1.58 1.51 0.24 01017272 A Destruction of skin lesions 1.82 3.33 3.30 1.78 1.70 0.27 01017273 A Destruction of skin lesions 2.10 3.63 3.60 1.97 1.87 0.31 01017274 A Destruction of skin lesions 2.64 4.11 4.07 2.31 2.19 0.38 01017276 A Destruction of skin lesions 3.25 4.56 4.47 2.66 2.51 0.49 01017280 A Destruction of skin lesions 1.22 2.64 2.62 1.33 1.26 0.18 01017281 A Destruction of skin lesions 1.77 3.10 3.08 1.74 1.66 0.27 01017282 A Destruction of skin lesions 2.09 3.57 3.52 1.97 1.87 0.31 01017283 A Destruction of skin lesions 2.69 4.11 4.05 2.38 2.25 0.40 01017284 A Destruction of skin lesions 3.26 4.62 4.55 2.74 2.59 0.47 01017286 A Destruction of skin lesions 4.48 5.47 5.32 3.49 3.30 0.69 01017311 A Mohs, 1 stage, h/n/hf/g 6.20 11.87 12.34 4.54 4.24 0.90 000CMS-1503-P822**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**17312 A Mohs addl stage 3.30 7.46 7.83 2.41 2.25 0.47 ZZZ17313 A Mohs, 1 stage, t/a/l 5.56 10.92 11.37 4.08 3.81 0.81 00017314 A Mohs, addl stage, t/a/l 3.06 6.91 7.25 2.24 2.09 0.44 ZZZ17315 A Mohs surg, addl block 0.87 1.32 1.35 0.64 0.60 0.11 ZZZ17340 A Cryotherapy of skin 0.77 0.64 0.57 0.58 0.51 0.10 01017360 A Skin peel therapy 1.46 2.15 2.14 1.35 1.28 0.23 01017380 R Hair removal by electrolysis 0.00 0.00 0.00 0.00 0.00 0.00 00017999 C Skin tissue procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY19000 A Drainage of breast lesion 0.84 2.06 2.19 0.32 0.34 0.11 00019001 A Drain breast lesion add-on 0.42 0.28 0.30 0.16 0.17 0.06 ZZZ19020 A Incision of breast lesion 3.83 8.70 8.27 4.23 3.90 0.81 09019030 A Injection for breast x-ray 1.53 2.68 2.99 0.53 0.61 0.14 00019100 A Bx breast percut w/o image 1.27 2.71 2.60 0.54 0.50 0.27 00019101 A Biopsy of breast, open 3.23 5.78 5.54 2.57 2.40 0.69 01019102 A Bx breast percut w/image 2.00 3.55 3.93 0.71 0.79 0.23 00019103 A Bx breast percut w/device 3.69 10.68 11.60 1.36 1.46 0.49 00019105 A Cryosurg ablate fa, each 3.69 48.12 54.84 1.58 1.57 0.41 00019110 A Nipple exploration 4.44 8.57 8.03 4.61 4.22 0.96 09019112 A Excise breast duct fistula 3.81 8.44 7.95 4.43 4.06 0.83 09019120 A Removal of breast lesion 5.92 7.03 6.51 4.89 4.47 1.30 09019125 A Excision, breast lesion 6.69 7.68 7.09 5.31 4.84 1.47 09019126 A Excision, addl breast lesion 2.93 NA NA 1.26 1.14 0.65 ZZZ19260 A Removal of chest wall lesion 17.78 NA NA 13.92 13.34 4.11 09019271 A Revision of chest wall 22.19 NA NA 20.51 20.28 5.24 09019272 A Extensive chest wall surgery 25.17 NA NA 21.62 21.51 6.19 09019290 A Place needle wire, breast 1.27 2.93 3.20 0.44 0.50 0.13 000CMS-1503-P823**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**19291 A Place needle wire, breast 0.63 1.15 1.27 0.22 0.25 0.06 ZZZ19295 A Place breast clip, percut 0.00 2.34 2.59 NA NA 0.01 ZZZ19296 A Place po breast cath for rad 3.63 106.59 110.18 1.87 1.73 0.76 00019297 A Place breast cath for rad 1.72 NA NA 0.74 0.68 0.37 ZZZ19298 A Place breast rad tube/caths 6.00 25.46 29.02 3.07 2.90 0.79 00019300 A Removal of breast tissue 5.31 8.40 8.06 5.45 4.99 1.17 09019301 A Partical mastectomy 10.13 NA NA 6.92 6.14 2.23 09019302 A P-mastectomy w/ln removal 13.99 NA NA 9.20 8.43 3.09 09019303 A Mast, simple, complete 15.85 NA NA 10.52 9.29 3.50 09019304 A Mast, subq 7.95 NA NA 7.14 6.55 1.74 09019305 A Mast, radical 17.46 NA NA 12.12 11.02 3.87 09019306 A Mast, rad, urban type18.13 NA NA 13.24 11.92 4.01 09019307 A Mast, mod rad 18.23 NA NA 13.04 11.84 4.01 09019316 A Suspension of breast 11.09 NA NA 10.03 9.32 2.27 09019318 A Reduction of large breast 16.03 NA NA 14.65 13.61 3.28 09019324 A Enlarge breast 6.80 NA NA 6.06 5.75 1.51 09019325 A Enlarge breast with implant 8.64 NA NA 9.28 8.58 1.75 09019328 A Removal of breast implant 6.48 NA NA 7.21 6.66 1.33 09019330 A Removal of implant material 8.54 NA NA 8.94 8.22 1.72 09019340 A Immediate breast prosthesis 13.99 NA NA 13.86 8.78 2.85 09019342 A Delayed breast prosthesis 12.63 NA NA 13.05 12.01 2.53 09019350 A Breast reconstruction 9.11 13.59 13.34 9.55 8.88 1.85 09019355 A Correct inverted nipple(s) 8.52 9.94 9.94 6.40 6.12 1.89 09019357 A Breast reconstruction 21.07 NA NA 22.41 20.64 4.28 09019361 A Breast reconstr w/lat flap 23.36 NA NA 24.02 21.59 4.78 09019364 A Breast reconstruction 42.58 NA NA 34.17 31.19 8.56 090CMS-1503-P824**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**19366 A Breast reconstruction 21.84 NA NA 15.49 14.15 4.63 09019367 A Breast reconstruction 26.80 NA NA 22.89 21.08 5.47 09019368 A Breast reconstruction 33.90 NA NA 27.67 25.16 6.92 09019369 A Breast reconstruction 31.31 NA NA 25.83 23.22 6.39 09019370 A Surgery of breast capsule 9.17 NA NA 9.86 9.09 1.87 09019371 A Removal of breast capsule 10.62 NA NA 11.18 10.31 2.15 09019380 A Revise breast reconstruction 10.41 NA NA 11.02 10.17 2.11 09019396 A Design custom breast implant 2.17 5.03 4.34 1.56 1.37 0.47 00019499 C Breast surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY20000 A Incision of abscess 2.17 3.40 3.35 1.92 1.91 0.28 01020005 A Incision of deep abscess 3.58 4.89 4.63 2.80 2.67 0.61 01020100 A Explore wound, neck 10.38 NA NA 5.64 5.04 2.03 01020101 A Explore wound, chest 3.23 7.72 7.56 2.00 1.94 0.72 01020102 A Explore wound, abdomen3.98 9.11 8.79 2.75 2.53 0.83 01020103 A Explore wound, extremity 5.34 10.39 10.00 4.07 3.85 1.03 01020150 A Excise epiphyseal bar 14.75 NA NA 12.26 11.04 3.04 09020200 A Muscle biopsy 1.46 4.02 3.87 1.01 0.95 0.34 00020205 A Deep muscle biopsy 2.35 5.16 4.89 1.64 1.52 0.58 00020206 A Needle biopsy, muscle 0.99 5.41 6.02 0.60 0.66 0.10 00020220 A Bone biopsy, trocar/needle 1.27 2.82 3.32 0.71 0.79 0.11 00020225 A Bone biopsy, trocar/needle 1.87 12.76 15.44 1.09 1.20 0.24 00020240 A Bone biopsy, excisional 3.28 NA NA 2.79 2.72 0.54 01020245 A Bone biopsy, excisional 8.95 NA NA 8.15 7.70 1.71 01020250 A Open bone biopsy 5.19 NA NA 4.87 4.60 1.27 01020251 A Open bone biopsy 5.72 NA NA 5.18 5.00 1.37 01020500 A Injection of sinus tract 1.28 1.62 1.76 1.07 1.17 0.13 010CMS-1503-P825**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**20501 A Inject sinus tract for x-ray 0.76 2.41 2.71 0.26 0.31 0.07 0002050F I Wound char size etc docd 0.00 0.00 0.00 0.00 0.00 0.00 XXX20520 A Removal of foreign body 1.90 3.53 3.37 2.05 1.95 0.31 01020525 A Removal of foreign body 3.54 9.46 9.29 3.18 3.01 0.66 01020526 A Ther injection, carp tunnel 0.94 1.10 1.07 0.61 0.58 0.1400020550 A Inj tendon sheath/ligament 0.75 0.83 0.81 0.39 0.36 0.08 00020551 A Inj tendon origin/insertion 0.75 0.89 0.83 0.44 0.40 0.08 00020552 A Inj trigger point, 1/2 muscl 0.66 0.84 0.79 0.39 0.34 0.07 00020553 A Inject trigger points, =/> 3 0.75 0.99 0.91 0.44 0.38 0.07 00020555 A Place ndl musc/tis for rt 6.00 NA NA 2.91 2.86 0.89 00020600 A Drain/inject, joint/bursa 0.66 0.84 0.82 0.41 0.40 0.07 00020605 A Drain/inject, joint/bursa 0.68 0.96 0.92 0.45 0.43 0.08 0002060F I Pt talk eval hlthwkr re mdd 0.00 0.00 0.00 0.00 0.00 0.00 XXX20610 A Drain/inject, joint/bursa 0.79 1.39 1.32 0.57 0.54 0.13 00020612 A Aspirate/inj ganglion cyst 0.70 0.94 0.89 0.45 0.43 0.08 00020615 A Treatment of bone cyst 2.33 3.67 3.60 2.02 1.95 0.30 01020650 A Insert and remove bone pin 2.28 3.24 3.08 1.92 1.85 0.30 01020660 A Apply, rem fixation device 4.00 NA NA 2.18 2.06 1.14 00020661 A Application of head brace 5.26 NA NA 7.58 7.20 1.71 09020662 A Application of pelvis brace 6.38 NA NA 4.71 5.55 0.64 09020663 A Application of thigh brace 5.74 NA NA 6.80 6.30 1.19 09020664 A Halo brace application 10.06 NA NA 10.36 9.92 3.74 09020665 A Removal of fixation device 1.36 1.64 1.77 1.24 1.27 0.11 01020670 A Removal of support implant 1.79 8.59 8.96 2.24 2.19 0.31 01020680 A Removal of support implant 5.96 10.89 10.43 5.61 5.24 1.10 09020690 A Apply bone fixation device 8.78 NA NA 7.09 6.26 1.68 090CMS-1503-P826**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**20692 A Apply bone fixation device 16.27 NA NA 14.05 12.25 2.91 09020693 A Adjust bone fixation device 6.06 NA NA 6.23 6.03 1.12 09020694 A Remove bone fixation device 4.28 7.22 7.09 4.88 4.67 0.79 09020696 A Comp multiplane ext fixation 17.56 NA NA 15.12 12.38 1.30 09020697 A Comp ext fixate strut change 0.00 56.39 48.20 NA NA 0.01 00020802 A Replantation, arm, complete 42.62 NA NA 22.68 21.70 3.17 09020805 A Replant forearm, complete 51.46 NA NA 17.56 21.78 10.53 09020808 A Replantation hand, complete 63.09 NA NA 49.13 46.17 12.90 09020816 A Replantation digit, complete 31.95 NA NA 26.30 26.63 4.14 09020822 A Replantation digit, complete 26.66 NA NA 23.70 23.46 5.47 09020824 A Replantation thumb, complete 31.95 NA NA 23.54 25.07 6.53 09020827 A Replantation thumb, complete 27.48 NA NA 24.28 24.62 5.62 09020838 A Replantation foot, complete 42.88 NA NA 23.08 23.21 3.18 09020900 A Removal of bone for graft 3.00 8.40 8.30 2.71 3.18 0.58 00020902 A Removal of bone for graft 4.58 NA NA 3.66 4.08 0.90 00020910 A Remove cartilage for graft 5.53 NA NA 6.14 6.02 0.73 09020912 A Remove cartilage for graft 6.54 NA NA 7.07 6.67 1.03 09020920 A Removal of fascia for graft 5.51 NA NA 5.74 5.47 0.72 09020922 A Removal of fascia for graft 6.93 8.79 9.08 6.08 6.15 1.33 09020924 A Removal of tendon for graft 6.68 NA NA 7.03 6.72 1.24 09020926 A Removal of tissue for graft 5.79 NA NA 5.85 5.70 1.22 09020930 B Sp bone algrft morsel add-on 0.00 0.00 0.00 0.00 0.00 0.00 XXX20931 A Sp bone algrft struct add-on 1.81 NA NA 1.00 0.97 0.58 ZZZ20936 B Sp bone agrft local add-on 0.00 0.00 0.00 0.00 0.00 0.00 XXX20937 A Sp bone agrft morsel add-on 2.79 NA NA 1.58 1.53 0.71 ZZZ20938 A Sp bone agrft struct add-on 3.02 NA NA 1.70 1.64 0.86 ZZZCMS-1503-P827**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**20950 A Fluid pressure, muscle 1.26 5.47 5.55 1.19 1.14 0.24 00020955 A Fibula bone graft, microvasc 40.26 NA NA 30.36 28.00 6.92 09020956 A Iliac bone graft, microvasc 41.18 NA NA 29.90 28.07 8.44 09020957 A Mt bone graft, microvasc 42.61 NA NA 27.65 24.20 8.73 09020962 A Other bone graft, microvasc 39.21 NA NA 32.35 29.73 8.03 09020969 A Bone/skin graft, microvasc 45.43 NA NA 33.09 30.51 6.92 09020970 A Bone/skin graft, iliac crest 44.58 NA NA 30.61 29.27 9.14 09020972 A Bone/skin graft, metatarsal 44.51 NA NA 23.39 22.38 3.56 09020973 A Bone/skin graft, great toe 47.27 NA NA 33.77 27.80 3.50 09020974 A Electrical bone stimulation 0.62 1.39 1.26 0.70 0.66 0.13 00020975 A Electrical bone stimulation 2.60 NA NA 2.04 1.97 0.61 00020979 A Us bone stimulation 0.62 0.82 0.80 0.28 0.29 0.08 00020982 A Ablate, bone tumor(s) perq 7.27 85.61 94.84 2.92 3.21 0.83 00020985 A Cptr-asst dir ms px 2.50 NA NA 1.46 1.37 0.51 ZZZ20999 C Musculoskeletal surgery 0.00 0.00 0.00 0.00 0.00 0.00 YYY21010 A Incision of jaw joint 11.04 NA NA 9.31 8.59 1.47 09021011 A Exc face les sc < 2 cm 2.99 6.10 6.10 3.85 3.85 0.47 09021012 A Exc face les sc = 2 cm 4.45 NA NA 4.91 4.91 0.75 09021013 A Exc face tum deep < 2 cm 5.42 8.52 8.52 5.52 5.52 0.85 09021014 A Exc face tum deep = 2 cm 7.13 NA NA 7.30 7.30 1.20 09021015 A Resect face tum < 2 cm 9.89 NA NA 9.32 7.43 1.94 09021016 A Resect face tum = 2 cm 15.26 NA NA 12.82 12.82 3.02 09021025 A Excision of bone, lower jaw 10.03 14.85 14.13 11.07 10.29 1.50 09021026 A Excision of facial bone(s) 5.70 11.48 10.89 8.23 7.76 0.86 09021029 A Contour of face bone lesion 8.39 12.93 12.22 9.37 8.74 1.71 09021030 A Excise max/zygoma b9 tumor 4.91 9.50 8.94 6.73 6.26 0.79 090CMS-1503-P828**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**21031 A Remove exostosis, mandible 3.30 7.64 7.29 4.96 4.63 0.42 09021032 A Remove exostosis, maxilla 3.34 7.81 7.44 4.85 4.50 0.44 09021034 A Excise max/zygoma mlg tumor 17.38 20.12 18.87 15.69 14.48 2.53 09021040 A Excise mandible lesion 4.91 9.63 9.07 6.81 6.27 0.78 09021044 A Removal of jaw bone lesion 12.80 NA NA 12.11 11.23 1.85 09021045 A Extensive jaw surgery 18.37 NA NA 16.33 15.06 2.61 09021046 A Remove mandible cyst complex 14.21 NA NA 17.08 15.71 1.89 09021047 A Excise lwr jaw cyst w/repair 20.07 NA NA 16.88 15.33 2.68 09021048 A Remove maxilla cyst complex 14.71 NA NA 17.45 15.84 1.96 09021049 A Excis uppr jaw cyst w/repair 19.32 NA NA 15.42 14.62 2.56 09021050 A Removal of jaw joint 11.76 NA NA 12.14 11.52 2.39 09021060 A Remove jaw joint cartilage 11.07 NA NA 11.95 10.71 2.43 09021070 A Remove coronoid process 8.62 NA NA 8.89 8.46 1.14 09021073 A Mnpj of tmj w/anesth 3.45 7.50 7.01 3.63 3.22 0.71 09021076 A Prepare face/oral prosthesis 13.40 13.89 12.60 10.30 8.97 1.77 01021077 A Prepare face/oral prosthesis 33.70 33.11 30.23 26.05 22.98 4.49 09021079 A Prepare face/oral prosthesis 22.31 23.73 21.66 17.40 15.24 2.98 09021080 A Prepare face/oral prosthesis 25.06 26.92 24.69 19.26 16.93 3.35 09021081 A Prepare face/oral prosthesis 22.85 24.80 22.75 17.55 15.48 3.07 09021082 A Prepare face/oral prosthesis 20.84 24.27 21.98 17.25 14.99 2.77 09021083 A Prepare face/oral prosthesis 19.27 23.63 21.52 16.10 13.96 1.43 09021084 A Prepare face/oral prosthesis 22.48 26.71 24.52 18.45 16.19 3.01 09021085 A Prepare face/oral prosthesis 8.99 10.82 9.84 7.11 6.26 3.48 01021086 A Prepare face/oral prosthesis 24.88 23.80 21.55 19.03 16.55 3.32 09021087 A Prepare face/oral prosthesis 24.88 23.51 21.41 18.67 16.40 3.32 09021088 C Prepare face/oral prosthesis 0.00 0.00 0.00 0.00 0.00 0.00 090CMS-1503-P829**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**21089 C Prepare face/oral prosthesis 0.00 0.00 0.00 0.00 0.00 0.00 YYY21100 A Maxillofacial fixation4.73 11.55 13.39 4.59 5.35 0.66 09021110 A Interdental fixation 5.99 16.37 15.46 12.81 12.04 0.79 09021116 A Injection, jaw joint x-ray 0.81 3.24 3.34 0.37 0.34 0.06 00021120 A Reconstruction of chin 5.10 12.68 12.28 9.22 8.75 1.05 09021121 A Reconstruction of chin 7.81 14.78 13.83 11.02 10.28 0.57 09021122 A Reconstruction of chin 8.71 NA NA 11.47 10.90 0.64 09021123 A Reconstruction of chin 11.34 NA NA 15.27 13.20 0.83 09021125 A Augmentation, lower jaw bone 10.80 72.64 74.63 11.26 10.12 2.22 09021127 A Augmentation, lower jaw bone 12.44 94.29 92.85 12.98 11.64 1.65 09021137 A Reduction of forehead 10.24 NA NA 9.01 8.70 2.08 09021138 A Reduction of forehead 12.87 NA NA 12.36 11.33 1.89 09021139 A Reduction of forehead 15.02 NA NA 10.82 11.11 1.10 09021141 A Reconstruct midface, lefort 19.57 NA NA 17.94 16.76 4.00 09021142 A Reconstruct midface, lefort 20.28 NA NA 18.28 16.23 4.15 09021143 A Reconstruct midface, lefort 21.05 NA NA 20.66 18.02 4.66 09021145 A Reconstruct midface, lefort 23.94 NA NA 20.09 18.00 1.75 09021146 A Reconstruct midface, lefort 24.87 NA NA 22.78 20.31 5.09 09021147 A Reconstruct midface, lefort 26.47 NA NA 20.46 19.39 1.95 09021150 A Reconstruct midface, lefort 25.96 NA NA 22.17 20.00 1.91 09021151 A Reconstruct midface, lefort 29.02 NA NA 23.91 24.50 3.89 09021154 A Reconstruct midface, lefort 31.29 NA NA 30.79 26.84 4.17 09021155 A Reconstruct midface, lefort 35.22 NA NA 27.89 25.49 2.60 09021159 A Reconstruct midface, lefort 43.14 NA NA 39.22 33.18 5.74 09021160 A Reconstruct midface, lefort 47.19 NA NA 28.17 27.96 3.49 09021172 A Reconstruct orbit/forehead 28.20 NA NA 24.01 20.66 3.76 090CMS-1503-P830**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**21175 A Reconstruct orbit/forehead 33.56 NA NA 28.35 24.71 12.49 09021179 A Reconstruct entire forehead 22.65 NA NA 19.85 17.58 4.63 09021180 A Reconstruct entire forehead 25.58 NA NA 22.03 19.77 3.42 09021181 A Contour cranial bone lesion 10.28 NA NA 10.40 9.21 1.36 09021182 A Reconstruct cranial bone 32.58 NA NA 22.12 21.33 4.34 09021183 A Reconstruct cranial bone 35.70 NA NA 23.92 23.36 7.29 09021184 A Reconstruct cranial bone 38.62 NA NA 30.69 26.90 7.91 09021188 A Reconstruction of midface 23.15 NA NA 21.65 20.91 3.09 09021193 A Reconst lwr jaw w/o graft 18.90 NA NA 16.31 14.79 4.20 09021194 A Reconst lwr jaw w/graft 21.82 NA NA 17.13 16.20 2.91 09021195 A Reconst lwr jaw w/o fixation 19.16 NA NA 18.91 17.59 2.54 09021196 A Reconst lwr jaw w/fixation 20.83 NA NA 21.42 19.48 2.77 09021198 A Reconstr lwr jaw segment 15.71 NA NA 17.19 16.00 2.26 09021199 A Reconstr lwr jaw w/advance 16.73 NA NA 12.01 11.03 2.23 09021206 A Reconstruct upper jaw bone 15.59 NA NA 19.16 16.85 3.21 09021208 A Augmentation of facial bones 11.42 40.02 38.42 11.19 10.84 2.33 09021209 A Reduction of facial bones 7.82 15.39 14.86 10.48 9.87 1.60 09021210 A Face bone graft 11.69 51.85 49.16 12.63 11.31 1.57 09021215 A Lower jaw bone graft 12.23 99.07 93.97 12.88 11.55 2.49 09021230 A Rib cartilage graft11.17 NA NA 10.04 9.38 2.27 09021235 A Ear cartilage graft7.50 13.01 12.58 8.58 8.12 1.14 09021240 A Reconstruction of jaw joint 16.07 NA NA 15.34 13.97 2.12 09021242 A Reconstruction of jaw joint 14.59 NA NA 14.01 12.96 1.95 09021243 A Reconstruction of jaw joint 24.53 NA NA 22.87 20.76 3.28 09021244 A Reconstruction of lower jaw 13.62 NA NA 16.43 15.34 2.01 09021245 A Reconstruction of jaw 13.12 18.58 17.97 12.21 11.65 1.74 090CMS-1503-P831**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**21246 A Reconstruction of jaw 12.92 NA NA 10.52 9.87 1.71 09021247 A Reconstruct lower jaw bone 24.37 NA NA 19.26 18.40 5.00 09021248 A Reconstruction of jaw 12.74 18.47 16.99 12.85 11.47 1.70 09021249 A Reconstruction of jaw 18.77 23.91 21.84 17.57 15.35 2.49 09021255 A Reconstruct lower jaw bone 18.46 NA NA 19.29 19.42 2.44 09021256 A Reconstruction of orbit 17.66 NA NA 16.58 14.83 2.35 09021260 A Revise eye sockets 17.90 NA NA 21.40 19.56 1.31 09021261 A Revise eye sockets 34.07 NA NA 23.21 23.84 6.98 09021263 A Revise eye sockets 31.01 NA NA 21.88 21.94 2.29 09021267 A Revise eye sockets 20.69 NA NA 24.09 22.30 4.24 09021268 A Revise eye sockets 27.07 NA NA 20.18 21.31 5.54 09021270 A Augmentation, cheek bone 10.63 16.83 15.31 10.35 9.07 1.57 09021275 A Revision, orbitofacial bones 11.76 NA NA 11.64 10.42 2.39 09021280 A Revision of eyelid 7.13 NA NA 8.85 7.93 1.46 09021282 A Revision of eyelid 4.27 NA NA 6.30 5.76 0.81 09021295 A Revision of jaw muscle/bone 1.90 NA NA 2.84 2.86 0.38 09021296 A Revision of jaw muscle/bone 4.78 NA NA 5.81 6.27 0.64 09021299 C Cranio/maxillofacial surgery 0.00 0.00 0.00 0.00 0.00 0.00 YYY21310 A Treatment of nose fracture 0.58 2.65 2.53 0.16 0.15 0.10 00021315 A Treatment of nose fracture 1.83 5.88 5.66 2.39 2.27 0.30 01021320 A Treatment of nose fracture 1.88 5.37 5.19 1.95 1.84 0.28 01021325 A Treatment of nose fracture 4.18 NA NA 8.94 8.86 0.69 09021330 A Treatment of nose fracture 5.79 NA NA 10.30 10.04 0.76 09021335 A Treatment of nose fracture 9.02 NA NA 11.56 11.12 1.27 09021336 A Treat nasal septal fracture 6.77 NA NA 11.63 11.17 0.95 09021337 A Treat nasal septal fracture 3.39 7.92 7.64 4.89 4.61 0.54 090CMS-1503-P832**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**21338 A Treat nasoethmoid fracture 6.87 NA NA 13.99 13.52 1.41 09021339 A Treat nasoethmoid fracture 8.50 NA NA 13.06 13.25 1.72 09021340 A Treatment of nose fracture 11.49 NA NA 9.89 9.75 1.54 09021343 A Treatment of sinus fracture 14.32 NA NA 16.68 16.45 2.94 09021344 A Treatment of sinus fracture 21.57 NA NA 21.71 19.58 8.04 09021345 A Treat nose/jaw fracture 9.06 12.77 12.57 8.54 8.37 1.22 09021346 A Treat nose/jaw fracture 11.45 NA NA 14.43 14.18 1.54 09021347 A Treat nose/jaw fracture 13.53 NA NA 15.41 15.58 1.78 09021348 A Treat nose/jaw fracture 17.52 NA NA 16.29 14.18 2.33 09021355 A Treat cheek bone fracture 4.45 8.32 7.88 5.07 4.64 0.58 01021356 A Treat cheek bone fracture 4.83 9.10 8.77 5.72 5.41 0.73 01021360 A Treat cheek bone fracture 7.19 NA NA 7.97 7.37 0.95 09021365 A Treat cheek bone fracture 16.77 NA NA 14.39 13.13 2.91 09021366 A Treat cheek bone fracture 18.60 NA NA 17.07 14.84 3.82 09021385 A Treat eye socket fracture 9.57 NA NA 9.92 9.56 1.27 09021386 A Treat eye socket fracture 9.57 NA NA 8.26 8.00 1.95 09021387 A Treat eye socket fracture 10.11 NA NA 10.22 9.80 2.05 09021390 A Treat eye socket fracture 11.23 NA NA 11.16 10.08 1.96 09021395 A Treat eye socket fracture 14.70 NA NA 13.51 11.90 1.95 09021400 A Treat eye socket fracture 1.50 3.71 3.53 2.73 2.58 0.28 09021401 A Treat eye socket fracture 3.68 9.31 9.29 4.49 4.33 0.75 09021406 A Treat eye socket fracture 7.42 NA NA 8.57 7.67 0.99 09021407 A Treat eye socket fracture 9.02 NA NA 9.10 8.36 1.65 09021408 A Treat eye socket fracture 12.78 NA NA 12.39 11.13 2.61 09021421 A Treat mouth roof fracture 6.02 14.95 14.41 11.73 11.24 1.23 09021422 A Treat mouth roof fracture 8.73 NA NA 10.07 9.46 1.17 090CMS-1503-P833**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**21423 A Treat mouth roof fracture 10.85 NA NA 12.18 11.03 2.22 09021431 A Treat craniofacial fracture 7.90 NA NA 12.20 12.12 1.61 09021432 A Treat craniofacial fracture 8.82 NA NA 11.13 9.96 1.78 09021433 A Treat craniofacial fracture 26.29 NA NA 18.47 17.97 5.38 09021435 A Treat craniofacial fracture 20.26 NA NA 15.80 15.24 2.70 09021436 A Treat craniofacial fracture 30.30 NA NA 26.90 23.86 6.20 09021440 A Treat dental ridge fracture 3.44 12.29 11.82 9.38 9.05 0.69 09021445 A Treat dental ridge fracture 6.26 15.23 14.74 11.29 10.84 0.83 09021450 A Treat lower jaw fracture 3.71 12.98 12.35 9.71 9.38 0.68 09021451 A Treat lower jaw fracture 5.65 16.18 15.28 12.39 11.79 0.75 09021452 A Treat lower jaw fracture 2.40 15.93 15.32 8.36 7.61 0.49 09021453 A Treat lower jaw fracture 6.64 18.78 17.66 15.19 14.47 1.09 09021454 A Treat lower jaw fracture 7.36 NA NA 8.60 7.90 0.96 09021461 A Treat lower jaw fracture 9.31 50.62 47.65 17.16 16.34 1.46 09021462 A Treat lower jaw fracture 11.01 52.11 49.52 18.36 17.26 1.47 09021465 A Treat lower jaw fracture 13.12 NA NA 13.50 12.06 2.68 09021470 A Treat lower jaw fracture 17.54 NA NA 16.37 14.84 3.01 09021480 A Reset dislocated jaw 0.61 1.96 1.93 0.26 0.24 0.10 00021485 A Reset dislocated jaw 4.77 14.95 14.11 11.70 11.08 0.64 09021490 A Repair dislocated jaw 12.95 NA NA 12.67 11.74 2.66 09021495 A Treat hyoid bone fracture 6.79 NA NA 13.46 12.72 0.89 09021497 A Interdental wiring 4.64 14.40 14.01 11.46 11.14 0.93 09021499 C Head surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY21501 A Drain neck/chest lesion 3.98 8.43 8.13 4.77 4.57 0.78 09021502 A Drain chest lesion 7.55 NA NA 5.60 5.75 1.67 09021510 A Drainage of bone lesion 6.20 NA NA 6.23 6.06 1.51 090CMS-1503-P834**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**21550 A Biopsy of neck/chest 2.11 5.05 4.98 2.23 2.18 0.31 01021552 A Exc neck les sc = 3 cm 6.49 NA NA 5.53 5.53 1.33 09021554 A Exc neck tum deep = 5 cm 11.13 NA NA 8.61 8.61 2.16 09021555 A Exc neck les sc < 3 cm 3.96 7.29 7.10 4.29 4.20 0.81 09021556 A Exc neck tum deep < 5 cm 7.66 NA NA 6.78 5.92 1.50 09021557 A Resect neck tum < 5 cm 14.75 NA NA 11.17 8.53 2.90 09021558 A Resect neck tum = 5 cm 21.58 NA NA 14.95 14.95 4.24 09021600 A Partial removal of rib 7.26 NA NA 7.93 7.54 1.62 09021610 A Partial removal of rib 15.91 NA NA 13.75 12.21 5.93 09021615 A Removal of rib 10.45 NA NA 6.47 6.58 2.56 09021616 A Removal of rib and nerves 12.69 NA NA 7.06 8.16 3.15 09021620 A Partial removal of sternum 7.28 NA NA 6.60 6.44 1.68 09021627 A Sternal debridement 7.30 NA NA 7.21 7.12 1.71 09021630 A Extensive sternum surgery 19.18 NA NA 14.61 14.00 4.20 09021632 A Extensive sternum surgery 19.68 NA NA 12.60 12.44 5.13 09021685 A Hyoid myotomy & suspension 15.26 NA NA 13.20 12.19 2.03 09021700 A Revision of neck muscle 6.31 NA NA 3.61 4.28 1.55 09021705 A Revision of neck muscle/rib 9.92 NA NA 4.81 5.68 2.43 09021720 A Revision of neck muscle 5.80 NA NA 5.72 5.20 2.15 09021725 A Revision of neck muscle 7.19 NA NA 7.26 6.85 1.47 09021740 A Reconstruction of sternum 17.57 NA NA 9.15 9.60 3.60 09021742 C Repair stern/nuss w/o scope 0.00 0.00 0.00 0.00 0.00 0.00 09021743 C Repair sternum/nuss w/scope 0.00 0.00 0.00 0.00 0.00 0.00 09021750 A Repair of sternum separation 11.40 NA NA 6.54 6.73 2.81 09021800 A Treatment of rib fracture 1.01 1.86 1.74 1.95 1.81 0.18 09021805 A Treatment of rib fracture 2.88 NA NA 4.12 4.06 0.69 090CMS-1503-P835**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**21810 A Treatment of rib fracture(s) 7.03 NA NA 7.13 6.52 1.70 09021820 A Treat sternum fracture 1.36 2.43 2.27 2.51 2.34 0.27 09021825 A Treat sternum fracture 7.76 NA NA 6.97 6.95 1.89 09021899 C Neck/chest surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY21920 A Biopsy soft tissue of back 2.11 5.01 4.96 2.35 2.25 0.35 01021925 A Biopsy soft tissue of back 4.63 7.19 6.81 4.73 4.40 0.96 09021930 A Exc back les sc < 3 cm 4.94 7.63 7.41 4.69 4.59 1.06 09021931 A Exc back les sc = 3 cm 6.88 NA NA 5.60 5.60 1.47 09021932 A Exc back tum deep < 5 cm 9.82 NA NA 7.89 7.89 2.16 09021933 A Exc back tum deep = 5 cm 11.13 NA NA 8.35 8.35 2.44 09021935 A Resect back tum < 5 cm 15.72 NA NA 11.50 11.19 3.33 09021936 A Resect back tum = 5 cm 22.55 NA NA 15.22 15.22 4.78 09022010 A I&d, p-spine, c/t/cerv-thor 12.75 NA NA 11.74 11.11 3.42 09022015 A I&d, p-spine, l/s/ls 12.64 NA NA 11.51 10.99 3.19 09022100 A Remove part of neck vertebra 11.00 NA NA 11.05 10.37 4.11 09022101 A Remove part, thorax vertebra 11.08 NA NA 9.83 9.76 4.13 09022102 A Remove part, lumbar vertebra 11.08 NA NA 10.55 10.09 2.77 09022103 A Remove extra spine segment 2.34 NA NA 1.34 1.29 0.66 ZZZ22110 A Remove part of neck vertebra 14.00 NA NA 12.78 12.13 5.23 09022112 A Remove part, thorax vertebra 14.07 NA NA 12.60 11.61 5.24 09022114 A Remove part, lumbar vertebra 14.07 NA NA 12.50 11.89 2.88 09022116 A Remove extra spine segment 2.32 NA NA 1.30 1.24 0.62 ZZZ22206 A Cut spine 3 col, thor 37.18 NA NA 25.80 24.14 7.60 09022207 A Cut spine 3 col, lumb 36.68 NA NA 25.50 23.89 9.55 09022208 A Cut spine 3 col, addl seg 9.66 NA NA 5.49 5.15 2.68 ZZZ22210 A Revision of neck spine 25.38 NA NA 20.23 19.28 7.01 090CMS-1503-P836**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**22212 A Revision of thorax spine 20.99 NA NA 17.57 16.64 5.16 09022214 A Revision of lumbar spine 21.02 NA NA 17.53 16.74 5.31 09022216 A Revise, extra spine segment 6.03 NA NA 3.43 3.32 1.57 ZZZ22220 A Revision of neck spine 22.94 NA NA 18.58 17.44 6.67 09022222 A Revision of thorax spine 23.09 NA NA 18.85 15.77 4.72 09022224 A Revision of lumbar spine 23.09 NA NA 18.42 17.38 5.58 09022226 A Revise, extra spine segment 6.03 NA NA 3.40 3.28 1.64 ZZZ22305 A Treat spine process fracture 2.13 2.99 2.82 2.53 2.38 0.42 09022310 A Treat spine fracture 3.89 4.26 3.93 3.62 3.33 0.81 09022315 A Treat spine fracture 10.11 13.22 12.52 10.21 9.61 2.64 09022318 A Treat odontoid fx w/o graft 22.72 NA NA 17.85 17.05 7.97 09022319 A Treat odontoid fx w/graft 25.33 NA NA 19.66 18.43 9.45 09022325 A Treat spine fracture 19.87 NA NA 16.75 15.88 5.91 09022326 A Treat neck spine fracture 20.84 NA NA 16.75 15.92 6.54 09022327 A Treat thorax spine fracture 20.77 NA NA 17.49 16.37 5.84 09022328 A Treat each add spine fx 4.60 NA NA 2.56 2.47 1.41 ZZZ22505 A Manipulation of spine 1.87 NA NA 1.40 1.28 0.30 01022520 A Percut vertebroplastythor 9.22 51.31 54.01 4.59 4.99 1.10 01022521 A Percut vertebroplastylumb 8.65 51.12 53.41 4.41 4.78 1.05 01022522 A Percut vertebroplasty addl 4.30 NA NA 1.81 1.91 0.57 ZZZ22523 A Percut kyphoplasty, thor 9.26 NA NA 5.93 6.06 1.89 01022524 A Percut kyphoplasty, lumbar 8.86 NA NA 5.78 5.88 1.81 01022525 A Percut kyphoplasty, add-on 4.47 NA NA 2.26 2.29 0.99 ZZZ22526 N Idet, single level 6.10 57.67 53.91 3.43 2.87 0.57 01022527 N Idet, 1 or more levels 3.03 49.50 45.38 1.31 1.00 0.25 ZZZ22532 A Lat thorax spine fusion 25.99 NA NA 19.41 18.40 7.86 090CMS-1503-P837**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**22533 A Lat lumbar spine fusion 24.79 NA NA 18.77 17.78 6.63 09022534 A Lat thor/lumb, addl seg 5.99 NA NA 3.35 3.24 1.65 ZZZ22548 A Neck spine fusion 27.06 NA NA 21.32 19.89 10.09 09022554 A Neck spine fusion 17.69 NA NA 14.35 13.96 5.68 09022556 A Thorax spine fusion 24.70 NA NA 18.20 17.38 6.88 09022558 A Lumbar spine fusion 23.53 NA NA 16.79 15.85 5.88 09022585 A Additional spinal fusion 5.52 NA NA 3.03 2.93 1.65 ZZZ22590 A Spine & skull spinal fusion 21.76 NA NA 17.81 16.99 7.32 09022595 A Neck spinal fusion 20.64 NA NA 17.13 16.32 6.82 09022600 A Neck spine fusion 17.40 NA NA 15.16 14.44 5.52 09022610 A Thorax spine fusion 17.28 NA NA 14.97 14.26 5.04 09022612 A Lumbar spine fusion 23.53 NA NA 17.61 16.84 6.47 09022614 A Spine fusion, extra segment 6.43 NA NA 3.61 3.50 1.84 ZZZ22630 A Lumbar spine fusion 22.09 NA NA 17.25 16.53 6.51 09022632 A Spine fusion, extra segment 5.22 NA NA 2.92 2.82 1.55 ZZZ22800 A Fusion of spine 19.50 NA NA 15.68 15.03 5.09 09022802 A Fusion of spine 32.11 NA NA 23.08 22.14 7.80 09022804 A Fusion of spine 37.50 NA NA 26.26 25.16 8.86 09022808 A Fusion of spine 27.51 NA NA 19.76 18.93 7.55 09022810 A Fusion of spine 31.50 NA NA 21.22 20.33 8.24 09022812 A Fusion of spine 34.25 NA NA 25.20 23.54 7.01 09022818 A Kyphectomy, 1-2 segments 34.33 NA NA 24.29 22.76 7.02 09022819 A Kyphectomy, 3 or more 39.38 NA NA 28.06 26.29 14.70 09022830 A Exploration of spinal fusion 11.22 NA NA 9.74 9.36 3.01 09022840 A Insert spine fixation device 12.52 NA NA 7.00 6.79 3.62 ZZZ22841 B Insert spine fixation device 0.00 0.00 0.00 0.00 0.00 0.00 XXXCMS-1503-P838**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**22842 A Insert spine fixation device 12.56 NA NA 7.04 6.83 3.57 ZZZ22843 A Insert spine fixation device 13.44 NA NA 7.60 7.30 3.63 ZZZ22844 A Insert spine fixation device 16.42 NA NA 9.40 9.15 3.83 ZZZ22845 A Insert spine fixation device 11.94 NA NA 6.61 6.39 3.80 ZZZ22846 A Insert spine fixation device 12.40 NA NA 6.87 6.64 3.91 ZZZ22847 A Insert spine fixation device 13.78 NA NA 7.55 7.36 5.14 ZZZ22848 A Insert pelv fixation device 5.99 NA NA 3.43 3.34 1.44 ZZZ22849 A Reinsert spinal fixation 19.17 NA NA 14.30 13.73 5.34 09022850 A Remove spine fixation device 9.82 NA NA 8.77 8.42 2.71 09022851 A Apply spine prosth device 6.70 NA NA 3.74 3.60 1.96 ZZZ22852 A Remove spine fixation device 9.37 NA NA 8.51 8.15 2.50 09022855 A Remove spine fixation device 15.86 NA NA 12.49 11.97 4.93 09022856 A Cerv artific diskectomy 24.05 NA NA 17.70 17.07 7.56 09022857 R Lumbar artif diskectomy 27.13 NA NA 15.92 16.24 6.01 09022861 A Revise cerv artific disc 33.36 NA NA 17.11 16.72 9.47 09022862 R Revise lumbar artif disc 32.63 NA NA 17.28 16.91 6.67 09022864 A Remove cerv artif disc 29.40 NA NA 21.23 18.01 8.35 09022865 R Remove lumb artif disc 31.75 NA NA 20.60 21.27 6.49 09022899 C Spine surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY22900 A Exc back tum deep < 5 cm 8.32 NA NA 6.49 5.37 1.78 09022901 A Exc back tum deep = 5 cm 10.11 NA NA 7.26 7.26 2.18 09022902 A Exc abd les sc < 3 cm 4.42 7.55 7.55 4.82 4.82 0.73 09022903 A Exc abd les sc > 3 cm 6.39 NA NA 5.45 5.45 1.26 09022904 A Resect abd tum < 5 cm 16.69 NA NA 10.14 10.14 3.69 09022905 A Resect abd tum > 5 cm 21.58 NA NA 13.45 13.45 4.78 09022999 C Abdomen surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYYCMS-1503-P839**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**23000 A Removal of calcium deposits 4.48 11.06 10.41 5.44 5.12 0.89 09023020 A Release shoulder joint 9.36 NA NA 9.01 8.66 1.87 09023030 A Drain shoulder lesion 3.47 8.37 8.11 3.38 3.24 0.71 01023031 A Drain shoulder bursa 2.79 8.45 8.07 3.03 2.86 0.55 01023035 A Drain shoulder bone lesion 9.16 NA NA 8.97 8.71 1.87 09023040 A Exploratory shoulder surgery 9.75 NA NA 9.50 9.08 1.98 09023044 A Exploratory shoulder surgery 7.59 NA NA 7.64 7.36 1.55 09023065 A Biopsy shoulder tissues2.30 3.61 3.51 2.30 2.18 0.40 01023066 A Biopsy shoulder tissues4.30 10.25 9.75 5.03 4.76 0.88 09023071 A Exc shoulder les sc > 3 cm 5.91 NA NA 5.25 5.25 1.26 09023073 A Exc shoulder tum deep > 5 cm 10.13 NA NA 8.33 8.33 2.12 09023075 A Exc shoulder les sc < 3 cm 4.21 8.30 6.38 4.44 3.29 0.89 09023076 A Exc shoulder tum deep < 5 cm 7.41 NA NA 6.87 6.71 1.57 09023077 A Resect shoulder tum < 5 cm 17.66 NA NA 12.90 12.46 3.73 09023078 A Resect shoulder tum > 5 cm 22.55 NA NA 13.86 13.86 5.00 09023100 A Biopsy of shoulder joint 6.20 NA NA 7.18 6.77 1.27 09023101 A Shoulder joint surgery 5.72 NA NA 6.28 6.05 1.17 09023105 A Remove shoulder joint lining 8.48 NA NA 8.55 8.20 1.72 09023106 A Incision of collarbone joint 6.13 NA NA 7.14 6.64 1.26 09023107 A Explore treat shoulder joint 8.87 NA NA 8.80 8.43 1.78 09023120 A Partial removal, collar bone 7.39 NA NA 8.23 7.83 1.51 09023125 A Removal of collar bone 9.64 NA NA 9.33 8.81 1.96 09023130 A Remove shoulder bone, part 7.77 NA NA 8.53 8.15 1.58 09023140 A Removal of bone lesion 7.12 NA NA 6.86 6.44 1.47 09023145 A Removal of bone lesion 9.40 NA NA 9.19 8.74 1.92 09023146 A Removal of bone lesion 8.08 NA NA 8.52 7.91 1.65 090CMS-1503-P840**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**23150 A Removal of humerus lesion 8.91 NA NA 8.68 8.30 1.78 09023155 A Removal of humerus lesion 10.86 NA NA 10.36 9.85 2.22 09023156 A Removal of humerus lesion 9.11 NA NA 9.02 8.56 1.87 09023170 A Remove collar bone lesion 7.21 NA NA 7.77 7.07 1.47 09023172 A Remove shoulder blade lesion 7.31 NA NA 7.83 7.29 1.51 09023174 A Remove humerus lesion 10.05 NA NA 10.24 9.76 2.05 09023180 A Remove collar bone lesion 8.99 NA NA 8.90 8.77 1.88 09023182 A Remove shoulder blade lesion 8.61 NA NA 9.15 8.82 1.75 09023184 A Remove humerus lesion 9.90 NA NA 9.74 9.50 1.98 09023190 A Partial removal of scapula 7.47 NA NA 7.81 7.32 1.54 09023195 A Removal of head of humerus 10.36 NA NA 9.86 9.35 2.11 09023200 A Resect clavicle tumor 22.71 NA NA 17.96 13.89 4.65 09023210 A Resect scapula tumor 27.21 NA NA 20.59 15.51 5.57 09023220 A Resect prox humerus tumor 30.21 NA NA 22.03 16.93 6.19 09023330 A Remove shoulder foreign body 1.90 4.42 4.27 2.13 2.05 0.37 01023331 A Remove shoulder foreign body 7.63 NA NA 8.19 7.83 1.55 09023332 A Remove shoulder foreign body 12.37 NA NA 11.23 10.75 2.49 09023350 A Injection for shoulder x-ray 1.00 2.85 3.17 0.38 0.41 0.10 00023395 A Muscle transfer,shoulder/arm 18.54 NA NA 15.88 15.15 3.73 09023397 A Muscle transfers 16.76 NA NA 13.81 13.17 3.43 09023400 A Fixation of shoulder blade 13.87 NA NA 12.12 11.59 2.84 09023405 A Incision of tendon & muscle 8.54 NA NA 8.20 7.91 1.72 09023406 A Incise tendon(s) & muscle(s) 11.01 NA NA 9.77 9.40 2.25 09023410 A Repair rotator cuff, acute 11.39 NA NA 10.59 10.22 2.30 09023412 A Repair rotator cuff, chronic 11.93 NA NA 10.90 10.56 2.40 09023415 A Release of shoulder ligament 9.23 NA NA 9.39 8.99 1.88 090CMS-1503-P841**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**23420 A Repair of shoulder 13.54 NA NA 12.41 11.94 2.76 09023430 A Repair biceps tendon 10.17 NA NA 9.48 9.12 2.05 09023440 A Remove/transplant tendon 10.64 NA NA 9.54 9.18 2.15 09023450 A Repair shoulder capsule 13.70 NA NA 11.62 11.10 2.81 09023455 A Repair shoulder capsule 14.67 NA NA 12.20 11.70 2.97 09023460 A Repair shoulder capsule 15.82 NA NA 13.37 12.80 3.25 09023462 A Repair shoulder capsule 15.72 NA NA 12.99 12.37 3.24 09023465 A Repair shoulder capsule 16.30 NA NA 13.57 12.96 3.33 09023466 A Repair shoulder capsule 15.80 NA NA 14.16 13.51 3.24 09023470 A Reconstruct shoulder joint 17.89 NA NA 14.44 13.85 3.65 09023472 A Reconstruct shoulder joint 22.65 NA NA 17.39 16.62 4.59 09023480 A Revision of collar bone 11.54 NA NA 10.44 9.94 2.35 09023485 A Revision of collar bone 13.91 NA NA 11.76 11.26 2.83 09023490 A Reinforce clavicle 12.16 NA NA 11.93 10.77 2.49 09023491 A Reinforce shoulder bones 14.54 NA NA 12.56 12.02 2.98 09023500 A Treat clavicle fracture 2.21 3.57 3.41 3.67 3.44 0.42 09023505 A Treat clavicle fracture 3.83 5.53 5.26 5.02 4.74 0.75 09023515 A Treat clavicle fracture 9.69 NA NA 9.84 9.18 1.96 09023520 A Treat clavicle dislocation 2.29 3.88 3.61 3.97 3.68 0.45 09023525 A Treat clavicle dislocation 3.79 6.72 5.85 5.68 5.02 0.76 09023530 A Treat clavicle dislocation 7.48 NA NA 7.82 7.04 1.54 09023532 A Treat clavicle dislocation 8.20 NA NA 8.49 8.09 1.67 09023540 A Treat clavicle dislocation 2.36 3.53 3.38 3.62 3.38 0.44 09023545 A Treat clavicle dislocation 3.43 5.25 4.97 4.45 4.22 0.62 09023550 A Treat clavicle dislocation 7.59 NA NA 7.67 7.38 1.53 09023552 A Treat clavicle dislocation 8.82 NA NA 8.81 8.42 1.77 090CMS-1503-P842**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**23570 A Treat shoulder blade fx 2.36 3.80 3.62 3.99 3.76 0.45 09023575 A Treat shoulder blade fx 4.23 6.47 6.05 5.79 5.39 0.86 09023585 A Treat scapula fracture 14.23 NA NA 12.09 11.21 2.87 09023600 A Treat humerus fracture 3.11 5.53 5.29 4.98 4.68 0.62 09023605 A Treat humerus fracture 5.06 7.37 7.06 6.34 6.04 1.02 09023615 A Treat humerus fracture 12.30 NA NA 11.42 10.82 2.49 09023616 A Treat humerus fracture 18.37 NA NA 14.93 14.53 3.72 09023620 A Treat humerus fracture 2.55 4.63 4.40 4.28 4.02 0.51 09023625 A Treat humerus fracture 4.10 6.05 5.77 5.35 5.10 0.81 09023630 A Treat humerus fracture 10.57 NA NA 10.41 9.65 2.15 09023650 A Treat shoulder dislocation 3.53 4.45 4.24 3.82 3.57 0.64 09023655 A Treat shoulder dislocation 4.76 NA NA 5.85 5.46 0.92 09023660 A Treat shoulder dislocation 7.66 NA NA 7.95 7.57 1.55 09023665 A Treat dislocation/fracture 4.66 6.65 6.34 5.88 5.61 0.92 09023670 A Treat dislocation/fracture 12.28 NA NA 11.15 10.33 2.49 09023675 A Treat dislocation/fracture 6.27 8.45 8.01 7.15 6.79 1.24 09023680 A Treat dislocation/fracture 13.15 NA NA 11.70 10.96 2.67 09023700 A Fixation of shoulder 2.57 NA NA 2.63 2.52 0.51 01023800 A Fusion of shoulder joint 14.73 NA NA 12.73 12.13 3.04 09023802 A Fusion of shoulder joint 18.42 NA NA 15.99 14.79 3.76 09023900 A Amputation of arm & girdle 20.72 NA NA 16.48 14.67 4.25 09023920 A Amputation at shoulder joint 16.23 NA NA 13.97 12.62 3.32 09023921 A Amputation follow-up surgery 5.72 NA NA 6.79 5.61 1.41 09023929 C Shoulder surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY23930 A Drainage of arm lesion 2.99 6.54 6.48 2.77 2.66 0.64 01023931 A Drainage of arm bursa 1.84 5.87 5.77 2.46 2.36 0.35 010CMS-1503-P843**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**23935 A Drain arm/elbow bone lesion 6.38 NA NA 7.24 6.81 1.29 09024000 A Exploratory elbow surgery 6.08 NA NA 6.73 6.39 1.22 09024006 A Release elbow joint 9.74 NA NA 9.40 8.94 1.89 09024065 A Biopsy arm/elbow soft tissue 2.13 4.92 4.82 2.50 2.40 0.35 01024066 A Biopsy arm/elbow soft tissue 5.35 11.17 10.66 5.61 5.23 1.12 09024071 A Exc arm/elbow les sc = 3 cm 5.70 NA NA 5.20 5.20 1.20 09024073 A Ex arm/elbow tum deep > 5 cm 10.13 NA NA 8.43 8.43 2.09 09024075 A Exc arm/elbow les sc < 3 cm 4.24 8.94 8.80 4.56 4.30 0.88 09024076 A Ex arm/elbow tum deep < 5 cm 7.41 NA NA 7.02 6.36 1.54 09024077 A Resect arm/elbow tum < 5 cm 15.72 NA NA 11.93 10.30 3.31 09024079 A Resect arm/elbow tum > 5 cm 20.61 NA NA 13.03 13.03 4.55 09024100 A Biopsy elbow joint lining 5.07 NA NA 6.09 5.70 1.05 09024101 A Explore/treat elbow joint 6.30 NA NA 7.13 6.81 1.26 09024102 A Remove elbow joint lining 8.26 NA NA 8.27 7.86 1.61 09024105 A Removal of elbow bursa 3.78 NA NA 5.61 5.31 0.75 09024110 A Remove humerus lesion 7.58 NA NA 8.12 7.73 1.55 09024115 A Remove/graft bone lesion 10.12 NA NA 9.61 9.06 2.06 09024116 A Remove/graft bone lesion 12.23 NA NA 10.84 10.31 2.50 09024120 A Remove elbow lesion 6.82 NA NA 7.37 6.96 1.34 09024125 A Remove/graft bone lesion 8.14 NA NA 8.45 7.94 1.65 09024126 A Remove/graft bone lesion 8.62 NA NA 8.73 8.30 1.75 09024130 A Removal of head of radius 6.42 NA NA 7.22 6.89 1.24 09024134 A Removal of arm bone lesion 10.22 NA NA 9.77 9.42 2.08 09024136 A Remove radius bone lesion 8.40 NA NA 8.46 7.60 1.71 09024138 A Remove elbow bone lesion 8.50 NA NA 9.55 9.07 1.72 09024140 A Partial removal of arm bone 9.55 NA NA 9.40 9.15 1.85 090CMS-1503-P844**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**24145 A Partial removal of radius 7.81 NA NA 8.01 7.87 1.60 09024147 A Partial removal of elbow 7.84 NA NA 8.89 8.65 1.57 09024149 A Radical resection of elbow 16.22 NA NA 15.56 14.56 3.09 09024150 A Resect distal humerus tumor 23.46 NA NA 18.29 14.66 4.80 09024152 A Resect radius tumor 19.99 NA NA 16.26 12.43 4.08 09024155 A Removal of elbow joint 12.09 NA NA 10.75 10.16 2.47 09024160 A Remove elbow joint implant 8.00 NA NA 8.33 7.92 1.55 09024164 A Remove radius head implant 6.43 NA NA 6.87 6.58 1.31 09024200 A Removal of arm foreign body 1.81 3.76 3.61 1.98 1.85 0.32 01024201 A Removal of arm foreign body 4.70 10.32 10.13 5.11 4.88 0.96 09024220 A Injection for elbow x-ray 1.31 2.88 3.23 0.55 0.57 0.13 00024300 A Manipulate elbow w/anesth 4.04 NA NA 7.04 6.71 0.75 09024301 A Muscle/tendon transfer 10.38 NA NA 9.70 9.30 2.11 09024305 A Arm tendon lengthening 7.62 NA NA 8.07 7.67 1.41 09024310 A Revision of arm tendon 6.12 NA NA 6.67 6.37 1.23 09024320 A Repair of arm tendon 10.86 NA NA 10.03 9.49 2.22 09024330 A Revision of arm muscles 9.79 NA NA 9.41 8.97 1.99 09024331 A Revision of arm muscles 10.95 NA NA 10.98 10.13 2.25 09024332 A Tenolysis, triceps 7.91 NA NA 8.47 8.06 1.61 09024340 A Repair of biceps tendon 8.08 NA NA 8.35 7.98 1.64 09024341 A Repair arm tendon/muscle 9.49 NA NA 10.55 9.94 1.92 09024342 A Repair of ruptured tendon 10.86 NA NA 10.02 9.60 2.15 09024343 A Repr elbow lat ligmnt w/tiss 9.16 NA NA 9.83 9.40 1.74 09024344 A Reconstruct elbow lat ligmnt 15.21 NA NA 14.20 13.47 3.12 09024345 A Repr elbw med ligmnt w/tissu 9.16 NA NA 9.74 9.28 1.74 09024346 A Reconstruct elbow med ligmnt 15.21 NA NA 14.20 13.51 3.12 090CMS-1503-P845**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**24357 A Repair elbow, perc 5.44 NA NA 6.53 6.27 1.07 09024358 A Repair elbow w/deb,open 6.66 NA NA 7.45 7.10 1.30 09024359 A Repair elbow deb/attchopen 8.98 NA NA 8.82 8.25 1.74 09024360 A Reconstruct elbow joint 12.67 NA NA 11.40 10.90 2.57 09024361 A Reconstruct elbow joint 14.41 NA NA 12.52 12.01 2.95 09024362 A Reconstruct elbow joint 15.32 NA NA 13.05 12.44 3.15 09024363 A Replace elbow joint 22.65 NA NA 17.74 16.70 4.37 09024365 A Reconstruct head of radius 8.62 NA NA 8.47 8.12 1.75 09024366 A Reconstruct head of radius 9.36 NA NA 8.97 8.56 1.84 09024400 A Revision of humerus 11.33 NA NA 10.60 10.17 2.27 09024410 A Revision of humerus 15.11 NA NA 13.19 12.38 3.11 09024420 A Revision of humerus 13.73 NA NA 12.80 12.21 2.81 09024430 A Repair of humerus 15.25 NA NA 13.19 12.41 3.07 09024435 A Repair humerus with graft 14.99 NA NA 13.96 13.21 3.04 09024470 A Revision of elbow joint 8.93 NA NA 9.01 8.05 1.84 09024495 A Decompression of forearm 8.41 NA NA 9.07 8.88 1.87 09024498 A Reinforce humerus 12.28 NA NA 10.88 10.44 2.50 09024500 A Treat humerus fracture 3.41 6.06 5.78 5.22 4.90 0.66 09024505 A Treat humerus fracture 5.39 7.95 7.62 6.69 6.39 1.09 09024515 A Treat humerus fracture 12.12 NA NA 11.37 10.85 2.43 09024516 A Treat humerus fracture 12.19 NA NA 10.84 10.38 2.47 09024530 A Treat humerus fracture 3.69 6.45 6.15 5.50 5.18 0.72 09024535 A Treat humerus fracture 7.11 9.36 8.98 8.12 7.75 1.43 09024538 A Treat humerus fracture 9.77 NA NA 10.13 9.73 1.99 09024545 A Treat humerus fracture 13.15 NA NA 11.79 11.06 2.66 09024546 A Treat humerus fracture 14.91 NA NA 13.00 12.48 3.01 090CMS-1503-P846**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**24560 A Treat humerus fracture 2.98 5.53 5.29 4.65 4.35 0.58 09024565 A Treat humerus fracture 5.78 8.45 7.83 7.27 6.70 1.19 09024566 A Treat humerus fracture 9.06 NA NA 10.12 9.62 1.87 09024575 A Treat humerus fracture 9.71 NA NA 9.93 9.52 1.95 09024576 A Treat humerus fracture 3.06 6.01 5.71 5.09 4.78 0.61 09024577 A Treat humerus fracture 6.01 8.65 8.08 7.41 6.87 1.23 09024579 A Treat humerus fracture 11.44 NA NA 10.97 10.43 2.29 09024582 A Treat humerus fracture 10.14 NA NA 11.49 10.82 2.06 09024586 A Treat elbow fracture 15.78 NA NA 13.35 12.78 3.17 09024587 A Treat elbow fracture 15.79 NA NA 13.50 12.82 3.04 09024600 A Treat elbow dislocation 4.37 5.11 4.97 4.35 4.13 0.79 09024605 A Treat elbow dislocation 5.64 NA NA 6.86 6.50 1.13 09024615 A Treat elbow dislocation 9.83 NA NA 9.30 8.90 1.91 09024620 A Treat elbow fracture 7.22 NA NA 7.58 7.24 1.41 09024635 A Treat elbow fracture 8.80 NA NA 9.27 9.80 1.74 09024640 A Treat elbow dislocation 1.25 2.29 2.08 1.15 1.05 0.24 01024650 A Treat radius fracture 2.31 4.65 4.44 4.09 3.82 0.44 09024655 A Treat radius fracture 4.62 6.94 6.70 5.95 5.69 0.89 09024665 A Treat radius fracture 8.36 NA NA 9.16 8.73 1.65 09024666 A Treat radius fracture 9.86 NA NA 9.83 9.37 1.94 09024670 A Treat ulnar fracture 2.69 5.05 4.83 4.30 4.05 0.52 09024675 A Treat ulnar fracture 4.91 7.28 6.99 6.24 5.96 0.96 09024685 A Treat ulnar fracture 8.37 NA NA 9.15 8.73 1.68 09024800 A Fusion of elbow joint 11.41 NA NA 10.78 9.87 2.33 09024802 A Fusion/graft of elbow joint 14.32 NA NA 12.48 11.85 2.94 09024900 A Amputation of upper arm 10.18 NA NA 9.42 8.82 2.09 090CMS-1503-P847**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**24920 A Amputation of upper arm 10.13 NA NA 9.47 8.75 2.06 09024925 A Amputation follow-up surgery 7.30 NA NA 7.81 7.42 1.50 09024930 A Amputation follow-up surgery 10.83 NA NA 9.88 9.16 2.22 09024931 A Amputate upper arm & implant 13.44 NA NA 8.26 8.02 0.99 09024935 A Revision of amputation 16.45 NA NA 7.72 8.55 3.36 09024940 C Revision of upper arm 0.00 0.00 0.00 0.00 0.00 0.00 09024999 C Upper arm/elbow surgery 0.00 0.00 0.00 0.00 0.00 0.00 YYY25000 A Incision of tendon sheath 3.55 NA NA 5.53 5.62 0.66 09025001 A Incise flexor carpi radialis 3.79 NA NA 5.55 5.21 0.69 09025020 A Decompress forearm 1 space 6.06 NA NA 9.64 9.38 1.10 09025023 A Decompress forearm 1 space 13.83 NA NA 15.83 15.26 2.84 09025024 A Decompress forearm 2 spaces 10.79 NA NA 10.01 9.53 2.20 09025025 A Decompress forearm 2 spaces 17.94 NA NA 14.90 13.70 3.67 09025028 A Drainage of forearm lesion 5.39 NA NA 8.61 8.39 1.07 09025031 A Drainage of forearm bursa 4.26 NA NA 5.02 5.32 0.86 09025035 A Treat forearm bone lesion 7.65 NA NA 7.98 8.60 1.54 09025040 A Explore/treat wrist joint 7.50 NA NA 7.65 7.44 1.41 09025065 A Biopsy forearm soft tissues 2.04 4.98 4.88 2.51 2.43 0.34 01025066 A Biopsy forearm soft tissues 4.27 NA NA 5.36 5.50 0.83 09025071 A Exc forearm les sc > 3 cm 5.91 NA NA 5.59 5.59 1.22 09025073 A Exc forearm tum deep = 3 cm 7.13 NA NA 7.33 7.33 1.41 09025075 A Exc forearm les sc < 3 cm 3.96 8.99 6.91 4.55 4.67 0.79 09025076 A Exc forearm tum deep < 3 cm 6.74 NA NA 7.11 6.88 1.33 09025077 A Resect forearm/wrist tum<3cm 12.93 NA NA 10.70 10.03 2.71 09025078 A Resect forearm/wrist tum=3cm 17.69 NA NA 11.77 11.77 3.93 09025085 A Incision of wrist capsule 5.64 NA NA 6.45 6.43 1.14 090CMS-1503-P848**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**25100 A Biopsy of wrist joint 4.02 NA NA 5.22 5.11 0.81 09025101 A Explore/treat wrist joint 4.83 NA NA 6.05 5.90 0.93 09025105 A Remove wrist joint lining 6.02 NA NA 7.01 6.90 1.14 09025107 A Remove wrist joint cartilage 7.70 NA NA 9.03 8.70 1.41 09025109 A Excise tendon forearm/wrist 6.94 NA NA 7.65 7.11 1.29 09025110 A Remove wrist tendon lesion 4.04 NA NA 5.09 5.27 0.78 09025111 A Remove wrist tendon lesion 3.53 NA NA 5.07 4.90 0.69 09025112 A Reremove wrist tendon lesion 4.67 NA NA 5.74 5.51 0.90 09025115 A Remove wrist/forearm lesion 10.09 NA NA 10.57 10.80 1.87 09025116 A Remove wrist/forearm lesion 7.56 NA NA 8.73 9.18 1.38 09025118 A Excise wrist tendon sheath 4.51 NA NA 5.82 5.67 0.83 09025119 A Partial removal of ulna 6.21 NA NA 7.10 7.03 1.27 09025120 A Removal of forearm lesion 6.27 NA NA 7.14 7.74 1.22 09025125 A Remove/graft forearm lesion 7.67 NA NA 8.18 8.75 1.57 09025126 A Remove/graft forearm lesion 7.74 NA NA 8.22 8.74 1.58 09025130 A Removal of wrist lesion 5.43 NA NA 6.71 6.51 1.03 09025135 A Remove & graft wrist lesion 7.08 NA NA 7.82 7.65 1.44 09025136 A Remove & graft wrist lesion 6.14 NA NA 7.03 6.85 1.26 09025145 A Remove forearm bone lesion 6.54 NA NA 7.27 7.86 1.33 09025150 A Partial removal of ulna 7.38 NA NA 7.84 7.73 1.41 09025151 A Partial removal of radius 7.68 NA NA 7.98 8.52 1.57 09025170 A Resect radius/ulnar tumor 22.21 NA NA 17.45 14.53 4.54 09025210 A Removal of wrist bone 6.12 NA NA 7.14 6.92 1.12 09025215 A Removal of wrist bones 8.14 NA NA 8.64 8.45 1.46 09025230 A Partial removal of radius 5.37 NA NA 6.36 6.17 0.93 09025240 A Partial removal of ulna 5.31 NA NA 6.29 6.25 0.95 090CMS-1503-P849**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**25246 A Injection for wrist x-ray 1.45 2.81 3.14 0.56 0.60 0.14 00025248 A Remove forearm foreign body 5.31 NA NA 5.69 5.97 1.09 09025250 A Removal of wrist prosthesis 6.77 NA NA 7.39 7.06 1.37 09025251 A Removal of wrist prosthesis 9.82 NA NA 9.42 8.99 2.01 09025259 A Manipulate wrist w/anesthes 4.04 NA NA 7.12 6.77 0.75 09025260 A Repair forearm tendon/muscle 8.04 NA NA 9.03 9.44 1.54 09025263 A Repair forearm tendon/muscle 8.04 NA NA 8.74 9.27 1.64 09025265 A Repair forearm tendon/muscle 10.10 NA NA 9.92 10.40 2.05 09025270 A Repair forearm tendon/muscle 6.17 NA NA 7.12 7.68 1.20 09025272 A Repair forearm tendon/muscle 7.21 NA NA 7.74 8.32 1.37 09025274 A Repair forearm tendon/muscle 8.94 NA NA 8.92 9.47 1.84 09025275 A Repair forearm tendon sheath 8.96 NA NA 9.08 8.72 1.84 09025280 A Revise wrist/forearm tendon 7.39 NA NA 7.89 8.42 1.33 09025290 A Incise wrist/forearm tendon 5.43 NA NA 6.37 7.51 1.02 09025295 A Release wrist/forearm tendon 6.72 NA NA 7.47 8.01 1.23 09025300 A Fusion of tendons at wrist 9.02 NA NA 9.28 8.99 1.85 09025301 A Fusion of tendons at wrist 8.59 NA NA 8.79 8.49 1.62 09025310 A Transplant forearm tendon 8.08 NA NA 8.72 9.16 1.44 09025312 A Transplant forearm tendon 9.82 NA NA 9.60 10.04 1.85 09025315 A Revise palsy hand tendon(s) 10.68 NA NA 9.93 10.46 2.18 09025316 A Revise palsy hand tendon(s) 12.90 NA NA 11.55 11.83 1.67 09025320 A Repair/revise wrist joint 12.75 NA NA 14.11 13.33 2.35 09025332 A Revise wrist joint 11.74 NA NA 11.08 10.50 2.26 09025335 A Realignment of hand 13.39 NA NA 8.45 9.86 0.99 09025337 A Reconstruct ulna/radioulnar 11.73 NA NA 12.49 11.94 2.09 09025350 A Revision of radius 9.09 NA NA 9.11 9.65 1.67 090CMS-1503-P850**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**25355 A Revision of radius 10.53 NA NA 9.96 10.47 2.15 09025360 A Revision of ulna 8.74 NA NA 8.81 9.40 1.71 09025365 A Revise radius & ulna 12.91 NA NA 11.56 11.85 2.64 09025370 A Revise radius or ulna 14.10 NA NA 12.82 13.05 2.88 09025375 A Revise radius & ulna 13.55 NA NA 11.93 12.37 0.99 09025390 A Shorten radius or ulna 10.70 NA NA 10.16 10.57 1.95 09025391 A Lengthen radius or ulna 14.28 NA NA 12.36 12.69 2.94 09025392 A Shorten radius & ulna 14.58 NA NA 12.53 12.88 3.01 09025393 A Lengthen radius & ulna 16.56 NA NA 15.11 14.72 3.41 09025394 A Repair carpal bone, shorten 10.85 NA NA 10.10 9.62 2.22 09025400 A Repair radius or ulna 11.28 NA NA 10.39 10.88 2.15 09025405 A Repair/graft radius or ulna 15.01 NA NA 12.93 13.28 2.84 09025415 A Repair radius & ulna 13.80 NA NA 12.57 12.88 2.83 09025420 A Repair/graft radius & ulna 17.04 NA NA 14.22 14.57 3.50 09025425 A Repair/graft radius or ulna 13.72 NA NA 12.03 13.15 2.81 09025426 A Repair/graft radius & ulna 16.45 NA NA 13.63 12.88 3.36 09025430 A Vasc graft into carpal bone 9.71 NA NA 9.84 9.28 1.26 09025431 A Repair nonunion carpal bone 10.89 NA NA 10.21 9.63 2.23 09025440 A Repair/graft wrist bone 10.68 NA NA 10.04 9.71 1.96 09025441 A Reconstruct wrist joint 13.29 NA NA 12.86 11.86 1.71 09025442 A Reconstruct wrist joint 11.12 NA NA 10.81 10.26 1.44 09025443 A Reconstruct wrist joint 10.66 NA NA 10.22 9.81 2.18 09025444 A Reconstruct wrist joint 11.42 NA NA 11.66 10.71 0.83 09025445 A Reconstruct wrist joint 9.88 NA NA 9.58 9.11 1.87 09025446 A Wrist replacement 17.30 NA NA 14.58 13.78 3.07 09025447 A Repair wrist joint(s) 11.14 NA NA 11.30 10.63 2.03 090CMS-1503-P851**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**25449 A Remove wrist joint implant 14.94 NA NA 13.18 12.40 3.07 09025450 A Revision of wrist joint 8.06 NA NA 5.93 6.70 1.64 09025455 A Revision of wrist joint 9.71 NA NA 6.86 7.60 0.71 09025490 A Reinforce radius 9.73 NA NA 8.61 9.34 1.30 09025491 A Reinforce ulna 10.15 NA NA 9.63 10.16 2.06 09025492 A Reinforce radius and ulna 12.66 NA NA 11.52 11.86 2.57 09025500 A Treat fracture of radius 2.60 4.62 4.34 4.03 3.72 0.47 09025505 A Treat fracture of radius 5.45 7.93 7.61 6.84 6.52 1.07 09025515 A Treat fracture of radius 8.80 NA NA 9.13 8.71 1.74 09025520 A Treat fracture of radius 6.50 8.65 8.01 7.87 7.25 1.33 09025525 A Treat fracture of radius 10.55 NA NA 10.49 10.21 2.09 09025526 A Treat fracture of radius 13.15 NA NA 12.39 12.32 2.70 09025530 A Treat fracture of ulna 2.24 4.73 4.51 4.08 3.82 0.42 09025535 A Treat fracture of ulna 5.36 7.73 7.34 6.78 6.43 1.06 09025545 A Treat fracture of ulna 7.94 NA NA 8.77 8.43 1.57 09025560 A Treat fracture radius & ulna 2.59 4.70 4.44 4.02 3.70 0.49 09025565 A Treat fracture radius & ulna 5.85 8.08 7.76 6.79 6.49 1.14 09025574 A Treat fracture radius & ulna 8.80 NA NA 9.20 8.73 1.77 09025575 A Treat fracture radius/ulna 12.29 NA NA 11.82 11.25 2.43 09025600 A Treat fracture radius/ulna 2.78 5.00 4.78 4.34 4.06 0.54 09025605 A Treat fracture radius/ulna 7.25 9.41 8.92 8.45 7.98 1.44 09025606 A Treat fx distal radial 8.31 NA NA 9.45 9.18 1.67 09025607 A Treat fx rad extra-articul 9.56 NA NA 10.18 9.54 1.89 09025608 A Treat fx rad intra-articul 11.07 NA NA 11.08 10.38 2.15 09025609 A Treat fx radial 3+ frag 14.38 NA NA 13.84 12.93 2.80 09025622 A Treat wrist bone fracture 2.79 5.32 5.05 4.60 4.28 0.54 090CMS-1503-P852**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**25624 A Treat wrist bone fracture 4.77 7.52 7.27 6.42 6.16 0.92 09025628 A Treat wrist bone fracture 9.67 NA NA 9.77 9.28 1.81 09025630 A Treat wrist bone fracture 3.03 5.12 4.88 4.46 4.14 0.58 09025635 A Treat wrist bone fracture 4.61 7.54 7.03 6.48 5.84 0.93 09025645 A Treat wrist bone fracture 7.42 NA NA 7.78 7.42 1.53 09025650 A Treat wrist bone fracture 3.23 5.32 5.05 4.79 4.44 0.62 09025651 A Pin ulnar styloid fracture 5.82 NA NA 7.26 6.83 1.14 09025652 A Treat fracture ulnar styloid 8.06 NA NA 8.74 8.29 1.53 09025660 A Treat wrist dislocation 4.98 NA NA 5.78 5.56 0.93 09025670 A Treat wrist dislocation 8.09 NA NA 8.12 7.82 1.55 09025671 A Pin radioulnar dislocation 6.46 NA NA 7.80 7.36 1.31 09025675 A Treat wrist dislocation 4.89 6.64 6.36 5.67 5.40 0.90 09025676 A Treat wrist dislocation 8.29 NA NA 8.72 8.31 1.60 09025680 A Treat wrist fracture 6.23 NA NA 6.20 5.84 1.12 09025685 A Treat wrist fracture 10.09 NA NA 9.58 9.09 2.05 09025690 A Treat wrist dislocation 5.72 NA NA 7.11 6.64 1.19 09025695 A Treat wrist dislocation 8.51 NA NA 8.41 8.05 1.72 09025800 A Fusion of wrist joint 10.07 NA NA 9.70 9.39 1.88 09025805 A Fusion/graft of wrist joint 11.73 NA NA 10.86 10.59 2.39 09025810 A Fusion/graft of wrist joint 11.95 NA NA 11.57 11.03 2.20 09025820 A Fusion of hand bones 7.64 NA NA 8.97 8.60 1.43 09025825 A Fuse hand bones with graft 9.69 NA NA 10.85 10.36 1.75 09025830 A Fusion, radioulnar jnt/ulna 10.88 NA NA 14.61 14.32 2.23 09025900 A Amputation of forearm 9.61 NA NA 9.57 9.77 1.89 09025905 A Amputation of forearm 9.59 NA NA 9.16 9.38 1.96 09025907 A Amputation follow-up surgery 8.09 NA NA 8.28 8.57 1.65 090CMS-1503-P853**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**25909 A Amputation follow-up surgery 9.31 NA NA 9.00 9.27 1.91 09025915 A Amputation of forearm 17.52 NA NA 9.98 12.37 3.22 09025920 A Amputate hand at wrist 9.03 NA NA 9.59 9.13 1.85 09025922 A Amputate hand at wrist 7.65 NA NA 6.10 6.71 0.55 09025924 A Amputation follow-up surgery 8.81 NA NA 7.52 7.99 1.78 09025927 A Amputation of hand 9.09 NA NA 12.58 12.01 1.87 09025929 A Amputation follow-up surgery 7.82 NA NA 8.72 7.63 1.60 09025931 A Amputation follow-up surgery 8.04 NA NA 11.86 11.30 1.77 09025999 C Forearm or wrist surgery 0.00 0.00 0.00 0.00 0.00 0.00 YYY26010 A Drainage of finger abscess 1.59 5.37 5.34 2.11 1.99 0.28 01026011 A Drainage of finger abscess 2.24 8.29 8.27 2.77 2.64 0.41 01026020 A Drain hand tendon sheath 5.08 NA NA 6.68 6.32 0.96 09026025 A Drainage of palm bursa 5.08 NA NA 6.32 5.98 0.95 09026030 A Drainage of palm bursa(s) 6.25 NA NA 7.08 6.70 1.20 09026034 A Treat hand bone lesion 6.63 NA NA 7.87 7.47 1.27 09026035 A Decompress fingers/hand 11.37 NA NA 11.57 10.71 2.32 09026037 A Decompress fingers/hand 7.57 NA NA 7.84 7.41 1.50 09026040 A Release palm contracture 3.46 NA NA 5.03 4.76 0.58 09026045 A Release palm contracture 5.73 NA NA 6.83 6.51 1.13 09026055 A Incise finger tendon sheath 3.11 11.99 12.18 5.28 4.97 0.58 09026060 A Incision of finger tendon 2.91 NA NA 4.34 4.12 0.57 09026070 A Explore/treat hand joint 3.81 NA NA 4.55 4.22 0.68 09026075 A Explore/treat finger joint 3.91 NA NA 4.83 4.54 0.69 09026080 A Explore/treat finger joint 4.47 NA NA 6.09 5.76 0.81 09026100 A Biopsy hand joint lining 3.79 NA NA 5.15 4.83 0.76 09026105 A Biopsy finger joint lining 3.83 NA NA 5.17 4.91 0.78 090CMS-1503-P854**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**26110 A Biopsy finger joint lining 3.65 NA NA 5.08 4.80 0.66 09026111 A Exc hand les sc > 1.5 cm 5.42 NA NA 5.95 5.95 1.03 09026113 A Exc hand tum deep > 1.5 cm 7.13 NA NA 7.81 7.81 1.30 09026115 A Exc hand les sc < 1.5 cm 3.96 9.67 11.19 5.05 5.17 0.73 09026116 A Exc hand tum deep < 1.5 cm 6.74 NA NA 7.56 7.12 1.24 09026117 A Exc hand tum ra < 3 cm 10.13 NA NA 10.29 9.08 1.92 09026118 A Exc hand tum ra > 3 cm 14.81 NA NA 13.92 13.92 3.05 09026121 A Release palm contracture 7.73 NA NA 8.45 8.02 1.46 09026123 A Release palm contracture 10.88 NA NA 11.78 11.03 1.99 09026125 A Release palm contracture 4.60 NA NA 2.89 2.72 0.85 ZZZ26130 A Remove wrist joint lining 5.59 NA NA 6.87 6.47 1.10 09026135 A Revise finger joint, each 7.13 NA NA 7.80 7.40 1.31 09026140 A Revise finger joint, each 6.34 NA NA 7.34 6.97 1.19 09026145 A Tendon excision, palm/finger 6.49 NA NA 7.37 6.99 1.23 09026160 A Remove tendon sheath lesion 3.57 11.96 11.88 5.47 5.15 0.68 09026170 A Removal of palm tendon, each 4.91 NA NA 6.12 5.81 0.89 09026180 A Removal of finger tendon 5.35 NA NA 6.60 6.32 0.93 09026185 A Remove finger bone 6.52 NA NA 8.19 7.71 1.33 09026200 A Remove hand bone lesion 5.65 NA NA 6.52 6.21 1.07 09026205 A Remove/graft bone lesion 7.93 NA NA 8.15 7.82 1.62 09026210 A Removal of finger lesion 5.32 NA NA 6.66 6.33 0.99 09026215 A Remove/graft finger lesion 7.27 NA NA 7.76 7.37 1.50 09026230 A Partial removal of hand bone 6.47 NA NA 7.05 6.73 1.17 09026235 A Partial removal, finger bone 6.33 NA NA 7.11 6.74 1.14 09026236 A Partial removal, finger bone 5.46 NA NA 6.48 6.16 1.02 09026250 A Extensive hand surgery 15.21 NA NA 13.47 10.39 3.12 090CMS-1503-P855**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**26260 A Resect prox finger tumor 11.16 NA NA 11.26 9.07 2.27 09026262 A Resect distal finger tumor 8.29 NA NA 8.67 7.31 1.68 09026320 A Removal of implant from hand 4.10 NA NA 5.34 5.06 0.73 09026340 A Manipulate finger w/anesth 2.80 NA NA 6.26 5.94 0.54 09026350 A Repair finger/hand tendon 6.21 NA NA 12.80 12.88 1.17 09026352 A Repair/graft hand tendon 7.87 NA NA 13.70 13.68 1.61 09026356 A Repair finger/hand tendon 10.62 NA NA 18.73 18.34 1.99 09026357 A Repair finger/hand tendon 8.77 NA NA 14.23 14.20 1.78 09026358 A Repair/graft hand tendon 9.36 NA NA 15.40 15.16 1.92 09026370 A Repair finger/hand tendon 7.28 NA NA 13.07 13.14 1.41 09026372 A Repair/graft hand tendon 9.01 NA NA 14.37 14.45 1.85 09026373 A Repair finger/hand tendon 8.41 NA NA 14.02 14.06 1.71 09026390 A Revise hand/finger tendon 9.43 NA NA 12.67 12.46 1.94 09026392 A Repair/graft hand tendon 10.50 NA NA 15.24 15.12 2.15 09026410 A Repair hand tendon 4.77 NA NA 10.33 10.41 0.90 09026412 A Repair/graft hand tendon 6.48 NA NA 11.80 11.82 1.20 09026415 A Excision, hand/finger tendon 8.51 NA NA 9.99 10.20 1.22 09026416 A Graft hand or finger tendon 9.56 NA NA 14.10 12.48 1.95 09026418 A Repair finger tendon 4.47 NA NA 10.95 10.99 0.85 09026420 A Repair/graft finger tendon 6.94 NA NA 11.80 11.90 1.43 09026426 A Repair finger/hand tendon 6.32 NA NA 7.25 7.98 1.19 09026428 A Repair/graft finger tendon 7.40 NA NA 12.58 12.55 1.53 09026432 A Repair finger tendon 4.16 NA NA 9.16 9.18 0.76 09026433 A Repair finger tendon 4.70 NA NA 9.47 9.51 0.89 09026434 A Repair/graft finger tendon 6.26 NA NA 10.82 10.74 1.29 09026437 A Realignment of tendons 5.99 NA NA 10.68 10.61 1.07 090CMS-1503-P856**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**26440 A Release palm/finger tendon 5.16 NA NA 11.44 11.58 0.93 09026442 A Release palm & finger tendon 9.75 NA NA 16.16 15.83 1.81 09026445 A Release hand/finger tendon 4.45 NA NA 11.01 11.17 0.81 09026449 A Release forearm/hand tendon 8.59 NA NA 10.43 10.96 1.57 09026450 A Incision of palm tendon 3.79 NA NA 7.04 6.97 0.71 09026455 A Incision of finger tendon 3.76 NA NA 7.04 6.95 0.72 09026460 A Incise hand/finger tendon 3.58 NA NA 6.99 6.88 0.65 09026471 A Fusion of finger tendons 5.90 NA NA 10.60 10.49 1.07 09026474 A Fusion of finger tendons 5.49 NA NA 10.59 10.42 1.12 09026476 A Tendon lengthening 5.35 NA NA 10.50 10.22 1.10 09026477 A Tendon shortening 5.32 NA NA 10.24 10.17 1.06 09026478 A Lengthening of hand tendon 5.97 NA NA 10.64 10.67 1.13 09026479 A Shortening of hand tendon 5.91 NA NA 10.61 10.58 1.22 09026480 A Transplant hand tendon 6.90 NA NA 13.23 13.25 1.26 09026483 A Transplant/graft hand tendon 8.48 NA NA 13.97 13.99 1.62 09026485 A Transplant palm tendon 7.89 NA NA 13.69 13.73 1.46 09026489 A Transplant/graft palm tendon 9.86 NA NA 14.87 14.07 2.01 09026490 A Revise thumb tendon 8.60 NA NA 12.59 12.32 1.75 09026492 A Tendon transfer with graft 9.84 NA NA 13.48 13.28 2.01 09026494 A Hand tendon/muscle transfer 8.66 NA NA 12.47 12.34 1.75 09026496 A Revise thumb tendon 9.78 NA NA 13.23 12.97 1.71 09026497 A Finger tendon transfer 9.76 NA NA 13.11 12.95 1.99 09026498 A Finger tendon transfer 14.21 NA NA 16.03 15.75 2.91 09026499 A Revision of finger 9.17 NA NA 12.76 12.59 1.88 09026500 A Hand tendon reconstruction 6.13 NA NA 10.66 10.57 1.19 09026502 A Hand tendon reconstruction 7.31 NA NA 11.83 11.54 1.51 090CMS-1503-P857**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**26508 A Release thumb contracture 6.18 NA NA 10.77 10.61 1.14 09026510 A Thumb tendon transfer 5.60 NA NA 10.32 10.33 1.02 09026516 A Fusion of knuckle joint 7.32 NA NA 11.40 11.30 1.34 09026517 A Fusion of knuckle joints 9.08 NA NA 12.71 12.62 1.87 09026518 A Fusion of knuckle joints 9.27 NA NA 13.14 12.86 1.89 09026520 A Release knuckle contracture 5.47 NA NA 11.96 12.06 1.03 09026525 A Release finger contracture 5.50 NA NA 11.97 12.08 0.99 09026530 A Revise knuckle joint 6.88 NA NA 7.65 7.25 1.27 09026531 A Revise knuckle with implant 8.13 NA NA 8.83 8.35 1.44 09026535 A Revise finger joint 5.41 NA NA 5.96 5.44 0.86 09026536 A Revise/implant finger joint 6.56 NA NA 12.62 11.95 1.17 09026540 A Repair hand joint 6.60 NA NA 11.01 10.94 1.23 09026541 A Repair hand joint with graft 8.81 NA NA 12.50 12.41 1.58 09026542 A Repair hand joint with graft 6.95 NA NA 11.26 11.18 1.30 09026545 A Reconstruct finger joint 7.11 NA NA 11.56 11.41 1.31 09026546 A Repair nonunion hand 10.83 NA NA 15.76 15.37 1.92 09026548 A Reconstruct finger joint 8.22 NA NA 12.23 12.05 1.55 09026550 A Construct thumb replacement 21.68 NA NA 21.94 19.26 4.42 09026551 A Great toe-hand transfer 48.48 NA NA 28.34 30.29 9.92 09026553 A Single transfer, toe-hand 48.17 NA NA 44.03 34.58 3.56 09026554 A Double transfer, toe-hand 57.01 NA NA 32.34 33.56 4.21 09026555 A Positional change of finger 17.08 NA NA 19.26 18.86 3.50 09026556 A Toe joint transfer 49.75 NA NA 31.98 28.92 4.11 09026560 A Repair of web finger 5.52 NA NA 10.31 9.94 1.13 09026561 A Repair of web finger 11.10 NA NA 14.64 13.59 2.44 09026562 A Repair of web finger 16.68 NA NA 18.89 18.26 1.23 090CMS-1503-P858**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**26565 A Correct metacarpal flaw 6.91 NA NA 11.12 11.05 1.41 09026567 A Correct finger deformity 6.99 NA NA 11.16 11.11 1.29 09026568 A Lengthen metacarpal/finger 9.27 NA NA 14.52 14.43 1.89 09026580 A Repair hand deformity 19.75 NA NA 15.35 15.80 4.04 09026587 A Reconstruct extra finger 14.50 NA NA 14.57 12.28 3.22 09026590 A Repair finger deformity 18.67 NA NA 14.91 14.12 3.84 09026591 A Repair muscles of hand 3.38 NA NA 8.28 8.39 0.64 09026593 A Release muscles of hand 5.50 NA NA 10.59 10.51 0.96 09026596 A Excision constricting tissue 9.14 NA NA 11.05 10.39 1.88 09026600 A Treat metacarpal fracture 2.60 5.23 4.89 4.78 4.37 0.49 09026605 A Treat metacarpal fracture 3.03 5.58 5.32 4.82 4.55 0.58 09026607 A Treat metacarpal fracture 5.48 NA NA 6.80 6.24 1.10 09026608 A Treat metacarpal fracture 5.55 NA NA 7.32 7.01 1.07 09026615 A Treat metacarpal fracture 7.07 NA NA 8.53 7.85 1.34 09026641 A Treat thumb dislocation 4.13 5.34 5.25 4.58 4.43 0.75 09026645 A Treat thumb fracture 4.58 6.82 6.34 5.89 5.42 0.92 09026650 A Treat thumb fracture 5.35 NA NA 7.52 7.23 1.06 09026665 A Treat thumb fracture 7.94 NA NA 8.97 8.41 1.53 09026670 A Treat hand dislocation 3.83 4.92 4.70 4.15 3.87 0.69 09026675 A Treat hand dislocation 4.83 7.29 6.78 6.31 5.82 0.99 09026676 A Pin hand dislocation 5.74 NA NA 7.72 7.43 1.10 09026685 A Treat hand dislocation 7.07 NA NA 8.43 7.91 1.44 09026686 A Treat hand dislocation 8.17 NA NA 8.49 8.09 1.67 09026700 A Treatknuckle dislocation 3.83 4.56 4.32 4.07 3.78 0.6809026705 A Treatknuckle dislocation 4.38 6.87 6.37 5.92 5.43 0.8509026706 A Pin knuckle dislocation 5.31 NA NA 6.62 6.19 0.99 090CMS-1503-P859**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**26715 A Treatknuckle dislocation 7.03 NA NA 8.40 7.80 1.3609026720 A Treat finger fracture, each 1.76 3.47 3.31 3.12 2.90 0.34 09026725 A Treat finger fracture, each 3.48 5.55 5.34 4.68 4.42 0.66 09026727 A Treat finger fracture, each 5.42 NA NA 7.28 6.96 1.03 09026735 A Treat finger fracture, each 7.42 NA NA 8.72 8.04 1.43 09026740 A Treat finger fracture, each 2.07 4.10 3.87 3.73 3.49 0.37 09026742 A Treat finger fracture, each 3.99 5.78 5.58 4.88 4.66 0.75 09026746 A Treat finger fracture, each 9.80 NA NA 10.28 9.32 1.85 09026750 A Treat finger fracture, each 1.80 3.04 2.90 3.05 2.84 0.34 09026755 A Treat finger fracture, each 3.23 5.06 4.89 4.02 3.80 0.61 09026756 A Pin finger fracture, each 4.58 NA NA 6.74 6.44 0.86 09026765 A Treat finger fracture, each 5.86 NA NA 7.72 7.02 1.13 09026770 A Treat finger dislocation 3.15 3.99 3.80 3.49 3.24 0.57 09026775 A Treat finger dislocation 3.90 6.32 6.04 5.36 5.02 0.72 09026776 A Pin finger dislocation 4.99 NA NA 6.95 6.66 0.95 09026785 A Treat finger dislocation 6.60 NA NA 8.20 7.43 1.26 09026820 A Thumb fusion with graft 8.45 NA NA 12.34 12.27 1.72 09026841 A Fusion of thumb 7.35 NA NA 12.05 11.99 1.44 09026842 A Thumb fusion with graft 8.49 NA NA 12.41 12.34 1.72 09026843 A Fusion of hand joint 7.78 NA NA 11.71 11.61 1.60 09026844 A Fusion/graft of hand joint 8.98 NA NA 12.65 12.55 1.85 09026850 A Fusion of knuckle 7.14 NA NA 11.40 11.31 1.29 09026852 A Fusion of knuckle with graft 8.71 NA NA 12.63 12.43 1.53 09026860 A Fusion of finger joint 4.88 NA NA 10.22 10.19 0.88 09026861 A Fusion of finger jnt, add-on 1.74 NA NA 1.08 1.02 0.32 ZZZ26862 A Fusion/graft of finger joint 7.56 NA NA 11.89 11.74 1.36 090CMS-1503-P860**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**26863 A Fuse/graft added joint 3.89 NA NA 2.27 2.21 0.78 ZZZ26910 A Amputate metacarpal bone 7.79 NA NA 11.33 11.12 1.55 09026951 A Amputation of finger/thumb 6.04 NA NA 11.39 11.01 1.19 09026952 A Amputation of finger/thumb 6.48 NA NA 10.82 10.75 1.26 09026989 C Hand/finger surgery 0.00 0.00 0.00 0.00 0.00 0.00 YYY26990 A Drainage of pelvis lesion 7.95 NA NA 8.73 8.33 1.64 09026991 A Drainage of pelvis bursa 7.06 11.92 11.58 7.01 6.61 1.44 09026992 A Drainage of bone lesion 13.48 NA NA 12.23 11.66 2.77 09027000 A Incision of hip tendon 5.74 NA NA 5.91 5.82 1.12 09027001 A Incision of hip tendon 7.14 NA NA 7.31 6.99 1.46 09027003 A Incision of hip tendon 7.81 NA NA 8.12 7.65 1.60 09027005 A Incision of hip tendon 10.07 NA NA 9.37 8.95 2.05 09027006 A Incision of hip tendons 10.11 NA NA 9.65 9.20 2.03 09027025 A Incision of hip/thigh fascia 12.89 NA NA 11.55 10.83 2.67 09027027 A Buttock fasciotomy 13.04 NA NA 11.16 10.15 0.95 09027030 A Drainage of hip joint 13.65 NA NA 11.28 10.89 2.77 09027033 A Exploration of hip joint 14.11 NA NA 11.93 11.42 2.88 09027035 A Denervation of hip joint 17.37 NA NA 14.16 12.42 3.56 09027036 A Excision of hip joint/muscle 14.38 NA NA 12.58 11.99 2.90 09027040 A Biopsy of soft tissues 2.92 6.17 6.25 2.37 2.38 0.49 01027041 A Biopsy of soft tissues 10.18 NA NA 7.77 7.63 1.88 09027043 A Exc hip pelvis les sc > 3 cm 6.88 NA NA 5.59 5.59 1.47 09027045 A Exc hip/pelv tum deep > 5 cm 11.13 NA NA 8.64 8.64 2.35 09027047 A Exc hip/pelvis les sc < 3 cm 4.94 7.57 8.03 4.69 5.12 1.06 09027048 A Exc hip/pelv tum deep < 5 cm 8.85 NA NA 7.38 6.55 1.88 09027049 A Resect hip/pelv tum < 5 cm 21.55 NA NA 14.66 12.41 4.49 090CMS-1503-P861**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**27050 A Biopsy of sacroiliac joint 4.74 NA NA 6.01 5.16 0.96 09027052 A Biopsy of hip joint 7.42 NA NA 7.97 7.47 1.53 09027054 A Removal of hip joint lining 9.21 NA NA 9.10 8.67 1.88 09027057 A Buttock fasciotomy w/dbrdmt 14.91 NA NA 12.26 11.15 1.10 09027059 A Resect hip/pelv tum > 5 cm 29.35 NA NA 18.88 18.88 6.01 09027060 A Removal of ischial bursa 5.87 NA NA 6.56 5.89 1.22 09027062 A Remove femur lesion/bursa 5.75 NA NA 6.47 6.15 1.17 09027065 A Removal of hip bone lesion 6.55 NA NA 6.96 6.66 1.33 09027066 A Removal of hip bone lesion 11.20 NA NA 10.53 10.02 2.29 09027067 A Remove/graft hip bone lesion 14.72 NA NA 12.97 12.37 3.02 09027070 A Partial removal of hip bone 11.56 NA NA 11.25 10.75 2.36 09027071 A Partial removal of hip bone 12.39 NA NA 11.98 11.49 2.53 09027075 A Resect hip tumor 32.71 NA NA 22.82 22.15 6.68 09027076 A Resect hip tum incl acetabul 40.21 NA NA 27.55 21.99 8.24 09027077 A Resect hip tum w/innom bone 45.21 NA NA 31.00 28.06 9.26 09027078 A Rsect hip tum incl femur 32.21 NA NA 23.40 17.43 6.58 09027080 A Removal of tail bone 6.89 NA NA 6.70 6.25 1.47 09027086 A Remove hip foreign body 1.92 4.36 4.53 1.92 1.93 0.32 01027087 A Remove hip foreign body 8.83 NA NA 7.94 7.66 1.77 09027090 A Removal of hip prosthesis 11.69 NA NA 10.52 10.06 2.37 09027091 A Removal of hip prosthesis 24.35 NA NA 18.49 17.47 4.99 09027093 A Injection for hip x-ray 1.30 3.91 4.05 0.64 0.62 0.14 00027095 A Injection for hip x-ray 1.50 4.93 5.04 0.76 0.72 0.18 00027096 A Inject sacroiliac joint 1.40 4.09 3.85 0.68 0.55 0.13 00027097 A Revision of hip tendon 9.27 NA NA 8.97 8.34 1.89 09027098 A Transfer tendon to pelvis 9.32 NA NA 9.24 8.04 1.91 090CMS-1503-P862**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**27100 A Transfer of abdominal muscle 11.35 NA NA 10.75 10.22 2.32 09027105 A Transfer of spinal muscle 12.04 NA NA 11.15 10.63 2.44 09027110 A Transfer of iliopsoas muscle 13.77 NA NA 12.16 11.43 2.83 09027111 A Transfer of iliopsoas muscle 12.60 NA NA 11.48 10.33 2.56 09027120 A Reconstruction of hip socket 19.25 NA NA 15.59 14.63 3.94 09027122 A Reconstruction of hip socket 16.09 NA NA 13.42 12.81 3.28 09027125 A Partial hip replacement 16.64 NA NA 13.73 12.99 3.41 09027130 A Total hip arthroplasty 21.79 NA NA 16.83 16.00 4.45 09027132 A Total hip arthroplasty 25.69 NA NA 19.28 18.38 5.26 09027134 A Revise hip joint replacement 30.28 NA NA 21.18 20.30 6.19 09027137 A Revise hip joint replacement 22.70 NA NA 16.84 16.10 4.63 09027138 A Revise hip joint replacement 23.70 NA NA 17.43 16.65 4.85 09027140 A Transplant femur ridge 12.78 NA NA 11.11 10.68 2.61 09027146 A Incision of hip bone 18.92 NA NA 15.53 14.49 3.89 09027147 A Revision of hip bone 22.07 NA NA 17.37 16.44 4.51 09027151 A Incision of hip bones 24.12 NA NA 18.57 16.61 4.95 09027156 A Revision of hip bones 26.23 NA NA 19.80 18.62 5.36 09027158 A Revision of pelvis 21.04 NA NA 16.55 15.39 4.31 09027161 A Incision of neck of femur 17.89 NA NA 14.62 14.00 3.65 09027165 A Incision/fixation of femur 20.29 NA NA 16.57 15.68 4.14 09027170 A Repair/graft femur head/neck 17.61 NA NA 13.93 13.27 3.60 09027175 A Treat slipped epiphysis 9.38 NA NA 8.47 8.03 1.92 09027176 A Treat slipped epiphysis 12.92 NA NA 11.67 11.04 2.66 09027177 A Treat slipped epiphysis 16.09 NA NA 13.76 13.06 3.29 09027178 A Treat slipped epiphysis 12.92 NA NA 11.67 10.95 2.66 09027179 A Revise head/neck of femur 13.97 NA NA 12.17 11.56 2.85 090CMS-1503-P863**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**27181 A Treat slipped epiphysis 16.18 NA NA 13.93 13.09 3.32 09027185 A Revision of femur epiphysis 9.79 NA NA 6.68 6.94 0.72 09027187 A Reinforce hip bones 14.23 NA NA 12.30 11.79 2.91 09027193 A Treat pelvic ring fracture 6.09 6.50 6.16 6.67 6.31 1.24 09027194 A Treat pelvic ring fracture 10.20 NA NA 8.36 8.20 1.72 09027200 A Treat tail bone fracture 1.92 2.89 2.71 3.09 2.87 0.37 09027202 A Treat tail bone fracture 7.31 NA NA 7.67 8.60 1.51 09027215 I Treat pelvic fracture(s) 10.45 NA NA 6.46 7.26 0.76 09027216 I Treat pelvic ring fracture 15.73 NA NA 9.35 10.40 1.17 09027217 I Treat pelvic ring fracture 14.65 NA NA 8.88 10.04 1.09 09027218 I Treat pelvic ring fracture 20.93 NA NA 11.59 12.82 1.55 09027220 A Treat hip socket fracture 6.83 7.36 6.98 7.23 6.86 1.38 09027222 A Treat hip socket fracture 14.11 NA NA 11.95 11.46 2.87 09027226 A Treat hip wall fracture 15.57 NA NA 12.85 11.85 3.19 09027227 A Treat hip fracture(s) 25.41 NA NA 19.23 18.28 5.20 09027228 A Treat hip fracture(s) 29.33 NA NA 21.47 20.50 6.01 09027230 A Treat thigh fracture 5.81 6.84 6.53 6.75 6.40 1.19 09027232 A Treat thigh fracture 11.72 NA NA 8.65 8.29 2.33 09027235 A Treat thigh fracture 13.00 NA NA 11.39 10.87 2.66 09027236 A Treat thigh fracture 17.61 NA NA 14.47 13.69 3.60 09027238 A Treat thigh fracture 5.75 NA NA 6.48 6.18 1.17 09027240 A Treat thigh fracture 13.81 NA NA 11.76 11.21 2.80 09027244 A Treat thigh fracture 18.18 NA NA 14.83 14.02 3.70 09027245 A Treat thigh fracture 18.18 NA NA 14.86 14.41 3.70 09027246 A Treat thigh fracture 4.83 5.45 5.20 5.50 5.24 0.96 09027248 A Treat thigh fracture 10.78 NA NA 9.11 8.80 2.20 090CMS-1503-P864**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**27250 A Treat hip dislocation 3.82 NA NA 0.95 1.51 0.69 00027252 A Treat hip dislocation 11.03 NA NA 9.13 8.71 2.22 09027253 A Treat hip dislocation 13.58 NA NA 11.62 11.13 2.77 09027254 A Treat hip dislocation 18.94 NA NA 14.94 14.24 3.87 09027256 A Treat hip dislocation 4.28 3.43 3.34 1.73 1.82 0.78 01027257 A Treat hip dislocation 5.38 NA NA 3.48 3.32 1.02 01027258 A Treat hip dislocation 16.18 NA NA 13.57 12.86 3.32 09027259 A Treat hip dislocation 23.26 NA NA 18.39 17.39 4.75 09027265 A Treat hip dislocation 5.24 NA NA 5.15 5.04 0.96 09027266 A Treat hip dislocation 7.78 NA NA 7.78 7.41 1.58 09027267 A Cltx thigh fx 5.50 NA NA 6.09 5.63 1.13 09027268 A Cltx thigh fx w/mnpj 7.12 NA NA 7.28 6.62 1.46 09027269 A Optx thigh fx 18.89 NA NA 14.25 13.10 3.84 09027275 A Manipulation of hip joint 2.32 NA NA 2.48 2.39 0.41 01027280 A Fusion of sacroiliac joint 14.64 NA NA 12.79 12.20 3.15 09027282 A Fusion of pubic bones 11.85 NA NA 11.04 9.90 2.40 09027284 A Fusion of hip joint 25.06 NA NA 18.38 16.28 5.14 09027286 A Fusion of hip joint 25.17 NA NA 19.18 18.29 5.16 09027290 A Amputation of leg at hip 24.55 NA NA 19.03 17.33 5.03 09027295 A Amputation of leg at hip 19.66 NA NA 14.16 13.40 4.17 09027299 C Pelvis/hip joint surgery 0.00 0.00 0.00 0.00 0.00 0.00 YYY27301 A Drain thigh/knee lesion 6.78 11.18 10.84 6.60 6.24 1.43 09027303 A Drainage of bone lesion 8.63 NA NA 8.48 8.09 1.75 09027305 A Incise thigh tendon & fascia 6.18 NA NA 6.64 6.22 1.27 09027306 A Incision of thigh tendon 4.74 NA NA 5.23 5.10 0.96 09027307 A Incision of thigh tendons 6.06 NA NA 6.77 6.32 1.24 090CMS-1503-P865**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**27310 A Exploration of knee joint 10.00 NA NA 9.58 9.09 2.03 09027323 A Biopsy, thigh soft tissues 2.33 5.10 4.97 2.53 2.44 0.42 01027324 A Biopsy, thigh soft tissues 5.04 NA NA 5.42 5.10 1.09 09027325 A Neurectomy, hamstring 7.20 NA NA 7.69 7.01 1.47 09027326 A Neurectomy, popliteal6.47 NA NA 7.26 6.64 1.31 09027327 A Exc thigh/knee les sc < 3 cm 3.96 8.29 7.78 4.35 4.38 0.83 09027328 A Exc thigh/knee tum deep <5cm 8.85 NA NA 7.62 6.36 1.88 09027329 A Resect thigh/knee tum < 5 cm 15.72 NA NA 12.05 11.36 3.31 09027330 A Biopsy, knee joint lining 5.11 NA NA 5.97 5.57 0.99 09027331 A Explore/treat knee joint 6.02 NA NA 6.70 6.40 1.23 09027332 A Removal of knee cartilage 8.46 NA NA 8.69 8.29 1.71 09027333 A Removal of knee cartilage 7.55 NA NA 8.11 7.72 1.55 09027334 A Remove knee joint lining 9.19 NA NA 9.11 8.65 1.88 09027335 A Remove knee joint lining 10.55 NA NA 9.87 9.45 2.15 09027337 A Exc thigh/knee les sc > 3 cm 5.91 NA NA 5.30 5.30 1.26 09027339 A Exc thigh/knee tum deep >5cm 11.13 NA NA 8.94 8.94 2.35 09027340 A Removal of kneecap bursa 4.32 NA NA 5.64 5.36 0.88 09027345 A Removal of knee cyst 6.09 NA NA 6.76 6.50 1.24 09027347 A Remove knee cyst 6.73 NA NA 7.41 6.98 1.37 09027350 A Removal of kneecap 8.66 NA NA 8.78 8.40 1.75 09027355 A Remove femur lesion 8.00 NA NA 8.10 7.77 1.64 09027356 A Remove femur lesion/graft 10.09 NA NA 9.60 9.18 2.05 09027357 A Remove femur lesion/graft 11.16 NA NA 10.62 10.14 2.29 09027358 A Remove femur lesion/fixation 4.73 NA NA 2.76 2.67 0.95 ZZZ27360 A Partial removal, leg bone(s) 11.46 NA NA 11.32 10.84 2.35 09027364 A Resect thigh/knee tum >5 cm 24.49 NA NA 16.94 16.94 5.16 090CMS-1503-P866**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**27365 A Resect femur/knee tumor 32.21 NA NA 23.28 18.34 6.60 09027370 A Injection for knee x-ray 0.96 3.75 3.77 0.50 0.46 0.13 00027372 A Removal of foreign body 5.21 11.12 10.85 5.65 5.40 1.07 09027380 A Repair of kneecap tendon 7.45 NA NA 8.39 8.09 1.53 09027381 A Repair/graft kneecap tendon 10.76 NA NA 10.56 10.18 2.20 09027385 A Repair of thigh muscle 8.11 NA NA 8.81 8.48 1.65 09027386 A Repair/graft of thigh muscle 11.13 NA NA 11.09 10.65 2.27 09027390 A Incision of thigh tendon 5.53 NA NA 6.46 6.12 1.13 09027391 A Incision of thigh tendons 7.49 NA NA 7.93 7.54 1.54 09027392 A Incision of thigh tendons 9.63 NA NA 9.42 8.86 1.96 09027393 A Lengthening of thigh tendon 6.59 NA NA 6.91 6.65 1.34 09027394 A Lengthening of thigh tendons 8.79 NA NA 8.55 8.22 1.77 09027395 A Lengthening of thigh tendons 12.24 NA NA 11.27 10.76 2.50 09027396 A Transplant of thigh tendon 8.15 NA NA 8.31 7.95 1.67 09027397 A Transplants of thigh tendons 12.66 NA NA 11.87 11.23 2.57 09027400 A Revise thigh muscles/tendons 9.33 NA NA 9.25 8.78 1.91 09027403 A Repair of knee cartilage8.62 NA NA 8.51 8.16 1.74 09027405 A Repair of knee ligament 9.08 NA NA 9.01 8.63 1.87 09027407 A Repair of knee ligament 10.85 NA NA 10.35 9.58 2.22 09027409 A Repair of knee ligaments 13.71 NA NA 12.13 11.54 2.81 09027412 A Autochondrocyte implant knee 24.74 NA NA 19.52 18.46 5.07 09027415 A Osteochondral knee allograft 20.00 NA NA 16.86 15.88 4.08 09027416 A Osteochondral knee autograft 14.16 NA NA 12.10 11.28 2.90 09027418 A Repair degenerated kneecap 11.60 NA NA 10.63 10.21 2.35 09027420 A Revision of unstable kneecap 10.26 NA NA 9.70 9.29 2.08 09027422 A Revision of unstable kneecap 10.21 NA NA 9.67 9.26 2.06 090CMS-1503-P867**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**27424 A Revision/removal of kneecap 10.24 NA NA 9.61 9.25 2.08 09027425 A Lat retinacular release open 5.39 NA NA 6.59 6.29 1.10 09027427 A Reconstruction, knee 9.79 NA NA 9.39 8.99 1.99 09027428 A Reconstruction, knee 15.58 NA NA 14.22 13.51 3.21 09027429 A Reconstruction, knee 17.54 NA NA 15.72 14.99 3.60 09027430 A Revision of thigh muscles 10.16 NA NA 9.63 9.21 2.06 09027435 A Incision of knee joint 10.88 NA NA 10.69 10.16 2.23 09027437 A Revise kneecap 8.93 NA NA 8.75 8.35 1.84 09027438 A Revise kneecap with implant 11.89 NA NA 10.60 10.11 2.42 09027440 A Revision of knee joint 11.09 NA NA 10.26 9.38 2.26 09027441 A Revision of knee joint 11.54 NA NA 10.53 9.59 2.35 09027442 A Revision of knee joint 12.37 NA NA 10.91 10.37 2.52 09027443 A Revision of knee joint 11.41 NA NA 10.45 9.96 2.33 09027445 A Revision of knee joint 18.66 NA NA 14.87 14.22 3.84 09027446 A Revision of knee joint 16.38 NA NA 13.20 12.68 3.35 09027447 A Total knee arthroplasty 23.25 NA NA 17.99 17.16 4.75 09027448 A Incision of thigh 11.60 NA NA 10.29 9.84 2.37 09027450 A Incision of thigh 14.61 NA NA 12.49 11.99 3.01 09027454 A Realignment of thigh bone 19.17 NA NA 15.68 14.65 3.93 09027455 A Realignment of knee 13.36 NA NA 11.87 11.33 2.73 09027457 A Realignment of knee 14.03 NA NA 11.75 11.25 2.87 09027465 A Shortening of thigh bone 18.60 NA NA 15.00 13.92 3.83 09027466 A Lengthening of thigh bone 17.28 NA NA 14.20 13.63 3.55 09027468 A Shorten/lengthen thighs 19.97 NA NA 16.03 15.10 4.08 09027470 A Repair of thigh 17.14 NA NA 14.44 13.79 3.52 09027472 A Repair/graft of thigh 18.72 NA NA 15.13 14.51 3.84 090CMS-1503-P868**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**27475 A Surgery to stop leg growth 8.93 NA NA 6.22 7.08 1.84 09027477 A Surgery to stop leg growth 10.14 NA NA 9.47 9.03 2.06 09027479 A Surgery to stop leg growth 13.16 NA NA 11.48 10.98 0.96 09027485 A Surgery to stop leg growth 9.13 NA NA 8.81 8.43 1.88 09027486 A Revise/replace knee joint 21.12 NA NA 16.62 15.85 4.31 09027487 A Revise/replace knee joint 27.11 NA NA 20.08 19.19 5.54 09027488 A Removal of knee prosthesis 17.60 NA NA 14.59 13.89 3.60 09027495 A Reinforce thigh 16.54 NA NA 13.67 13.09 3.38 09027496 A Decompression of thigh/knee 6.78 NA NA 7.76 6.98 1.38 09027497 A Decompression of thigh/knee 7.79 NA NA 7.78 6.95 1.60 09027498 A Decompression of thigh/knee 8.66 NA NA 8.86 7.68 1.75 09027499 A Decompression of thigh/knee 9.43 NA NA 9.31 8.32 1.94 09027500 A Treatment of thigh fracture 6.30 7.56 7.19 6.53 6.15 1.27 09027501 A Treatment of thigh fracture 6.45 7.02 6.71 6.91 6.55 1.31 09027502 A Treatment of thigh fracture 11.36 NA NA 9.44 9.09 2.27 09027503 A Treatment of thigh fracture 11.27 NA NA 10.26 9.76 2.29 09027506 A Treatment of thigh fracture 19.65 NA NA 16.25 15.41 4.01 09027507 A Treatment of thigh fracture 14.48 NA NA 11.60 11.13 2.97 09027508 A Treatment of thigh fracture 6.20 7.81 7.47 6.99 6.64 1.24 09027509 A Treatment of thigh fracture 8.14 NA NA 9.17 8.82 1.65 09027510 A Treatment of thigh fracture 9.80 NA NA 8.62 8.35 1.95 09027511 A Treatment of thigh fracture 15.11 NA NA 11.65 11.36 3.09 09027513 A Treatment of thigh fracture 19.25 NA NA 14.06 13.77 3.94 09027514 A Treatment of thigh fracture 14.60 NA NA 11.34 11.42 2.98 09027516 A Treat thigh fx growth plate 5.59 8.00 7.52 7.16 6.71 1.14 09027517 A Treat thigh fx growth plate 9.12 NA NA 9.23 8.77 1.87 090CMS-1503-P869**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**27519 A Treat thigh fx growth plate 13.25 NA NA 10.64 10.57 2.71 09027520 A Treat kneecap fracture 3.04 5.57 5.33 4.83 4.53 0.61 09027524 A Treat kneecap fracture 10.37 NA NA 9.78 9.37 2.11 09027530 A Treat knee fracture 4.09 6.57 6.28 5.85 5.53 0.81 09027532 A Treat knee fracture 7.55 8.96 8.54 7.95 7.56 1.54 09027535 A Treat knee fracture 13.41 NA NA 10.66 10.37 2.73 09027536 A Treat knee fracture 17.39 NA NA 14.57 13.84 3.56 09027538 A Treat knee fracture(s) 5.09 7.56 7.22 6.76 6.40 1.03 09027540 A Treat knee fracture 11.30 NA NA 10.49 10.16 2.30 09027550 A Treat knee dislocation 5.98 7.29 6.97 6.33 6.00 1.14 09027552 A Treat knee dislocation 8.18 NA NA 8.61 8.18 1.67 09027556 A Treat knee dislocation 13.00 NA NA 10.49 10.43 2.67 09027557 A Treat knee dislocation 15.90 NA NA 12.19 12.08 3.26 09027558 A Treat knee dislocation 18.39 NA NA 13.64 13.31 3.76 09027560 A Treat kneecap dislocation 3.99 6.19 5.83 5.49 5.00 0.79 09027562 A Treat kneecap dislocation 5.98 NA NA 6.94 6.40 1.23 09027566 A Treat kneecap dislocation 12.71 NA NA 11.11 10.65 2.60 09027570 A Fixation of knee joint 1.79 NA NA 2.25 2.14 0.35 01027580 A Fusion of knee 21.10 NA NA 17.45 16.72 4.31 09027590 A Amputate leg at thigh 13.47 NA NA 8.36 7.99 3.07 09027591 A Amputate leg at thigh 13.94 NA NA 9.99 9.76 3.02 09027592 A Amputate leg at thigh 10.98 NA NA 7.71 7.38 2.43 09027594 A Amputation follow-up surgery 7.29 NA NA 6.34 6.14 1.61 09027596 A Amputation follow-up surgery 11.29 NA NA 8.26 7.94 2.49 09027598 A Amputate lower leg at knee 11.22 NA NA 8.70 8.35 2.42 09027599 C Leg surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYYCMS-1503-P870**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**27600 A Decompression of lower leg 6.03 NA NA 5.07 5.01 1.31 09027601 A Decompression of lower leg 6.05 NA NA 5.91 5.68 1.31 09027602 A Decompression of lower leg 7.82 NA NA 5.64 5.57 1.81 09027603 A Drain lower leg lesion 5.23 9.43 9.01 5.42 5.12 1.05 09027604 A Drain lower leg bursa 4.59 8.46 7.98 4.61 4.42 0.81 09027605 A Incision of achilles tendon 2.92 6.43 6.68 2.17 2.23 0.35 01027606 A Incision of achilles tendon 4.18 NA NA 3.59 3.51 0.75 01027607 A Treat lower leg bone lesion 8.62 NA NA 7.96 7.59 1.64 09027610 A Explore/treat ankle joint 9.13 NA NA 8.54 8.16 1.70 09027612 A Exploration of ankle joint 8.15 NA NA 7.21 6.95 1.20 09027613 A Biopsy lower leg soft tissue 2.22 4.80 4.66 2.33 2.26 0.32 01027614 A Biopsy lower leg soft tissue 5.80 9.92 9.46 5.20 5.03 1.07 09027615 A Resect leg/ankle tum < 5 cm 15.72 NA NA 12.02 10.80 3.26 09027616 A Resect leg/ankle tum > 5 cm 19.63 NA NA 14.38 14.38 4.06 09027618 A Exc leg/ankle tum < 3 cm 3.96 8.18 7.90 4.30 4.50 0.76 09027619 A Exc leg/ankle tum deep <5 cm 6.91 NA NA 6.21 6.39 1.27 09027620 A Explore/treat ankle joint 6.15 NA NA 6.29 6.07 1.09 09027625 A Remove ankle joint lining 8.49 NA NA 7.16 7.02 1.31 09027626 A Remove ankle joint lining 9.10 NA NA 7.96 7.69 1.58 09027630 A Removal of tendon lesion 4.94 10.38 9.86 5.06 4.90 0.81 09027632 A Exc leg/ankle les sc > 3 cm 5.91 NA NA 5.25 5.25 1.17 09027634 A Exc leg/ankle tum deep >5 cm 10.13 NA NA 8.00 8.00 1.87 09027635 A Remove lower leg bone lesion 8.03 NA NA 7.97 7.64 1.55 09027637 A Remove/graft leg bone lesion 10.31 NA NA 10.15 9.63 2.09 09027638 A Remove/graft leg bone lesion 10.99 NA NA 9.69 9.38 2.25 09027640 A Partial removal of tibia 12.24 NA NA 10.50 10.30 2.29 090CMS-1503-P871**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**27641 A Partial removal of fibula 9.84 NA NA 8.32 8.21 1.74 09027645 A Resect tibia tumor 27.21 NA NA 20.59 16.35 5.57 09027646 A Resect fibula tumor 23.21 NA NA 18.25 14.43 4.75 09027647 A Resect talus/calcaneus tum 20.26 NA NA 10.73 9.36 2.11 09027648 A Injection for ankle x-ray 0.96 3.54 3.57 0.48 0.45 0.13 00027650 A Repair achilles tendon 9.21 NA NA 8.97 8.64 1.57 09027652 A Repair/graft achilles tendon 10.78 NA NA 8.43 8.36 1.57 09027654 A Repair of achilles tendon 10.53 NA NA 8.99 8.63 1.57 09027656 A Repair leg fascia defect 4.71 12.33 11.05 5.90 5.18 0.95 09027658 A Repair of leg tendon, each 5.12 NA NA 5.18 5.04 0.81 09027659 A Repair of leg tendon, each 7.10 NA NA 6.31 6.12 1.03 09027664 A Repair of leg tendon, each 4.73 NA NA 5.27 5.06 0.78 09027665 A Repair of leg tendon, each 5.57 NA NA 5.59 5.48 0.92 09027675 A Repair lower leg tendons 7.35 NA NA 6.07 5.98 1.06 09027676 A Repair lower leg tendons 8.73 NA NA 7.95 7.66 1.77 09027680 A Release of lower leg tendon 5.88 NA NA 5.92 5.67 1.02 09027681 A Release of lower leg tendons 7.05 NA NA 7.57 6.97 1.44 09027685 A Revision of lower leg tendon 6.69 11.58 10.80 6.11 5.95 0.95 09027686 A Revise lower leg tendons 7.75 NA NA 7.30 7.09 1.34 09027687 A Revision of calf tendon 6.41 NA NA 6.08 5.87 1.03 09027690 A Revise lower leg tendon 9.17 NA NA 8.38 7.94 1.37 09027691 A Revise lower leg tendon 10.49 NA NA 9.94 9.48 1.89 09027692 A Revise additional leg tendon 1.87 NA NA 1.03 0.99 0.35 ZZZ27695 A Repair of ankle ligament 6.70 NA NA 6.37 6.28 1.12 09027696 A Repair of ankle ligaments 8.58 NA NA 6.89 6.77 1.20 09027698 A Repair of ankle ligament 9.61 NA NA 7.94 7.70 1.57 090CMS-1503-P872**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**27700 A Revision of ankle joint 9.66 NA NA 6.69 6.57 1.24 09027702 A Reconstruct ankle joint 14.42 NA NA 11.88 11.55 2.76 09027703 A Reconstruction, ankle joint 16.94 NA NA 13.44 13.05 3.31 09027704 A Removal of ankle implant 7.81 NA NA 7.82 7.36 1.47 09027705 A Incision of tibia 10.86 NA NA 9.73 9.31 2.09 09027707 A Incision of fibula 4.78 NA NA 6.19 5.89 0.93 09027709 A Incision of tibia & fibula 17.48 NA NA 14.29 13.01 3.50 09027712 A Realignment of lower leg 15.87 NA NA 13.76 13.04 3.26 09027715 A Revision of lower leg 15.50 NA NA 12.71 12.30 3.19 09027720 A Repair of tibia 12.36 NA NA 11.14 10.71 2.49 09027722 A Repair/graft of tibia 12.45 NA NA 11.40 10.75 2.53 09027724 A Repair/graft of tibia 19.31 NA NA 14.74 14.12 3.94 09027725 A Repair of lower leg 17.41 NA NA 15.30 14.44 3.57 09027726 A Repair fibula nonunion 14.34 NA NA 11.83 10.67 2.88 09027727 A Repair of lower leg 14.84 NA NA 12.93 11.43 3.05 09027730 A Repair of tibia epiphysis 7.70 NA NA 7.98 7.59 1.58 09027732 A Repair of fibula epiphysis 5.46 NA NA 6.51 5.74 1.12 09027734 A Repair lower leg epiphyses 8.83 NA NA 8.72 7.60 0.65 09027740 A Repair of leg epiphyses 9.61 NA NA 6.63 6.97 1.96 09027742 A Repair of leg epiphyses 10.63 NA NA 8.77 7.91 2.16 09027745 A Reinforce tibia 10.49 NA NA 9.68 9.31 2.12 09027750 A Treatment of tibia fracture 3.37 5.87 5.61 5.11 4.83 0.66 09027752 A Treatment of tibia fracture 6.27 8.16 7.80 7.06 6.73 1.26 09027756 A Treatment of tibia fracture 7.45 NA NA 7.94 7.58 1.51 09027758 A Treatment of tibia fracture 12.54 NA NA 11.37 10.82 2.54 09027759 A Treatment of tibia fracture 14.45 NA NA 12.34 11.80 2.95 090CMS-1503-P873**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**27760 A Cltx medial ankle fx 3.21 5.74 5.49 4.96 4.68 0.61 09027762 A Cltx med ankle fx w/mnpj 5.47 7.40 7.15 6.30 6.08 1.05 09027766 A Optx medial ankle fx 7.89 NA NA 8.55 8.19 1.57 09027767 A Cltx post ankle fx 2.64 4.94 4.56 4.98 4.60 0.52 09027768 A Cltx post ankle fx w/mnpj 5.14 NA NA 6.63 5.98 1.06 09027769 A Optx post ankle fx 10.14 NA NA 9.60 8.63 2.06 09027780 A Treatment of fibula fracture 2.83 5.33 5.05 4.60 4.29 0.55 09027781 A Treatment of fibula fracture 4.59 6.81 6.49 5.99 5.67 0.90 09027784 A Treatment of fibula fracture 9.67 NA NA 9.63 8.97 1.95 09027786 A Treatment of ankle fracture 3.02 5.47 5.23 4.66 4.39 0.57 09027788 A Treatment of ankle fracture 4.64 6.70 6.45 5.74 5.50 0.88 09027792 A Treatment of ankle fracture 9.71 NA NA 9.54 8.98 1.91 09027808 A Treatment of ankle fracture 3.03 5.90 5.65 5.00 4.73 0.58 09027810 A Treatment of ankle fracture 5.32 7.24 7.01 6.12 5.92 1.05 09027814 A Treatment of ankle fracture 10.62 NA NA 10.17 9.75 2.12 09027816 A Treatment of ankle fracture 3.07 5.47 5.17 4.60 4.30 0.57 09027818 A Treatment of ankle fracture 5.69 7.14 6.95 5.86 5.70 1.09 09027822 A Treatment of ankle fracture 11.21 NA NA 11.46 11.14 2.25 09027823 A Treatment of ankle fracture 13.16 NA NA 12.59 12.18 2.64 09027824 A Treat lower leg fracture 3.31 5.06 4.83 4.82 4.55 0.64 09027825 A Treat lower leg fracture 6.69 7.95 7.64 6.59 6.32 1.33 09027826 A Treat lower leg fracture 11.10 NA NA 11.46 10.87 2.22 09027827 A Treat lower leg fracture 14.79 NA NA 14.37 13.84 3.01 09027828 A Treat lower leg fracture 18.43 NA NA 16.45 15.76 3.73 09027829 A Treat lower leg joint 8.80 NA NA 9.63 9.06 1.75 09027830 A Treat lower leg dislocation 3.96 6.23 5.71 5.53 5.04 0.79 090CMS-1503-P874**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**27831 A Treat lower leg dislocation 4.73 NA NA 5.97 5.51 0.95 09027832 A Treat lower leg dislocation 10.17 NA NA 10.09 9.18 2.06 09027840 A Treat ankle dislocation 4.77 NA NA 4.82 4.59 0.86 09027842 A Treat ankle dislocation 6.46 NA NA 6.90 6.46 1.26 09027846 A Treat ankle dislocation 10.28 NA NA 9.47 9.11 2.02 09027848 A Treat ankle dislocation 11.68 NA NA 10.30 10.06 2.33 09027860 A Fixation of ankle joint 2.39 NA NA 2.32 2.28 0.41 01027870 A Fusion of ankle joint, open 15.41 NA NA 12.66 12.17 2.91 09027871 A Fusion of tibiofibular joint 9.54 NA NA 9.07 8.70 1.92 09027880 A Amputation of lower leg 15.37 NA NA 9.43 8.92 3.45 09027881 A Amputation of lower leg 13.47 NA NA 10.11 9.83 2.91 09027882 A Amputation of lower leg 9.79 NA NA 6.66 6.56 2.23 09027884 A Amputation follow-up surgery 8.76 NA NA 6.93 6.68 1.94 09027886 A Amputation follow-up surgery 10.02 NA NA 7.82 7.56 2.22 09027888 A Amputation of foot at ankle 10.37 NA NA 8.07 8.01 2.01 09027889 A Amputation of foot at ankle 10.86 NA NA 7.07 6.98 2.50 09027892 A Decompression of leg 7.94 NA NA 6.94 6.56 1.70 09027893 A Decompression of leg 7.90 NA NA 8.41 7.43 1.74 09027894 A Decompression of leg 12.67 NA NA 10.30 9.82 2.77 09027899 C Leg/ankle surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY28001 A Drainage of bursa of foot 2.78 4.91 4.66 1.95 1.99 0.24 01028002 A Treatment of foot infection 5.93 8.40 7.92 4.52 4.44 0.69 01028003 A Treatment of foot infection 9.06 9.65 9.24 5.68 5.70 1.10 09028005 A Treat foot bone lesion 9.44 NA NA 7.03 6.93 1.06 09028008 A Incision of foot fascia 4.59 7.52 7.13 3.63 3.61 0.42 09028010 A Incision of toe tendon 2.97 3.58 3.41 2.93 2.86 0.28 090CMS-1503-P875**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**28011 A Incision of toe tendons 4.28 4.97 4.69 3.97 3.85 0.51 09028020 A Exploration of foot joint 5.15 9.70 9.01 4.77 4.62 0.69 09028022 A Exploration of foot joint 4.81 8.58 8.11 4.11 4.11 0.51 09028024 A Exploration of toe joint 4.52 8.13 7.74 3.86 3.91 0.44 09028035 A Decompression of tibia nerve 5.23 9.30 8.81 4.56 4.52 0.68 09028039 A Exc foot/toe tum sc > 1.5 cm 5.42 8.21 8.21 3.98 3.98 0.57 09028041 A Exc foot/toe tum deep >1.5cm 7.13 NA NA 5.20 5.20 0.76 09028043 A Exc foot/toe tum sc < 1.5 cm 3.96 7.38 6.38 3.47 3.43 0.41 09028045 A Exc foot/toe tum deep <1.5cm 5.45 8.72 8.28 4.47 4.24 0.58 09028046 A Resect foot/toe tumor <3 cm 12.38 NA NA 8.42 7.79 1.72 09028047 A Resect foot/toe tumor >3 cm 17.45 NA NA 8.45 8.45 1.38 09028050 A Biopsy of foot joint lining 4.39 7.59 7.58 3.51 3.76 0.41 09028052 A Biopsy of foot joint lining 4.06 7.91 7.46 3.61 3.60 0.51 09028054 A Biopsy of toe joint lining 3.57 7.01 6.95 3.07 3.26 0.28 09028055 A Neurectomy, foot 6.29 NA NA 4.35 4.30 0.55 09028060 A Partial removal, foot fascia 5.40 9.03 8.48 4.52 4.43 0.57 09028062 A Removal of foot fascia 6.69 9.78 9.34 4.75 4.69 0.62 09028070 A Removal of foot joint lining 5.24 9.70 8.83 4.69 4.47 0.58 09028072 A Removal of foot joint lining 4.72 9.60 9.00 4.59 4.58 0.66 09028080 A Removal of foot lesion 4.86 9.68 8.98 5.30 5.06 0.49 09028086 A Excise foot tendon sheath 4.92 10.04 9.60 4.92 4.83 0.75 09028088 A Excise foot tendon sheath 3.98 9.60 8.82 4.47 4.29 0.57 09028090 A Removal of foot lesion 4.55 8.56 8.04 4.02 3.95 0.49 09028092 A Removal of toe lesions 3.78 8.18 7.70 3.79 3.75 0.41 09028100 A Removal of ankle/heel lesion 5.83 10.59 10.14 5.31 5.20 0.79 09028102 A Remove/graft foot lesion 7.92 NA NA 8.32 7.63 0.64 090CMS-1503-P876**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**28103 A Remove/graft foot lesion 6.67 NA NA 4.39 4.84 0.52 09028104 A Removal of foot lesion 5.26 9.04 8.52 4.33 4.30 0.57 09028106 A Remove/graft foot lesion 7.35 NA NA 4.76 4.99 0.58 09028107 A Remove/graft foot lesion 5.73 8.85 8.94 4.11 4.40 0.44 09028108 A Removal of toe lesions 4.30 7.97 7.46 3.73 3.68 0.40 09028110 A Part removal of metatarsal 4.22 8.69 8.17 3.83 3.76 0.42 09028111 A Part removal of metatarsal 5.15 9.06 8.65 4.13 4.07 0.62 09028112 A Part removal of metatarsal 4.63 9.12 8.62 4.13 4.06 0.54 09028113 A Part removal of metatarsal 6.11 10.59 9.92 5.85 5.64 0.65 09028114 A Removal of metatarsal heads 12.00 17.65 16.56 11.06 10.55 1.71 09028116 A Revision of foot 9.14 11.97 11.12 6.76 6.51 0.99 09028118 A Removal of heel bone 6.13 10.26 9.64 5.26 5.13 0.78 09028119 A Removal of heel spur 5.56 9.11 8.54 4.50 4.40 0.55 09028120 A Part removal of ankle/heel 8.27 11.86 10.61 6.83 5.87 1.19 09028122 A Partial removal of footbone 7.72 10.51 10.05 6.05 5.97 0.85 09028124 A Partial removal of toe 5.00 8.41 7.94 4.27 4.23 0.44 09028126 A Partial removal of toe 3.64 7.43 6.98 3.30 3.29 0.35 09028130 A Removal of ankle bone 9.50 NA NA 10.03 8.73 1.94 09028140 A Removal of metatarsal 7.14 9.71 9.42 5.16 5.16 0.93 09028150 A Removal of toe 4.23 7.98 7.51 3.74 3.69 0.44 09028153 A Partial removal of toe 3.80 7.83 7.30 3.64 3.51 0.38 09028160 A Partial removal of toe 3.88 7.98 7.47 3.69 3.66 0.40 09028171 A Resect tarsal tumor 16.41 NA NA 7.61 6.96 1.30 09028173 A Resect metatarsal tumor 14.16 NA NA 7.36 6.55 1.62 09028175 A Resect phalanx of toe tumor 8.29 NA NA 5.49 4.93 0.83 09028190 A Removal of foot foreign body 2.01 5.11 4.84 1.72 1.68 0.21 010CMS-1503-P877**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**28192 A Removal of foot foreign body 4.78 8.45 7.99 4.02 3.98 0.51 09028193 A Removal of foot foreign body 5.90 9.05 8.59 4.47 4.44 0.58 09028200 A Repair of foot tendon 4.74 8.62 8.11 4.03 3.99 0.47 09028202 A Repair/graft of foot tendon 7.07 9.36 9.21 4.68 4.79 0.66 09028208 A Repair of foot tendon 4.51 8.58 7.98 4.09 3.97 0.51 09028210 A Repair/graft of foot tendon 6.52 9.44 9.01 4.84 4.78 0.66 09028220 A Release of foot tendon 4.67 7.93 7.48 3.77 3.77 0.42 09028222 A Release of foot tendons 5.76 8.61 8.13 4.12 4.16 0.52 09028225 A Release of foot tendon 3.78 7.42 6.95 3.33 3.28 0.37 09028226 A Release of foot tendons 4.67 7.78 7.68 3.59 3.84 0.37 09028230 A Incision of foot tendon(s) 4.36 7.74 7.32 3.52 3.59 0.41 09028232 A Incision of toe tendon 3.51 7.48 7.04 3.36 3.37 0.35 09028234 A Incision of foot tendon 3.54 8.03 7.52 3.90 3.83 0.37 09028238 A Revision of foot tendon 7.96 10.91 10.27 5.70 5.57 0.89 09028240 A Release of big toe 4.48 7.83 7.46 3.60 3.67 0.45 09028250 A Revision of foot fascia 6.06 9.88 9.20 5.04 4.90 0.79 09028260 A Release of midfoot joint 8.19 11.31 10.33 6.24 5.94 1.07 09028261 A Revision of foot tendon 13.11 13.88 13.02 8.26 8.11 1.33 09028262 A Revision of foot and ankle 17.21 20.54 19.24 13.19 12.68 3.12 09028264 A Release of midfoot joint 10.65 16.54 14.29 9.95 8.94 0.85 09028270 A Release of foot contracture 4.93 8.90 8.25 4.43 4.32 0.52 09028272 A Release of toe joint, each 3.92 7.17 6.77 3.23 3.22 0.32 09028280 A Fusion of toes 5.33 9.16 8.76 4.44 4.49 0.62 09028285 A Repair of hammertoe 4.76 8.51 7.95 4.24 4.13 0.47 09028286 A Repair of hammertoe 4.70 8.17 7.66 3.80 3.75 0.41 09028288 A Partial removal of footbone 6.02 11.10 10.23 6.09 5.87 0.69 090CMS-1503-P878**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**28289 A Repair hallux rigidus 8.31 12.20 11.47 6.95 6.73 1.05 09028290 A Correction of bunion 5.83 10.57 9.83 5.14 5.05 0.72 09028292 A Correction of bunion 9.05 13.15 12.29 7.83 7.51 0.90 09028293 A Correction of bunion 11.48 17.93 16.94 8.52 8.26 0.99 09028294 A Correction of bunion 8.75 11.46 11.04 5.72 5.72 0.96 09028296 A Correction of bunion 8.35 11.70 11.20 6.27 6.20 0.79 09028297 A Correction of bunion 9.43 13.36 12.67 6.83 6.77 1.23 09028298 A Correction of bunion 8.13 12.02 11.24 5.95 5.81 0.90 09028299 A Correction of bunion 11.57 13.50 12.79 7.32 7.19 1.19 09028300 A Incision of heel bone 9.73 NA NA 8.25 7.97 1.67 09028302 A Incision of ankle bone 9.74 NA NA 9.42 8.51 1.99 09028304 A Incision of midfoot bones 9.41 12.98 12.03 7.01 6.73 1.26 09028305 A Incise/graft midfoot bones 10.77 NA NA 7.50 7.56 0.85 09028306 A Incision of metatarsal 6.00 11.15 10.40 5.22 5.03 0.86 09028307 A Incision of metatarsal 6.50 12.25 12.19 5.81 5.82 1.33 09028308 A Incision of metatarsal 5.48 10.22 9.50 4.95 4.76 0.64 09028309 A Incision of metatarsals 14.16 NA NA 10.42 9.81 2.18 09028310 A Revision of big toe 5.57 9.63 9.01 4.36 4.25 0.57 09028312 A Revision of toe 4.69 9.41 8.81 4.13 4.08 0.52 09028313 A Repair deformity of toe 5.15 9.60 8.95 4.81 4.83 0.72 09028315 A Removal of sesamoid bone 5.00 8.35 7.84 4.01 3.94 0.51 09028320 A Repair of foot bones 9.37 NA NA 7.35 7.23 1.44 09028322 A Repair of metatarsals 8.53 13.11 12.29 7.28 7.01 1.36 09028340 A Resect enlarged toe tissue 7.15 9.22 9.04 4.53 4.66 0.57 09028341 A Resect enlarged toe 8.72 10.28 9.93 5.19 5.26 0.69 09028344 A Repair extra toe(s) 4.40 7.71 7.96 3.58 3.88 0.35 090CMS-1503-P879**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**28345 A Repair webbed toe(s)6.09 8.68 8.76 4.22 4.58 0.47 09028360 A Reconstruct cleft foot 14.92 NA NA 14.15 12.26 3.31 09028400 A Treatment of heel fracture 2.31 4.44 4.26 3.86 3.69 0.38 09028405 A Treatment of heel fracture 4.74 6.10 5.72 5.10 4.86 0.68 09028406 A Treatment of heel fracture 6.56 NA NA 7.65 7.40 1.22 09028415 A Treat heel fracture 16.19 NA NA 14.09 13.73 2.94 09028420 A Treat/graft heel fracture 17.52 NA NA 16.11 14.81 3.59 09028430 A Treatment of ankle fracture 2.22 4.16 3.96 3.45 3.25 0.37 09028435 A Treatment of ankle fracture 3.54 6.13 5.42 5.09 4.57 0.72 09028436 A Treatment of ankle fracture 4.90 NA NA 7.14 6.70 1.02 09028445 A Treat ankle fracture 15.76 NA NA 12.81 12.39 2.88 09028446 A Osteochondral talus autogrft 17.71 NA NA 15.13 13.99 3.63 09028450 A Treat midfoot fracture,each 2.03 3.85 3.68 3.20 3.05 0.31 09028455 A Treat midfoot fracture,each 3.24 4.82 4.57 4.01 3.89 0.45 09028456 A Treat midfoot fracture 2.86 NA NA 5.94 5.21 0.58 09028465 A Treat midfoot fracture, each 8.80 NA NA 7.93 7.64 1.31 09028470 A Treat metatarsal fracture 2.03 3.72 3.59 3.15 3.01 0.34 09028475 A Treat metatarsal fracture 3.01 4.04 3.92 3.25 3.23 0.40 09028476 A Treat metatarsal fracture 3.60 NA NA 5.92 5.69 0.55 09028485 A Treat metatarsal fracture 7.44 NA NA 7.27 6.96 0.99 09028490 A Treat big toe fracture 1.17 2.76 2.61 2.22 2.10 0.17 09028495 A Treat big toe fracture 1.68 3.25 3.05 2.47 2.38 0.21 09028496 A Treat big toe fracture 2.48 9.63 9.25 3.93 3.76 0.37 09028505 A Treat big toe fracture 7.44 11.18 10.58 6.43 5.99 0.96 09028510 A Treatment of toe fracture 1.17 2.20 2.07 2.11 2.00 0.14 09028515 A Treatment of toe fracture 1.56 2.87 2.70 2.35 2.27 0.18 090CMS-1503-P880**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**28525 A Treat toe fracture 5.62 10.26 9.73 5.48 5.13 0.73 09028530 A Treat sesamoid bone fracture 1.11 2.13 2.00 1.76 1.69 0.11 09028531 A Treat sesamoid bone fracture 2.57 7.10 7.22 2.57 2.55 0.52 09028540 A Treat foot dislocation 2.19 3.47 3.28 2.91 2.81 0.23 09028545 A Treat foot dislocation 2.60 5.35 4.61 4.43 3.87 0.52 09028546 A Treat foot dislocation 3.40 12.24 10.71 5.72 5.14 0.69 09028555 A Repair foot dislocation 9.65 14.27 13.56 8.46 8.02 1.67 09028570 A Treat foot dislocation 1.76 2.81 2.80 2.16 2.23 0.13 09028575 A Treat foot dislocation 3.49 6.31 5.72 5.36 4.93 0.71 09028576 A Treat foot dislocation 4.60 NA NA 6.01 5.32 0.93 09028585 A Repair foot dislocation 11.13 14.17 13.40 8.56 8.36 1.71 09028600 A Treat foot dislocation 2.02 4.02 3.77 3.17 3.04 0.30 09028605 A Treat foot dislocation 2.89 5.90 5.05 5.01 4.35 0.58 09028606 A Treat foot dislocation 5.09 NA NA 5.63 5.35 0.88 09028615 A Repair foot dislocation 10.70 NA NA 10.81 10.31 1.84 09028630 A Treat toe dislocation 1.75 2.48 2.29 1.23 1.18 0.24 01028635 A Treat toe dislocation 1.96 3.04 2.84 1.79 1.73 0.23 01028636 A Treat toe dislocation 2.77 4.36 4.60 1.96 2.25 0.41 01028645 A Repair toe dislocation 7.44 10.63 9.79 5.89 5.54 0.83 09028660 A Treat toe dislocation 1.28 1.79 1.67 1.08 1.02 0.21 01028665 A Treat toe dislocation 1.97 2.35 2.20 1.71 1.67 0.25 01028666 A Treat toe dislocation 2.66 NA NA 3.02 2.72 0.54 01028675 A Repair of toe dislocation 5.62 10.45 10.03 5.67 5.38 0.78 09028705 A Fusion of foot bones 20.33 NA NA 14.60 14.13 3.59 09028715 A Fusion of foot bones 14.60 NA NA 11.73 11.27 2.57 09028725 A Fusion of foot bones 12.18 NA NA 9.40 9.04 1.95 090CMS-1503-P881**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**28730 A Fusion of foot bones 12.42 NA NA 10.66 10.17 1.99 09028735 A Fusion of foot bones 12.23 NA NA 9.52 9.15 1.85 09028737 A Revision of foot bones 11.03 NA NA 7.63 7.62 1.33 09028740 A Fusion of foot bones 9.29 14.33 13.64 8.01 7.70 1.41 09028750 A Fusion of big toe joint 8.57 14.23 13.73 7.89 7.64 1.36 09028755 A Fusion of big toe joint 4.88 9.21 8.76 4.25 4.20 0.54 09028760 A Fusion of big toe joint 9.14 13.12 12.21 7.06 6.78 1.09 09028800 A Amputation of midfoot 8.79 NA NA 6.49 6.39 1.36 09028805 A Amputation thru metatarsal 12.71 NA NA 7.75 7.44 2.22 09028810 A Amputation toe & metatarsal 6.64 NA NA 5.32 5.18 1.23 09028820 A Amputation of toe 5.00 9.51 9.28 4.51 4.42 0.76 09028825 A Partial amputation of toe 6.01 10.16 9.72 5.27 5.02 0.88 09028890 A High energy eswt, plantar f 3.45 6.12 5.95 2.98 2.79 0.37 09028899 C Foot/toes surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY29000 A Application of body cast 2.25 6.82 5.82 2.70 2.41 0.18 00029010 A Application of body cast 2.06 6.72 5.52 2.60 2.26 0.41 00029015 A Application of body cast 2.41 4.02 3.91 1.87 1.81 0.42 00029020 A Application of body cast 2.11 3.81 3.84 1.49 1.55 0.08 00029025 A Application of body cast 2.40 4.15 4.22 1.93 2.01 0.49 00029035 A Application of body cast 1.77 5.10 4.86 2.10 1.99 0.35 00029040 A Application of body cast 2.22 4.34 4.06 1.95 1.85 0.44 00029044 A Application of body cast 2.12 5.59 5.16 2.40 2.24 0.42 00029046 A Application of body cast 2.41 4.43 4.72 2.00 2.20 0.49 00029049 A Application of figure eight 0.89 1.76 1.55 0.99 0.83 0.18 00029055 A Application of shoulder cast 1.78 4.19 3.90 1.94 1.81 0.37 00029058 A Application of shoulder cast 1.31 1.20 1.36 0.77 0.78 0.24 000CMS-1503-P882**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**29065 A Application of long arm cast 0.87 1.70 1.63 0.97 0.92 0.17 00029075 A Application of forearm cast 0.77 1.65 1.57 0.91 0.86 0.14 00029085 A Apply hand/wrist cast 0.87 1.70 1.61 0.96 0.89 0.14 00029086 A Apply finger cast 0.62 1.51 1.38 0.79 0.72 0.08 00029105 A Apply long arm splint 0.87 1.45 1.40 0.73 0.69 0.14 00029125 A Apply forearm splint 0.59 1.29 1.23 0.59 0.55 0.10 00029126 A Apply forearm splint 0.77 1.38 1.31 0.68 0.63 0.11 00029130 A Application of finger splint 0.50 0.60 0.56 0.28 0.25 0.07 00029131 A Application of finger splint 0.55 0.86 0.82 0.36 0.33 0.08 00029200 A Strapping of chest 0.65 0.85 0.80 0.49 0.45 0.06 00029240 A Strapping of shoulder 0.71 0.86 0.85 0.51 0.48 0.06 00029260 A Strapping of elbow or wrist 0.55 0.88 0.84 0.50 0.46 0.06 00029280 A Strapping of hand or finger 0.51 0.89 0.86 0.51 0.46 0.04 00029305 A Application of hip cast 2.03 4.61 4.32 2.25 2.13 0.41 00029325 A Application of hip casts 2.32 5.02 4.72 2.48 2.36 0.47 00029345 A Application of long leg cast 1.40 2.24 2.14 1.31 1.25 0.28 00029355 A Application of long leg cast 1.53 2.28 2.14 1.36 1.29 0.30 00029358 A Apply long leg cast brace 1.43 2.87 2.68 1.36 1.28 0.30 00029365 A Application of long leg cast 1.18 2.12 2.02 1.18 1.14 0.24 00029405 A Apply short leg cast 0.86 1.57 1.50 0.88 0.84 0.13 00029425 A Apply short leg cast 1.01 1.59 1.52 0.86 0.84 0.13 00029435 A Apply short leg cast 1.18 1.99 1.92 1.09 1.06 0.24 00029440 A Addition of walker tocast 0.57 0.65 0.72 0.24 0.28 0.08 00029445 A Apply rigid leg cast 1.78 2.03 1.99 1.17 1.13 0.25 00029450 A Application of leg cast 2.08 1.88 1.85 1.05 1.08 0.23 00029505 A Application, long leg splint 0.69 1.42 1.36 0.62 0.58 0.11 000CMS-1503-P883**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**29515 A Application lower leg splint 0.73 1.26 1.19 0.62 0.59 0.10 00029520 A Strapping of hip 0.54 0.84 0.82 0.47 0.46 0.04 00029530 A Strapping of knee 0.57 0.88 0.84 0.49 0.46 0.06 00029540 A Strapping of ankle and/or ft 0.51 0.67 0.64 0.37 0.37 0.04 00029550 A Strapping of toes 0.47 0.69 0.65 0.36 0.36 0.04 00029580 A Application of paste boot 0.55 0.90 0.87 0.44 0.42 0.07 00029581 A Apply multlay comprs lwrleg 0.60 2.00 2.00 0.27 0.27 0.07 00029590 A Application of foot splint 0.76 0.73 0.70 0.31 0.32 0.06 00029700 A Removal/revision of cast 0.57 1.22 1.17 0.35 0.34 0.10 00029705 A Removal/revision of cast 0.76 1.05 1.00 0.52 0.49 0.13 00029710 A Removal/revision of cast 1.34 1.97 1.82 0.91 0.83 0.28 00029715 A Removal/revision of cast 0.94 1.28 1.35 0.52 0.52 0.13 00029720 A Repair of body cast 0.68 1.57 1.48 0.50 0.47 0.13 00029730 A Windowing of cast 0.75 1.01 0.96 0.48 0.45 0.11 00029740 A Wedging of cast 1.12 1.27 1.26 0.58 0.58 0.18 00029750 A Wedging of clubfoot cast 1.26 1.43 1.37 0.76 0.73 0.27 00029799 C Casting/strapping procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY29800 A Jaw arthroscopy/surgery 6.84 NA NA 7.33 6.98 1.38 09029804 A Jaw arthroscopy/surgery 8.87 NA NA 9.01 8.34 1.81 09029805 A Shoulder arthroscopy, dx 6.03 NA NA 6.62 6.35 1.23 09029806 A Shoulder arthroscopy/surgery 15.14 NA NA 13.30 12.73 3.09 09029807 A Shoulder arthroscopy/surgery 14.67 NA NA 13.13 12.55 2.98 09029819 A Shoulder arthroscopy/surgery 7.79 NA NA 7.96 7.63 1.58 09029820 A Shoulder arthroscopy/surgery 7.21 NA NA 7.26 6.98 1.46 09029821 A Shoulder arthroscopy/surgery 7.89 NA NA 7.94 7.63 1.61 09029822 A Shoulder arthroscopy/surgery 7.60 NA NA 7.79 7.49 1.55 090CMS-1503-P884**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**29823 A Shoulder arthroscopy/surgery 8.36 NA NA 8.44 8.12 1.70 09029824 A Shoulder arthroscopy/surgery 8.98 NA NA 9.11 8.73 1.84 09029825 A Shoulder arthroscopy/surgery 7.79 NA NA 7.90 7.59 1.58 09029826 A Shoulder arthroscopy/surgery 9.16 NA NA 8.68 8.36 1.87 09029827 A Arthroscop rotator cuff repr 15.59 NA NA 13.22 12.73 3.19 09029828 A Arthroscopy biceps tenodesis 13.16 NA NA 11.56 10.88 2.68 09029830 A Elbow arthroscopy 5.88 NA NA 6.31 6.04 1.22 09029834 A Elbow arthroscopy/surgery 6.42 NA NA 6.85 6.57 1.27 09029835 A Elbow arthroscopy/surgery 6.62 NA NA 6.98 6.69 1.34 09029836 A Elbow arthroscopy/surgery 7.72 NA NA 7.92 7.60 1.58 09029837 A Elbow arthroscopy/surgery 7.01 NA NA 7.20 6.91 1.41 09029838 A Elbow arthroscopy/surgery 7.88 NA NA 8.05 7.71 1.55 09029840 A Wrist arthroscopy 5.68 NA NA 6.43 6.16 1.17 09029843 A Wrist arthroscopy/surgery 6.15 NA NA 6.82 6.53 1.26 09029844 A Wrist arthroscopy/surgery 6.51 NA NA 7.02 6.65 1.23 09029845 A Wrist arthroscopy/surgery 7.69 NA NA 7.97 7.50 1.43 09029846 A Wrist arthroscopy/surgery 6.89 NA NA 7.29 6.92 1.27 09029847 A Wrist arthroscopy/surgery 7.22 NA NA 7.33 7.04 1.47 09029848 A Wrist endoscopy/surgery 6.39 NA NA 7.49 7.02 1.22 09029850 A Knee arthroscopy/surgery 8.27 NA NA 8.45 7.39 1.68 09029851 A Knee arthroscopy/surgery 13.26 NA NA 11.74 11.20 2.71 09029855 A Tibial arthroscopy/surgery 10.76 NA NA 10.32 9.89 2.20 09029856 A Tibial arthroscopy/surgery 14.28 NA NA 12.44 11.92 2.94 09029860 A Hip arthroscopy, dx 9.00 NA NA 8.88 8.33 1.85 09029861 A Hip arthroscopy/surgery 10.10 NA NA 9.52 8.96 2.05 09029862 A Hip arthroscopy/surgery 11.17 NA NA 10.80 10.24 2.27 090CMS-1503-P885**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**29863 A Hip arthroscopy/surgery 11.17 NA NA 10.76 10.17 2.29 09029866 A Autgrft implnt, knee w/scope 14.67 NA NA 13.47 12.82 3.02 09029867 A Allgrft implnt, knee w/scope 18.39 NA NA 15.92 15.01 3.76 09029868 A Meniscal trnspl, knee w/scpe 25.10 NA NA 19.84 18.76 5.14 09029870 A Knee arthroscopy, dx 5.19 10.54 10.54 5.89 5.62 1.06 09029871 A Knee arthroscopy/drainage 6.69 NA NA 7.11 6.79 1.36 09029873 A Knee arthroscopy/surgery 6.24 NA NA 7.84 7.49 1.27 09029874 A Knee arthroscopy/surgery 7.19 NA NA 7.29 6.96 1.46 09029875 A Knee arthroscopy/surgery 6.45 NA NA 6.86 6.58 1.31 09029876 A Knee arthroscopy/surgery 8.87 NA NA 8.78 8.33 1.81 09029877 A Knee arthroscopy/surgery 8.30 NA NA 8.44 8.02 1.68 09029879 A Knee arthroscopy/surgery 8.99 NA NA 8.83 8.40 1.84 09029880 A Knee arthroscopy/surgery 9.45 NA NA 9.11 8.67 1.92 09029881 A Knee arthroscopy/surgery 8.71 NA NA 8.68 8.25 1.77 09029882 A Knee arthroscopy/surgery 9.60 NA NA 9.17 8.69 1.96 09029883 A Knee arthroscopy/surgery 11.77 NA NA 10.74 10.30 2.39 09029884 A Knee arthroscopy/surgery 8.28 NA NA 8.41 7.99 1.68 09029885 A Knee arthroscopy/surgery 10.21 NA NA 9.98 9.47 2.08 09029886 A Knee arthroscopy/surgery 8.49 NA NA 8.58 8.15 1.72 09029887 A Knee arthroscopy/surgery 10.16 NA NA 9.90 9.40 2.06 09029888 A Knee arthroscopy/surgery 14.30 NA NA 12.21 11.67 2.91 09029889 A Knee arthroscopy/surgery 17.41 NA NA 15.41 14.64 3.55 09029891 A Ankle arthroscopy/surgery 9.67 NA NA 9.06 8.72 1.71 09029892 A Ankle arthroscopy/surgery 10.27 NA NA 6.09 7.09 2.09 09029893 A Scope, plantar fasciotomy 6.32 10.85 10.24 5.70 5.51 0.52 09029894 A Ankle arthroscopy/surgery 7.35 NA NA 6.68 6.36 1.27 090CMS-1503-P886**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**29895 A Ankle arthroscopy/surgery 7.13 NA NA 6.26 6.03 1.17 09029897 A Ankle arthroscopy/surgery 7.32 NA NA 6.59 6.42 1.29 09029898 A Ankle arthroscopy/surgery 8.49 NA NA 7.11 6.88 1.34 09029899 A Ankle arthroscopy/surgery 15.41 NA NA 12.66 12.19 2.98 09029900 A Mcp joint arthroscopy, dx 5.88 NA NA 7.39 6.70 0.42 09029901 A Mcp joint arthroscopy, surg 6.59 NA NA 7.70 7.03 1.34 09029902 A Mcp joint arthroscopy, surg 7.16 NA NA 8.50 7.58 2.67 09029904 A Subtalar arthro w/fb rmvl 8.65 NA NA 8.46 7.90 1.75 09029905 A Subtalar arthro w/exc 9.18 NA NA 9.33 8.72 1.88 09029906 A Subtalar arthro w/deb 9.65 NA NA 9.85 9.19 1.96 09029907 A Subtalar arthro w/fusion 12.18 NA NA 11.33 10.58 2.49 09029999 C Arthroscopy of joint 0.00 0.00 0.00 0.00 0.00 0.00 YYY30000 A Drainage of nose lesion 1.48 5.02 4.94 1.86 1.76 0.23 01030020 A Drainage of nose lesion 1.48 5.12 4.89 1.90 1.79 0.21 0103008F I Body mass index docd 0.00 0.00 0.00 0.00 0.00 0.00 XXX30100 A Intranasal biopsy 0.94 3.10 2.99 1.00 0.97 0.11 00030110 A Removal of nose polyp(s) 1.68 4.86 4.67 2.02 1.91 0.24 01030115 A Removal of nose polyp(s) 4.44 NA NA 7.79 7.47 0.58 09030117 A Removal of intranasal lesion 3.26 21.57 20.83 6.32 6.07 0.42 09030118 A Removal of intranasal lesion 9.92 NA NA 11.74 11.16 1.36 09030120 A Revision of nose 5.39 9.09 8.81 6.85 6.72 0.88 09030124 A Removal of nose lesion 3.20 NA NA 4.57 4.33 0.42 09030125 A Removal of nose lesion 7.30 NA NA 9.95 9.56 0.96 09030130 A Excise inferior turbinate 3.47 NA NA 7.31 7.04 0.45 09030140 A Resect inferior turbinate 3.57 NA NA 8.92 8.58 0.47 09030150 A Partial removal of nose 9.55 NA NA 12.06 11.76 1.47 090CMS-1503-P887**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**3015F I Cerv cancer screen docd 0.00 0.00 0.00 0.00 0.00 0.00 XXX30160 A Removal of nose 9.99 NA NA 11.96 11.52 1.33 0903018F I Pre-prxd rsk et aldocd 0.00 0.00 0.00 0.00 0.00 0.00 XXX30200 A Injection treatment of nose 0.78 2.46 2.37 0.92 0.88 0.10 00030210 A Nasal sinus therapy 1.13 3.14 3.02 1.70 1.63 0.14 01030220 A Insert nasal septal button 1.59 7.04 6.76 1.97 1.87 0.23 01030300 A Remove nasal foreign body 1.09 5.42 5.32 2.47 2.36 0.14 01030310 A Remove nasal foreign body 2.01 NA NA 3.81 3.68 0.27 01030320 A Remove nasal foreign body 4.64 NA NA 8.17 7.88 0.62 0903038F I Pulm fx w/in 12 mon b/4 surg 0.00 0.00 0.00 0.00 0.00 0.00 XXX30400 R Reconstruction of nose 10.86 NA NA 17.73 17.49 1.44 09030410 R Reconstruction of nose 14.00 NA NA 19.54 19.21 1.87 09030420 R Reconstruction of nose 16.90 NA NA 21.71 20.80 2.49 09030430 R Revision of nose 8.24 NA NA 16.23 16.49 1.68 09030435 R Revision of nose 12.73 NA NA 21.85 20.74 1.70 09030450 R Revision of nose 19.66 NA NA 22.79 22.57 2.61 09030460 A Revision of nose 10.32 NA NA 10.36 10.04 2.09 09030462 A Revision of nose 20.28 NA NA 23.08 21.43 4.15 09030465 A Repair nasal stenosis 12.36 NA NA 15.35 14.55 1.81 09030520 A Repair of nasal septum 7.01 NA NA 10.70 10.01 0.93 09030540 A Repair nasal defect 7.92 NA NA 11.58 10.83 1.06 09030545 A Repair nasal defect 11.62 NA NA 12.04 12.86 0.85 09030560 A Release of nasal adhesions 1.31 6.39 6.27 2.61 2.54 0.18 01030580 A Repair upper jaw fistula 6.88 11.21 10.52 7.43 6.79 0.90 09030600 A Repair mouth/nose fistula 6.16 10.08 9.69 6.02 5.73 0.81 09030620 A Intranasal reconstruction 6.16 NA NA 11.35 10.95 0.92 090CMS-1503-P888**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**30630 A Repair nasal septum defect 7.29 NA NA 10.39 9.92 1.03 09030801 A Ablate inf turbinate, superf 1.14 5.31 5.22 2.73 2.62 0.14 01030802 A Ablate inf turbinate submuc 2.08 6.15 6.00 3.31 3.15 0.28 01030901 A Control of nosebleed 1.21 1.69 1.62 0.50 0.44 0.18 00030903 A Control of nosebleed 1.54 4.11 3.92 0.68 0.62 0.24 00030905 A Control of nosebleed 1.97 5.01 4.79 0.82 0.77 0.31 00030906 A Repeat control of nosebleed 2.45 5.42 5.23 1.27 1.19 0.34 00030915 A Ligation, nasal sinus artery 7.44 NA NA 8.88 8.40 1.03 09030920 A Ligation, upper jaw artery 11.14 NA NA 12.48 11.70 1.51 09030930 A Ther fx, nasal inf turbinate 1.31 NA NA 2.19 2.09 0.18 01030999 C Nasal surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY31000 A Irrigation, maxillary sinus 1.20 3.94 3.83 1.78 1.71 0.14 01031002 A Irrigation, sphenoid sinus 1.96 NA NA 3.67 3.60 0.27 01031020 A Exploration, maxillarysinus 3.07 10.53 10.40 7.01 6.79 0.41 09031030 A Exploration, maxillarysinus 6.01 13.39 13.14 8.78 8.35 0.78 09031032 A Explore sinus, remove polyps 6.69 NA NA 9.49 9.03 0.90 09031040 A Exploration behind upper jaw 9.77 NA NA 11.31 10.69 1.44 09031050 A Exploration, sphenoid sinus 5.37 NA NA 8.37 8.13 0.71 09031051 A Sphenoid sinus surgery 7.25 NA NA 11.04 10.55 0.95 09031070 A Exploration of frontal sinus 4.40 NA NA 8.03 7.71 0.61 09031075 A Exploration of frontal sinus 9.51 NA NA 12.63 12.07 1.27 09031080 A Removal of frontal sinus 12.74 NA NA 16.46 15.32 1.70 09031081 A Removal of frontal sinus 14.19 NA NA 23.58 20.88 5.28 09031084 A Removal of frontal sinus 14.95 NA NA 17.73 17.17 1.99 09031085 A Removal of frontal sinus 15.64 NA NA 18.13 17.75 5.84 09031086 A Removal of frontal sinus 14.36 NA NA 17.39 16.46 1.92 090CMS-1503-P889**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**31087 A Removal of frontal sinus 14.57 NA NA 16.07 15.36 1.94 09031090 A Exploration of sinuses 11.17 NA NA 17.81 16.87 1.53 09031200 A Removal of ethmoid sinus 5.14 NA NA 10.54 10.06 0.76 09031201 A Removal of ethmoid sinus 8.60 NA NA 12.28 11.62 1.19 09031205 A Removal of ethmoid sinus 10.58 NA NA 14.49 13.48 1.65 09031225 A Removal of upper jaw 26.70 NA NA 26.13 24.09 3.69 09031230 A Removal of upper jaw 30.82 NA NA 28.11 25.86 4.11 09031231 A Nasal endoscopy, dx 1.10 4.36 4.29 1.10 1.04 0.13 00031233 A Nasal/sinus endoscopy, dx 2.18 5.35 5.23 1.72 1.61 0.30 00031235 A Nasal/sinus endoscopy, dx 2.64 5.83 5.77 1.95 1.84 0.34 00031237 A Nasal/sinus endoscopy, surg 2.98 6.23 6.10 2.18 2.03 0.40 00031238 A Nasal/sinus endoscopy, surg 3.26 6.20 6.07 2.34 2.19 0.42 00031239 A Nasal/sinus endoscopy, surg 9.33 NA NA 9.99 9.22 1.29 01031240 A Nasal/sinus endoscopy, surg 2.61 NA NA 1.97 1.85 0.35 00031254 A Revision of ethmoid sinus 4.64 NA NA 3.15 2.93 0.62 00031255 A Removal of ethmoid sinus 6.95 NA NA 4.47 4.15 0.92 00031256 A Exploration maxillary sinus 3.29 NA NA 2.36 2.20 0.42 00031267 A Endoscopy, maxillary sinus 5.45 NA NA 3.60 3.35 0.72 00031276 A Sinus endoscopy, surgical 8.84 NA NA 5.55 5.14 1.19 00031287 A Nasal/sinus endoscopy, surg 3.91 NA NA 2.71 2.53 0.52 00031288 A Nasal/sinus endoscopy, surg 4.57 NA NA 3.10 2.89 0.62 00031290 A Nasal/sinus endoscopy, surg 18.61 NA NA 14.09 13.15 2.74 01031291 A Nasal/sinus endoscopy, surg 19.56 NA NA 14.79 13.77 3.26 01031292 A Nasal/sinus endoscopy, surg 15.90 NA NA 12.48 11.66 2.12 01031293 A Nasal/sinus endoscopy, surg 17.47 NA NA 13.44 12.54 2.32 01031294 A Nasal/sinus endoscopy, surg 20.31 NA NA 15.08 14.04 2.71 010CMS-1503-P890**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**31299 C Sinus surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY31300 A Removal of larynx lesion 15.91 NA NA 20.03 18.99 2.11 09031320 A Diagnostic incision, larynx 5.73 NA NA 12.91 12.52 0.7509031360 A Removal of larynx 29.91 NA NA 29.10 26.38 4.07 09031365 A Removal of larynx 38.81 NA NA 34.18 30.92 5.27 09031367 A Partial removal of larynx 30.57 NA NA 32.02 29.72 4.1309031368 A Partial removal of larynx 34.19 NA NA 35.23 32.80 4.5509031370 A Partial removal of larynx 27.57 NA NA 31.26 29.23 3.6709031375 A Partial removal of larynx 26.07 NA NA 29.77 27.77 3.4909031380 A Partial removal of larynx 25.57 NA NA 29.49 27.48 3.4209031382 A Partial removal of larynx 28.57 NA NA 31.84 29.58 3.8309031390 A Removal of larynx & pharynx 42.51 NA NA 37.97 34.79 6.06 09031395 A Reconstruct larynx & pharynx 43.80 NA NA 41.62 38.31 5.85 09031400 A Revision of larynx 11.60 NA NA 16.72 16.15 1.5509031420 A Removal of epiglottis11.43 NA NA 12.30 11.61 1.53 09031500 A Insert emergency airway 2.33 NA NA 0.62 0.59 0.32 00031502 A Change of windpipe airway 0.65 NA NA 0.33 0.31 0.07 00031505 A Diagnostic laryngoscopy 0.61 1.75 1.73 0.79 0.76 0.07 00031510 A Laryngoscopy with biopsy 1.92 4.04 3.97 1.50 1.42 0.27 00031511 A Remove foreign body, larynx 2.16 3.74 3.67 1.38 1.33 0.3200031512 A Removal of larynx lesion 2.07 3.85 3.74 1.66 1.54 0.28 00031513 A Injection into vocal cord 2.10 NA NA 1.67 1.57 0.28 00031515 A Laryngoscopy for aspiration 1.80 4.06 4.02 1.29 1.22 0.25 00031520 A Dx laryngoscopy, newborn 2.56 NA NA 1.94 1.76 0.34 00031525 A Dx laryngoscopy excl nb 2.63 4.50 4.36 1.91 1.79 0.35 00031526 A Dx laryngoscopy w/oper scope 2.57 NA NA 1.94 1.82 0.34 000CMS-1503-P891**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**31527 A Laryngoscopy for treatment 3.27 NA NA 2.35 2.13 0.42 00031528 A Laryngoscopy and dilation 2.37 NA NA 1.77 1.65 0.32 00031529 A Laryngoscopy and dilation 2.68 NA NA 1.95 1.83 0.35 00031530 A Laryngoscopy w/fb removal 3.38 NA NA 2.27 2.11 0.45 00031531 A Laryngoscopy w/fb & op scope 3.58 NA NA 2.50 2.34 0.47 00031535 A Laryngoscopy w/biopsy 3.16 NA NA 2.27 2.12 0.42 00031536 A Laryngoscopy w/bx & op scope 3.55 NA NA 2.51 2.34 0.47 00031540 A Laryngoscopy w/exc of tumor 4.12 NA NA 2.83 2.64 0.55 00031541 A Larynscop w/tumr exc + scope 4.52 NA NA 3.06 2.86 0.61 00031545 A Remove vc lesion w/scope 6.30 NA NA 4.12 3.80 0.83 00031546 A Remove vc lesion scope/graft 9.73 NA NA 6.11 5.53 1.30 00031560 A Laryngoscop w/arytenoidectom 5.45 NA NA 3.56 3.29 0.72 00031561 A Larynscop, remve cart + scop 5.99 NA NA 3.87 3.57 0.79 00031570 A Laryngoscope w/vc inj 3.86 5.74 5.67 2.65 2.47 0.55 00031571 A Laryngoscop w/vc inj + scope 4.26 NA NA 2.90 2.71 0.57 00031575 A Diagnostic laryngoscopy 1.10 2.16 2.13 1.09 1.03 0.13 00031576 A Laryngoscopy with biopsy 1.97 4.39 4.35 1.56 1.47 0.25 00031577 A Remove foreign body, larynx 2.47 4.40 4.29 1.73 1.64 0.3400031578 A Removal of larynx lesion 2.84 5.16 5.03 2.10 1.91 0.37 00031579 A Diagnostic laryngoscopy 2.26 3.74 3.74 1.76 1.65 0.31 00031580 A Revision of larynx 14.66 NA NA 20.07 18.98 1.9509031582 A Revision of larynx 23.22 NA NA 30.63 29.54 3.1109031584 A Treat larynx fracture 20.47 NA NA 22.41 21.22 2.73 09031587 A Revision of larynx 15.27 NA NA 13.26 12.13 2.0209031588 A Revision of larynx 14.99 NA NA 17.48 16.54 2.0109031590 A Reinnervate larynx 7.85 NA NA 17.45 17.12 1.06090CMS-1503-P892**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**31595 A Larynx nerve surgery 8.84 NA NA 12.87 12.41 1.19 09031599 C Larynx surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY31600 A Incision of windpipe 7.17 NA NA 3.58 3.37 1.31 00031601 A Incision of windpipe 4.44 NA NA 2.98 2.77 0.58 00031603 A Incision of windpipe 4.14 NA NA 1.97 1.83 0.72 00031605 A Incision of windpipe 3.57 NA NA 1.31 1.23 0.65 00031610 A Incision of windpipe 9.38 NA NA 10.71 10.14 1.37 09031611 A Surgery/speech prosthesis 6.00 NA NA 9.34 8.94 0.79 09031612 A Puncture/clear windpipe 0.91 1.40 1.35 0.43 0.39 0.11 00031613 A Repair windpipe opening 4.71 NA NA 7.95 7.66 0.75 09031614 A Repair windpipe opening 8.63 NA NA 12.77 12.06 1.23 09031615 A Visualization of windpipe 2.09 3.03 2.98 1.54 1.44 0.27 00031620 A Endobronchial us add-on 1.40 6.07 6.52 0.48 0.48 0.13 ZZZ31622 A Dx bronchoscope/wash 2.78 5.65 5.99 1.23 1.19 0.35 00031623 A Dx bronchoscope/brush2.88 6.07 6.62 1.20 1.17 0.27 00031624 A Dx bronchoscope/lavage2.88 5.56 5.99 1.22 1.18 0.27 00031625 A Bronchoscopy w/biopsy(s) 3.36 5.71 6.14 1.38 1.34 0.32 00031626 A Bronchoscopy w/markers 4.16 8.30 8.30 1.66 1.66 0.32 00031627 A Navigational bronchoscopy 2.00 34.63 34.63 0.86 0.86 0.14 ZZZ31628 A Bronchoscopy/lung bx,each 3.80 6.57 7.38 1.51 1.46 0.31 00031629 A Bronchoscopy/needle bx, each 4.09 12.03 13.39 1.62 1.56 0.35 00031630 A Bronchoscopy dilate/fx repr 3.81 NA NA 1.71 1.71 0.51 00031631 A Bronchoscopy, dilate w/stent 4.36 NA NA 1.92 1.89 0.62 00031632 A Bronchoscopy/lung bx, addl 1.03 0.95 0.98 0.36 0.34 0.07 ZZZ31633 A Bronchoscopy/needle bx addl 1.32 1.10 1.13 0.45 0.43 0.10 ZZZ31635 A Bronchoscopy w/fb removal 3.67 5.60 6.02 1.54 1.51 0.41 000CMS-1503-P893**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**31636 A Bronchoscopy, bronch stents 4.30 NA NA 1.77 1.78 0.58 00031637 A Bronchoscopy, stent add-on 1.58 NA NA 0.59 0.57 0.11 ZZZ31638 A Bronchoscopy, revise stent 4.88 NA NA 2.09 2.07 0.68 00031640 A Bronchoscopy w/tumor excise 4.93 NA NA 2.10 2.09 0.66 00031641 A Bronchoscopy, treat blockage 5.02 NA NA 2.10 2.03 0.61 00031643 A Diag bronchoscope/catheter 3.49 NA NA 1.39 1.36 0.30 00031645 A Bronchoscopy, clear airways 3.16 4.99 5.35 1.31 1.27 0.30 00031646 A Bronchoscopy, reclear airway 2.72 4.70 5.04 1.15 1.12 0.27 00031656 A Bronchoscopy, inj for x-ray 2.17 5.86 6.56 0.89 0.89 0.17 00031715 A Injection for bronchus x-ray 1.11 NA NA 0.35 0.37 0.08 00031717 A Bronchial brush biopsy 2.12 5.26 6.00 1.00 0.94 0.17 00031720 A Clearance of airways 1.06 NA NA 0.39 0.37 0.08 00031725 A Clearance of airways 1.96 NA NA 0.71 0.63 0.21 00031730 A Intro, windpipe wire/tube 2.85 28.92 26.09 1.16 1.10 0.47 00031750 A Repair of windpipe 15.39 NA NA 23.15 22.16 2.36 09031755 A Repair of windpipe 17.54 NA NA 31.53 30.45 2.33 09031760 A Repair of windpipe 23.48 NA NA 12.10 12.53 5.69 09031766 A Reconstruction of windpipe 31.67 NA NA 14.36 14.70 7.69 09031770 A Repair/graft of bronchus 23.54 NA NA 10.96 11.21 5.71 09031775 A Reconstruct bronchus 24.59 NA NA 10.05 10.77 5.98 09031780 A Reconstruct windpipe 19.84 NA NA 13.20 12.46 3.35 09031781 A Reconstruct windpipe 24.85 NA NA 10.97 11.93 6.03 09031785 A Remove windpipe lesion 18.35 NA NA 11.86 11.11 2.71 09031786 A Remove windpipe lesion 25.42 NA NA 11.93 12.78 6.19 09031800 A Repair of windpipe injury 8.18 NA NA 11.79 11.26 1.09 09031805 A Repair of windpipe injury 13.42 NA NA 7.77 8.02 3.28 090CMS-1503-P894**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**31820 A Closure of windpipe lesion 4.64 7.68 7.35 4.64 4.38 0.69 09031825 A Repair of windpipe defect 7.07 10.00 9.57 6.55 6.18 1.03 09031830 A Revise windpipe scar 4.62 7.79 7.45 5.00 4.74 0.73 09031899 C Airways surgical procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY32035 A Exploration of chest 11.29 NA NA 7.84 7.65 2.67 09032036 A Exploration of chest 12.30 NA NA 8.10 8.04 3.01 09032095 A Biopsy through chest wall 10.14 NA NA 6.47 6.46 2.43 09032100 A Exploration/biopsy of chest 16.16 NA NA 8.78 8.91 3.94 09032110 A Explore/repair chest 25.28 NA NA 13.03 12.84 5.96 09032120 A Re-exploration of chest 14.39 NA NA 8.47 8.53 3.53 09032124 A Explore chest free adhesions 15.45 NA NA 8.84 8.82 3.82 09032140 A Removal of lung lesion(s) 16.66 NA NA 9.22 9.26 4.04 09032141 A Remove/treat lung lesions 27.18 NA NA 12.77 12.51 6.64 09032150 A Removal of lung lesion(s) 16.82 NA NA 9.40 9.35 4.08 09032151 A Remove lung foreign body 16.94 NA NA 9.23 9.54 4.13 09032160 A Open chest heart massage 13.10 NA NA 7.38 7.24 3.11 09032200 A Drain, open, lung lesion 18.68 NA NA 11.20 11.04 4.45 09032201 A Drain, percut, lung lesion 3.99 20.33 22.22 1.39 1.60 0.40 00032215 A Treat chest lining 13.05 NA NA 7.90 7.99 3.17 09032220 A Release of lung 26.65 NA NA 14.91 15.10 6.54 09032225 A Partial release of lung 16.75 NA NA 9.33 9.35 4.07 09032310 A Removal of chest lining 15.28 NA NA 8.65 8.73 3.76 09032320 A Free/remove chest lining 27.25 NA NA 14.66 14.66 6.57 09032400 A Needle biopsy chest lining 1.76 2.20 2.40 0.61 0.67 0.18 00032402 A Open biopsy chest lining 8.97 NA NA 5.93 5.99 2.11 09032405 A Biopsy, lung or mediastinum 1.93 0.66 0.78 0.66 0.77 0.18 000CMS-1503-P895**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**32420 A Puncture/clear lung 2.18 NA NA 0.78 0.85 0.25 00032421 A Thoracentesis for aspiration 1.54 2.54 2.82 0.56 0.58 0.14 00032422 A Thoracentesis w/tube insert 2.19 3.00 3.29 1.14 1.23 0.23 00032440 A Removal of lung 27.28 NA NA 13.62 13.99 6.60 09032442 A Sleeve pneumonectomy 56.47 NA NA 22.74 22.33 4.41 09032445 A Removal of lung 63.84 NA NA 27.64 26.82 15.51 09032480 A Partial removal of lung 25.82 NA NA 12.91 13.18 6.29 09032482 A Bilobectomy 27.44 NA NA 14.04 14.31 6.67 09032484 A Segmentectomy 25.38 NA NA 12.15 12.39 6.13 09032486 A Sleeve lobectomy 42.88 NA NA 18.31 18.28 10.53 09032488 A Completion pneumonectomy 42.99 NA NA 19.47 19.21 10.50 09032491 R Lung volume reduction 25.24 NA NA 13.28 13.78 6.10 09032500 A Partial removal of lung 24.64 NA NA 12.91 13.23 6.02 09032501 A Repair bronchus add-on 4.68 NA NA 1.67 1.74 1.13 ZZZ32503 A Resect apical lung tumor 31.74 NA NA 15.37 15.71 7.79 09032504 A Resect apical lung tum/chest 36.54 NA NA 16.52 17.39 8.85 09032540 A Removal of lung lesion 30.35 NA NA 14.59 14.45 7.38 09032550 A Insert pleural cath 4.17 16.95 18.19 1.80 1.89 0.72 00032551 A Insertion of chest tube 3.29 NA NA 1.25 1.31 0.54 00032552 A Remove lung catheter 2.53 2.34 2.34 1.69 1.69 0.62 01032553 A Ins mark thor for rt perq 3.80 13.17 13.17 1.48 1.48 0.92 00032560 A Treat pleurodesis w/agent 1.54 5.06 5.75 0.55 0.67 0.28 00032561 A Lyse chest fibrin init day 1.39 1.18 1.18 0.50 0.50 0.25 00032562 A Lyse chest fibrin subq day 1.24 1.05 1.05 0.45 0.45 0.24 00032601 A Thoracoscopy, diagnostic 5.45 NA NA 2.59 2.65 1.31 00032602 A Thoracoscopy, diagnostic 5.95 NA NA 2.78 2.83 1.41 000CMS-1503-P896**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**32603 A Thoracoscopy, diagnostic 7.80 NA NA 3.36 3.49 2.02 00032604 A Thoracoscopy, diagnostic 8.77 NA NA 3.70 3.89 2.12 00032605 A Thoracoscopy, diagnostic 6.92 NA NA 3.05 3.13 1.68 00032606 A Thoracoscopy, diagnostic 8.39 NA NA 3.65 3.76 2.01 00032650 A Thoracoscopy, surgical 10.83 NA NA 6.67 6.83 2.57 09032651 A Thoracoscopy, surgical 18.78 NA NA 9.92 9.70 4.48 09032652 A Thoracoscopy, surgical 29.13 NA NA 14.15 13.95 6.98 09032653 A Thoracoscopy, surgical 18.17 NA NA 9.43 9.30 4.28 09032654 A Thoracoscopy, surgical 20.52 NA NA 10.26 10.11 4.83 09032655 A Thoracoscopy, surgical 16.17 NA NA 8.86 8.80 3.91 09032656 A Thoracoscopy, surgical 13.26 NA NA 7.67 7.85 3.12 09032657 A Thoracoscopy, surgical 12.93 NA NA 7.65 7.82 3.15 09032658 A Thoracoscopy, surgical 11.71 NA NA 6.87 7.19 2.85 09032659 A Thoracoscopy, surgical 11.94 NA NA 7.22 7.46 2.91 09032660 A Thoracoscopy, surgical 17.77 NA NA 9.15 9.51 4.62 09032661 A Thoracoscopy, surgical 13.33 NA NA 7.43 7.75 3.25 09032662 A Thoracoscopy, surgical 14.99 NA NA 8.35 8.65 3.63 09032663 A Thoracoscopy, surgical 24.64 NA NA 11.79 12.05 5.96 09032664 A Thoracoscopy, surgical 14.28 NA NA 7.76 7.99 3.49 09032665 A Thoracoscopy, surgical 21.53 NA NA 10.45 10.53 4.78 09032800 A Repair lung hernia 15.71 NA NA 8.82 8.86 3.83 09032810 A Close chest after drainage 14.95 NA NA 8.50 8.70 3.65 09032815 A Close bronchial fistula 50.03 NA NA 22.77 21.95 12.35 09032820 A Reconstruct injured chest 22.51 NA NA 12.06 12.66 5.48 09032850 X Donor pneumonectomy 0.00 0.00 0.00 0.00 0.00 0.00 XXX32851 A Lung transplant, single 41.61 NA NA 25.75 26.79 10.17 090CMS-1503-P897**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**32852 A Lung transplant with bypass 45.48 NA NA 28.96 30.35 11.06 09032853 A Lung transplant, double 50.78 NA NA 28.96 30.22 12.48 09032854 A Lung transplant with bypass 54.74 NA NA 32.74 34.13 13.40 09032855 C Prepare donor lung, single 0.00 0.00 0.00 0.00 0.00 0.00 XXX32856 C Prepare donor lung, double 0.00 0.00 0.00 0.00 0.00 0.00 XXX32900 A Removal of rib(s) 23.81 NA NA 12.93 12.53 5.69 09032905 A Revise & repair chest wall 23.29 NA NA 11.39 11.69 5.65 09032906 A Revise & repair chest wall 29.30 NA NA 13.47 13.91 7.14 0903293F I Abo rh blood typing docd 0.00 0.00 0.00 0.00 0.00 0.00 XXX32940 A Revision of lung 21.34 NA NA 10.80 10.91 5.20 0903294F I Grp b strep screeningdocd 0.00 0.00 0.00 0.00 0.00 0.00 XXX32960 A Therapeutic pneumothorax 1.84 1.66 1.85 0.77 0.82 0.44 00032997 A Total lung lavage 7.31 NA NA 2.32 2.28 0.9500032998 A Perq rf ablate tx, pul tumor 5.68 71.17 76.62 2.09 2.45 0.62 00032999 C Chest surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY33010 A Drainage of heart sac 2.24 NA NA 0.84 1.02 0.47 00033011 A Repeat drainage of heart sac 2.24 NA NA 0.87 0.99 0.51 00033015 A Incision of heart sac 8.52 NA NA 4.72 5.54 1.74 09033020 A Incision of heart sac 14.95 NA NA 8.06 8.12 3.65 09033025 A Incision of heart sac 13.70 NA NA 7.21 7.37 3.38 09033030 A Partial removal of heart sac 22.39 NA NA 11.38 11.48 5.52 09033031 A Partial removal of heart sac 25.38 NA NA 11.85 12.13 6.34 09033050 A Removal of heart sac lesion 16.97 NA NA 9.46 9.45 4.13 09033120 A Removal of heart lesion 27.45 NA NA 13.05 13.41 6.82 09033130 A Removal of heart lesion 24.17 NA NA 11.69 12.02 6.27 09033140 A Heart revascularize (tmr) 28.34 NA NA 12.77 13.17 7.35 090CMS-1503-P898**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**33141 A Heart tmr w/other procedure 2.54 NA NA 0.91 1.07 0.64 ZZZ33202 A Insert epicard eltrd, open 13.20 NA NA 6.97 7.28 3.28 09033203 A Insert epicard eltrd, endo 13.97 NA NA 6.90 7.58 3.41 09033206 A Insertion of heart pacemaker 7.39 NA NA 4.33 5.15 1.68 09033207 A Insertion of heart pacemaker 8.05 NA NA 4.39 5.27 1.84 09033208 A Insertion of heart pacemaker 8.77 NA NA 4.66 5.61 1.99 09033210 A Insertion of heart electrode 3.30 NA NA 1.28 1.59 0.73 00033211 A Insertion of heart electrode 3.39 NA NA 1.29 1.54 0.78 00033212 A Insertion of pulse generator 5.52 NA NA 3.15 3.76 1.26 09033213 A Insertion of pulse generator 6.37 NA NA 3.47 4.20 1.46 09033214 A Upgrade of pacemaker system 7.84 NA NA 4.57 5.40 1.77 09033215 A Reposition pacing-defib lead 4.92 NA NA 2.87 3.48 1.12 09033216 A Insert 1 electrode pm-defib 5.87 NA NA 3.73 4.55 1.33 09033217 A Insert 2 electrode pm-defib 5.84 NA NA 3.74 4.51 1.33 09033218 A Repair lead pace-defib, one 6.07 NA NA 4.01 4.81 1.37 0903321F I AJCC cncr 0/IA melan docd 0.00 0.00 0.00 0.00 0.00 0.00 XXX33220 A Repair lead pace-defib,dual 6.15 NA NA 4.01 4.82 1.38 09033222 A Revise pocket, pacemaker 5.10 NA NA 3.81 4.48 1.19 09033223 A Revise pocket for defib 6.55 NA NA 3.99 4.88 1.51 09033224 A Insert pacing lead & connect 9.04 NA NA 3.87 4.78 2.06 00033225 A L ventric pacing lead add-on 8.33 NA NA 3.27 4.10 1.89 ZZZ33226 A Reposition l ventric lead 8.68 NA NA 3.75 4.63 1.98 0003322F I Melan >AJCC stage 0 or IA 0.00 0.00 0.00 0.00 0.00 0.00 XXX33233 A Removal of pacemaker system 3.39 NA NA 2.70 3.29 0.76 09033234 A Removal of pacemaker system 7.91 NA NA 4.52 5.47 1.81 09033235 A Removal pacemaker electrode 10.15 NA NA 6.10 7.33 2.33 090CMS-1503-P899**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**33236 A Remove electrode/thoracotomy 12.73 NA NA 7.72 8.02 3.31 09033237 A Remove electrode/thoracotomy 13.84 NA NA 7.60 8.63 3.36 09033238 A Remove electrode/thoracotomy 15.40 NA NA 9.16 9.40 3.83 09033240 A Insert pulse generator 7.64 NA NA 4.11 5.11 1.72 09033241 A Remove pulse generator 3.29 NA NA 2.41 2.98 0.73 09033243 A Remove eltrd/thoracotomy 23.57 NA NA 11.94 12.84 5.78 09033244 A Remove eltrd, transven 13.99 NA NA 7.75 9.48 3.22 09033249 A Eltrd/insert pace-defib 15.17 NA NA 7.91 9.77 3.45 0903324F I Mri ct scan ord rvwd rqstd 0.00 0.00 0.00 0.00 0.00 0.00 XXX33250 A Ablate heart dysrhythm focus 25.90 NA NA 12.29 12.70 6.71 09033251 A Ablate heart dysrhythm focus 28.92 NA NA 13.82 14.01 7.28 09033254 A Ablate atria, lmtd 23.71 NA NA 12.00 12.25 6.15 09033255 A Ablate atria w/o bypass, ext 29.04 NA NA 13.81 14.57 7.53 09033256 A Ablate atria w/bypass, exten 34.90 NA NA 15.83 16.78 9.09 09033257 A Ablate atria, lmtd, add-on 9.63 NA NA 5.72 5.90 2.40 ZZZ33258 A Ablate atria, x10sv, add-on 11.00 NA NA 6.23 6.44 2.73 ZZZ33259 A Ablate atria w/bypass add-on 14.14 NA NA 8.07 8.36 3.56 ZZZ33261 A Ablate heart dysrhythm focus 28.92 NA NA 13.20 13.62 7.50 09033265 A Ablate atria, lmtd, endo 23.71 NA NA 11.68 12.04 5.86 09033266 A Ablate atria, x10sv, endo 33.04 NA NA 15.01 15.60 8.28 09033282 A Implant pat-active ht record 4.80 NA NA 3.42 4.20 1.09 09033284 A Remove pat-active ht record 3.14 NA NA 2.78 3.41 0.71 0903328F I Prfrmnc docd 2 wks b/4 surg 0.00 0.00 0.00 0.00 0.00 0.00 XXX33300 A Repair of heart wound 44.97 NA NA 18.86 18.22 11.15 09033305 A Repair of heart wound 76.93 NA NA 30.02 29.02 19.13 09033310 A Exploratory heart surgery 20.34 NA NA 10.26 10.55 4.66 090CMS-1503-P900**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**33315 A Exploratory heart surgery 26.17 NA NA 12.48 12.93 6.53 09033320 A Repair major blood vessel(s) 18.54 NA NA 9.41 9.65 4.47 09033321 A Repair major vessel 20.81 NA NA 10.37 10.60 5.06 09033322 A Repair major blood vessel(s) 24.42 NA NA 12.07 12.37 6.09 09033330 A Insert major vessel graft 25.29 NA NA 11.96 12.01 6.57 09033332 A Insert major vessel graft 24.56 NA NA 11.55 12.13 6.36 09033335 A Insert major vessel graft 33.91 NA NA 15.30 15.70 8.49 09033400 A Repair of aortic valve 41.50 NA NA 18.22 18.82 10.27 09033401 A Valvuloplasty, open 24.63 NA NA 12.37 14.05 5.58 09033403 A Valvuloplasty, w/cp bypass 25.61 NA NA 13.00 13.90 6.64 09033404 A Prepare heart-aorta conduit 31.37 NA NA 14.46 15.24 7.62 09033405 A Replacement of aortic valve 41.32 NA NA 18.53 19.35 10.30 09033406 A Replacement of aortic valve 52.68 NA NA 22.29 22.99 13.25 09033410 A Replacement of aortic valve 46.41 NA NA 20.30 20.71 11.57 09033411 A Replacement of aortic valve 62.07 NA NA 25.83 26.05 15.50 09033412 A Replacement of aortic valve 43.94 NA NA 19.78 20.93 11.42 09033413 A Replacement of aortic valve 59.87 NA NA 24.56 25.57 14.55 09033414 A Repair of aortic valve 39.37 NA NA 16.73 17.56 10.22 09033415 A Revision, subvalvular tissue 37.27 NA NA 16.02 16.10 8.85 09033416 A Revise ventricle muscle 36.56 NA NA 16.80 16.93 9.14 09033417 A Repair of aortic valve 29.33 NA NA 14.33 14.89 7.31 09033420 A Revision of mitral valve 25.79 NA NA 15.33 13.35 3.67 09033422 A Revision of mitral valve 29.73 NA NA 13.93 14.60 7.70 09033425 A Repair of mitral valve 49.96 NA NA 21.58 21.29 12.45 09033426 A Repair of mitral valve 43.28 NA NA 19.29 19.88 10.81 09033427 A Repair of mitral valve 44.83 NA NA 19.19 20.14 11.19 090CMS-1503-P901**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**33430 A Replacement of mitral valve 50.93 NA NA 22.69 22.97 12.73 09033460 A Revision of tricuspid valve 44.70 NA NA 18.02 18.24 11.60 09033463 A Valvuloplasty, tricuspid 57.08 NA NA 23.79 23.42 14.31 09033464 A Valvuloplasty, tricuspid 44.62 NA NA 19.65 19.54 11.15 09033465 A Replace tricuspid valve 50.72 NA NA 21.44 21.21 12.76 09033468 A Revision of tricuspid valve 32.94 NA NA 14.77 16.12 8.56 09033470 A Revision of pulmonary valve 21.54 NA NA 12.29 11.93 5.24 09033471 A Valvotomy, pulmonary valve 22.96 NA NA 12.85 12.55 1.68 09033472 A Revision of pulmonary valve 23.06 NA NA 10.85 11.65 1.70 09033474 A Revision of pulmonary valve 39.40 NA NA 16.96 16.42 9.58 09033475 A Replacement, pulmonary valve 42.40 NA NA 18.49 18.85 11.01 09033476 A Revision of heart chamber 26.57 NA NA 13.04 13.10 6.90 09033478 A Revision of heart chamber 27.54 NA NA 13.24 13.79 7.15 09033496 A Repair, prosth valve clot 29.84 NA NA 13.95 14.40 7.25 09033500 A Repair heart vessel fistula 27.94 NA NA 12.99 13.50 7.25 09033501 A Repair heart vessel fistula 19.51 NA NA 9.70 9.95 5.07 09033502 A Coronary artery correction 21.85 NA NA 11.29 11.68 5.67 09033503 A Coronary artery graft 22.51 NA NA 11.56 13.40 5.12 09033504 A Coronary artery graft 25.46 NA NA 12.57 12.88 6.60 09033505 A Repair artery w/tunnel 38.40 NA NA 15.07 15.40 9.96 09033506 A Repair artery, translocation 37.85 NA NA 22.35 19.60 9.21 09033507 A Repair art, intramural 31.40 NA NA 13.20 14.03 7.63 09033508 A Endoscopic vein harvest 0.31 NA NA 0.11 0.12 0.07 ZZZ33510 A CABG, vein, single 34.98 NA NA 15.97 16.71 8.73 09033511 A CABG, vein, two 38.45 NA NA 17.40 18.15 9.61 09033512 A CABG, vein, three 43.98 NA NA 19.42 20.12 11.01 090CMS-1503-P902**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**33513 A CABG, vein, four 45.37 NA NA 19.79 20.21 11.39 09033514 A CABG, vein, five 48.08 NA NA 20.68 21.43 11.98 09033516 A Cabg, vein, six or more 49.76 NA NA 21.35 22.27 12.90 09033517 A CABG, artery-vein, single 3.61 NA NA 1.29 1.31 0.89 ZZZ33518 A CABG, artery-vein, two 7.93 NA NA 2.84 2.83 1.98 ZZZ33519 A CABG, artery-vein, three 10.49 NA NA 3.76 3.79 2.61 ZZZ3351F I Neg scrn dep symp by deptool 0.00 0.00 0.00 0.00 0.00 0.00 XXX33521 A CABG, artery-vein, four 12.59 NA NA 4.53 4.60 3.17 ZZZ33522 A CABG, artery-vein, five 14.14 NA NA 5.09 5.22 3.56 ZZZ33523 A Cabg, art-vein, six or more 16.08 NA NA 5.75 5.92 4.01 ZZZ3352F I No sig dep symp by deptool 0.00 0.00 0.00 0.00 0.00 0.00 XXX33530 A Coronary artery, bypass/reop 10.13 NA NA 3.62 3.59 2.52 ZZZ33533 A CABG, arterial, single 33.75 NA NA 15.36 16.26 8.44 09033534 A CABG, arterial, two 39.88 NA NA 17.88 18.76 9.95 09033535 A CABG, arterial, three 44.75 NA NA 19.62 20.48 11.16 09033536 A Cabg, arterial, four or more 48.43 NA NA 20.99 21.61 12.15 0903353F I Mild-mod dep symp by deptool 0.00 0.00 0.00 0.00 0.00 0.00 XXX33542 A Removal of heart lesion 48.21 NA NA 20.71 20.49 12.08 09033545 A Repair of heart damage 57.06 NA NA 23.76 23.69 14.20 09033548 A Restore/remodel, ventricle 54.14 NA NA 23.60 24.39 13.61 0903354F I Clin sig dep sym by deptool 0.00 0.00 0.00 0.00 0.00 0.00 XXX33572 A Open coronary endarterectomy 4.44 NA NA 1.59 1.66 1.12 ZZZ33600 A Closure of valve 30.31 NA NA 14.38 14.72 7.35 09033602 A Closure of valve 29.34 NA NA 14.05 14.07 6.49 09033606 A Anastomosis/artery-aorta 31.53 NA NA 16.73 16.21 6.98 09033608 A Repair anomaly w/conduit 31.88 NA NA 14.93 15.72 7.74 090CMS-1503-P903**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**33610 A Repair by enlargement 31.40 NA NA 14.60 15.21 7.63 09033611 A Repair double ventricle 35.57 NA NA 15.10 15.78 9.24 09033612 A Repair double ventricle 36.57 NA NA 15.28 15.92 8.28 09033615 A Repair, modified fontan 35.89 NA NA 16.28 17.16 8.73 09033617 A Repair single ventricle 39.09 NA NA 17.09 17.44 9.51 09033619 A Repair single ventricle 48.76 NA NA 25.36 23.27 11.86 09033641 A Repair heart septum defect 29.58 NA NA 13.53 13.48 7.39 09033645 A Revision of heart veins 28.10 NA NA 12.96 13.51 7.29 09033647 A Repair heart septum defects 29.53 NA NA 14.11 15.06 7.66 09033660 A Repair of heart defects 31.83 NA NA 19.60 17.20 8.27 09033665 A Repair of heart defects 34.85 NA NA 14.85 15.50 9.07 09033670 A Repair of heart chambers 36.63 NA NA 14.54 15.20 9.52 09033675 A Close mult vsd 35.95 NA NA 15.11 15.74 9.33 09033676 A Close mult vsd w/resection 36.95 NA NA 18.30 17.85 2.73 09033677 A Cl mult vsd w/rem pul band 38.45 NA NA 13.77 15.86 2.84 09033681 A Repair heart septum defect 32.34 NA NA 15.88 16.19 8.10 09033684 A Repair heart septum defect 34.37 NA NA 14.68 15.32 8.93 09033688 A Repair heart septum defect 34.75 NA NA 13.98 14.32 9.03 09033690 A Reinforce pulmonary artery 20.36 NA NA 13.04 12.11 4.95 09033692 A Repair of heart defects 31.54 NA NA 16.04 15.66 2.32 09033694 A Repair of heart defects 35.57 NA NA 14.94 15.92 9.24 09033697 A Repair of heart defects 37.57 NA NA 16.44 18.42 8.51 09033702 A Repair of heart defects 27.24 NA NA 12.98 13.30 7.07 09033710 A Repair of heart defects 30.41 NA NA 13.93 16.77 7.39 09033720 A Repair of heart defect 27.26 NA NA 12.85 13.49 6.63 09033722 A Repair of heart defect 29.21 NA NA 15.03 14.31 7.57 090CMS-1503-P904**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**33724 A Repair venous anomaly 27.63 NA NA 12.59 13.41 6.70 09033726 A Repair pul venous stenosis 37.12 NA NA 19.08 18.28 9.64 09033730 A Repair heart-vein defect(s) 36.14 NA NA 15.77 15.67 9.40 09033732 A Repair heart-vein defect 28.96 NA NA 13.92 14.45 7.52 09033735 A Revision of heart chamber 22.20 NA NA 11.45 11.72 5.78 09033736 A Revision of heart chamber 24.32 NA NA 12.18 12.65 6.30 09033737 A Revision of heart chamber 22.47 NA NA 11.21 11.70 5.47 09033750 A Major vessel shunt 22.22 NA NA 9.14 11.81 8.28 09033755 A Major vessel shunt 22.60 NA NA 11.71 11.76 5.13 09033762 A Major vessel shunt 22.60 NA NA 12.17 12.00 1.67 09033764 A Major vessel shunt & graft 22.60 NA NA 12.97 12.15 5.02 09033766 A Major vessel shunt 23.57 NA NA 10.96 12.35 5.33 09033767 A Major vessel shunt 25.30 NA NA 11.68 11.85 6.57 09033768 A Cavopulmonary shunting 8.00 NA NA 3.46 3.35 0.58 ZZZ33770 A Repair great vessels defect 39.07 NA NA 15.68 16.51 9.51 09033771 A Repair great vessels defect 40.63 NA NA 19.02 18.13 3.01 09033774 A Repair great vessels defect 31.73 NA NA 14.92 15.63 8.24 09033775 A Repair great vessels defect 32.99 NA NA 17.37 17.19 2.42 09033776 A Repair great vessels defect 34.75 NA NA 18.46 18.25 2.54 09033777 A Repair great vessels defect 34.17 NA NA 17.34 17.23 2.52 09033778 A Repair great vessels defect 42.75 NA NA 21.31 20.82 3.17 09033779 A Repair great vessels defect 43.23 NA NA 20.42 19.78 3.21 09033780 A Repair great vessels defect 43.90 NA NA 20.89 20.76 3.25 09033781 A Repair great vessels defect 43.21 NA NA 20.14 19.23 3.21 09033782 A Nikaidoh proc 60.08 NA NA 23.63 23.63 14.61 09033783 A Nikaidoh proc w/ostia implt 65.08 NA NA 25.37 25.37 15.83 090CMS-1503-P905**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**33786 A Repair arterial trunk 41.87 NA NA 16.98 17.98 3.09 09033788 A Revision of pulmonary artery 27.42 NA NA 12.28 13.05 2.01 09033800 A Aortic suspension 17.28 NA NA 8.33 8.45 4.48 09033802 A Repair vessel defect 18.37 NA NA 11.81 10.85 4.78 09033803 A Repair vessel defect 20.31 NA NA 9.51 9.62 5.27 09033813 A Repair septal defect 21.36 NA NA 12.15 12.83 5.20 09033814 A Repair septal defect 26.57 NA NA 12.95 13.50 6.90 09033820 A Revise major vessel 16.69 NA NA 8.56 9.01 4.34 09033822 A Revise major vessel 17.71 NA NA 9.95 9.93 1.30 09033824 A Revise major vessel 20.23 NA NA 11.63 11.38 4.92 09033840 A Remove aorta constriction 21.34 NA NA 10.93 10.84 5.54 09033845 A Remove aorta constriction 22.93 NA NA 11.70 12.81 5.95 09033851 A Remove aorta constriction 21.98 NA NA 18.08 14.82 5.69 09033852 A Repair septal defect 24.41 NA NA 11.81 12.33 6.33 09033853 A Repair septal defect 32.51 NA NA 14.98 16.45 8.45 09033860 A Ascending aortic graft 59.46 NA NA 24.60 24.67 14.79 09033861 A Ascending aortic graft 44.07 NA NA 19.10 19.83 11.05 09033863 A Ascending aortic graft 58.79 NA NA 23.56 24.15 14.61 09033864 A Ascending aortic graft 60.08 NA NA 24.06 24.97 14.86 09033870 A Transverse aortic arch graft 46.06 NA NA 19.72 20.56 11.42 09033875 A Thoracic aortic graft 35.78 NA NA 16.84 16.81 8.87 09033877 A Thoracoabdominal graft 69.03 NA NA 26.65 26.03 16.97 09033880 A Endovasc taa repr incl subcl 34.58 NA NA 13.61 14.22 8.01 09033881 A Endovasc taa repr w/o subcl 29.58 NA NA 11.98 12.44 6.85 09033883 A Insert endovasc prosth, taa 21.09 NA NA 9.12 9.44 4.87 09033884 A Endovasc prosth, taa, add-on 8.20 NA NA 2.78 2.82 1.91 ZZZCMS-1503-P906**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**33886 A Endovasc prosth, delayed 18.09 NA NA 7.98 8.21 4.47 09033889 A Artery transpose/endovas taa 15.92 NA NA 5.52 5.48 3.93 00033891 A Car-car bp grft/endovas taa 20.00 NA NA 6.15 6.41 4.93 00033910 A Remove lung artery emboli 29.71 NA NA 14.03 14.36 7.70 09033915 A Remove lung artery emboli 24.95 NA NA 10.36 10.94 5.65 09033916 A Surgery of great vessel 28.42 NA NA 13.03 14.69 7.38 09033917 A Repair pulmonary artery 25.30 NA NA 12.65 13.87 6.15 09033920 A Repair pulmonary atresia 32.74 NA NA 14.25 14.91 8.49 09033922 A Transect pulmonary artery 24.22 NA NA 11.81 12.22 6.29 09033924 A Remove pulmonary shunt 5.49 NA NA 1.88 1.96 1.33 ZZZ33925 A Rpr pul art unifocal w/o cpb 31.30 NA NA 13.31 14.37 7.60 09033926 A Repr pul art, unifocal w/cpb 44.73 NA NA 26.15 21.44 11.60 09033930 X Removal of donor heart/lung 0.00 0.00 0.00 0.00 0.00 0.00 XXX33933 C Prepare donor heart/lung 0.00 0.00 0.00 0.00 0.00 0.00 XXX33935 R Transplantation, heart/lung 62.01 NA NA 27.41 28.77 16.09 09033940 X Removal of donor heart 0.00 0.00 0.00 0.00 0.00 0.00 XXX33944 C Prepare donor heart 0.00 0.00 0.00 0.00 0.00 0.00 XXX33945 R Transplantation of heart 89.50 NA NA 36.75 36.43 22.16 09033960 A External circulation assist 19.33 NA NA 6.99 6.97 3.97 00033961 A External circulation assist 10.91 NA NA 3.93 4.06 1.72 ZZZ33967 A Insert ia percut device 4.84 NA NA 1.87 2.32 1.12 00033968 A Remove aortic assist device 0.64 NA NA 0.25 0.28 0.14 00033970 A Aortic circulation assist 6.74 NA NA 2.47 2.81 1.62 00033971 A Aortic circulation assist 11.99 NA NA 6.62 7.11 2.91 09033973 A Insert balloon device 9.75 NA NA 3.64 4.13 2.35 00033974 A Remove intra-aortic balloon 15.03 NA NA 7.91 8.88 3.91 090CMS-1503-P907**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**33975 A Implant ventricular device 20.97 NA NA 7.51 7.87 5.19 XXX33976 A Implant ventricular device 22.97 NA NA 8.00 8.84 5.96 XXX33977 A Remove ventricular device 20.28 NA NA 11.27 11.78 5.00 09033978 A Remove ventricular device 22.72 NA NA 12.21 12.54 5.91 09033979 A Insert intracorporeal device 45.93 NA NA 16.15 17.04 11.42 XXX33980 A Remove intracorporeal device 65.20 NA NA 29.25 30.10 16.33 09033981 C Replace vad pump ext 0.00 0.00 0.00 0.00 0.00 0.00 XXX33982 C Replace vad intra w/o bp 0.00 0.00 0.00 0.00 0.00 0.00 XXX33983 C Replace vad intra w/bp 0.00 0.00 0.00 0.00 0.00 0.00 XXX33999 C Cardiac surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY34001 A Removal of artery clot 17.88 NA NA 8.76 8.50 4.22 09034051 A Removal of artery clot 16.99 NA NA 8.91 9.01 4.41 09034101 A Removal of artery clot 10.93 NA NA 5.67 5.66 2.56 09034111 A Removal of arm artery clot 10.93 NA NA 5.69 5.66 2.53 09034151 A Removal of artery clot 26.52 NA NA 11.81 11.52 6.20 09034201 A Removal of artery clot 19.48 NA NA 8.81 8.32 4.65 09034203 A Removal of leg artery clot 17.86 NA NA 8.48 8.48 4.27 09034401 A Removal of vein clot 26.52 NA NA 14.36 13.71 5.88 09034421 A Removal of vein clot 13.37 NA NA 6.81 6.80 3.08 09034451 A Removal of vein clot 28.52 NA NA 10.62 11.43 7.04 09034471 A Removal of vein clot 21.11 NA NA 12.03 10.26 4.68 09034490 A Removal of vein clot 10.91 NA NA 6.00 5.89 2.52 09034501 A Repair valve, femoral vein 16.85 NA NA 7.66 8.26 4.15 09034502 A Reconstruct vena cava 28.07 NA NA 13.07 13.32 6.12 0903450F I Dyspnea scrnd, no-mild dysp 0.00 0.00 0.00 0.00 0.00 0.00 XXX34510 A Transposition of vein valve 19.91 NA NA 11.53 10.47 4.39 090CMS-1503-P908**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**3451F I Dyspnea scrnd mod-high dysp 0.00 0.00 0.00 0.00 0.00 0.00 XXX34520 A Cross-over vein graft 19.18 NA NA 7.86 8.39 4.72 0903452F I Dyspnea not screened 0.00 0.00 0.00 0.00 0.00 0.00 XXX34530 A Leg vein fusion 17.93 NA NA 7.78 8.33 3.97 09034800 A Endovas aaa repr w/sm tube 21.54 NA NA 9.06 9.47 4.75 09034802 A Endovas aaa repr w/2-p part 23.79 NA NA 10.10 10.42 5.28 09034803 A Endovas aaa repr w/3-p part 24.82 NA NA 10.25 10.48 5.54 09034804 A Endovas aaa repr w/1-p part 23.79 NA NA 10.08 10.41 5.34 09034805 A Endovas aaa repr w/long tube 22.67 NA NA 9.63 9.72 5.23 09034806 A Aneurysm press sensor add-on 2.06 NA NA 0.70 0.74 0.47 ZZZ34808 A Endovas iliac a device addon 4.12 NA NA 1.43 1.43 0.93 ZZZ34812 A Xpose for endoprosth, femorl 6.74 NA NA 2.35 2.33 1.61 00034813 A Femoral endovas graft add-on 4.79 NA NA 1.63 1.61 1.14 ZZZ34820 A Xpose for endoprosth, iliac 9.74 NA NA 3.34 3.36 2.26 00034825 A Endovasc extend prosth, init 12.80 NA NA 6.24 6.48 2.85 09034826 A Endovasc exten prosth, addl 4.12 NA NA 1.44 1.47 0.92 ZZZ34830 A Open aortic tube prosth repr 35.23 NA NA 12.77 13.53 8.68 09034831 A Open aortoiliac prosth repr 37.98 NA NA 13.62 13.95 9.37 09034832 A Open aortofemor prosth repr 37.98 NA NA 13.62 14.41 9.37 09034833 A Xpose for endoprosth, iliac 11.98 NA NA 4.41 4.46 2.90 00034834 A Xpose, endoprosth, brachial 5.34 NA NA 2.08 2.12 1.29 00034900 A Endovasc iliac repr w/graft 16.85 NA NA 7.60 7.87 3.72 0903491F I HIV unsure baby of HIV+moms 0.00 0.00 0.00 0.00 0.00 0.00 XXX3497F I CD4+ cell percentage <15% 0.00 0.00 0.00 0.00 0.00 0.00 XXX3498F I CD4+ cell percentage >=15% 0.00 0.00 0.00 0.00 0.00 0.00 XXX35001 A Repair defect of artery 20.81 NA NA 9.73 9.95 5.00 090CMS-1503-P909**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**35002 A Repair artery rupture, neck 22.23 NA NA 8.77 9.57 4.93 09035005 A Repair defect of artery 19.29 NA NA 11.38 10.59 4.75 09035011 A Repair defect of artery 18.58 NA NA 8.67 8.56 4.38 09035013 A Repair artery rupture, arm 23.23 NA NA 11.05 10.70 5.48 09035021 A Repair defect of artery 22.17 NA NA 8.97 9.97 5.40 09035022 A Repair artery rupture, chest 25.70 NA NA 11.90 11.79 6.25 09035045 A Repair defect of arm artery 18.01 NA NA 9.13 8.72 4.15 09035081 A Repair defect of artery 33.53 NA NA 14.42 14.06 8.07 09035082 A Repair artery rupture, aorta 42.09 NA NA 17.71 17.28 10.03 09035091 A Repair defect of artery 35.35 NA NA 13.49 13.59 8.51 09035092 A Repair artery rupture, aorta 50.97 NA NA 19.80 19.55 12.24 09035102 A Repair defect of artery 36.53 NA NA 15.13 14.84 8.77 09035103 A Repair artery rupture, groin 43.62 NA NA 17.45 17.27 10.37 0903510F I Doc tb scrng-rslts interpd 0.00 0.00 0.00 0.00 0.00 0.00 XXX35111 A Repair defect of artery 26.28 NA NA 14.26 12.83 5.82 09035112 A Repair artery rupture,spleen 32.57 NA NA 17.11 15.37 7.21 09035121 A Repair defect of artery 31.52 NA NA 13.64 13.29 7.53 09035122 A Repair artery rupture, belly 37.89 NA NA 13.59 14.59 8.39 09035131 A Repair defect of artery 26.40 NA NA 11.56 11.54 6.33 09035132 A Repair artery rupture, groin 32.57 NA NA 11.96 12.65 7.73 0903513F I Hep B scrng docd as done 0.00 0.00 0.00 0.00 0.00 0.00 XXX35141 A Repair defect of artery 20.91 NA NA 9.31 9.29 5.02 09035142 A Repair artery rupture, thigh 25.16 NA NA 11.02 11.03 6.01 0903514F I Hep C scrng docd as done 0.00 0.00 0.00 0.00 0.00 0.00 XXX35151 A Repair defect of artery 23.72 NA NA 10.42 10.37 5.68 09035152 A Repair artery rupture, knee 27.66 NA NA 10.44 11.20 6.82 090CMS-1503-P910**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**3515F I Pt has docd immun to hep C 0.00 0.00 0.00 0.00 0.00 0.00 XXX35180 A Repair blood vessel lesion 15.10 NA NA 11.10 9.88 3.72 09035182 A Repair blood vessel lesion 31.71 NA NA 14.79 14.87 7.02 09035184 A Repair blood vessel lesion 18.82 NA NA 9.25 8.98 4.17 09035188 A Repair blood vessel lesion 15.16 NA NA 6.59 7.32 3.36 09035189 A Repair blood vessel lesion 29.98 NA NA 16.00 14.48 7.79 09035190 A Repair blood vessel lesion 13.42 NA NA 7.11 6.99 3.18 09035201 A Repair blood vessel lesion 16.93 NA NA 8.72 8.57 3.90 09035206 A Repair blood vessel lesion 13.84 NA NA 7.36 7.14 3.18 09035207 A Repair blood vessel lesion 10.94 NA NA 9.66 9.03 2.01 09035211 A Repair blood vessel lesion 24.58 NA NA 11.80 12.06 6.13 09035216 A Repair blood vessel lesion 36.61 NA NA 17.67 16.69 8.97 09035221 A Repair blood vessel lesion 26.62 NA NA 12.20 11.62 6.05 09035226 A Repair blood vessel lesion 15.30 NA NA 7.36 7.50 3.66 09035231 A Repair blood vessel lesion 21.16 NA NA 11.45 11.05 4.32 09035236 A Repair blood vessel lesion 18.02 NA NA 8.71 8.56 4.14 09035241 A Repair blood vessel lesion 25.58 NA NA 13.01 12.92 6.54 09035246 A Repair blood vessel lesion 28.23 NA NA 10.74 12.06 6.95 09035251 A Repair blood vessel lesion 31.91 NA NA 13.95 13.32 7.26 09035256 A Repair blood vessel lesion 19.06 NA NA 8.66 8.65 4.52 09035261 A Repair blood vessel lesion 18.96 NA NA 9.52 9.33 4.82 09035266 A Repair blood vessel lesion 15.83 NA NA 7.71 7.61 3.76 09035271 A Repair blood vessel lesion 24.58 NA NA 11.82 12.05 6.37 09035276 A Repair blood vessel lesion 25.83 NA NA 12.33 12.54 6.27 09035281 A Repair blood vessel lesion 30.06 NA NA 13.64 13.17 7.05 09035286 A Repair blood vessel lesion 17.19 NA NA 8.41 8.41 4.11 090CMS-1503-P911**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**35301 A Rechanneling of artery 19.61 NA NA 9.03 8.97 4.73 09035302 A Rechanneling of artery 21.35 NA NA 9.42 9.10 5.12 09035303 A Rechanneling of artery 23.60 NA NA 10.40 9.97 5.64 09035304 A Rechanneling of artery 24.60 NA NA 10.55 10.19 5.86 09035305 A Rechanneling of artery 23.60 NA NA 10.30 9.89 5.64 09035306 A Rechanneling of artery 9.25 NA NA 3.98 3.45 2.27 ZZZ35311 A Rechanneling of artery 28.60 NA NA 12.01 12.24 6.95 09035321 A Rechanneling of artery 16.59 NA NA 7.84 7.78 3.91 09035331 A Rechanneling of artery 27.72 NA NA 12.12 12.17 6.68 09035341 A Rechanneling of artery 26.21 NA NA 11.02 11.12 6.29 09035351 A Rechanneling of artery 24.61 NA NA 10.53 10.39 5.86 09035355 A Rechanneling of artery 19.86 NA NA 8.62 8.57 4.73 09035361 A Rechanneling of artery 30.24 NA NA 11.24 11.96 7.46 09035363 A Rechanneling of artery 32.35 NA NA 14.02 14.34 7.86 09035371 A Rechanneling of artery 15.31 NA NA 7.26 7.20 3.66 09035372 A Rechanneling of artery 18.58 NA NA 8.31 8.28 4.42 09035390 A Reoperation, carotid add-on 3.19 NA NA 1.12 1.12 0.76 ZZZ35400 A Angioscopy 3.00 NA NA 1.02 1.05 0.71 ZZZ35450 A Repair arterial blockage 10.05 NA NA 3.82 3.89 2.33 00035452 A Repair arterial blockage 6.90 NA NA 2.78 2.78 1.64 00035454 A Repair arterial blockage 6.03 NA NA 2.38 2.41 1.41 00035456 A Repair arterial blockage 7.34 NA NA 2.89 2.90 1.72 00035458 A Repair arterial blockage 9.48 NA NA 3.76 3.73 2.22 00035459 A Repair arterial blockage 8.62 NA NA 3.31 3.39 2.02 00035460 A Repair venous blockage 6.03 NA NA 2.53 2.45 1.37 00035470 A Repair arterial blockage 8.62 59.94 70.16 3.35 3.80 1.84 000CMS-1503-P912**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**35471 A Repair arterial blockage 10.05 60.21 73.93 3.96 4.73 2.06 00035472 A Repair arterial blockage 6.90 46.98 53.91 2.78 3.07 1.50 00035473 A Repair arterial blockage 6.03 45.52 52.16 2.44 2.75 1.29 00035474 A Repair arterial blockage 7.35 59.13 69.24 2.91 3.29 1.54 00035475 R Repair arterial blockage 9.48 52.40 56.10 3.63 3.98 1.58 00035476 A Repair venous blockage 6.03 40.84 43.75 2.41 2.62 0.86 00035480 A Atherectomy, open 11.06 NA NA 5.13 4.65 2.73 00035481 A Atherectomy, open 7.60 NA NA 3.09 3.19 1.85 00035482 A Atherectomy, open 6.64 NA NA 2.27 2.61 1.64 00035483 A Atherectomy, open 8.09 NA NA 3.34 3.38 1.89 00035484 A Atherectomy, open 10.42 NA NA 3.43 3.70 2.56 00035485 A Atherectomy, open 9.48 NA NA 3.86 3.85 2.22 00035490 A Atherectomy, percutaneous 11.06 NA NA 4.89 5.62 2.47 00035491 A Atherectomy, percutaneous 7.60 NA NA 3.54 3.69 1.88 00035492 A Atherectomy, percutaneous 6.64 NA NA 3.12 3.55 1.51 00035493 A Atherectomy, percutaneous 8.09 NA NA 3.64 4.23 1.77 00035494 A Atherectomy, percutaneous 10.42 NA NA 4.48 5.24 2.26 00035495 A Atherectomy, percutaneous 9.48 NA NA 4.15 4.79 2.09 00035500 A Harvest vein for bypass 6.44 NA NA 2.23 2.20 1.55 ZZZ35501 A Artery bypass graft 29.09 NA NA 14.25 13.79 6.95 09035506 A Artery bypass graft 25.33 NA NA 10.66 10.90 6.25 09035508 A Artery bypass graft 26.09 NA NA 12.06 11.91 6.77 09035509 A Artery bypass graft 28.09 NA NA 12.28 12.47 6.92 0903550F I Low rsk thromboembolism 0.00 0.00 0.00 0.00 0.00 0.00 XXX35510 A Artery bypass graft 24.39 NA NA 9.18 9.88 6.01 09035511 A Artery bypass graft 22.20 NA NA 12.61 11.38 5.48 090CMS-1503-P913**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**35512 A Artery bypass graft 23.89 NA NA 9.02 9.58 5.89 09035515 A Artery bypass graft 26.09 NA NA 10.20 10.19 6.43 09035516 A Artery bypass graft 24.21 NA NA 9.08 9.09 5.96 09035518 A Artery bypass graft 22.65 NA NA 8.51 9.34 5.58 0903551F I Intrmed rsk thromboembolism 0.00 0.00 0.00 0.00 0.00 0.00 XXX35521 A Artery bypass graft 24.13 NA NA 13.48 11.98 5.95 09035522 A Artery bypass graft 23.15 NA NA 10.18 10.14 5.69 09035523 A Artery bypass graft 24.13 NA NA 10.91 11.10 5.69 09035525 A Artery bypass graft 21.69 NA NA 9.81 9.63 5.02 09035526 A Artery bypass graft 31.55 NA NA 11.67 12.82 8.20 0903552F I Hgh risk for thromboembolism 0.00 0.00 0.00 0.00 0.00 0.00 XXX35531 A Artery bypass graft 39.11 NA NA 16.25 15.99 9.26 09035533 A Artery bypass graft 29.92 NA NA 15.97 14.39 7.38 09035535 A Artery bypass graft 38.13 NA NA 13.71 15.02 2.81 09035536 A Artery bypass graft 33.73 NA NA 12.31 12.87 8.32 09035537 A Artery bypass graft 41.88 NA NA 21.25 18.94 10.31 09035538 A Artery bypass graft 47.03 NA NA 23.51 21.13 11.59 09035539 A Artery bypass graft 44.11 NA NA 15.58 16.07 10.88 09035540 A Artery bypass graft 49.33 NA NA 20.81 19.73 11.78 09035548 A Artery bypass graft 22.68 NA NA 8.91 9.51 5.60 09035549 A Artery bypass graft 24.45 NA NA 15.70 13.47 5.41 09035551 A Artery bypass graft 27.83 NA NA 15.06 13.93 6.17 09035556 A Artery bypass graft 26.75 NA NA 11.68 11.40 6.37 09035558 A Artery bypass graft 23.13 NA NA 10.81 10.58 5.54 0903555F I Pt inr measurement performed 0.00 0.00 0.00 0.00 0.00 0.00 XXX35560 A Artery bypass graft 34.03 NA NA 12.40 13.30 8.39 090CMS-1503-P914**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**35563 A Artery bypass graft 26.12 NA NA 9.97 10.47 6.43 09035565 A Artery bypass graft 25.13 NA NA 11.07 11.00 5.96 09035566 A Artery bypass graft 32.35 NA NA 13.56 13.24 7.79 09035570 A Artery bypass graft 29.15 NA NA 11.05 12.11 2.15 09035571 A Artery bypass graft 25.52 NA NA 11.02 11.01 6.12 09035572 A Harvest femoropopliteal vein 6.81 NA NA 2.45 2.51 1.65 ZZZ35583 A Vein bypass graft 27.75 NA NA 12.07 11.71 6.60 09035585 A Vein bypass graft 32.35 NA NA 13.87 13.53 7.69 09035587 A Vein bypass graft 26.21 NA NA 11.73 11.61 6.27 09035600 A Harvest art for cabg add-on 4.94 NA NA 1.81 1.89 1.24 ZZZ35601 A Artery bypass graft 27.09 NA NA 13.32 12.73 6.58 09035606 A Artery bypass graft 22.46 NA NA 9.63 9.65 5.45 09035612 A Artery bypass graft 16.82 NA NA 7.10 7.82 4.15 09035616 A Artery bypass graft 21.82 NA NA 11.85 10.51 4.83 09035621 A Artery bypass graft 21.03 NA NA 9.12 9.08 5.06 09035623 A Bypass graft, not vein 25.92 NA NA 14.25 12.69 6.37 09035626 A Artery bypass graft 29.14 NA NA 12.75 13.04 7.25 09035631 A Artery bypass graft 36.03 NA NA 14.29 14.28 8.75 09035632 A Artery bypass graft 36.13 NA NA 13.10 14.35 2.67 09035633 A Artery bypass graft 39.11 NA NA 15.24 15.97 2.88 09035634 A Artery bypass graft 35.33 NA NA 13.72 14.52 2.60 09035636 A Artery bypass graft 31.75 NA NA 16.76 15.01 7.83 09035637 A Artery bypass graft 33.05 NA NA 14.02 13.64 7.94 09035638 A Artery bypass graft 33.60 NA NA 14.41 14.09 8.12 09035642 A Artery bypass graft 18.94 NA NA 11.74 10.72 4.66 09035645 A Artery bypass graft 18.43 NA NA 10.73 9.54 4.79 090CMS-1503-P915**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**35646 A Artery bypass graft 32.98 NA NA 13.93 13.90 7.88 09035647 A Artery bypass graft 29.73 NA NA 12.92 12.82 7.16 09035650 A Artery bypass graft 20.16 NA NA 9.28 9.10 4.78 09035651 A Artery bypass graft 26.08 NA NA 9.95 10.82 5.79 09035654 A Artery bypass graft 26.28 NA NA 11.38 11.28 6.30 09035656 A Artery bypass graft 20.47 NA NA 9.24 9.16 4.89 09035661 A Artery bypass graft 20.35 NA NA 9.51 9.45 4.87 09035663 A Artery bypass graft 23.93 NA NA 10.34 10.41 5.68 09035665 A Artery bypass graft 22.35 NA NA 9.89 9.87 5.31 09035666 A Artery bypass graft 23.66 NA NA 11.30 11.26 5.65 09035671 A Artery bypass graft 20.77 NA NA 10.02 10.01 4.96 09035681 A Composite bypass graft 1.60 NA NA 0.57 0.56 0.38 ZZZ35682 A Composite bypass graft 7.19 NA NA 2.41 2.41 1.72 ZZZ35683 A Composite bypass graft 8.49 NA NA 2.61 2.72 2.08 ZZZ35685 A Bypass graft patency/patch 4.04 NA NA 1.39 1.37 0.96 ZZZ35686 A Bypass graft/av fist patency 3.34 NA NA 1.14 1.17 0.78 ZZZ35691 A Arterial transposition 18.41 NA NA 7.42 7.97 4.54 09035693 A Arterial transposition 15.73 NA NA 7.17 7.77 3.89 09035694 A Arterial transposition 19.28 NA NA 8.62 8.56 4.75 09035695 A Arterial transposition 20.06 NA NA 7.93 8.43 4.95 09035697 A Reimplant artery each 3.00 NA NA 1.03 1.03 0.72 ZZZ35700 A Reoperation, bypass graft 3.08 NA NA 1.07 1.07 0.73 ZZZ35701 A Exploration, carotid artery 9.19 NA NA 6.46 6.07 1.87 09035721 A Exploration, femoral artery 7.72 NA NA 4.71 4.77 1.81 0903572F I Pt consid poss risk fx 0.00 0.00 0.00 0.00 0.00 0.00 XXX3573F I Pt not consid poss risk fx 0.00 0.00 0.00 0.00 0.00 0.00 XXXCMS-1503-P916**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**35741 A Exploration popliteal artery 8.69 NA NA 5.29 5.16 2.01 09035761 A Exploration of artery/vein 5.93 NA NA 4.77 4.60 1.34 09035800 A Explore neck vessels 8.07 NA NA 5.51 5.31 1.77 09035820 A Explore chest vessels 36.89 NA NA 15.72 15.21 9.17 09035840 A Explore abdominal vessels 10.96 NA NA 6.70 6.39 2.44 09035860 A Explore limb vessels 6.80 NA NA 4.42 4.40 1.61 09035870 A Repair vessel graft defect 24.50 NA NA 9.47 9.99 6.03 09035875 A Removal of clot in graft 10.72 NA NA 5.71 5.64 2.53 09035876 A Removal of clot in graft 17.82 NA NA 8.15 8.04 4.24 09035879 A Revise graft w/vein 17.41 NA NA 8.10 8.01 4.17 09035881 A Revise graft w/vein 19.35 NA NA 8.74 8.76 4.66 09035883 A Revise graft w/nonauto graft 23.15 NA NA 10.04 9.66 5.54 09035884 A Revise graft w/vein 24.65 NA NA 9.19 9.32 6.06 09035901 A Excision, graft, neck 8.38 NA NA 5.58 5.55 1.98 09035903 A Excision, graft, extremity 9.53 NA NA 6.13 6.13 2.23 09035905 A Excision, graft, thorax 33.52 NA NA 12.25 13.00 8.27 09035907 A Excision, graft, abdomen 37.27 NA NA 15.31 15.01 8.92 09036000 A Place needle in vein 0.18 0.47 0.53 0.08 0.08 0.03 XXX36002 A Pseudoaneurysm injectiontrt 1.96 2.37 2.65 0.92 1.02 0.31 00036005 A Injection ext venography 0.95 8.31 9.00 0.34 0.39 0.14 00036010 A Place catheter in vein 2.43 11.63 13.65 0.85 0.93 0.37 XXX36011 A Place catheter in vein 3.14 20.91 23.32 1.13 1.22 0.45 XXX36012 A Place catheter in vein 3.51 20.65 22.10 1.26 1.41 0.54 XXX36013 A Place catheter in artery 2.52 19.04 20.82 0.92 0.99 0.47 XXX36014 A Place catheter in artery 3.02 19.80 21.48 1.07 1.24 0.34 XXX36015 A Place catheter in artery 3.51 21.05 23.10 1.25 1.43 0.38 XXXCMS-1503-P917**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**36100 A Establish access to artery 3.02 10.70 11.99 1.13 1.28 0.69 XXX36120 A Establish access to artery 2.01 10.13 10.89 0.70 0.74 0.34 XXX36140 A Establish access to artery 2.01 10.48 11.79 0.73 0.80 0.41 XXX36147 A Access av dial grft foreval 3.72 19.47 19.47 1.37 1.37 0.52 XXX36148 A Access av dial grft for proc 1.00 6.33 6.33 0.35 0.35 0.13 ZZZ36160 A Establish access to aorta 2.52 10.84 12.41 0.88 1.04 0.40 XXX36200 A Place catheter in aorta 3.02 14.04 15.57 1.06 1.17 0.62 XXX36215 A Place catheter in artery 4.67 25.88 28.46 1.76 2.01 0.85 XXX36216 A Place catheter in artery 5.27 28.59 31.15 2.04 2.29 0.96 XXX36217 A Place catheter in artery 6.29 49.15 53.44 2.45 2.73 1.10 XXX36218 A Place catheter in artery 1.01 4.04 4.47 0.39 0.43 0.17 ZZZ36245 A Place catheter in artery 4.67 26.00 30.38 1.76 2.12 0.90 XXX36246 A Place catheter in artery 5.27 26.81 30.05 1.91 2.18 1.02 XXX36247 A Place catheter in artery 6.29 44.40 49.59 2.27 2.58 1.23 XXX36248 A Place catheter in artery 1.01 3.13 3.58 0.35 0.41 0.17 ZZZ36260 A Insertion of infusion pump 9.91 NA NA 7.08 6.43 2.20 09036261 A Revision of infusion pump 5.63 NA NA 4.92 4.52 1.38 09036262 A Removal of infusion pump 4.11 NA NA 3.99 3.67 0.90 09036299 C Vessel injection procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY36400 A Bl draw < 3 yrs fem/jugular 0.38 0.50 0.42 0.07 0.08 0.06 XXX36405 A Bl draw < 3 yrs scalp vein 0.31 0.32 0.34 0.12 0.11 0.06 XXX36406 A Bl draw < 3 yrs other vein 0.18 0.27 0.29 0.07 0.07 0.03 XXX36410 A Non-routine bl draw > 3 yrs 0.18 0.40 0.39 0.08 0.07 0.03 XXX36415 X Routine venipuncture 0.00 0.00 0.00 0.00 0.00 0.00 XXX36416 B Capillary blood draw0.00 0.00 0.00 0.00 0.00 0.00 XXX36420 A Vein access cutdown < 1 yr 1.01 NA NA 0.22 0.26 0.13 XXXCMS-1503-P918**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**36425 A Vein access cutdown > 1 yr 0.76 NA NA 0.33 0.31 0.11 XXX36430 A Blood transfusion service 0.00 0.87 1.00 NA NA 0.01 XXX36440 A Bl push transfuse, 2 yr or < 1.03 NA NA 0.49 0.41 0.25 XXX36450 A Bl exchange/transfuse, nb 2.23 NA NA 1.06 1.01 0.11 XXX36455 A Bl exchange/transfuse non-nb 2.43 NA NA 0.83 0.97 0.14 XXX36460 A Transfusion service, fetal 6.58 NA NA 2.96 2.64 1.46 XXX36468 R Injection(s), spider veins 0.00 0.00 0.00 0.00 0.00 0.00 00036469 R Injection(s), spider veins 0.00 0.00 0.00 0.00 0.00 0.00 00036470 A Injection therapy of vein 1.10 2.86 2.89 0.83 0.82 0.23 01036471 A Injection therapy of veins 1.65 3.17 3.22 1.09 1.06 0.34 01036475 A Endovenous rf, 1st vein 6.72 43.24 45.70 2.77 2.71 1.47 00036476 A Endovenous rf, vein add-on 3.38 7.50 7.70 1.23 1.21 0.75 ZZZ36478 A Endovenous laser, 1st vein 6.72 30.82 34.49 2.70 2.73 1.37 00036479 A Endovenous laser vein addon 3.38 7.63 8.08 1.27 1.24 0.68 ZZZ36481 A Insertion of catheter, vein 6.98 51.68 28.38 2.88 2.88 0.92 00036500 A Insertion of catheter, vein 3.51 NA NA 1.31 1.45 0.55 0003650F I Eeg ordered rvwd reqstd 0.00 0.00 0.00 0.00 0.00 0.00 XXX36510 A Insertion of catheter, vein 1.09 1.48 1.78 0.52 0.49 0.25 00036511 A Apheresis wbc 1.74 NA NA 0.85 0.80 0.28 00036512 A Apheresis rbc 1.74 NA NA 0.84 0.82 0.17 00036513 A Apheresis platelets 1.74 NA NA 0.95 0.89 0.35 00036514 A Apheresis plasma 1.74 11.68 13.00 0.76 0.74 0.28 00036515 A Apheresis, adsorp/reinfuse 1.74 48.65 54.00 0.85 0.76 0.25 00036516 A Apheresis, selective 1.22 52.68 60.37 0.54 0.52 0.37 00036522 A Photopheresis 1.67 33.80 37.55 1.16 1.16 0.17 00036555 A Insert non-tunnel cv cath 2.68 4.50 4.95 0.63 0.72 0.23 000CMS-1503-P919**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**36556 A Insert non-tunnel cv cath 2.50 3.80 4.04 0.82 0.78 0.32 00036557 A Insert tunneled cv cath 5.14 22.24 21.23 3.54 3.31 1.13 01036558 A Insert tunneled cv cath 4.84 16.33 18.00 2.71 2.87 0.75 01036560 A Insert tunneled cv cath 6.29 31.33 30.09 4.05 3.76 0.61 01036561 A Insert tunneled cv cath 6.04 26.10 27.41 3.51 3.45 1.14 01036563 A Insert tunneled cv cath 6.24 29.87 29.29 3.82 3.59 1.36 01036565 A Insert tunneled cv cath 6.04 21.21 22.16 3.30 3.27 1.34 01036566 A Insert tunneled cv cath 6.54 137.55 122.33 3.63 3.52 1.31 01036568 A Insert picc cath 1.92 5.58 6.54 0.69 0.73 0.18 00036569 A Insert picc cath 1.82 4.75 5.51 0.69 0.76 0.18 00036570 A Insert picvad cath 5.36 23.21 26.86 2.83 3.10 0.51 01036571 A Insert picvad cath 5.34 29.61 30.79 3.27 3.19 1.06 01036575 A Repair tunneled cv cath 0.67 3.72 3.94 0.28 0.29 0.10 00036576 A Repair tunneled cv cath 3.24 6.95 7.18 2.01 2.02 0.58 01036578 A Replace tunneled cv cath 3.54 10.17 10.88 2.29 2.41 0.55 01036580 A Replace cvad cath 1.31 4.42 5.04 0.52 0.54 0.17 00036581 A Replace tunneled cv cath 3.48 16.91 18.37 1.88 2.06 0.45 01036582 A Replace tunneled cv cath 5.24 24.83 26.04 3.03 3.10 0.92 01036583 A Replace tunneled cv cath 5.29 31.74 29.50 3.61 3.38 1.19 01036584 A Replace picc cath 1.20 4.17 4.93 0.62 0.69 0.11 00036585 A Replace picvad cath4.84 24.90 26.77 2.76 2.92 0.69 01036589 A Removal tunneled cv cath 2.28 2.21 2.30 1.50 1.54 0.38 01036590 A Removal tunneled cv cath 3.35 4.55 4.43 2.17 2.10 0.65 01036591 T Draw blood off venous device 0.00 0.59 0.66 NA NA 0.01 XXX36592 T Collect blood from picc 0.00 0.67 0.73 NA NA 0.01 XXX36593 A Declot vascular device 0.00 0.79 0.82 NA NA 0.01 XXXCMS-1503-P920**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**36595 A Mech remov tunneled cv cath 3.59 11.42 13.19 1.45 1.63 0.41 00036596 A Mech remov tunneled cv cath 0.75 2.80 3.11 0.47 0.51 0.10 00036597 A Reposition venous catheter 1.21 2.11 2.35 0.46 0.52 0.11 00036598 T Inj w/fluor, eval cv device 0.74 2.21 2.48 0.26 0.65 0.07 00036600 A Withdrawal of arterialblood 0.32 0.51 0.55 0.11 0.10 0.03 XXX36620 A Insertion catheter, artery 1.15 NA NA 0.28 0.24 0.10 00036625 A Insertion catheter, artery 2.11 NA NA 0.70 0.69 0.44 00036640 A Insertion catheter, artery 2.10 NA NA 1.38 1.27 0.44 00036660 A Insertion catheter, artery 1.40 NA NA 0.67 0.52 0.35 00036680 A Insert needle, bone cavity 1.20 NA NA 0.34 0.36 0.23 00036800 A Insertion of cannula 2.43 NA NA 1.97 1.96 0.44 00036810 A Insertion of cannula 3.96 NA NA 1.76 1.71 0.76 00036815 A Insertion of cannula 2.62 NA NA 1.44 1.40 0.58 00036818 A Av fuse, uppr arm, cephalic 11.89 NA NA 6.33 6.20 2.76 09036819 A Av fuse, uppr arm, basilic 14.47 NA NA 7.21 7.00 3.38 09036820 A Av fusion/forearm vein 14.47 NA NA 7.46 7.17 3.36 09036821 A Av fusion direct any site 12.11 NA NA 6.76 6.37 2.81 09036822 A Insertion of cannula(s) 5.57 NA NA 4.63 4.72 1.34 09036823 A Insertion of cannula(s) 22.98 NA NA 12.27 11.75 5.20 09036825 A Artery-vein autograft 15.13 NA NA 7.77 6.64 3.50 09036830 A Artery-vein nonautograft 12.03 NA NA 5.79 5.64 2.81 09036831 A Open thrombect av fistula 8.04 NA NA 4.42 4.30 1.87 09036832 A Av fistula revision, open 10.53 NA NA 5.26 5.11 2.43 09036833 A Av fistula revision 11.98 NA NA 5.82 5.65 2.80 09036835 A Artery to vein shunt 7.51 NA NA 5.84 5.42 1.85 09036838 A Dist revas ligation, hemo 21.69 NA NA 9.51 9.48 5.13 090CMS-1503-P921**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**36860 A External cannula declotting 2.01 3.69 3.64 1.02 0.92 0.27 00036861 A Cannula declotting2.52 NA NA 1.57 1.59 0.49 00036870 A Percut thrombect av fistula 5.20 44.72 48.60 2.98 3.26 0.71 09037140 A Revision of circulation 25.23 NA NA 13.94 12.69 5.58 09037145 A Revision of circulation 26.24 NA NA 14.28 13.48 5.93 09037160 A Revision of circulation 23.24 NA NA 13.08 11.81 5.16 09037180 A Revision of circulation 26.24 NA NA 14.37 12.88 5.82 09037181 A Splice spleen/kidney veins 28.37 NA NA 15.29 13.88 6.27 09037182 A Insert hepatic shunt (tips) 16.97 NA NA 5.96 7.07 1.68 00037183 A Remove hepatic shunt (tips) 7.99 145.78 145.78 2.83 3.41 0.76 00037184 A Prim art mech thrombectomy 8.66 53.20 59.90 3.47 3.83 1.57 00037185 A Prim art m-thrombect add-on 3.28 17.07 19.28 1.18 1.30 0.64 ZZZ37186 A Sec art m-thrombect add-on 4.92 33.73 39.87 1.80 2.07 0.99 ZZZ37187 A Venous mech thrombectomy 8.03 50.66 57.41 3.08 3.49 1.17 00037188 A Venous m-thrombectomy add-on 5.71 43.51 49.71 2.31 2.63 0.72 00037195 C Thrombolytic therapy, stroke 0.00 0.00 0.00 0.00 0.00 0.00 XXX37200 A Transcatheter biopsy 4.55 NA NA 1.54 1.83 0.44 00037201 A Transcatheter therapy infuse 4.99 NA NA 2.41 2.70 0.79 00037202 A Transcatheter therapy infuse 5.67 NA NA 2.94 3.45 1.23 00037203 A Transcatheter retrieval 5.02 30.61 33.65 2.01 2.31 0.71 00037204 A Transcatheter occlusion 18.11 NA NA 6.22 7.13 2.30 00037205 A Transcath iv stent, percut 8.27 106.19 116.33 3.01 3.58 1.62 00037206 A Transcath iv stent/perc addl 4.12 64.76 71.03 1.48 1.69 0.85 ZZZ37207 A Transcath iv stent, open 8.27 NA NA 3.24 3.25 1.94 00037208 A Transcath iv stent/open addl 4.12 NA NA 1.42 1.41 0.96 ZZZ37209 A Change iv cath at thromb tx 2.27 NA NA 0.77 0.87 0.34 000CMS-1503-P922**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**37210 A Embolization uterine fibroid 10.60 84.76 92.32 3.65 4.45 1.06 00037215 R Transcath stent, cca w/eps 19.68 NA NA 8.88 10.37 4.35 09037216 N Transcath stent, cca w/o eps 18.95 NA NA 9.92 9.85 1.38 09037250 A Iv us first vessel add-on 2.10 NA NA 0.74 0.84 0.47 ZZZ37251 A Iv us each add vessel add-on 1.60 NA NA 0.54 0.58 0.37 ZZZ37500 A Endoscopy ligate perf veins 11.67 NA NA 7.08 7.07 2.73 09037501 C Vascular endoscopy procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY37565 A Ligation of neck vein 12.05 NA NA 7.65 7.11 2.67 09037600 A Ligation of neck artery 12.42 NA NA 7.08 6.81 2.64 09037605 A Ligation of neck artery 14.28 NA NA 7.47 7.28 3.52 09037606 A Ligation of neck artery 8.81 NA NA 4.41 4.87 1.95 09037607 A Ligation of a-v fistula 6.25 NA NA 4.08 3.98 1.43 09037609 A Temporal artery procedure 3.05 5.54 5.34 2.64 2.46 0.66 01037615 A Ligation of neck artery 7.80 NA NA 6.81 5.94 1.71 09037616 A Ligation of chest artery 18.97 NA NA 10.21 10.10 4.21 09037617 A Ligation of abdomen artery 23.79 NA NA 11.64 10.93 5.21 09037618 A Ligation of extremity artery 6.03 NA NA 4.48 4.34 1.37 09037620 A Revision of major vein 11.57 NA NA 5.81 6.38 1.77 09037650 A Revision of major vein 8.49 NA NA 4.16 4.73 1.95 09037660 A Revision of major vein 22.28 NA NA 12.06 10.94 4.93 09037700 A Revise leg vein 3.82 NA NA 3.13 3.08 0.88 09037718 A Ligate/strip short leg vein 7.13 NA NA 4.82 4.68 1.62 09037722 A Ligate/strip long leg vein 8.16 NA NA 5.09 4.93 1.88 09037735 A Removal of leg veins/lesion 10.90 NA NA 6.12 6.06 2.49 09037760 A Ligate leg veins radical 10.78 NA NA 7.35 6.61 2.37 09037761 A Ligate leg veins open 9.13 NA NA 6.14 6.14 2.03 090CMS-1503-P923**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**37765 A Phleb veins - extrem - to 20 7.71 10.42 7.61 NA NA 1.62 09037766 A Phleb veins - extrem 20+ 9.66 11.80 8.66 NA NA 2.09 09037780 A Revision of leg vein 3.93 NA NA 3.23 3.19 0.89 09037785 A Ligate/divide/excise vein 3.93 5.90 5.94 3.24 3.20 0.89 09037788 A Revascularization, penis 23.33 NA NA 12.62 13.48 5.17 09037790 A Penile venous occlusion 8.43 NA NA 5.00 5.22 0.85 09037799 C Vascular surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY38100 A Removal of spleen, total 19.55 NA NA 10.62 9.49 4.24 09038101 A Removal of spleen, partial 19.55 NA NA 10.89 9.67 4.32 09038102 A Removal of spleen, total 4.79 NA NA 2.05 1.88 1.03 ZZZ38115 A Repair of ruptured spleen 21.88 NA NA 11.65 10.41 4.45 09038120 A Laparoscopy, splenectomy 17.07 NA NA 10.56 9.63 3.74 09038129 C Laparoscope proc, spleen 0.00 0.00 0.00 0.00 0.00 0.00 YYY38200 A Injection for spleen x-ray 2.64 NA NA 1.14 1.16 0.65 00038204 B Bl donor search management 2.00 NA NA 0.86 0.84 0.14 XXX38205 R Harvest allogenic stem cells 1.50 NA NA 0.78 0.75 0.08 00038206 R Harvest auto stem cells 1.50 NA NA 0.78 0.75 0.11 00038207 I Cryopreserve stem cells 0.89 NA NA 0.38 0.46 0.06 XXX38208 I Thaw preserved stem cells 0.56 NA NA 0.24 0.29 0.04 XXX38209 I Wash harvest stem cells 0.24 NA NA 0.10 0.12 0.01 XXX38210 I T-cell depletion of harvest 1.57 NA NA 0.68 0.81 0.10 XXX38211 I Tumor cell deplete of harvst 1.42 NA NA 0.61 0.73 0.10 XXX38212 I Rbc depletion of harvest 0.94 NA NA 0.41 0.49 0.06 XXX38213 I Platelet deplete of harvest 0.24 NA NA 0.10 0.12 0.01 XXX38214 I Volume deplete of harvest 0.81 NA NA 0.35 0.42 0.06 XXX38215 I Harvest stem cell concentrte 0.94 NA NA 0.41 0.49 0.06 XXXCMS-1503-P924**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**38220 A Bone marrow aspiration 1.08 2.85 3.20 0.61 0.61 0.11 XXX38221 A Bone marrow biopsy 1.37 2.87 3.29 0.77 0.76 0.08 XXX38230 R Bone marrow collection 4.85 NA NA 4.34 4.07 1.14 01038240 R Bone marrow/stem transplant 2.24 NA NA 1.31 1.27 0.17 XXX38241 R Bone marrow/stem transplant 2.24 NA NA 1.30 1.27 0.14 XXX38242 A Lymphocyte infuse transplant 1.71 NA NA 1.03 0.98 0.10 00038300 A Drainage, lymph node lesion 2.36 5.20 5.16 2.66 2.57 0.42 01038305 A Drainage, lymph node lesion 6.68 NA NA 5.61 5.38 1.38 09038308 A Incision of lymph channels 6.81 NA NA 5.09 4.75 1.51 09038380 A Thoracic duct procedure 8.46 NA NA 7.87 7.13 1.13 09038381 A Thoracic duct procedure 13.38 NA NA 7.51 7.64 3.26 09038382 A Thoracic duct procedure 10.65 NA NA 6.92 6.81 2.35 09038500 A Biopsy/removal, lymph nodes 3.79 5.05 4.78 2.92 2.72 0.81 01038505 A Needle biopsy, lymph nodes 1.14 2.23 2.38 0.80 0.86 0.13 00038510 A Biopsy/removal, lymph nodes 6.74 7.45 7.03 4.70 4.33 1.26 01038520 A Biopsy/removal, lymph nodes 7.03 NA NA 5.42 5.08 1.47 09038525 A Biopsy/removal, lymph nodes 6.43 NA NA 5.03 4.62 1.41 09038530 A Biopsy/removal, lymph nodes 8.34 NA NA 6.17 5.69 1.89 09038542 A Explore deep node(s), neck 7.95 NA NA 6.37 5.89 1.38 09038550 A Removal, neck/armpit lesion 7.11 NA NA 6.27 5.69 1.58 09038555 A Removal, neck/armpit lesion 15.59 NA NA 10.89 10.24 3.48 09038562 A Removal, pelvic lymph nodes 11.06 NA NA 7.51 7.32 2.03 09038564 A Removal, abdomen lymph nodes 11.38 NA NA 7.23 6.82 2.33 09038570 A Laparoscopy, lymph node biop 9.34 NA NA 5.08 5.09 1.43 01038571 A Laparoscopy, lymphadenectomy 14.76 NA NA 7.03 7.71 1.54 01038572 A Laparoscopy, lymphadenectomy 16.94 NA NA 8.70 8.26 2.49 010CMS-1503-P925**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**38589 C Laparoscope proc, lymphatic 0.00 0.00 0.00 0.00 0.00 0.00 YYY38700 A Removal of lymph nodes, neck 12.81 NA NA 9.92 8.97 1.84 09038720 A Removal of lymph nodes, neck 21.95 NA NA 15.57 14.02 3.52 09038724 A Removal of lymph nodes, neck 23.95 NA NA 17.22 15.28 3.48 09038740 A Remove armpit lymph nodes 10.70 NA NA 7.42 6.80 2.35 09038745 A Remove armpit lymph nodes 13.87 NA NA 9.09 8.29 3.07 09038746 A Remove thoracic lymph nodes 4.88 NA NA 1.77 1.83 1.19 ZZZ38747 A Remove abdominal lymph nodes 4.88 NA NA 2.07 1.90 1.07 ZZZ38760 A Remove groin lymph nodes 13.62 NA NA 8.58 8.01 2.90 09038765 A Remove groin lymph nodes 21.91 NA NA 12.14 11.42 4.39 09038770 A Remove pelvis lymph nodes 14.06 NA NA 7.77 7.97 1.84 09038780 A Remove abdomen lymph nodes 17.70 NA NA 10.09 10.17 2.66 09038790 A Inject for lymphatic x-ray 1.29 NA NA 0.94 0.93 0.25 00038792 A Identify sentinel node 0.52 NA NA 0.57 0.58 0.08 00038794 A Access thoracic lymph duct 4.62 NA NA 3.22 3.65 0.44 09038999 C Blood/lymph system procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY39000 A Exploration of chest 7.57 NA NA 5.67 5.58 1.74 09039010 A Exploration of chest 13.19 NA NA 7.47 7.73 3.25 09039200 A Removal chest lesion 15.09 NA NA 7.80 7.98 3.67 09039220 A Removal chest lesion 19.55 NA NA 10.27 10.39 4.61 09039400 A Visualization of chest 8.05 NA NA 5.23 5.30 1.95 01039499 C Chest procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY39501 A Repair diaphragm laceration 13.98 NA NA 8.32 7.88 3.07 09039502 A Repair paraesophageal hernia 17.18 NA NA 9.98 9.17 3.82 09039503 A Repair of diaphragm hernia 108.91 NA NA 51.39 45.17 24.12 09039520 A Repair of diaphragm hernia 16.74 NA NA 9.50 9.17 3.84 090CMS-1503-P926**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**39530 A Repair of diaphragm hernia 16.30 NA NA 9.03 8.58 3.74 09039531 A Repair of diaphragm hernia 17.31 NA NA 10.09 9.11 3.84 09039540 A Repair of diaphragm hernia 14.57 NA NA 8.64 7.93 3.24 09039541 A Repair of diaphragm hernia 15.75 NA NA 9.08 8.43 3.53 09039545 A Revision of diaphragm 14.67 NA NA 8.61 8.68 3.55 09039560 A Resect diaphragm, simple 13.06 NA NA 7.72 7.41 2.90 09039561 A Resect diaphragm, complex 19.99 NA NA 12.81 12.20 4.55 09039599 C Diaphragm surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY4004F I Pt tobacco use done rcvd tlk 0.00 0.00 0.00 0.00 0.00 0.00 XXX40490 A Biopsy of lip 1.22 2.34 2.35 0.87 0.81 0.18 00040500 A Partial excision of lip 4.47 9.80 9.47 5.85 5.55 0.69 09040510 A Partial excision of lip 4.82 8.81 8.46 5.28 4.93 0.73 09040520 A Partial excision of lip 4.79 9.01 8.77 5.37 5.04 0.78 09040525 A Reconstruct lip with flap 7.72 NA NA 7.81 7.38 1.31 09040527 A Reconstruct lip with flap 9.32 NA NA 8.43 8.19 1.24 09040530 A Partial removal of lip5.54 9.66 9.39 5.89 5.57 0.89 0904063F I Antidepres rxthxpy not rxd 0.00 0.00 0.00 0.00 0.00 0.00 XXX40650 A Repair lip 3.78 7.80 7.60 4.20 4.03 0.68 09040652 A Repair lip 4.43 9.07 8.87 5.40 5.14 0.79 09040654 A Repair lip 5.48 10.39 10.14 6.41 6.10 0.96 09040700 A Repair cleft lip/nasal 14.17 NA NA 14.13 12.32 1.89 09040701 A Repair cleft lip/nasal 17.23 NA NA 13.54 13.27 2.29 09040702 A Repair cleft lip/nasal 14.27 NA NA 8.96 9.01 1.06 09040720 A Repair cleft lip/nasal 14.72 NA NA 11.81 11.33 3.02 09040761 A Repair cleft lip/nasal 15.84 NA NA 14.67 13.27 3.25 09040799 C Lip surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYYCMS-1503-P927**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**40800 A Drainage of mouth lesion 1.23 4.68 4.51 2.48 2.36 0.18 01040801 A Drainage of mouth lesion 2.63 6.25 5.96 3.68 3.45 0.38 01040804 A Removal, foreign body, mouth 1.30 4.89 4.64 2.53 2.37 0.17 01040805 A Removal, foreign body, mouth 2.79 6.38 6.14 3.63 3.44 0.37 01040806 A Incision of lip fold 0.31 2.66 2.68 0.51 0.56 0.04 00040808 A Biopsy of mouth lesion 1.01 4.30 4.16 2.09 2.01 0.13 01040810 A Excision of mouth lesion 1.36 4.52 4.34 2.30 2.18 0.18 01040812 A Excise/repair mouth lesion 2.37 5.78 5.51 3.27 3.05 0.32 01040814 A Excise/repair mouth lesion 3.52 7.42 7.02 5.20 4.88 0.49 09040816 A Excision of mouth lesion 3.77 7.69 7.31 5.30 4.99 0.54 09040818 A Excise oral mucosa for graft 2.83 7.15 7.00 4.81 4.73 0.38 09040819 A Excise lip or cheek fold 2.51 6.18 5.92 4.19 3.97 0.34 09040820 A Treatment of mouth lesion 1.34 6.16 6.09 3.56 3.50 0.18 01040830 A Repair mouth laceration 1.82 5.16 4.96 2.65 2.54 0.32 01040831 A Repair mouth laceration 2.57 6.78 6.45 3.69 3.55 0.44 01040840 R Reconstruction of mouth 9.15 15.44 13.84 9.74 8.57 1.23 09040842 R Reconstruction of mouth 9.15 13.83 12.84 9.27 8.14 1.23 09040843 R Reconstruction of mouth 12.79 16.79 15.62 9.80 8.90 2.61 09040844 R Reconstruction of mouth 16.80 21.94 20.60 15.76 14.12 3.45 09040845 R Reconstruction of mouth 19.36 22.03 20.88 15.51 14.48 2.57 09040899 C Mouth surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY41000 A Drainage of mouth lesion 1.35 3.24 3.11 1.84 1.74 0.18 01041005 A Drainage of mouth lesion 1.31 4.99 4.96 2.36 2.26 0.17 01041006 A Drainage of mouth lesion 3.34 6.94 6.62 4.25 3.89 0.44 09041007 A Drainage of mouth lesion 3.20 6.94 6.74 3.87 3.69 0.42 09041008 A Drainage of mouth lesion 3.46 7.23 6.83 4.23 3.93 0.45 090CMS-1503-P928**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**41009 A Drainage of mouth lesion 3.71 7.67 7.24 4.64 4.32 0.49 09041010 A Incision of tongue fold 1.11 4.77 4.66 2.04 1.97 0.14 01041015 A Drainage of mouth lesion 4.08 8.63 7.94 5.82 5.34 0.54 09041016 A Drainage of mouth lesion 4.19 8.25 7.81 5.82 5.43 0.55 09041017 A Drainage of mouth lesion 4.19 8.38 7.93 5.86 5.48 0.55 09041018 A Drainage of mouth lesion 5.22 8.79 8.39 6.18 5.84 0.69 09041019 A Place needles h&n for rt 8.84 NA NA 4.78 4.52 0.75 00041100 A Biopsy of tongue 1.42 3.37 3.26 1.67 1.59 0.21 01041105 A Biopsy of tongue 1.47 3.40 3.25 1.73 1.62 0.21 01041108 A Biopsy of floor of mouth 1.10 3.13 3.01 1.50 1.41 0.14 01041110 A Excision of tongue lesion 1.56 4.53 4.35 2.23 2.11 0.23 01041112 A Excision of tongue lesion 2.83 6.70 6.40 4.43 4.18 0.38 09041113 A Excision of tongue lesion 3.29 7.10 6.76 4.74 4.44 0.44 09041114 A Excision of tongue lesion 8.82 NA NA 9.43 8.74 1.22 09041115 A Excision of tongue fold 1.79 5.17 5.01 2.56 2.37 0.24 01041116 A Excision of mouth lesion 2.52 6.93 6.61 3.80 3.59 0.35 09041120 A Partial removal of tongue 11.14 NA NA 18.83 18.25 1.54 09041130 A Partial removal of tongue 15.74 NA NA 21.48 20.42 2.16 09041135 A Tongue and neck surgery 30.14 NA NA 31.21 29.21 4.2009041140 A Removal of tongue 29.15 NA NA 33.27 31.63 3.90 09041145 A Tongue removal, neck surgery 37.93 NA NA 41.01 38.48 5.0609041150 A Tongue, mouth, jaw surgery 29.86 NA NA 32.33 30.53 4.1109041153 A Tongue, mouth, neck surgery 33.59 NA NA 34.21 31.96 4.5809041155 A Tongue, jaw, & neck surgery 44.30 NA NA 40.59 37.26 6.1509041250 A Repair tongue laceration 1.96 5.08 4.63 2.20 1.99 0.34 01041251 A Repair tongue laceration 2.32 5.28 4.62 2.45 2.23 0.31 010CMS-1503-P929**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**41252 A Repair tongue laceration 3.02 5.84 5.51 2.93 2.75 0.49 01041500 A Fixation of tongue 3.80 NA NA 9.19 8.89 0.51 09041510 A Tongue to lip surgery 3.51 NA NA 6.44 7.17 0.4509041512 A Tongue suspension 6.86 NA NA 11.44 10.82 0.5109041520 A Reconstruction, tongue fold 2.83 7.12 6.83 4.50 4.26 0.37 09041530 A Tongue base vol reduction 4.51 88.45 88.27 7.42 7.07 0.3201041599 C Tongue and mouth surgery 0.00 0.00 0.00 0.00 0.00 0.00 YYY41800 A Drainage of gum lesion 1.27 6.03 5.55 2.73 2.51 0.23 01041805 A Removal foreign body, gum 1.34 5.60 5.39 3.50 3.36 0.18 01041806 A Removal foreign body,jawbone 2.79 7.54 6.97 4.71 4.36 0.57 01041820 R Excision, gum, each quadrant 0.00 0.00 0.00 0.00 0.00 0.00 00041821 R Excision of gum flap 0.00 0.00 0.00 0.00 0.00 0.00 00041822 R Excision of gum lesion 2.41 5.80 5.55 2.83 2.51 0.32 01041823 R Excision of gum lesion 3.77 8.33 8.02 5.48 5.12 0.49 09041825 A Excision of gum lesion 1.41 4.54 4.39 2.07 2.05 0.21 01041826 A Excision of gum lesion 2.41 6.44 5.90 3.65 3.33 0.32 01041827 A Excision of gum lesion 3.83 8.59 8.15 4.97 4.61 0.51 09041828 R Excision of gum lesion 3.14 5.54 5.18 2.98 2.71 0.41 01041830 R Removal of gum tissue 3.45 7.65 7.25 4.66 4.29 0.45 01041850 R Treatment of gum lesion 0.00 0.00 0.00 0.00 0.00 0.00 00041870 R Gum graft 0.00 0.00 0.00 0.00 0.00 0.00 00041872 R Repair gum 3.01 7.24 7.04 4.43 4.23 0.62 09041874 R Repair tooth socket 3.19 7.35 6.98 4.11 3.80 0.41 09041899 C Dental surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY42000 A Drainage mouth roof lesion 1.28 3.17 3.09 1.71 1.60 0.17 01042100 A Biopsy roof of mouth 1.36 2.92 2.80 1.78 1.67 0.18 010CMS-1503-P930**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**42104 A Excision lesion, mouth roof 1.69 4.48 4.23 2.32 2.15 0.24 01042106 A Excision lesion, mouth roof 2.15 5.60 5.30 2.95 2.80 0.30 01042107 A Excision lesion, mouth roof 4.56 8.56 8.13 5.35 4.99 0.61 09042120 A Remove palate/lesion 11.86 NA NA 16.62 15.67 1.62 09042140 A Excision of uvula 1.70 5.62 5.42 2.79 2.67 0.24 09042145 A Repair palate, pharynx/uvula 9.78 NA NA 10.51 9.81 1.30 09042160 A Treatment mouth roof lesion 1.85 4.81 4.77 2.38 2.32 0.25 01042180 A Repair palate 2.55 3.90 3.93 2.33 2.35 0.34 01042182 A Repair palate 3.87 5.36 5.11 3.52 3.34 0.51 01042200 A Reconstruct cleft palate 12.53 NA NA 11.95 11.44 1.67 09042205 A Reconstruct cleft palate 13.66 NA NA 14.21 12.64 1.84 09042210 A Reconstruct cleft palate 15.03 NA NA 13.41 13.03 3.08 09042215 A Reconstruct cleft palate 8.99 NA NA 11.31 10.41 1.85 09042220 A Reconstruct cleft palate 7.16 NA NA 8.15 7.78 0.52 09042225 A Reconstruct cleft palate 9.77 NA NA 15.53 15.80 1.30 09042226 A Lengthening of palate 10.35 NA NA 15.38 15.22 1.37 09042227 A Lengthening of palate 9.90 NA NA 14.23 14.52 1.31 09042235 A Repair palate 8.01 NA NA 13.14 12.71 1.07 09042260 A Repair nose to lip fistula 10.22 13.14 12.46 8.77 8.18 1.36 09042280 A Preparation, palate mold 1.59 3.02 2.81 1.55 1.34 0.35 01042281 A Insertion, palate prosthesis 1.98 3.92 3.71 2.37 2.24 0.27 01042299 C Palate/uvula surgery 0.00 0.00 0.00 0.00 0.00 0.00 YYY42300 A Drainage of salivary gland 1.98 4.03 3.84 2.41 2.27 0.28 01042305 A Drainage of salivary gland 6.31 NA NA 5.94 5.57 0.89 09042310 A Drainage of salivary gland 1.61 3.05 2.91 1.98 1.87 0.23 01042320 A Drainage of salivary gland 2.40 4.81 4.58 2.67 2.52 0.32 010CMS-1503-P931**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**42330 A Removal of salivary stone 2.26 4.40 4.21 2.48 2.32 0.31 01042335 A Removal of salivary stone 3.41 7.36 7.02 4.02 3.80 0.44 09042340 A Removal of salivary stone 4.72 8.58 8.20 4.95 4.67 0.64 09042400 A Biopsy of salivary gland 0.78 2.26 2.26 0.80 0.80 0.08 00042405 A Biopsy of salivary gland 3.34 5.13 4.98 3.09 2.92 0.44 01042408 A Excision of salivary cyst 4.66 8.46 8.02 4.81 4.46 0.62 09042409 A Drainage of salivary cyst 2.91 6.72 6.41 3.51 3.32 0.38 09042410 A Excise parotid gland/lesion 9.57 NA NA 8.01 7.45 1.50 09042415 A Excise parotid gland/lesion 18.12 NA NA 13.51 12.49 2.52 09042420 A Excise parotid gland/lesion 21.00 NA NA 15.19 14.01 2.94 09042425 A Excise parotid gland/lesion 13.42 NA NA 10.40 9.70 1.91 09042426 A Excise parotid gland/lesion 22.66 NA NA 15.78 14.61 3.24 09042440 A Excise submaxillary gland 7.13 NA NA 6.21 5.77 0.99 09042450 A Excise sublingual gland 4.74 8.22 7.86 5.56 5.25 0.66 09042500 A Repair salivary duct 4.42 7.99 7.63 5.40 5.11 0.62 09042505 A Repair salivary duct 6.32 9.59 9.14 6.70 6.31 0.83 09042507 A Parotid duct diversion 6.25 NA NA 8.55 8.17 0.83 09042508 A Parotid duct diversion 9.33 NA NA 10.54 10.39 1.24 09042509 A Parotid duct diversion 11.76 NA NA 9.97 10.28 2.39 09042510 A Parotid duct diversion 8.35 NA NA 9.76 9.24 1.12 09042550 A Injection for salivary x-ray 1.25 2.30 2.67 0.44 0.50 0.11 00042600 A Closure of salivary fistula 4.94 8.88 8.55 5.10 4.85 0.66 0904260F I Wound srfc culturetech used 0.00 0.00 0.00 0.00 0.00 0.00 XXX4261F I Tech other than surfc cultr 0.00 0.00 0.00 0.00 0.00 0.00 XXX42650 A Dilation of salivary duct 0.77 1.64 1.56 0.92 0.87 0.10 0004265F I Wet-dry dressings Rx-recmd 0.00 0.00 0.00 0.00 0.00 0.00 XXXCMS-1503-P932**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**42660 A Dilation of salivary duct 1.13 1.92 1.83 1.11 1.04 0.14 00042665 A Ligation of salivary duct 2.63 6.44 6.14 3.35 3.18 0.35 0904266F I No wet-dry drssings Rx-recmd 0.00 0.00 0.00 0.00 0.00 0.00 XXX4268F I Pt ed re comp thxpy rcvd 0.00 0.00 0.00 0.00 0.00 0.00 XXX42699 C Salivary surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY4269F I Appropos mthd offloadingRxd 0.00 0.00 0.00 0.00 0.00 0.00 XXX42700 A Drainage of tonsil abscess 1.67 3.75 3.61 2.22 2.12 0.24 01042720 A Drainage of throat abscess 6.31 6.70 6.28 4.94 4.56 0.86 01042725 A Drainage of throat abscess 12.41 NA NA 10.80 10.03 1.65 0904275F I Hep b vac inj admin/ rcvd 0.00 0.00 0.00 0.00 0.00 0.00 XXX4279F I PCP prophylaxis Rxd 0.00 0.00 0.00 0.00 0.00 0.00 XXX42800 A Biopsy of throat 1.44 3.13 3.00 1.79 1.70 0.21 01042802 A Biopsy of throat 1.59 5.08 5.11 2.24 2.19 0.23 01042804 A Biopsy of upper nose/throat 1.29 4.40 4.37 1.99 1.94 0.17 01042806 A Biopsy of upper nose/throat 1.63 4.74 4.70 2.18 2.12 0.23 01042808 A Excise pharynx lesion 2.35 4.20 4.02 2.32 2.20 0.31 01042809 A Remove pharynx foreign body 1.86 2.97 2.85 1.86 1.73 0.28 01042810 A Excision of neck cyst 3.38 7.84 7.54 4.99 4.70 0.44 09042815 A Excision of neck cyst 7.31 NA NA 8.64 8.16 1.05 09042820 A Remove tonsils and adenoids 4.22 NA NA 4.14 3.88 0.55 09042821 A Remove tonsils and adenoids 4.36 NA NA 4.33 4.08 0.58 09042825 A Removal of tonsils 3.51 NA NA 4.04 3.83 0.45 09042826 A Removal of tonsils 3.45 NA NA 3.79 3.59 0.45 09042830 A Removal of adenoids 2.65 NA NA 3.33 3.16 0.35 09042831 A Removal of adenoids 2.81 NA NA 3.64 3.47 0.37 09042835 A Removal of adenoids 2.38 NA NA 2.54 2.61 0.31 090CMS-1503-P933**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**42836 A Removal of adenoids 3.26 NA NA 3.68 3.50 0.42 09042842 A Extensive surgery of throat 12.23 NA NA 16.39 15.35 1.64 09042844 A Extensive surgery of throat 17.78 NA NA 21.50 20.33 2.36 09042845 A Extensive surgery of throat 32.56 NA NA 31.09 28.97 4.34 09042860 A Excision of tonsil tags 2.30 NA NA 3.13 2.98 0.31 09042870 A Excision of lingual tonsil 5.52 NA NA 11.16 10.80 0.73 09042890 A Partial removal of pharynx 19.13 NA NA 21.40 19.86 2.61 09042892 A Revision of pharyngeal walls 26.03 NA NA 27.69 25.32 3.55 09042894 A Revision of pharyngeal walls 33.92 NA NA 33.77 31.13 4.59 09042900 A Repair throat wound 5.29 NA NA 4.46 4.16 0.71 01042950 A Reconstruction of throat 8.27 NA NA 14.41 14.01 1.19 09042953 A Repair throat, esophagus 9.45 NA NA 17.80 17.69 1.36 09042955 A Surgical opening of throat 8.01 NA NA 13.64 13.03 1.07 09042960 A Control throat bleeding 2.38 NA NA 2.48 2.33 0.32 01042961 A Control throat bleeding 5.77 NA NA 6.33 5.97 0.76 09042962 A Control throat bleeding 7.40 NA NA 7.48 7.05 0.99 09042970 A Control nose/throat bleeding 5.82 NA NA 5.43 5.02 0.88 09042971 A Control nose/throat bleeding 6.60 NA NA 6.58 6.14 0.88 09042972 A Control nose/throat bleeding 7.59 NA NA 7.15 6.65 1.02 09042999 C Throat surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY4300F I Pt rcvng warf thxpy 0.00 0.00 0.00 0.00 0.00 0.00 XXX4301F I Pt not rcvng warf thxpy 0.00 0.00 0.00 0.00 0.00 0.00 XXX43020 A Incision of esophagus 8.23 NA NA 7.29 6.47 1.10 09043030 A Throat muscle surgery 7.99 NA NA 6.73 6.32 1.22 09043045 A Incision of esophagus 21.88 NA NA 11.98 12.15 5.31 0904305F I Pt ed re ft care inspct rcvd 0.00 0.00 0.00 0.00 0.00 0.00 XXXCMS-1503-P934**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**4306F I Pt tlk psych & Rx opd addic 0.00 0.00 0.00 0.00 0.00 0.00 XXX43100 A Excision of esophagus lesion 9.66 NA NA 8.37 7.63 1.29 09043101 A Excision of esophagus lesion 17.07 NA NA 9.09 9.22 4.15 09043107 A Removal of esophagus 44.18 NA NA 22.36 21.75 10.24 09043108 A Removal of esophagus 82.87 NA NA 39.73 34.35 18.34 09043112 A Removal of esophagus 47.48 NA NA 22.24 22.16 11.18 09043113 A Removal of esophagus 80.06 NA NA 39.87 35.93 17.73 09043116 A Partial removal of esophagus 92.99 NA NA 57.11 46.42 12.39 09043117 A Partial removal of esophagus 43.65 NA NA 20.54 20.25 10.24 09043118 A Partial removal of esophagus 67.07 NA NA 32.93 28.81 14.85 09043121 A Partial removal of esophagus 51.43 NA NA 22.70 22.03 12.49 09043122 A Partial removal of esophagus 44.18 NA NA 22.33 21.22 10.00 09043123 A Partial removal of esophagus 83.12 NA NA 41.19 35.25 18.38 09043124 A Removal of esophagus 69.09 NA NA 36.00 31.69 16.80 09043130 A Removal of esophagus pouch 12.53 NA NA 9.43 8.89 2.06 09043135 A Removal of esophagus pouch 26.17 NA NA 12.98 12.44 6.20 09043200 A Esophagus endoscopy 1.59 4.43 4.49 1.35 1.29 0.24 00043201 A Esoph scope w/submucous inj 2.09 6.06 6.22 1.46 1.45 0.31 00043202 A Esophagus endoscopy, biopsy 1.89 5.91 6.07 1.30 1.25 0.30 00043204 A Esoph scope w/sclerosis inj 3.76 NA NA 2.23 2.28 0.61 00043205 A Esophagus endoscopy/ligation 3.78 NA NA 2.35 2.35 0.58 0004320F I Pt talk psychsoc+rx oh dpnd 0.00 0.00 0.00 0.00 0.00 0.00 XXX43215 A Esophagus endoscopy 2.60 NA NA 1.64 1.60 0.42 00043216 A Esophagus endoscopy/lesion 2.40 3.57 3.31 1.56 1.52 0.37 00043217 A Esophagus endoscopy 2.90 7.48 7.66 1.77 1.71 0.51 00043219 A Esophagus endoscopy 2.80 NA NA 1.83 1.84 0.49 000CMS-1503-P935**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**43220 A Esoph endoscopy, dilation 2.10 NA NA 1.42 1.38 0.32 00043226 A Esoph endoscopy, dilation 2.34 NA NA 1.52 1.51 0.38 00043227 A Esoph endoscopy, repair 3.59 NA NA 2.18 2.14 0.57 00043228 A Esoph endoscopy, ablation 3.76 NA NA 2.33 2.31 0.61 00043231 A Esoph endoscopy w/us exam 3.19 NA NA 2.02 2.02 0.49 00043232 A Esoph endoscopy w/us fn bx 4.47 NA NA 2.68 2.67 0.72 00043234 A Upper GI endoscopy, exam 2.01 5.65 5.83 1.30 1.25 0.35 00043235 A Uppr gi endoscopy, diagnosis 2.39 5.59 5.90 1.58 1.57 0.38 00043236 A Uppr gi scope w/submuc inj 2.92 6.96 7.39 1.88 1.89 0.44 00043237 A Endoscopic us exam, esoph 3.98 NA NA 2.44 2.46 0.62 00043238 A Uppr gi endoscopy w/us fn bx 5.02 NA NA 2.98 3.01 0.78 00043239 A Upper GI endoscopy, biopsy 2.87 6.43 6.75 1.84 1.82 0.44 00043240 A Esoph endoscope w/drain cyst 6.85 NA NA 3.99 3.97 1.07 00043241 A Upper GI endoscopy with tube 2.59 NA NA 1.68 1.66 0.41 00043242 A Uppr gi endoscopy w/us fn bx 7.30 NA NA 4.28 4.28 1.12 00043243 A Upper gi endoscopy & inject 4.56 NA NA 2.75 2.75 0.71 00043244 A Upper GI endoscopy/ligation 5.04 NA NA 3.05 3.05 0.76 00043245 A Uppr gi scope dilate strictr 3.18 NA NA 1.96 1.93 0.52 00043246 A Place gastrostomy tube 4.32 NA NA 2.53 2.51 0.72 00043247 A Operative upper GI endoscopy 3.38 NA NA 2.10 2.09 0.54 00043248 A Uppr gi endoscopy/guide wire 3.15 NA NA 2.02 2.03 0.47 00043249 A Esoph endoscopy, dilation 2.90 NA NA 1.87 1.87 0.44 00043250 A Upper GI endoscopy/tumor 3.20 NA NA 1.96 1.92 0.54 00043251 A Operative upper GI endoscopy 3.69 NA NA 2.28 2.26 0.58 00043255 A Operative upper GI endoscopy 4.81 NA NA 2.92 2.92 0.73 00043256 A Uppr gi endoscopy w/stent 4.34 NA NA 2.59 2.59 0.71 000CMS-1503-P936**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**43257 A Uppr gi scope w/thrml txmnt 5.50 NA NA 3.39 3.20 0.83 00043258 A Operative upper GI endoscopy 4.54 NA NA 2.75 2.75 0.71 00043259 A Endoscopic ultrasound exam 5.19 NA NA 3.13 3.13 0.78 00043260 A Endo cholangiopancreatograph 5.95 NA NA 3.53 3.54 0.90 00043261 A Endo cholangiopancreatograph 6.26 NA NA 3.71 3.72 0.95 00043262 A Endo cholangiopancreatograph 7.38 NA NA 4.32 4.33 1.13 00043263 A Endo cholangiopancreatograph 7.28 NA NA 4.19 4.25 1.12 00043264 A Endo cholangiopancreatograph 8.89 NA NA 5.14 5.15 1.36 00043265 A Endo cholangiopancreatograph 10.00 NA NA 5.74 5.75 1.54 00043267 A Endo cholangiopancreatograph 7.38 NA NA 4.27 4.27 1.13 00043268 A Endo cholangiopancreatograph 7.38 NA NA 4.48 4.49 1.13 00043269 A Endo cholangiopancreatograph 8.20 NA NA 4.76 4.77 1.26 00043271 A Endo cholangiopancreatograph 7.38 NA NA 4.31 4.32 1.13 00043272 A Endo cholangiopancreatograph 7.38 NA NA 4.35 4.33 1.13 00043273 A Endoscopic pancreatoscopy 2.24 NA NA 1.22 1.26 0.34 ZZZ43279 A Lap myotomy, heller 22.10 NA NA 11.86 10.80 4.89 09043280 A Laparoscopy, fundoplasty 18.10 NA NA 10.27 9.38 4.00 09043281 A Lap paraesophag hern repair 26.60 NA NA 13.93 13.93 5.88 09043282 A Lap paraesoph her rpr w/mesh 30.10 NA NA 15.42 15.42 6.63 09043289 C Laparoscope proc, esoph 0.00 0.00 0.00 0.00 0.00 0.00 YYY43300 A Repair of esophagus 9.33 NA NA 8.37 7.69 1.24 09043305 A Repair esophagus and fistula 18.10 NA NA 13.27 12.19 2.40 0904330F I Cnslng epi spec sfty issues 0.00 0.00 0.00 0.00 0.00 0.00 XXX43310 A Repair of esophagus 26.26 NA NA 12.22 12.57 6.37 09043312 A Repair esophagus and fistula 29.25 NA NA 12.09 12.96 7.12 09043313 A Esophagoplasty congenital 48.45 NA NA 25.63 23.21 11.78 090CMS-1503-P937**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**43314 A Tracheo-esophagoplasty cong 53.43 NA NA 22.75 24.38 7.14 09043320 A Fuse esophagus & stomach 23.31 NA NA 13.19 12.35 5.17 09043324 A Revise esophagus & stomach 22.99 NA NA 12.40 11.50 5.19 09043325 A Revise esophagus & stomach 22.60 NA NA 12.19 11.37 5.02 09043326 A Revise esophagus & stomach 22.28 NA NA 12.32 11.92 5.24 09043330 A Repair of esophagus 22.19 NA NA 12.25 11.26 4.96 09043331 A Repair of esophagus 23.06 NA NA 12.06 12.16 5.61 09043340 A Fuse esophagus & intestine 22.99 NA NA 13.06 12.00 5.09 09043341 A Fuse esophagus & intestine 24.23 NA NA 14.62 13.91 5.89 09043350 A Surgical opening, esophagus 19.49 NA NA 14.14 12.15 4.31 09043351 A Surgical opening, esophagus 22.05 NA NA 11.70 11.96 5.36 09043352 A Surgical opening, esophagus 17.81 NA NA 9.97 10.09 4.32 09043360 A Gastrointestinal repair 40.11 NA NA 18.39 18.64 9.76 09043361 A Gastrointestinal repair 45.68 NA NA 20.18 20.49 10.12 09043400 A Ligate esophagus veins 25.60 NA NA 14.18 15.40 3.91 09043401 A Esophagus surgery for veins 26.49 NA NA 14.56 13.27 5.86 09043405 A Ligate/staple esophagus 24.73 NA NA 15.68 14.31 5.48 0904340F I Cnslng chldbrng+ women epi 0.00 0.00 0.00 0.00 0.00 0.00 XXX43410 A Repair esophagus wound 16.41 NA NA 11.16 10.42 3.98 09043415 A Repair esophagus wound 28.91 NA NA 16.04 15.41 6.85 09043420 A Repair esophagus opening 16.78 NA NA 12.48 10.98 2.23 09043425 A Repair esophagus opening 25.04 NA NA 14.97 14.20 5.55 09043450 A Dilate esophagus 1.38 2.82 2.99 1.05 1.06 0.23 00043453 A Dilate esophagus 1.51 6.41 6.86 1.12 1.13 0.24 00043456 A Dilate esophagus 2.57 13.49 14.45 1.69 1.67 0.40 00043458 A Dilate esophagus 3.06 7.49 7.80 1.94 1.90 0.47 000CMS-1503-P938**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**43460 A Pressure treatment esophagus 3.79 NA NA 2.38 2.27 0.57 00043496 C Free jejunum flap, microvasc 0.00 0.00 0.00 0.00 0.00 0.00 09043499 C Esophagus surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY43500 A Surgical opening of stomach 12.79 NA NA 7.80 7.11 2.81 09043501 A Surgical repair of stomach 22.60 NA NA 12.61 11.39 4.96 09043502 A Surgical repair of stomach 25.69 NA NA 14.17 12.73 5.68 09043510 A Surgical opening of stomach 15.14 NA NA 11.13 10.10 2.30 09043520 A Incision of pyloric muscle 11.29 NA NA 6.72 6.42 2.60 09043600 A Biopsy of stomach 1.91 NA NA 0.97 0.97 0.30 00043605 A Biopsy of stomach 13.72 NA NA 8.18 7.39 2.98 09043610 A Excision of stomach lesion 16.34 NA NA 9.36 8.46 3.59 09043611 A Excision of stomach lesion 20.38 NA NA 11.60 10.51 4.47 09043620 A Removal of stomach 34.04 NA NA 17.33 15.74 7.53 09043621 A Removal of stomach 39.53 NA NA 19.65 17.58 8.73 09043622 A Removal of stomach 40.03 NA NA 20.04 17.86 8.87 09043631 A Removal of stomach, partial 24.51 NA NA 13.45 12.18 5.40 09043632 A Removal of stomach, partial 35.14 NA NA 17.94 15.73 7.70 09043633 A Removal of stomach, partial 33.14 NA NA 17.11 15.09 7.26 09043634 A Removal of stomach, partial 36.64 NA NA 18.88 16.65 8.11 09043635 A Removal of stomach, partial 2.06 NA NA 0.88 0.79 0.44 ZZZ43640 A Vagotomy & pylorus repair 19.56 NA NA 11.38 10.24 4.28 09043641 A Vagotomy & pylorus repair 19.81 NA NA 11.64 10.37 4.38 09043644 A Lap gastric bypass/roux-en-y 29.40 NA NA 15.93 14.48 6.46 09043645 A Lap gastr bypass incl smll i 31.53 NA NA 16.82 15.26 6.99 09043647 C Lap impl electrode, antrum 0.00 0.00 0.00 0.00 0.00 0.00 YYY43648 C Lap revise/remv eltrd antrum 0.00 0.00 0.00 0.00 0.00 0.00 YYYCMS-1503-P939**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**43651 A Laparoscopy, vagus nerve 10.13 NA NA 7.05 6.43 2.25 09043652 A Laparoscopy, vagus nerve 12.13 NA NA 7.91 7.20 2.68 09043653 A Laparoscopy, gastrostomy 8.48 NA NA 6.54 5.97 1.88 09043659 C Laparoscope proc, stom 0.00 0.00 0.00 0.00 0.00 0.00 YYY43752 A Nasal/orogastric w/stent 0.81 NA NA 0.30 0.32 0.08 00043760 A Change gastrostomy tube 0.90 11.99 10.63 0.41 0.43 0.14 00043761 A Reposition gastrostomy tube 2.01 1.16 1.26 0.79 0.85 0.25 00043770 A Lap place gastr adj device 18.00 NA NA 11.35 10.34 3.96 09043771 A Lap revise gastr adj device 20.79 NA NA 12.58 11.41 4.61 09043772 A Lap rmvl gastr adj device 15.70 NA NA 9.35 8.54 3.49 09043773 A Lap replace gastr adj device 20.79 NA NA 12.56 11.41 4.61 09043774 A Lap rmvl gastr adj all parts 15.76 NA NA 9.35 8.56 3.49 09043775 A Lap sleeve gastrectomy 21.56 NA NA 12.74 12.74 4.78 09043800 A Reconstruction of pylorus 15.43 NA NA 8.87 8.08 3.43 09043810 A Fusion of stomach and bowel 16.88 NA NA 9.71 8.72 3.73 09043820 A Fusion of stomach and bowel 22.53 NA NA 12.59 11.10 4.95 09043825 A Fusion of stomach and bowel 21.76 NA NA 12.51 11.20 4.82 09043830 A Place gastrostomy tube 10.85 NA NA 7.58 6.93 2.32 09043831 A Place gastrostomy tube 8.49 NA NA 7.19 6.60 1.88 09043832 A Place gastrostomy tube 17.34 NA NA 10.23 9.49 3.72 09043840 A Repair of stomach lesion 22.83 NA NA 12.74 11.26 5.00 09043842 N V-band gastroplasty 21.03 NA NA 11.46 11.04 1.55 09043843 A Gastroplasty w/o v-band 21.21 NA NA 12.29 10.98 4.69 09043845 A Gastroplasty duodenal switch 33.30 NA NA 18.07 16.12 7.33 09043846 A Gastric bypass for obesity 27.41 NA NA 15.34 13.86 6.02 09043847 A Gastric bypass incl small i 30.28 NA NA 16.84 14.95 6.70 090CMS-1503-P940**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**43848 A Revision gastroplasty 32.75 NA NA 17.82 16.04 7.21 09043850 A Revise stomach-bowel fusion 27.58 NA NA 14.98 13.34 6.10 09043855 A Revise stomach-bowel fusion 28.69 NA NA 15.46 13.91 6.34 09043860 A Revise stomach-bowel fusion 27.89 NA NA 14.84 13.44 6.10 09043865 A Revise stomach-bowel fusion 29.05 NA NA 15.61 14.01 6.43 09043870 A Repair stomach opening 11.44 NA NA 7.31 6.62 2.44 09043880 A Repair stomach-bowel fistula 27.18 NA NA 14.61 13.22 5.92 09043881 C Impl/redo electrd, antrum 0.00 0.00 0.00 0.00 0.00 0.00 YYY43882 C Revise/remove electrd antrum 0.00 0.00 0.00 0.00 0.00 0.00 YYY43886 A Revise gastric port, open 4.64 NA NA 4.96 4.53 1.03 09043887 A Remove gastric port, open 4.32 NA NA 4.33 3.99 0.95 09043888 A Change gastric port, open 6.44 NA NA 5.70 5.22 1.43 09043999 C Stomach surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY44005 A Freeing of bowel adhesion 18.46 NA NA 10.24 9.25 3.98 09044010 A Incision of small bowel 14.26 NA NA 8.48 7.68 3.12 09044015 A Insert needle cath bowel 2.62 NA NA 1.09 1.01 0.58 ZZZ44020 A Explore small intestine 16.22 NA NA 9.32 8.40 3.53 09044021 A Decompress small bowel 16.31 NA NA 9.42 8.56 3.57 09044025 A Incision of large bowel 16.51 NA NA 9.44 8.52 3.56 09044050 A Reduce bowel obstruction 15.52 NA NA 9.02 8.16 3.36 09044055 A Correct malrotation of bowel 25.63 NA NA 13.49 12.12 5.62 09044100 A Biopsy of bowel 2.01 NA NA 1.06 1.07 0.32 00044110 A Excise intestine lesion(s) 14.04 NA NA 8.27 7.50 3.01 09044111 A Excision of bowel lesion(s) 16.52 NA NA 9.31 8.43 3.57 09044120 A Removal of small intestine 20.82 NA NA 11.26 10.10 4.49 09044121 A Removal of small intestine 4.44 NA NA 1.90 1.72 0.93 ZZZCMS-1503-P941**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**44125 A Removal of small intestine 20.03 NA NA 11.07 9.97 4.22 09044126 A Enterectomy w/o taper, cong 42.23 NA NA 22.20 19.72 9.34 09044127 A Enterectomy w/taper, cong 49.30 NA NA 25.15 22.38 10.91 09044128 A Enterectomy cong, add-on 4.44 NA NA 1.91 1.73 0.96 ZZZ44130 A Bowel to bowel fusion 22.11 NA NA 12.41 10.92 4.73 09044132 R Enterectomy, cadaver donor 0.00 0.00 0.00 0.00 0.00 0.00 XXX44133 R Enterectomy, live donor 0.00 0.00 0.00 0.00 0.00 0.00 XXX44135 R Intestine transplnt, cadaver 0.00 0.00 0.00 0.00 0.00 0.00 XXX44136 R Intestine transplant, live 0.00 0.00 0.00 0.00 0.00 0.00 XXX44137 C Remove intestinal allograft 0.00 0.00 0.00 0.00 0.00 0.00 XXX44139 A Mobilization of colon 2.23 NA NA 0.96 0.86 0.45 ZZZ44140 A Partial removal of colon 22.59 NA NA 12.68 11.47 4.82 09044141 A Partial removal of colon 29.91 NA NA 18.17 16.16 6.42 09044143 A Partial removal of colon 27.79 NA NA 16.03 14.49 5.96 09044144 A Partial removal of colon 29.91 NA NA 16.66 14.82 6.42 09044145 A Partial removal of colon 28.58 NA NA 15.25 13.77 5.88 09044146 A Partial removal of colon 35.30 NA NA 20.87 18.68 7.14 09044147 A Partial removal of colon 33.69 NA NA 17.49 15.22 7.04 09044150 A Removal of colon 30.18 NA NA 19.31 17.37 6.36 09044151 A Removal of colon/ileostomy 34.92 NA NA 21.34 19.21 7.73 09044155 A Removal of colon/ileostomy 34.42 NA NA 21.07 18.84 6.71 09044156 A Removal of colon/ileostomy 37.42 NA NA 23.24 20.85 8.29 09044157 A Colectomy w/ileoanal anast 35.70 NA NA 21.40 19.31 7.91 09044158 A Colectomy w/neo-rectum pouch 36.70 NA NA 21.69 19.59 8.12 09044160 A Removal of colon 20.89 NA NA 11.84 10.65 4.42 09044180 A Lap, enterolysis 15.27 NA NA 8.90 8.12 3.29 090CMS-1503-P942**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**44186 A Lap, jejunostomy 10.38 NA NA 6.73 6.23 2.30 09044187 A Lap, ileo/jejuno-stomy 17.40 NA NA 12.06 10.99 3.43 09044188 A Lap, colostomy 19.35 NA NA 13.18 11.99 3.98 09044202 A Lap, enterectomy 23.39 NA NA 13.07 11.82 5.03 09044203 A Lap resect s/intestine, addl 4.44 NA NA 1.89 1.71 0.96 ZZZ44204 A Laparo partial colectomy 26.42 NA NA 14.31 12.88 5.43 09044205 A Lap colectomy part w/ileum 22.95 NA NA 12.56 11.33 4.68 09044206 A Lap part colectomy w/stoma 29.79 NA NA 16.58 14.95 6.29 09044207 A L colectomy/coloproctostomy 31.92 NA NA 16.58 14.86 6.42 09044208 A L colectomy/coloproctostomy 33.99 NA NA 19.02 17.13 6.64 09044210 A Laparo total proctocolectomy 30.09 NA NA 17.64 15.89 6.03 09044211 A Lap colectomy w/proctectomy 37.08 NA NA 22.09 19.62 8.22 09044212 A Laparo total proctocolectomy 34.58 NA NA 20.41 18.43 6.61 09044213 A Lap, mobil splenic fl add-on 3.50 NA NA 1.50 1.35 0.69 ZZZ44227 A Lap, close enterostomy 28.62 NA NA 15.39 13.88 6.06 09044238 C Laparoscope proc, intestine 0.00 0.00 0.00 0.00 0.00 0.00 YYY44300 A Open bowel to skin 13.75 NA NA 8.37 7.63 3.02 09044310 A Ileostomy/jejunostomy 17.59 NA NA 10.03 9.06 3.59 09044312 A Revision of ileostomy 9.43 NA NA 6.37 5.95 1.78 09044314 A Revision of ileostomy 16.74 NA NA 10.06 9.22 3.28 09044316 A Devise bowel pouch 23.59 NA NA 13.39 11.99 5.23 09044320 A Colostomy 19.91 NA NA 11.76 10.62 4.22 09044322 A Colostomy with biopsies 13.32 NA NA 13.18 12.04 2.95 09044340 A Revision of colostomy 9.28 NA NA 7.25 6.55 1.95 09044345 A Revision of colostomy 17.22 NA NA 10.66 9.62 3.57 09044346 A Revision of colostomy 19.63 NA NA 11.71 10.51 4.03 090CMS-1503-P943**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**44360 A Small bowel endoscopy 2.59 NA NA 1.72 1.73 0.40 00044361 A Small bowel endoscopy/biopsy 2.87 NA NA 1.87 1.88 0.42 00044363 A Small bowel endoscopy 3.49 NA NA 2.19 2.15 0.54 00044364 A Small bowel endoscopy 3.73 NA NA 2.33 2.33 0.57 00044365 A Small bowel endoscopy 3.31 NA NA 2.10 2.09 0.51 00044366 A Small bowel endoscopy 4.40 NA NA 2.71 2.72 0.66 00044369 A Small bowel endoscopy 4.51 NA NA 2.77 2.77 0.68 00044370 A Small bowel endoscopy/stent 4.79 NA NA 3.11 3.09 0.72 00044372 A Small bowel endoscopy 4.40 NA NA 2.58 2.53 0.72 00044373 A Small bowel endoscopy 3.49 NA NA 2.11 2.11 0.55 00044376 A Small bowel endoscopy 5.25 NA NA 3.04 3.01 0.85 00044377 A Small bowel endoscopy/biopsy 5.52 NA NA 3.26 3.26 0.85 00044378 A Small bowel endoscopy 7.12 NA NA 4.18 4.16 1.09 00044379 A S bowel endoscope w/stent 7.46 NA NA 4.58 4.51 1.13 00044380 A Small bowel endoscopy 1.05 NA NA 0.82 0.84 0.14 00044382 A Small bowel endoscopy 1.27 NA NA 0.99 0.99 0.21 00044383 A Ileoscopy w/stent 2.94 NA NA 1.61 1.76 0.34 00044385 A Endoscopy of bowel pouch 1.82 5.27 5.28 1.09 1.06 0.27 00044386 A Endoscopy, bowel pouch/biop 2.12 7.48 7.68 1.36 1.29 0.34 00044388 A Colonoscopy 2.82 6.81 6.87 1.72 1.67 0.47 00044389 A Colonoscopy with biopsy 3.13 7.73 8.00 1.93 1.89 0.51 00044390 A Colonoscopy for foreign body 3.82 8.96 9.12 2.40 2.27 0.58 00044391 A Colonoscopy for bleeding 4.31 9.30 9.84 2.56 2.53 0.68 00044392 A Colonoscopy & polypectomy 3.81 8.20 8.31 2.17 2.09 0.65 00044393 A Colonoscopy, lesion removal 4.83 9.10 9.18 2.79 2.70 0.79 00044394 A Colonoscopy w/snare 4.42 9.30 9.60 2.58 2.53 0.72 000CMS-1503-P944**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**44397 A Colonoscopy w/stent 4.70 NA NA 2.88 2.83 0.71 00044500 A Intro, gastrointestinal tube 0.49 NA NA 0.18 0.20 0.04 00044602 A Suture, small intestine 24.72 NA NA 12.25 10.70 5.30 09044603 A Suture, small intestine 28.16 NA NA 14.35 12.55 5.98 09044604 A Suture, large intestine 18.16 NA NA 9.60 8.66 3.86 09044605 A Repair of bowel lesion 22.08 NA NA 12.33 11.13 4.73 09044615 A Intestinal stricturoplasty 18.16 NA NA 10.19 9.21 3.87 09044620 A Repair bowel opening 14.43 NA NA 8.57 7.68 2.94 09044625 A Repair bowel opening 17.28 NA NA 9.78 8.76 3.49 09044626 A Repair bowel opening 27.90 NA NA 14.34 12.91 5.92 09044640 A Repair bowel-skin fistula 24.20 NA NA 12.76 11.51 5.07 09044650 A Repair bowel fistula 25.12 NA NA 13.02 11.85 5.26 09044660 A Repair bowel-bladder fistula 23.91 NA NA 12.02 11.75 4.00 09044661 A Repair bowel-bladder fistula 27.35 NA NA 13.80 12.83 5.30 09044680 A Surgical revision, intestine 17.96 NA NA 10.10 9.12 3.98 09044700 A Suspend bowel w/prosthesis 17.48 NA NA 9.80 8.82 3.15 09044701 A Intraop colon lavage add-on 3.10 NA NA 1.32 1.19 0.61 ZZZ44715 C Prepare donor intestine 0.00 0.00 0.00 0.00 0.00 0.00 XXX44720 A Prep donor intestine/venous 5.00 NA NA 2.15 2.09 0.37 XXX44721 A Prep donor intestine/artery 7.00 NA NA 3.03 2.77 1.55 XXX44799 C Unlisted procedure intestine 0.00 0.00 0.00 0.00 0.00 0.00 YYY44800 A Excision of bowel pouch 12.05 NA NA 8.10 7.42 2.53 09044820 A Excision of mesentery lesion 13.73 NA NA 8.32 7.62 2.94 09044850 A Repair of mesentery 12.11 NA NA 7.63 6.87 2.61 09044899 C Bowel surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY44900 A Drain app abscess, open 12.57 NA NA 7.76 6.98 2.74 090CMS-1503-P945**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**44901 A Drain app abscess, percut 3.37 20.57 23.42 1.18 1.34 0.37 00044950 A Appendectomy 10.60 NA NA 6.24 5.68 2.32 09044955 A Appendectomy add-on 1.53 NA NA 0.66 0.61 0.32 ZZZ44960 A Appendectomy 14.50 NA NA 8.41 7.57 3.19 09044970 A Laparoscopy, appendectomy 9.45 NA NA 6.33 5.74 2.05 09044979 C Laparoscope proc, app 0.00 0.00 0.00 0.00 0.00 0.00 YYY45000 A Drainage of pelvic abscess 6.30 NA NA 5.03 4.63 1.13 09045005 A Drainage of rectal abscess 2.02 5.20 4.97 2.21 2.06 0.40 01045020 A Drainage of rectal abscess 8.56 NA NA 6.56 5.89 1.68 09045100 A Biopsy of rectum 4.04 NA NA 4.00 3.65 0.75 09045108 A Removal of anorectal lesion 5.12 NA NA 4.62 4.16 1.13 09045110 A Removal of rectum 30.76 NA NA 18.57 16.74 6.05 09045111 A Partial removal of rectum 18.01 NA NA 10.91 9.83 3.69 09045112 A Removal of rectum 33.18 NA NA 17.13 15.31 6.32 09045113 A Partial proctectomy 33.22 NA NA 18.65 16.75 7.35 09045114 A Partial removal of rectum 30.79 NA NA 16.71 14.81 6.82 09045116 A Partial removal of rectum 27.72 NA NA 15.37 13.52 4.11 09045119 A Remove rectum w/reservoir 33.48 NA NA 18.97 16.85 6.09 09045120 A Removal of rectum 26.40 NA NA 15.22 13.65 5.85 09045121 A Removal of rectum and colon 29.08 NA NA 16.37 14.64 6.43 09045123 A Partial proctectomy 18.86 NA NA 11.29 9.96 3.29 09045126 A Pelvic exenteration 49.10 NA NA 26.25 24.48 10.87 09045130 A Excision of rectal prolapse 18.50 NA NA 10.88 9.61 3.25 09045135 A Excision of rectal prolapse 22.36 NA NA 13.71 12.12 4.95 09045136 A Excise ileoanal reservior 30.82 NA NA 18.70 16.84 4.58 09045150 A Excision of rectal stricture 5.85 NA NA 5.06 4.64 0.86 090CMS-1503-P946**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**45160 A Excision of rectal lesion 16.33 NA NA 10.12 9.18 3.62 09045171 A Exc rect tum transanal part 8.13 NA NA 7.91 7.91 1.57 09045172 A Exc rect tum transanal full 12.13 NA NA 9.62 9.62 2.32 09045190 A Destruction, rectal tumor 10.42 NA NA 8.11 7.30 1.94 09045300 A Proctosigmoidoscopy dx0.80 2.53 2.38 0.67 0.59 0.13 00045303 A Proctosigmoidoscopy dilate 1.50 24.29 23.73 0.98 0.85 0.27 00045305 A Proctosigmoidoscopy w/bx 1.25 3.99 3.81 0.88 0.80 0.24 00045307 A Proctosigmoidoscopy fb1.70 4.15 3.92 1.05 0.91 0.34 00045308 A Proctosigmoidoscopy removal 1.40 4.27 3.93 0.96 0.83 0.27 00045309 A Proctosigmoidoscopy removal 1.50 4.35 4.19 1.01 0.95 0.28 00045315 A Proctosigmoidoscopy removal 1.80 4.76 4.47 1.12 1.05 0.34 00045317 A Proctosigmoidoscopy bleed 2.00 4.35 4.04 1.21 1.06 0.34 00045320 A Proctosigmoidoscopy ablate 1.78 4.38 4.20 1.12 1.06 0.32 00045321 A Proctosigmoidoscopy volvul 1.75 NA NA 1.14 1.05 0.34 00045327 A Proctosigmoidoscopy w/stent 2.00 NA NA 1.42 1.29 0.44 00045330 A Diagnostic sigmoidoscopy 0.96 2.86 2.89 0.78 0.75 0.14 00045331 A Sigmoidoscopy and biopsy 1.15 3.48 3.65 0.92 0.91 0.18 00045332 A Sigmoidoscopy w/fb removal 1.79 6.09 6.24 1.24 1.20 0.30 00045333 A Sigmoidoscopy & polypectomy 1.79 6.21 6.33 1.22 1.19 0.30 00045334 A Sigmoidoscopy for bleeding 2.73 NA NA 1.76 1.76 0.41 00045335 A Sigmoidoscopy w/submuc inj 1.46 5.67 5.64 1.06 1.04 0.24 00045337 A Sigmoidoscopy & decompress 2.36 NA NA 1.53 1.49 0.40 00045338 A Sigmoidoscopy w/tumr remove 2.34 6.31 6.53 1.53 1.51 0.37 00045339 A Sigmoidoscopy w/ablate tumr 3.14 6.13 6.11 1.95 1.93 0.49 00045340 A Sig w/balloon dilation 1.89 11.05 10.98 1.28 1.25 0.31 00045341 A Sigmoidoscopy w/ultrasound 2.60 NA NA 1.70 1.70 0.40 000CMS-1503-P947**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**45342 A Sigmoidoscopy w/us guide bx 4.05 NA NA 2.51 2.50 0.62 00045345 A Sigmoidoscopy w/stent 2.92 NA NA 1.86 1.84 0.45 00045355 A Surgical colonoscopy 3.51 NA NA 2.05 1.94 0.61 00045378 A Diagnostic colonoscopy 3.69 6.98 7.24 2.23 2.19 0.61 00045378 53 A Diagnostic colonoscopy 0.96 2.86 2.89 0.78 0.75 0.14 00045379 A Colonoscopy w/fb removal 4.68 9.04 9.29 2.77 2.68 0.75 00045380 A Colonoscopy and biopsy 4.43 8.30 8.67 2.67 2.64 0.69 00045381 A Colonoscopy, submucous inj 4.19 8.18 8.57 2.54 2.52 0.65 00045382 A Colonoscopy/control bleeding 5.68 10.88 11.50 3.37 3.36 0.88 00045383 A Lesion removal colonoscopy 5.86 9.55 9.77 3.31 3.22 0.95 00045384 A Lesion remove colonoscopy 4.69 7.99 8.21 2.71 2.65 0.76 00045385 A Lesion removal colonoscopy 5.30 9.04 9.42 3.12 3.08 0.83 00045386 A Colonoscopy dilate stricture 4.57 13.27 13.92 2.69 2.63 0.75 00045387 A Colonoscopy w/stent 5.90 NA NA 3.56 3.51 0.92 00045391 A Colonoscopy w/endoscope us 5.09 NA NA 3.03 3.01 0.76 00045392 A Colonoscopy w/endoscopic fnb 6.54 NA NA 3.81 3.78 1.06 00045395 A Lap, removal of rectum 33.00 NA NA 20.31 18.37 6.22 09045397 A Lap, remove rectum w/pouch 36.50 NA NA 21.65 19.36 6.25 09045400 A Laparoscopic proc 19.44 NA NA 11.34 10.20 3.70 09045402 A Lap proctopexy w/sig resect 26.51 NA NA 14.38 12.87 5.00 09045499 C Laparoscope proc, rectum 0.00 0.00 0.00 0.00 0.00 0.00 YYY45500 A Repair of rectum 7.73 NA NA 6.50 5.83 1.26 09045505 A Repair of rectum 8.36 NA NA 7.49 6.67 1.57 09045520 A Treatment of rectal prolapse 0.55 3.67 3.36 0.56 0.51 0.07 00045540 A Correct rectal prolapse 18.12 NA NA 10.24 9.19 3.24 09045541 A Correct rectal prolapse 14.85 NA NA 10.12 9.04 2.68 090CMS-1503-P948**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**45550 A Repair rectum/remove sigmoid 24.80 NA NA 14.42 12.84 4.65 09045560 A Repair of rectocele 11.50 NA NA 7.36 7.01 1.87 09045562 A Exploration/repair of rectum 17.98 NA NA 11.69 10.71 3.50 09045563 A Exploration/repair of rectum 26.38 NA NA 16.77 15.01 5.85 09045800 A Repair rect/bladder fistula 20.31 NA NA 11.81 11.35 3.52 09045805 A Repair fistula w/colostomy 23.32 NA NA 14.96 13.43 5.17 09045820 A Repair rectourethral fistula 20.37 NA NA 12.25 11.52 2.03 09045825 A Repair fistula w/colostomy 24.17 NA NA 15.26 14.17 3.59 09045900 A Reduction of rectal prolapse 2.99 NA NA 2.39 2.19 0.58 01045905 A Dilation of anal sphincter 2.35 NA NA 2.19 2.05 0.42 01045910 A Dilation of rectal narrowing 2.85 NA NA 2.40 2.29 0.49 01045915 A Remove rectal obstruction 3.19 5.60 5.33 2.87 2.67 0.54 01045990 A Surg dx exam, anorectal 1.80 NA NA 1.08 1.00 0.32 00045999 C Rectum surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY46020 A Placement of seton 3.00 4.43 4.00 3.31 2.98 0.57 01046030 A Removal of rectal marker 1.26 2.50 2.30 1.17 1.06 0.24 01046040 A Incision of rectal abscess 5.37 8.82 8.18 5.62 5.17 1.09 09046045 A Incision of rectal abscess 5.87 NA NA 5.62 5.05 1.22 09046050 A Incision of anal abscess 1.24 4.15 3.87 1.37 1.25 0.25 01046060 A Incision of rectal abscess 6.37 NA NA 6.34 5.69 1.23 09046070 A Incision of anal septum 2.79 NA NA 3.75 3.43 0.21 09046080 A Incision of anal sphincter 2.52 4.14 3.81 1.71 1.55 0.51 01046083 A Incise external hemorrhoid 1.45 3.24 3.25 1.41 1.35 0.25 01046200 A Removal of anal fissure 3.59 8.32 7.56 5.14 4.69 0.65 09046220 A Excise anal ext tag/papilla 1.61 3.96 3.68 1.58 1.44 0.31 01046221 A Ligation of hemorrhoid(s) 2.36 4.89 4.52 2.78 2.56 0.42 010CMS-1503-P949**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**46230 A Removal of anal tags 2.62 4.73 4.41 2.00 1.82 0.49 01046250 A Remove ext hem groups = 2 4.25 8.08 7.54 4.11 3.76 0.85 09046255 A Remove int/ext hem 1 group 4.96 8.46 7.98 4.41 4.05 0.99 09046257 A Remove in/ex hem grp & fiss 5.76 NA NA 5.51 4.94 1.12 09046258 A Remove in/ex hem grp w/fistu 6.41 NA NA 5.98 5.35 1.43 09046260 A Remove in/ex hem groups = 2 6.73 NA NA 5.91 5.30 1.31 09046261 A Remove in/ex hem grps & fiss 7.76 NA NA 6.39 5.72 1.44 09046262 A Remove in/ex hem grps w/fist 7.91 NA NA 6.87 6.18 1.50 09046270 A Remove anal fist subq 4.92 8.60 7.92 5.50 4.96 1.02 09046275 A Remove anal fist inter 5.42 8.95 8.16 5.66 5.09 1.02 09046280 A Remove anal fist complex 6.39 NA NA 6.17 5.53 1.17 09046285 A Remove anal fist 2 stage 5.42 8.90 7.97 5.69 5.07 0.95 09046288 A Repair anal fistula 7.81 NA NA 6.90 6.18 1.38 09046320 A Removal of hemorrhoid clot 1.64 3.28 3.04 1.33 1.20 0.31 01046500 A Injection into hemorrhoid(s) 1.69 4.71 4.29 1.80 1.65 0.30 01046505 A Chemodenervation anal musc 3.18 4.51 4.20 3.26 2.98 0.61 01046600 A Diagnostic anoscopy 0.55 1.82 1.76 0.56 0.50 0.08 00046604 A Anoscopy and dilation 1.03 15.57 14.62 0.76 0.71 0.17 00046606 A Anoscopy and biopsy 1.20 4.83 4.73 0.85 0.76 0.24 00046608 A Anoscopy, remove for body 1.30 4.99 4.82 0.84 0.78 0.25 00046610 A Anoscopy, remove lesion 1.28 4.86 4.74 0.89 0.81 0.25 00046611 A Anoscopy 1.30 3.48 3.36 0.91 0.84 0.24 00046612 A Anoscopy, remove lesions 1.50 5.65 5.57 0.99 0.95 0.32 00046614 A Anoscopy, control bleeding 1.00 2.44 2.44 0.76 0.75 0.14 00046615 A Anoscopy 1.50 2.34 2.32 0.99 0.95 0.30 00046700 A Repair of anal stricture 9.81 NA NA 7.82 6.94 1.70 090CMS-1503-P950**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**46705 A Repair of anal stricture 7.43 NA NA 6.10 5.90 0.54 09046706 A Repr of anal fistula w/glue 2.44 NA NA 2.04 1.90 0.44 01046707 A Repair anorectal fist w/plug 6.39 NA NA 6.40 6.40 0.93 09046710 A Repr per/vag pouch sngl proc 17.14 NA NA 11.37 10.60 3.82 09046712 A Repr per/vag pouch dbl proc 36.45 NA NA 21.84 19.62 2.68 09046715 A Rep perf anoper fistu 7.62 NA NA 6.25 5.75 0.55 09046716 A Rep perf anoper/vestib fistu 17.54 NA NA 13.54 14.23 1.29 09046730 A Construction of absent anus 30.65 NA NA 18.88 18.14 2.26 09046735 A Construction of absent anus 36.14 NA NA 21.26 20.39 2.67 09046740 A Construction of absent anus 33.90 NA NA 22.21 19.90 7.50 09046742 A Repair of imperforated anus 40.14 NA NA 24.80 22.55 8.89 09046744 A Repair of cloacal anomaly 58.94 NA NA 34.40 29.80 8.75 09046746 A Repair of cloacal anomaly 65.44 NA NA 34.06 33.03 4.82 09046748 A Repair of cloacal anomaly 71.42 NA NA 33.50 33.42 5.27 09046750 A Repair of anal sphincter 12.15 NA NA 8.44 7.70 2.05 09046751 A Repair of anal sphincter 9.30 NA NA 6.84 6.78 1.62 09046753 A Reconstruction of anus 8.89 NA NA 6.88 6.19 1.57 09046754 A Removal of suture from anus 3.01 5.07 4.76 3.31 2.95 0.44 01046760 A Repair of anal sphincter 17.45 NA NA 12.31 10.94 2.57 09046761 A Repair of anal sphincter 15.29 NA NA 9.99 8.94 2.52 09046762 A Implant artificial sphincter 14.82 NA NA 10.29 9.27 2.20 09046900 A Destruction, anal lesion(s) 1.91 4.65 4.37 1.86 1.73 0.31 01046910 A Destruction, anal lesion(s) 1.91 4.79 4.60 1.67 1.56 0.35 01046916 A Cryosurgery, anal lesion(s) 1.91 4.44 4.42 2.10 2.00 0.28 01046917 A Laser surgery, anal lesions 1.91 10.67 10.63 1.70 1.58 0.34 01046922 A Excision of anal lesion(s) 1.91 5.28 4.97 1.72 1.57 0.37 010CMS-1503-P951**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**46924 A Destruction, anal lesion(s) 2.81 11.75 11.47 2.20 2.02 0.47 01046930 A Destroy internal hemorrhoids 1.61 3.84 4.05 2.35 2.43 0.27 09046940 A Treatment of anal fissure 2.35 3.86 3.51 1.62 1.46 0.38 01046942 A Treatment of anal fissure 2.07 3.76 3.42 1.50 1.35 0.34 01046945 A Remove by ligat int hem grp 2.21 6.03 5.63 3.85 3.62 0.40 09046946 A Remove by ligat int hem grps 2.63 5.74 5.50 3.41 3.26 0.45 09046947 A Hemorrhoidopexy by stapling 5.57 NA NA 4.60 4.15 1.13 09046999 C Anus surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY47000 A Needle biopsy of liver 1.90 7.84 7.82 0.69 0.79 0.21 00047001 A Needle biopsy, liver add-on 1.90 NA NA 0.81 0.74 0.40 ZZZ47010 A Open drainage, liver lesion 19.40 NA NA 11.95 11.13 4.11 09047011 A Percut drain, liver lesion 3.69 NA NA 1.27 1.48 0.37 00047015 A Inject/aspirate liver cyst 18.50 NA NA 11.97 10.77 4.08 09047100 A Wedge biopsy of liver 12.91 NA NA 9.31 8.51 2.80 09047120 A Partial removal of liver 39.01 NA NA 21.81 19.85 8.58 09047122 A Extensive removal of liver 59.48 NA NA 29.82 27.14 13.13 09047125 A Partial removal of liver 53.04 NA NA 27.07 24.64 11.63 09047130 A Partial removal of liver 57.19 NA NA 28.70 26.18 12.51 09047133 X Removal of donor liver 0.00 0.00 0.00 0.00 0.00 0.00 XXX47135 R Transplantation of liver 83.64 NA NA 44.17 40.04 18.38 09047136 R Transplantation of liver 70.74 NA NA 36.91 34.18 15.67 09047140 A Partial removal, donor liver 59.40 NA NA 33.89 30.54 13.16 09047141 A Partial removal, donor liver 71.50 NA NA 37.78 34.96 5.27 09047142 A Partial removal, donor liver 79.44 NA NA 43.36 39.13 17.58 09047143 C Prep donor liver, whole 0.00 0.00 0.00 0.00 0.00 0.00 XXX47144 C Prep donor liver, 3-segment 0.00 0.00 0.00 0.00 0.00 0.00 090CMS-1503-P952**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**47145 C Prep donor liver, lobe split 0.00 0.00 0.00 0.00 0.00 0.00 XXX47146 A Prep donor liver/venous 6.00 NA NA 2.58 2.34 1.33 XXX47147 A Prep donor liver/arterial 7.00 NA NA 3.01 2.73 1.54 XXX47300 A Surgery for liver lesion 18.14 NA NA 11.67 10.51 3.98 09047350 A Repair liver wound 22.49 NA NA 13.48 12.27 4.87 09047360 A Repair liver wound 31.31 NA NA 17.76 15.99 6.92 09047361 A Repair liver wound 52.60 NA NA 26.27 23.95 11.11 09047362 A Repair liver wound 23.54 NA NA 14.42 12.89 5.13 09047370 A Laparo ablate liver tumor rf 20.80 NA NA 11.72 10.70 4.38 09047371 A Laparo ablate liver cryosurg 20.80 NA NA 12.05 11.18 4.61 09047379 C Laparoscope procedure, liver 0.00 0.00 0.00 0.00 0.00 0.00 YYY47380 A Open ablate liver tumor rf 24.56 NA NA 13.12 12.10 5.14 09047381 A Open ablate liver tumor cryo 24.88 NA NA 10.56 11.06 5.51 09047382 A Percut ablate liver rf 15.22 114.73 114.73 5.83 6.90 1.54 01047399 C Liver surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY47400 A Incision of liver duct 36.36 NA NA 19.93 17.99 8.04 09047420 A Incision of bile duct 22.03 NA NA 13.12 11.91 4.85 09047425 A Incision of bile duct 22.31 NA NA 13.46 12.12 4.95 09047460 A Incise bile duct sphincter 20.52 NA NA 12.69 11.87 4.54 09047480 A Incision of gallbladder 13.25 NA NA 9.72 8.85 2.85 09047490 A Incision of gallbladder 8.13 NA NA 5.24 5.98 0.79 09047500 A Injection for liver x-rays 1.96 NA NA 0.67 0.79 0.21 00047505 A Injection for liver x-rays 0.76 NA NA 0.26 0.30 0.07 00047510 A Insert catheter, bile duct 8.03 NA NA 4.61 5.27 0.83 09047511 A Insert bile duct drain 10.77 NA NA 4.86 5.68 1.06 09047525 A Change bile duct catheter 1.54 11.84 13.12 0.77 1.19 0.14 000CMS-1503-P953**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**47530 A Revise/reinsert bile tube 6.05 32.33 35.08 3.48 3.96 0.64 09047550 A Bile duct endoscopy add-on 3.02 NA NA 1.30 1.19 0.65 ZZZ47552 A Biliary endoscopy thruskin 6.03 NA NA 2.46 2.84 0.65 00047553 A Biliary endoscopy thruskin 6.34 NA NA 2.19 2.53 0.65 00047554 A Biliary endoscopy thruskin 9.05 NA NA 3.93 4.05 1.57 00047555 A Biliary endoscopy thruskin 7.55 NA NA 2.55 3.03 0.73 00047556 A Biliary endoscopy thruskin 8.55 NA NA 2.91 3.44 0.83 00047560 A Laparoscopy w/cholangio 4.88 NA NA 2.10 1.93 1.09 00047561 A Laparo w/cholangio/biopsy 5.17 NA NA 2.51 2.30 1.14 00047562 A Laparoscopic cholecystectomy 11.76 NA NA 7.94 7.18 2.57 09047563 A Laparo cholecystectomy/graph 12.11 NA NA 7.73 7.04 2.67 09047564 A Laparo cholecystectomy/explr 14.24 NA NA 8.35 7.63 3.15 09047570 A Laparo cholecystoenterostomy 12.56 NA NA 7.73 7.04 2.77 09047579 C Laparoscope proc, biliary 0.00 0.00 0.00 0.00 0.00 0.00 YYY47600 A Removal of gallbladder 17.48 NA NA 10.97 9.80 3.84 09047605 A Removal of gallbladder 15.98 NA NA 9.76 8.85 3.53 09047610 A Removal of gallbladder 20.92 NA NA 11.89 10.76 4.62 09047612 A Removal of gallbladder 21.21 NA NA 11.96 10.81 4.68 09047620 A Removal of gallbladder 23.07 NA NA 12.96 11.68 5.13 09047630 A Remove bile duct stone 9.65 NA NA 5.03 5.53 1.26 09047700 A Exploration of bile ducts 16.50 NA NA 11.09 10.15 3.66 09047701 A Bile duct revision 28.73 NA NA 16.64 15.91 6.34 09047711 A Excision of bile duct tumor 25.90 NA NA 14.92 13.52 5.69 09047712 A Excision of bile duct tumor 33.72 NA NA 18.52 16.65 7.47 09047715 A Excision of bile duct cyst 21.55 NA NA 13.28 11.91 4.78 09047720 A Fuse gallbladder & bowel 18.34 NA NA 11.71 10.61 4.03 090CMS-1503-P954**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**47721 A Fuse upper gi structures 21.99 NA NA 13.47 12.10 4.87 09047740 A Fuse gallbladder & bowel 21.23 NA NA 13.14 11.78 4.69 09047741 A Fuse gallbladder & bowel 24.21 NA NA 14.42 12.97 5.36 09047760 A Fuse bile ducts and bowel 38.32 NA NA 20.66 18.18 8.42 09047765 A Fuse liver ducts & bowel 52.19 NA NA 27.17 23.41 11.56 09047780 A Fuse bile ducts and bowel 42.32 NA NA 22.27 19.55 9.33 09047785 A Fuse bile ducts and bowel 56.19 NA NA 28.46 24.73 12.45 09047800 A Reconstruction of bile ducts 26.17 NA NA 15.21 13.71 5.81 09047801 A Placement, bile duct support 17.60 NA NA 9.59 10.09 2.53 09047802 A Fuse liver duct & intestine 24.93 NA NA 15.02 13.53 5.52 09047900 A Suture bile duct injury 22.44 NA NA 13.28 12.07 4.90 09047999 C Bile tract surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY48000 A Drainage of abdomen 31.95 NA NA 16.64 15.37 6.42 09048001 A Placement of drain, pancreas 39.69 NA NA 20.60 18.53 8.80 09048020 A Removal of pancreatic stone 19.09 NA NA 11.73 10.63 4.24 09048100 A Biopsy of pancreas, open 14.46 NA NA 8.84 8.04 3.11 09048102 A Needle biopsy, pancreas 4.70 9.76 10.47 1.85 2.16 0.45 01048105 A Resect/debride pancreas 49.26 NA NA 25.44 22.78 10.70 09048120 A Removal of pancreas lesion 18.41 NA NA 10.56 9.55 4.06 09048140 A Partial removal of pancreas 26.32 NA NA 14.53 13.14 5.79 09048145 A Partial removal of pancreas 27.39 NA NA 15.31 13.70 6.05 09048146 A Pancreatectomy 30.60 NA NA 18.60 16.68 6.77 09048148 A Removal of pancreatic duct 20.39 NA NA 12.29 11.02 4.51 09048150 A Partial removal of pancreas 52.84 NA NA 28.07 25.54 11.66 09048152 A Pancreatectomy 48.65 NA NA 26.79 24.17 10.78 09048153 A Pancreatectomy 52.79 NA NA 28.05 25.49 11.64 090CMS-1503-P955**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**48154 A Pancreatectomy 48.88 NA NA 26.89 24.18 10.82 09048155 A Removal of pancreas 29.45 NA NA 18.02 16.36 6.51 09048160 N Pancreas removal/transplant 0.00 0.00 0.00 0.00 0.00 0.00 XXX48400 A Injection, intraop add-on 1.95 NA NA 0.84 0.85 0.30 ZZZ48500 A Surgery of pancreatic cyst 18.16 NA NA 12.02 10.82 4.01 09048510 A Drain pancreatic pseudocyst 17.19 NA NA 11.36 10.32 3.73 09048511 A Drain pancreatic pseudocyst 3.99 20.88 22.73 1.39 1.61 0.40 00048520 A Fuse pancreas cyst and bowel 18.15 NA NA 10.47 9.49 3.98 09048540 A Fuse pancreas cyst and bowel 21.94 NA NA 12.33 11.03 4.85 09048545 A Pancreatorrhaphy 22.23 NA NA 12.96 11.54 4.93 09048547 A Duodenal exclusion 30.38 NA NA 16.47 14.70 6.71 09048548 A Fuse pancreas and bowel 28.09 NA NA 15.40 13.95 6.20 09048550 X Donor pancreatectomy0.00 0.00 0.00 0.00 0.00 0.00 XXX48551 C Prep donor pancreas 0.00 0.00 0.00 0.00 0.00 0.00 XXX48552 A Prep donor pancreas/venous 4.30 NA NA 1.85 1.70 0.93 XXX48554 R Transpl allograft pancreas 37.80 NA NA 29.62 27.12 8.20 09048556 A Removal, allograft pancreas 19.47 NA NA 14.00 12.66 4.31 09048999 C Pancreas surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY49000 A Exploration of abdomen 12.54 NA NA 7.71 7.12 2.67 09049002 A Reopening of abdomen 17.63 NA NA 9.80 8.68 3.80 09049010 A Exploration behind abdomen 16.06 NA NA 8.77 8.23 3.32 09049020 A Drain abdominal abscess 26.67 NA NA 15.14 13.79 5.62 09049021 A Drain abdominal abscess 3.37 20.15 22.09 1.16 1.35 0.32 00049040 A Drain, open, abdom abscess 16.52 NA NA 9.80 8.94 3.52 09049041 A Drain, percut, abdom abscess 3.99 20.58 22.22 1.37 1.60 0.40 00049060 A Drain, open, retrop abscess 18.53 NA NA 10.41 9.75 3.83 090CMS-1503-P956**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**49061 A Drain, percut, retroperabsc 3.69 20.21 21.97 1.27 1.48 0.35 00049062 A Drain to peritoneal cavity 12.22 NA NA 7.41 6.96 2.56 09049080 A Puncture, peritoneal cavity 1.35 2.84 3.25 0.50 0.56 0.13 00049081 A Removal of abdominal fluid 1.26 3.21 3.31 0.55 0.56 0.17 00049180 A Biopsy, abdominal mass 1.73 2.51 2.86 0.60 0.70 0.17 00049203 A Exc abd tum 5 cm or less 20.13 NA NA 11.36 10.52 4.08 09049204 A Exc abd tum over 5 cm 26.13 NA NA 13.92 12.85 5.27 09049205 A Exc abd tum over 10 cm 30.13 NA NA 15.66 14.42 6.26 09049215 A Excise sacral spine tumor 37.81 NA NA 20.39 18.39 7.83 09049220 A Multiple surgery, abdomen 15.79 NA NA 9.61 8.80 3.52 09049250 A Excision of umbilicus9.01 NA NA 6.41 5.88 1.91 09049255 A Removal of omentum 12.56 NA NA 8.23 7.59 2.64 09049320 A Diag laparo separateproc 5.14 NA NA 3.49 3.28 1.07 01049321 A Laparoscopy, biopsy 5.44 NA NA 3.70 3.44 1.17 01049322 A Laparoscopy, aspiration 6.01 NA NA 3.79 3.59 1.20 01049323 A Laparo drain lymphocele 10.23 NA NA 6.79 6.26 2.22 09049324 A Lap insertion perm ip cath 6.32 NA NA 4.07 3.75 1.38 01049325 A Lap revision perm ip cath 6.82 NA NA 4.26 3.92 1.53 01049326 A Lap w/omentopexy add-on 3.50 NA NA 1.45 1.30 0.76 ZZZ49329 C Laparo proc, abdm/per/oment 0.00 0.00 0.00 0.00 0.00 0.00 YYY49400 A Air injection into abdomen 1.88 2.65 2.93 0.67 0.74 0.25 00049402 A Remove foreign body, adbomen 14.09 NA NA 8.42 7.66 3.01 09049411 A Ins mark abd/pel for rtperq 3.82 10.89 10.89 1.62 1.62 0.37 00049419 A Insrt abdom cath for chemotx 7.08 NA NA 4.68 4.50 1.27 09049420 A Insert abdom drain, temp 2.22 NA NA 1.34 1.38 0.35 00049421 A Insert abdom drain, perm 5.90 NA NA 4.13 3.99 1.22 090CMS-1503-P957**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**49422 A Remove perm cannula/catheter 6.29 NA NA 3.78 3.56 1.34 01049423 A Exchange drainage catheter 1.46 13.58 14.82 0.53 0.63 0.13 00049424 A Assess cyst, contrast inject 0.76 3.19 3.55 0.29 0.34 0.07 00049425 A Insert abdomen-venous drain 12.22 NA NA 7.43 7.07 2.77 09049426 A Revise abdomen-venous shunt 10.41 NA NA 6.36 6.05 2.15 09049427 A Injection, abdominal shunt 0.89 NA NA 0.33 0.37 0.10 00049428 A Ligation of shunt 6.87 NA NA 4.45 4.28 1.53 01049429 A Removal of shunt 7.44 NA NA 4.58 4.24 1.65 01049435 A Insert subq exten to ip cath 2.25 NA NA 0.88 0.80 0.47 ZZZ49436 A Embedded ip cath exit-site 2.72 NA NA 2.19 2.07 0.61 01049440 A Place gastrostomy tube perc 4.18 24.11 26.74 1.91 2.10 0.49 01049441 A Place duod/jej tube perc4.77 27.19 29.50 2.19 2.37 0.57 01049442 A Place cecostomy tube perc 4.00 20.70 24.76 1.88 1.96 0.38 01049446 A Change g-tube to g-jperc 3.31 23.20 25.35 1.15 1.34 0.32 00049450 A Replace g/c tube perc1.36 16.44 19.20 0.49 0.53 0.13 00049451 A Replace duod/jej tube perc 1.84 17.53 18.88 0.65 0.75 0.21 00049452 A Replace g-j tube perc2.86 20.99 22.89 1.00 1.17 0.28 00049460 A Fix g/colon tube w/device 0.96 18.77 21.76 0.36 0.39 0.10 00049465 A Fluoro exam of g/colon tube 0.62 3.94 4.30 0.21 0.25 0.06 00049491 A Rpr hern preemie reduc 12.53 NA NA 8.25 7.42 2.77 09049492 A Rpr ing hern premie, blocked 15.43 NA NA 9.59 8.69 3.42 09049495 A Rpr ing hernia baby, reduc 6.20 NA NA 4.56 4.05 1.37 09049496 A Rpr ing hernia baby, blocked 9.42 NA NA 6.68 6.05 2.29 09049500 A Rpr ing hernia, init, reduce 5.84 NA NA 3.82 3.90 1.29 09049501 A Rpr ing hernia, init blocked 9.36 NA NA 6.50 5.90 2.06 09049505 A Prp i/hern init reduc >5 yr 7.96 NA NA 5.72 5.23 1.72 090CMS-1503-P958**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**49507 A Prp i/hern init block >5 yr 10.05 NA NA 6.68 6.09 2.20 09049520 A Rerepair ing hernia, reduce 9.99 NA NA 6.59 6.01 2.18 09049521 A Rerepair ing hernia, blocked 12.44 NA NA 7.61 6.94 2.71 09049525 A Repair ing hernia, sliding 8.93 NA NA 6.12 5.60 1.94 09049540 A Repair lumbar hernia 10.74 NA NA 7.05 6.39 2.35 09049550 A Rpr rem hernia, init, reduce 8.99 NA NA 6.14 5.61 1.96 09049553 A Rpr fem hernia, init blocked 9.92 NA NA 6.65 6.05 2.18 09049555 A Rerepair fem hernia, reduce 9.39 NA NA 6.30 5.76 2.05 09049557 A Rerepair fem hernia, blocked 11.62 NA NA 7.37 6.71 2.54 09049560 A Rpr ventral hern init, reduc 11.92 NA NA 7.43 6.78 2.57 09049561 A Rpr ventral hern init, block 15.38 NA NA 8.98 8.14 3.36 09049565 A Rerepair ventrl hern, reduce 12.37 NA NA 7.80 7.09 2.70 09049566 A Rerepair ventrl hern, block 15.53 NA NA 9.09 8.23 3.42 09049568 A Hernia repair w/mesh 4.88 NA NA 2.10 1.91 1.07 ZZZ49570 A Rpr epigastric hern, reduce 6.05 NA NA 4.89 4.48 1.33 09049572 A Rpr epigastric hern, blocked 7.87 NA NA 5.68 5.14 1.71 09049580 A Rpr umbil hern, reduc < 5 yr 4.47 NA NA 4.30 3.92 0.99 09049582 A Rpr umbil hern, block < 5 yr 7.13 NA NA 5.54 5.03 1.58 09049585 A Rpr umbil hern, reduc > 5 yr 6.59 NA NA 5.11 4.68 1.43 09049587 A Rpr umbil hern, block > 5 yr 8.04 NA NA 5.73 5.23 1.75 09049590 A Repair spigelian hernia 8.90 NA NA 6.13 5.59 1.95 09049600 A Repair umbilical lesion 11.55 NA NA 7.58 7.05 2.54 09049605 A Repair umbilical lesion 87.09 NA NA 41.56 38.48 19.29 09049606 A Repair umbilical lesion 19.00 NA NA 10.57 9.62 4.21 09049610 A Repair umbilical lesion 10.91 NA NA 7.09 6.54 2.40 09049611 A Repair umbilical lesion 9.34 NA NA 5.92 6.03 0.68 090CMS-1503-P959**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**49650 A Lap ing hernia repair init 6.36 NA NA 4.91 4.49 1.38 09049651 A Lap ing hernia repair recur 8.38 NA NA 6.27 5.70 1.85 09049652 A Lap vent/abd hernia repair 12.88 NA NA 8.01 7.28 0.93 09049653 A Lap vent/abd hern proc comp 16.21 NA NA 9.96 9.03 1.20 09049654 A Lap inc hernia repair 15.03 NA NA 8.96 8.12 1.10 09049655 A Lap inc hern repair comp 18.11 NA NA 10.75 9.74 1.33 09049656 A Lap inc hernia repair recur 15.08 NA NA 9.00 8.14 1.12 09049657 A Lap inc hern recur comp 22.11 NA NA 12.50 11.27 1.62 09049659 C Laparo proc, hernia repair 0.00 0.00 0.00 0.00 0.00 0.00 YYY49900 A Repair of abdominal wall 12.41 NA NA 9.14 8.44 2.64 09049904 A Omental flap, extra-abdom 22.35 NA NA 15.50 15.50 4.93 09049905 A Omental flap, intra-abdom 6.54 NA NA 2.77 2.56 1.29 ZZZ49906 C Free omental flap, microvasc 0.00 0.00 0.00 0.00 0.00 0.00 09049999 C Abdomen surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY50010 A Exploration of kidney 12.28 NA NA 7.71 7.82 1.87 09050020 A Renal abscess, open drain 18.08 NA NA 10.66 10.63 2.50 09050021 A Renal abscess, percut drain 3.37 21.56 23.54 1.15 1.35 0.32 00050040 A Drainage of kidney 16.68 NA NA 8.67 9.65 1.75 09050045 A Exploration of kidney 16.82 NA NA 8.90 9.71 1.68 09050060 A Removal of kidney stone 20.95 NA NA 10.52 11.64 2.09 09050065 A Incision of kidney 22.32 NA NA 11.06 11.98 2.25 09050070 A Incision of kidney 21.85 NA NA 10.88 12.12 2.20 09050075 A Removal of kidney stone 27.09 NA NA 13.16 14.63 2.73 09050080 A Removal of kidney stone 15.74 NA NA 8.23 9.16 1.61 09050081 A Removal of kidney stone 23.50 NA NA 11.75 13.03 2.40 09050100 A Revise kidney blood vessels 17.45 NA NA 7.41 8.35 3.87 090CMS-1503-P960**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**50120 A Exploration of kidney 17.21 NA NA 8.98 9.84 1.72 09050125 A Explore and drain kidney 17.82 NA NA 10.93 10.91 1.78 09050130 A Removal of kidney stone 18.82 NA NA 9.73 10.76 1.89 09050135 A Exploration of kidney 20.59 NA NA 10.38 11.43 2.06 09050200 A Renal biopsy perq 2.63 13.53 13.53 1.22 1.37 0.32 00050205 A Renal biopsy open 12.29 NA NA 7.53 7.11 2.49 0905020F I Txmnts 2 main Dr by 1 mon 0.00 0.00 0.00 0.00 0.00 0.00 XXX50220 A Remove kidney, open 18.68 NA NA 9.83 10.56 2.33 09050225 A Removal kidney open, complex 21.88 NA NA 11.02 11.91 2.47 09050230 A Removal kidney open, radical 23.81 NA NA 11.48 12.65 2.54 09050234 A Removal of kidney & ureter 24.05 NA NA 11.84 13.01 2.53 09050236 A Removal of kidney & ureter 26.94 NA NA 13.50 14.98 2.74 09050240 A Partial removal of kidney 24.21 NA NA 12.31 13.56 2.52 09050250 A Cryoablate renal mass open 22.22 NA NA 11.33 12.69 2.26 09050280 A Removal of kidney lesion 17.09 NA NA 9.19 9.96 1.94 09050290 A Removal of kidney lesion 16.15 NA NA 10.21 9.70 1.62 09050300 X Remove cadaver donor kidney 0.00 0.00 0.00 0.00 0.00 0.00 XXX50320 A Remove kidney, living donor 22.43 NA NA 15.25 15.13 4.03 09050323 C Prep cadaver renal allograft 0.00 0.00 0.00 0.00 0.00 0.00 XXX50325 C Prep donor renal graft 0.00 0.00 0.00 0.00 0.00 0.00 XXX50327 A Prep renal graft/venous 4.00 NA NA 1.68 1.58 0.81 XXX50328 A Prep renal graft/arterial 3.50 NA NA 1.47 1.39 0.69 XXX50329 A Prep renal graft/ureteral 3.34 NA NA 1.36 1.40 0.49 XXX50340 A Removal of kidney 14.04 NA NA 10.86 9.91 3.12 09050360 A Transplantation of kidney 40.90 NA NA 26.81 24.47 8.62 09050365 A Transplantation of kidney 46.13 NA NA 29.30 27.00 10.22 090CMS-1503-P961**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**50370 A Remove transplanted kidney 18.88 NA NA 12.81 11.77 3.90 09050380 A Reimplantation of kidney 30.11 NA NA 22.45 21.61 6.66 09050382 A Change ureter stent, percut 5.50 26.99 30.96 1.97 2.30 0.54 00050384 A Remove ureter stent, percut 5.00 21.18 25.44 1.77 2.08 0.49 00050385 A Change stent via transureth 4.44 27.38 31.38 1.92 2.25 0.44 00050386 A Remove stent via transureth 3.30 17.77 20.09 1.54 1.78 0.32 00050387 A Change ext/int ureter stent 2.00 12.94 14.90 0.68 0.82 0.21 00050389 A Remove renal tube w/fluoro 1.10 6.79 8.32 0.38 0.45 0.10 00050390 A Drainage of kidney lesion 1.96 NA NA 0.67 0.79 0.18 00050391 A Instll rx agnt into rnaltub 1.96 1.42 1.63 0.79 0.87 0.21 00050392 A Insert kidney drain 3.37 NA NA 1.46 1.71 0.32 00050393 A Insert ureteral tube 4.15 NA NA 1.73 2.03 0.40 00050394 A Injection for kidney x-ray 0.76 1.90 2.21 0.58 0.66 0.07 00050395 A Create passage to kidney 3.37 NA NA 1.53 1.75 0.34 00050396 A Measure kidney pressure 2.09 NA NA 1.02 1.21 0.21 00050398 A Change kidney tube 1.46 12.21 13.88 0.54 0.63 0.13 00050400 A Revision of kidney/ureter 21.27 NA NA 10.69 11.72 2.18 09050405 A Revision of kidney/ureter 25.86 NA NA 12.68 13.98 2.60 09050500 A Repair of kidney wound 21.22 NA NA 11.88 11.46 4.69 09050520 A Close kidney-skin fistula 18.88 NA NA 9.71 10.59 1.91 09050525 A Repair renal-abdomen fistula 24.39 NA NA 13.97 13.69 5.40 09050526 A Repair renal-abdomen fistula 26.31 NA NA 13.98 13.51 1.94 09050540 A Revision of horseshoe kidney 21.10 NA NA 10.58 11.37 2.11 09050541 A Laparo ablate renal cyst 16.86 NA NA 8.52 9.40 1.77 09050542 A Laparo ablate renal mass 21.36 NA NA 10.88 12.02 2.18 09050543 A Laparo partial nephrectomy 27.41 NA NA 13.69 15.14 2.83 090CMS-1503-P962**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**50544 A Laparoscopy, pyeloplasty 23.37 NA NA 11.07 12.28 2.40 09050545 A Laparo radical nephrectomy 25.06 NA NA 11.97 13.25 2.64 09050546 A Laparoscopic nephrectomy 21.87 NA NA 11.19 12.27 2.39 09050547 A Laparo removal donor kidney 26.34 NA NA 16.19 15.65 5.02 09050548 A Laparo remove w/ureter 25.36 NA NA 11.88 13.18 2.60 09050549 C Laparoscope proc, renal 0.00 0.00 0.00 0.00 0.00 0.00 YYY50551 A Kidney endoscopy 5.59 4.25 4.88 2.57 2.86 0.57 00050553 A Kidney endoscopy 5.98 4.46 5.03 2.63 2.94 0.68 00050555 A Kidney endoscopy & biopsy 6.52 4.75 5.42 2.94 3.26 0.65 00050557 A Kidney endoscopy & treatment 6.61 4.85 5.56 2.97 3.31 0.66 00050561 A Kidney endoscopy & treatment 7.58 5.43 6.21 3.35 3.74 0.78 00050562 A Renal scope w/tumor resect 10.90 NA NA 5.17 5.81 1.10 09050570 A Kidney endoscopy 9.53 NA NA 4.09 4.57 0.95 00050572 A Kidney endoscopy 10.33 NA NA 4.40 4.94 1.05 00050574 A Kidney endoscopy & biopsy 11.00 NA NA 4.67 5.22 1.12 00050575 A Kidney endoscopy 13.96 NA NA 5.83 6.53 1.41 00050576 A Kidney endoscopy & treatment 10.97 NA NA 4.65 5.21 1.10 00050580 A Kidney endoscopy & treatment 11.84 NA NA 5.00 5.53 1.20 00050590 A Fragmenting of kidney stone 9.77 15.23 17.22 5.81 6.42 0.99 09050592 A Perc rf ablate renaltumor 6.80 73.39 91.82 2.99 3.44 0.66 01050593 A Perc cryo ablate renaltum 9.13 111.59 126.81 4.04 4.18 0.89 01050600 A Exploration of ureter 17.17 NA NA 8.75 9.57 1.72 09050605 A Insert ureteral support 16.79 NA NA 9.31 9.38 2.76 09050610 A Removal of ureter stone 17.25 NA NA 8.84 9.79 1.72 09050620 A Removal of ureter stone 16.43 NA NA 8.52 9.43 1.65 09050630 A Removal of ureter stone 16.21 NA NA 8.43 9.12 1.62 090CMS-1503-P963**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**50650 A Removal of ureter 18.82 NA NA 9.74 10.70 1.96 09050660 A Removal of ureter 21.02 NA NA 10.55 11.58 2.11 09050684 A Injection for ureter x-ray 0.76 3.81 4.42 0.60 0.67 0.07 00050686 A Measure ureter pressure 1.51 2.57 1.88 1.01 1.09 0.23 00050688 A Change of ureter tube/stent 1.20 NA NA 0.94 1.08 0.11 01050690 A Injection for ureter x-ray 1.16 1.42 1.66 0.73 0.83 0.10 00050700 A Revision of ureter 16.69 NA NA 8.84 9.69 1.68 09050715 A Release of ureter 20.64 NA NA 11.39 11.08 3.12 09050722 A Release of ureter 17.95 NA NA 10.17 9.77 3.17 09050725 A Release/revise ureter 20.20 NA NA 11.95 11.80 2.02 09050727 A Revise ureter 8.28 NA NA 5.64 6.16 0.88 09050728 A Revise ureter 12.18 NA NA 7.07 7.61 1.23 09050740 A Fusion of ureter & kidney 20.07 NA NA 11.89 11.37 4.45 09050750 A Fusion of ureter & kidney 21.22 NA NA 10.63 11.84 2.12 09050760 A Fusion of ureters 20.07 NA NA 10.54 11.09 2.77 09050770 A Splicing of ureters 21.22 NA NA 10.63 11.18 2.12 09050780 A Reimplant ureter in bladder 19.95 NA NA 10.31 11.12 2.40 09050782 A Reimplant ureter in bladder 19.66 NA NA 10.01 10.76 4.35 09050783 A Reimplant ureter in bladder 20.70 NA NA 12.16 11.76 2.08 09050785 A Reimplant ureter in bladder 22.23 NA NA 11.15 12.21 2.33 09050800 A Implant ureter in bowel 16.41 NA NA 9.04 9.86 1.81 09050810 A Fusion of ureter & bowel 22.61 NA NA 11.84 12.01 5.02 09050815 A Urine shunt to intestine 22.26 NA NA 11.48 12.63 2.25 09050820 A Construct bowel bladder 24.07 NA NA 12.18 13.08 2.76 09050825 A Construct bowel bladder 30.68 NA NA 14.99 16.39 3.29 09050830 A Revise urine flow 33.77 NA NA 16.01 17.32 3.42 090CMS-1503-P964**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**50840 A Replace ureter by bowel 22.39 NA NA 11.53 12.73 2.26 09050845 A Appendico-vesicostomy 22.46 NA NA 12.00 13.22 2.26 09050860 A Transplant ureter to skin 17.08 NA NA 9.00 9.86 1.71 09050900 A Repair of ureter 15.04 NA NA 8.45 8.95 1.53 09050920 A Closure ureter/skin fistula 15.81 NA NA 8.50 9.37 1.60 09050930 A Closure ureter/bowel fistula 20.19 NA NA 10.22 10.62 4.47 09050940 A Release of ureter 15.93 NA NA 8.54 9.31 1.61 09050945 A Laparoscopy ureterolithotomy 17.97 NA NA 8.91 9.84 1.81 09050947 A Laparo new ureter/bladder 25.78 NA NA 12.42 13.57 2.60 09050948 A Laparo new ureter/bladder 23.82 NA NA 11.40 12.72 2.39 09050949 C Laparoscope proc, ureter 0.00 0.00 0.00 0.00 0.00 0.00 YYY50951 A Endoscopy of ureter 5.83 4.45 5.11 2.67 2.98 0.58 00050953 A Endoscopy of ureter 6.23 4.66 5.33 3.15 3.51 0.64 00050955 A Ureter endoscopy & biopsy 6.74 4.90 5.86 3.36 3.76 0.68 00050957 A Ureter endoscopy & treatment 6.78 4.96 5.66 3.04 3.38 0.68 00050961 A Ureter endoscopy & treatment 6.04 4.53 5.19 2.74 3.07 0.61 00050970 A Ureter endoscopy 7.13 NA NA 3.14 3.51 0.71 00050972 A Ureter endoscopy & catheter 6.88 NA NA 3.04 3.38 0.69 00050974 A Ureter endoscopy & biopsy 9.16 NA NA 3.94 4.41 0.92 00050976 A Ureter endoscopy & treatment 9.03 NA NA 3.89 4.33 0.90 00050980 A Ureter endoscopy & treatment 6.84 NA NA 3.03 3.39 0.68 0005100F I Rsk fx ref w/n 24 hrs x-ray 0.00 0.00 0.00 0.00 0.00 0.00 XXX51020 A Incise & treat bladder 7.69 NA NA 5.18 5.73 0.81 09051030 A Incise & treat bladder 7.81 NA NA 5.14 5.52 0.78 09051040 A Incise & drain bladder 4.49 NA NA 3.46 3.86 0.45 09051045 A Incise bladder/drain ureter 7.81 NA NA 5.53 5.79 1.10 090CMS-1503-P965**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**51050 A Removal of bladder stone 7.97 NA NA 5.04 5.58 0.81 09051060 A Removal of ureter stone 9.95 NA NA 6.05 6.71 1.02 09051065 A Remove ureter calculus 9.95 NA NA 5.97 6.60 1.02 09051080 A Drainage of bladder abscess 6.71 NA NA 4.53 4.97 0.68 09051100 A Drain bladder by needle 0.78 0.93 1.00 0.31 0.32 0.08 00051101 A Drain bladder by trocar/cath 1.02 2.40 2.65 0.44 0.45 0.13 00051102 A Drain bl w/cath insertion 2.70 3.45 3.96 1.29 1.48 0.30 00051500 A Removal of bladder cyst 11.05 NA NA 7.81 7.45 1.12 09051520 A Removal of bladder lesion 10.21 NA NA 6.16 6.65 1.03 09051525 A Removal of bladder lesion 15.42 NA NA 8.24 9.10 1.62 09051530 A Removal of bladder lesion 13.71 NA NA 7.91 8.35 1.71 09051535 A Repair of ureter lesion 13.90 NA NA 7.59 8.21 1.38 09051550 A Partial removal of bladder 17.23 NA NA 9.16 9.79 2.22 09051555 A Partial removal of bladder 23.18 NA NA 11.68 12.61 2.70 09051565 A Revise bladder & ureter(s) 23.68 NA NA 12.05 13.02 2.52 09051570 A Removal of bladder 27.46 NA NA 13.47 14.48 2.91 09051575 A Removal of bladder & nodes 34.18 NA NA 16.13 17.83 3.48 09051580 A Remove bladder/revise tract 35.37 NA NA 16.99 18.85 3.57 09051585 A Removal of bladder & nodes 39.64 NA NA 18.67 20.72 4.00 09051590 A Remove bladder/revise tract 36.33 NA NA 16.99 18.70 3.82 09051595 A Remove bladder/revise tract 41.32 NA NA 19.16 21.16 4.27 09051596 A Remove bladder/create pouch 44.26 NA NA 20.74 22.94 4.51 09051597 A Removal of pelvic structures 42.86 NA NA 20.35 22.15 4.71 09051600 A Injection for bladder x-ray 0.88 4.09 4.71 0.32 0.37 0.08 00051605 A Preparation for bladder xray 0.64 NA NA 0.42 0.46 0.06 00051610 A Injection for bladder x-ray 1.05 1.83 2.12 0.69 0.77 0.10 000CMS-1503-P966**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**51700 A Irrigation of bladder0.88 1.38 1.60 0.36 0.38 0.08 00051701 A Insert bladder catheter 0.50 0.98 1.19 0.26 0.27 0.06 00051702 A Insert temp bladder cath 0.50 1.41 1.70 0.33 0.36 0.06 00051703 A Insert bladder cath, complex 1.47 2.06 2.47 0.78 0.86 0.14 00051705 A Change of bladder tube 1.05 1.83 2.17 0.80 0.89 0.10 01051710 A Change of bladder tube 1.52 2.45 2.96 1.10 1.22 0.14 01051715 A Endoscopic injection/implant 3.73 4.12 4.66 1.78 1.92 0.41 00051720 A Treatment of bladder lesion 1.50 1.48 1.75 0.72 0.82 0.14 00051725 A Simple cystometrogram 1.51 3.56 4.50 NA NA 0.14 00051725 TC A Simple cystometrogram 0.00 2.94 3.85 NA NA 0.01 00051725 26 A Simple cystometrogram 1.51 0.62 0.65 0.62 0.65 0.13 00051726 A Complex cystometrogram 1.71 5.61 7.09 NA NA 0.17 00051726 TC A Complex cystometrogram 0.00 4.91 6.34 NA NA 0.03 00051726 26 A Complex cystometrogram 1.71 0.70 0.75 0.70 0.75 0.14 00051727 A Cystometrogram w/up 2.11 6.57 6.57 NA NA 0.24 00051727 TC A Cystometrogram w/up 0.00 5.68 5.68 NA NA 0.01 00051727 26 A Cystometrogram w/up 2.11 0.89 0.89 0.89 0.89 0.23 00051728 A Cystometrogram w/vp 2.11 6.54 6.54 NA NA 0.19 00051728 TC A Cystometrogram w/vp 0.00 5.68 5.68 NA NA 0.01 00051728 26 A Cystometrogram w/vp 2.11 0.86 0.86 0.86 0.86 0.18 00051729 A Cystometrogram w/vp&up 2.51 6.91 6.91 NA NA 0.26 00051729 TC A Cystometrogram w/vp&up 0.00 5.86 5.86 NA NA 0.01 00051729 26 A Cystometrogram w/vp&up 2.51 1.05 1.05 1.05 1.05 0.25 00051736 A Urine flow measurement 0.61 0.85 0.94 NA NA 0.05 00051736 TC A Urine flow measurement 0.00 0.60 0.67 NA NA 0.01 00051736 26 A Urine flow measurement 0.61 0.25 0.27 0.25 0.27 0.04 000CMS-1503-P967**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**51741 A Electro-uroflowmetry, first 1.14 1.16 1.28 NA NA 0.08 00051741 TC A Electro-uroflowmetry, first 0.00 0.70 0.78 NA NA 0.01 00051741 26 A Electro-uroflowmetry, first 1.14 0.46 0.50 0.46 0.50 0.07 00051784 A Anal/urinary muscle study 1.53 3.85 4.34 NA NA 0.14 00051784 TC A Anal/urinary muscle study 0.00 3.22 3.68 NA NA 0.01 00051784 26 A Anal/urinary muscle study 1.53 0.63 0.66 0.63 0.66 0.13 00051785 A Anal/urinary muscle study 1.53 4.43 4.92 NA NA 0.14 00051785 TC A Anal/urinary muscle study 0.00 3.79 4.25 NA NA 0.01 00051785 26 A Anal/urinary muscle study 1.53 0.64 0.67 0.64 0.67 0.13 00051792 A Urinary reflex study 1.10 4.89 5.57 NA NA 0.11 00051792 TC A Urinary reflex study 0.00 4.42 5.08 NA NA 0.01 00051792 26 A Urinary reflex study 1.10 0.47 0.49 0.47 0.49 0.10 00051797 A Intraabdominal pressure test 0.80 2.25 3.08 NA NA 0.07 ZZZ51797 TC A Intraabdominal pressure test 0.00 1.92 2.69 NA NA 0.01 ZZZ51797 26 A Intraabdominal pressure test 0.80 0.33 0.39 0.33 0.39 0.06 ZZZ51798 A Us urine capacity measure 0.00 0.50 0.56 NA NA 0.01 XXX51800 A Revision of bladder/urethra 18.89 NA NA 9.89 10.85 2.02 09051820 A Revision of urinary tract 19.59 NA NA 10.30 10.81 1.96 09051840 A Attach bladder/urethra 11.36 NA NA 6.69 6.92 1.55 09051841 A Attach bladder/urethra 13.68 NA NA 7.78 8.00 1.91 09051845 A Repair bladder neck 10.15 NA NA 6.00 6.46 1.24 09051860 A Repair of bladder wound 12.60 NA NA 7.62 7.84 1.92 09051865 A Repair of bladder wound 15.80 NA NA 8.69 9.29 1.99 09051880 A Repair of bladder opening 7.87 NA NA 4.94 5.28 1.03 09051900 A Repair bladder/vagina lesion 14.63 NA NA 8.29 8.75 1.47 09051920 A Close bladder-uterus fistula 13.41 NA NA 7.63 8.12 1.34 090CMS-1503-P968**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**51925 A Hysterectomy/bladder repair 17.53 NA NA 11.50 11.13 3.08 09051940 A Correction of bladder defect 30.66 NA NA 14.68 15.38 3.09 09051960 A Revision of bladder & bowel 25.40 NA NA 12.86 14.15 2.76 09051980 A Construct bladder opening 12.57 NA NA 7.09 7.78 1.27 09051990 A Laparo urethral suspension 13.36 NA NA 7.37 7.54 1.84 09051992 A Laparo sling operation 14.87 NA NA 8.29 8.21 2.32 09051999 C Laparoscope proc, bla 0.00 0.00 0.00 0.00 0.00 0.00 YYY52000 A Cystoscopy 2.23 3.27 3.79 1.25 1.36 0.24 00052001 A Cystoscopy, removal of clots 5.44 4.67 5.44 2.52 2.79 0.55 00052005 A Cystoscopy & ureter catheter 2.37 5.05 5.94 1.30 1.44 0.25 00052007 A Cystoscopy and biopsy 3.02 9.44 12.00 1.55 1.73 0.31 0005200F I Eval appros surg thxpy epi 0.00 0.00 0.00 0.00 0.00 0.00 XXX52010 A Cystoscopy & duct catheter 3.02 7.14 8.51 1.56 1.64 0.31 00052204 A Cystoscopy w/biopsy(s) 2.59 7.29 9.54 1.32 1.45 0.27 00052214 A Cystoscopy and treatment 3.70 13.73 14.44 1.76 2.29 0.37 00052224 A Cystoscopy and treatment 3.14 13.03 18.64 1.54 1.71 0.32 00052234 A Cystoscopy and treatment 4.62 NA NA 2.19 2.44 0.45 00052235 A Cystoscopy and treatment 5.44 NA NA 2.54 2.83 0.55 00052240 A Cystoscopy and treatment 9.71 NA NA 4.22 4.72 0.99 00052250 A Cystoscopy and radiotracer 4.49 NA NA 2.24 2.47 0.47 00052260 A Cystoscopy and treatment 3.91 NA NA 1.90 2.09 0.41 00052265 A Cystoscopy and treatment 2.94 6.88 8.78 1.55 1.64 0.37 00052270 A Cystoscopy & revise urethra 3.36 6.20 7.92 1.67 1.86 0.34 00052275 A Cystoscopy & revise urethra 4.69 8.23 10.65 2.19 2.44 0.47 00052276 A Cystoscopy and treatment 4.99 NA NA 2.35 2.63 0.51 00052277 A Cystoscopy and treatment 6.16 NA NA 2.87 3.16 0.62 000CMS-1503-P969**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**52281 A Cystoscopy and treatment 2.80 4.69 5.80 1.47 1.63 0.30 00052282 A Cystoscopy, implant stent 6.39 NA NA 2.92 3.22 0.68 00052283 A Cystoscopy and treatment 3.73 3.81 4.37 1.86 2.04 0.38 00052285 A Cystoscopy and treatment 3.60 3.96 4.56 1.81 1.98 0.38 00052290 A Cystoscopy and treatment 4.58 NA NA 2.18 2.43 0.45 00052300 A Cystoscopy and treatment 5.30 NA NA 2.54 2.78 0.58 00052301 A Cystoscopy and treatment 5.50 NA NA 2.60 2.90 0.55 00052305 A Cystoscopy and treatment 5.30 NA NA 2.42 2.69 0.54 00052310 A Cystoscopy and treatment 2.81 3.60 4.33 1.38 1.53 0.30 00052315 A Cystoscopy and treatment 5.20 5.96 7.31 2.39 2.67 0.52 00052317 A Remove bladder stone 6.71 15.00 19.51 2.91 3.25 0.68 00052318 A Remove bladder stone 9.18 NA NA 3.94 4.40 0.92 00052320 A Cystoscopy and treatment 4.69 NA NA 2.14 2.38 0.47 00052325 A Cystoscopy, stone removal 6.15 NA NA 2.72 3.03 0.62 00052327 A Cystoscopy, inject material 5.18 NA NA 2.06 2.30 0.54 00052330 A Cystoscopy and treatment 5.03 8.28 14.16 2.27 2.53 0.51 00052332 A Cystoscopy and treatment 2.83 10.83 11.82 1.48 1.64 0.30 00052334 A Create passage to kidney 4.82 NA NA 2.26 2.53 0.49 00052341 A Cysto w/ureter stricture tx 5.35 NA NA 2.63 2.97 0.54 00052342 A Cysto w/up stricture tx 5.85 NA NA 2.83 3.19 0.58 00052343 A Cysto w/renal stricture tx 6.55 NA NA 3.11 3.51 0.66 00052344 A Cysto/uretero, stricture tx 7.05 NA NA 3.45 3.88 0.71 00052345 A Cysto/uretero w/up stricture 7.55 NA NA 3.65 4.11 0.75 00052346 A Cystouretero w/renal strict 8.58 NA NA 4.04 4.56 0.86 00052351 A Cystouretero & or pyeloscope 5.85 NA NA 2.84 3.16 0.58 00052352 A Cystouretero w/stone remove 6.87 NA NA 3.33 3.71 0.69 000CMS-1503-P970**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**52353 A Cystouretero w/lithotripsy 7.96 NA NA 3.76 4.19 0.79 00052354 A Cystouretero w/biopsy 7.33 NA NA 3.51 3.91 0.73 00052355 A Cystouretero w/excise tumor 8.81 NA NA 4.09 4.57 0.89 00052400 A Cystouretero w/congen repr 8.69 NA NA 4.51 5.07 0.88 09052402 A Cystourethro cut ejacul duct 5.27 NA NA 2.12 2.38 0.52 00052450 A Incision of prostate 7.78 NA NA 5.16 5.70 0.78 09052500 A Revision of bladder neck 8.14 NA NA 5.30 5.88 0.81 09052601 A Prostatectomy (TURP) 15.26 NA NA 8.06 8.62 1.55 09052630 A Remove prostate regrowth 7.73 NA NA 4.54 4.99 0.78 09052640 A Relieve bladder contracture 4.79 NA NA 3.31 3.77 0.47 09052647 A Laser surgery of prostate 11.30 36.62 48.14 6.54 7.22 1.14 09052648 A Laser surgery of prostate 12.15 37.19 48.67 6.88 7.59 1.24 09052649 A Prostate laser enucleation 17.29 NA NA 8.93 10.40 1.74 09052700 A Drainage of prostate abscess 7.49 NA NA 4.65 5.04 0.75 09053000 A Incision of urethra 2.33 NA NA 1.74 1.94 0.25 01053010 A Incision of urethra 4.45 NA NA 3.64 4.04 0.44 09053020 A Incision of urethra 1.77 NA NA 0.91 1.01 0.18 00053025 A Incision of urethra 1.13 NA NA 0.82 0.80 0.07 00053040 A Drainage of urethra abscess 6.55 NA NA 4.26 4.69 0.66 09053060 A Drainage of urethra abscess 2.68 2.32 2.38 1.83 1.80 0.45 01053080 A Drainage of urinary leakage 6.92 NA NA 4.64 5.38 0.69 09053085 A Drainage of urinary leakage 11.18 NA NA 6.70 6.76 1.51 09053200 A Biopsy of urethra 2.59 1.67 1.83 1.31 1.42 0.28 00053210 A Removal of urethra 13.72 NA NA 7.64 8.35 1.37 09053215 A Removal of urethra 16.85 NA NA 8.76 9.75 1.70 09053220 A Treatment of urethra lesion 7.63 NA NA 4.91 5.36 0.76 090CMS-1503-P971**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**53230 A Removal of urethra lesion 10.44 NA NA 6.25 6.80 1.22 09053235 A Removal of urethra lesion 10.99 NA NA 6.44 7.22 1.10 09053240 A Surgery for urethra pouch 7.08 NA NA 4.61 5.17 0.71 09053250 A Removal of urethra gland 6.52 NA NA 4.75 5.06 1.47 09053260 A Treatment of urethra lesion 3.03 2.47 2.69 1.92 2.03 0.37 01053265 A Treatment of urethra lesion 3.17 2.78 3.14 1.95 2.11 0.35 01053270 A Removal of urethra gland 3.14 2.57 2.72 2.04 2.09 0.55 01053275 A Repair of urethra defect 4.57 NA NA 2.65 2.97 0.47 01053400 A Revise urethra, stage 1 14.13 NA NA 7.98 8.77 1.47 09053405 A Revise urethra, stage 2 15.66 NA NA 8.43 9.40 1.58 09053410 A Reconstruction of urethra 17.68 NA NA 9.36 10.36 1.78 09053415 A Reconstruction of urethra 20.70 NA NA 10.47 11.57 2.12 09053420 A Reconstruct urethra, stage 1 15.17 NA NA 8.03 8.26 1.54 09053425 A Reconstruct urethra, stage 2 17.07 NA NA 8.78 9.82 1.71 09053430 A Reconstruction of urethra 17.43 NA NA 9.14 9.74 2.05 09053431 A Reconstruct urethra/bladder 21.18 NA NA 10.68 11.80 2.12 09053440 A Male sling procedure 15.54 NA NA 8.83 9.70 1.58 09053442 A Remove/revise male sling 13.49 NA NA 8.09 8.84 1.36 09053444 A Insert tandem cuff 14.19 NA NA 7.69 8.56 1.43 09053445 A Insert uro/ves nck sphincter 15.39 NA NA 8.78 9.81 1.57 09053446 A Remove uro sphincter 11.02 NA NA 6.68 7.44 1.13 09053447 A Remove/replace ur sphincter 14.28 NA NA 8.01 8.95 1.46 09053448 A Remov/replc ur sphinctr comp 23.44 NA NA 11.90 13.21 2.35 09053449 A Repair uro sphincter 10.56 NA NA 6.29 7.00 1.09 09053450 A Revision of urethra 6.77 NA NA 4.47 4.97 0.68 09053460 A Revision of urethra 7.75 NA NA 4.86 5.40 0.76 090CMS-1503-P972**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**53500 A Urethrlys, transvag w/ scope 13.00 NA NA 7.54 8.16 1.55 09053502 A Repair of urethra injury 8.26 NA NA 5.14 5.63 0.83 09053505 A Repair of urethra injury 8.26 NA NA 5.13 5.70 0.83 09053510 A Repair of urethra injury 10.96 NA NA 6.43 7.15 1.10 09053515 A Repair of urethra injury 14.22 NA NA 7.72 8.51 1.43 09053520 A Repair of urethra defect 9.48 NA NA 5.85 6.48 0.95 09053600 A Dilate urethra stricture 1.21 1.06 1.23 0.56 0.62 0.11 00053601 A Dilate urethra stricture 0.98 1.23 1.42 0.50 0.56 0.08 00053605 A Dilate urethra stricture 1.28 NA NA 0.51 0.56 0.13 00053620 A Dilate urethra stricture 1.62 1.54 1.85 0.79 0.88 0.17 00053621 A Dilate urethra stricture 1.35 1.62 1.95 0.64 0.72 0.13 00053660 A Dilation of urethra 0.71 1.20 1.39 0.44 0.48 0.07 00053661 A Dilation of urethra 0.72 1.16 1.36 0.40 0.44 0.07 00053665 A Dilation of urethra 0.76 NA NA 0.31 0.32 0.08 00053850 A Prostatic microwave thermotx 10.08 42.86 57.47 5.59 6.18 1.03 09053852 A Prostatic rf thermotx 10.83 40.42 54.21 6.32 6.97 1.10 09053855 A Insert prost urethral stent 1.64 18.83 18.83 0.65 0.65 0.17 00053899 C Urology surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY54000 A Slitting of prepuce1.59 2.42 2.88 1.38 1.52 0.14 01054001 A Slitting of prepuce2.24 2.79 3.26 1.58 1.73 0.24 01054015 A Drain penis lesion 5.36 NA NA 3.08 3.45 0.58 01054050 A Destruction, penis lesion(s) 1.29 2.34 2.38 1.63 1.62 0.17 01054055 A Destruction, penis lesion(s) 1.25 1.98 2.13 1.29 1.34 0.14 01054056 A Cryosurgery, penis lesion(s) 1.29 2.65 2.63 1.82 1.77 0.18 01054057 A Laser surg, penis lesion(s) 1.29 2.43 2.72 1.31 1.40 0.13 01054060 A Excision of penis lesion(s) 1.98 2.90 3.33 1.61 1.72 0.23 010CMS-1503-P973**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**54065 A Destruction, penis lesion(s) 2.47 3.57 3.66 2.33 2.27 0.32 01054100 A Biopsy of penis 1.90 3.54 3.71 1.65 1.59 0.25 00054105 A Biopsy of penis 3.54 3.66 4.31 2.33 2.61 0.37 01054110 A Treatment of penis lesion 10.92 NA NA 6.28 6.95 1.10 09054111 A Treat penis lesion, graft 14.42 NA NA 7.66 8.53 1.46 09054112 A Treat penis lesion, graft 16.98 NA NA 8.89 9.93 1.70 09054115 A Treatment of penis lesion 6.95 5.43 6.07 4.72 5.21 0.69 09054120 A Partial removal of penis 11.01 NA NA 6.40 7.09 1.13 09054125 A Removal of penis 14.56 NA NA 7.84 8.66 1.54 09054130 A Remove penis & nodes 21.84 NA NA 11.09 12.33 2.20 09054135 A Remove penis & nodes 28.17 NA NA 13.59 15.12 2.84 09054150 A Circumcision w/regionlblock 1.90 2.31 2.80 0.80 0.85 0.24 00054160 A Circumcision, neonate 2.53 3.43 4.08 1.44 1.60 0.25 01054161 A Circum 28 days or older 3.32 NA NA 2.09 2.32 0.35 01054162 A Lysis penil circumic lesion 3.32 3.70 4.37 2.17 2.36 0.34 01054163 A Repair of circumcision 3.32 NA NA 2.70 2.99 0.34 01054164 A Frenulotomy of penis 2.82 NA NA 2.48 2.75 0.30 01054200 A Treatment of penis lesion 1.11 1.81 2.09 1.19 1.34 0.10 01054205 A Treatment of penis lesion 8.97 NA NA 5.69 6.40 0.89 09054220 A Treatment of penis lesion 2.42 3.03 3.60 1.29 1.42 0.27 00054230 A Prepare penis study 1.34 1.29 1.46 0.85 0.95 0.13 00054231 A Dynamic cavernosometry 2.04 1.79 2.01 1.17 1.31 0.21 00054235 A Penile injection1.19 1.28 1.43 0.84 0.93 0.11 00054240 A Penis study 1.31 1.42 1.58 NA NA 0.09 00054240 TC A Penis study 0.00 0.91 1.01 NA NA 0.01 00054240 26 A Penis study 1.31 0.51 0.57 0.51 0.57 0.08 000CMS-1503-P974**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**54250 A Penis study 2.22 1.20 1.34 NA NA 0.15 00054250 TC A Penis study 0.00 0.32 0.36 NA NA 0.01 00054250 26 A Penis study 2.22 0.88 0.98 0.88 0.98 0.14 00054300 A Revision of penis 11.20 NA NA 6.50 7.32 1.13 09054304 A Revision of penis 13.28 NA NA 7.40 8.36 1.33 09054308 A Reconstruction of urethra 12.62 NA NA 7.74 8.33 1.27 09054312 A Reconstruction of urethra 14.51 NA NA 8.79 9.48 1.46 09054316 A Reconstruction of urethra 18.05 NA NA 10.36 11.13 1.81 09054318 A Reconstruction of urethra 12.43 NA NA 7.81 8.37 0.90 09054322 A Reconstruction of urethra 13.98 NA NA 7.56 8.53 1.41 09054324 A Reconstruction of urethra 17.55 NA NA 9.19 10.39 1.75 09054326 A Reconstruction of urethra 17.02 NA NA 9.08 9.65 1.71 09054328 A Revise penis/urethra 16.89 NA NA 9.03 9.99 1.70 09054332 A Revise penis/urethra 18.37 NA NA 9.62 10.78 1.85 09054336 A Revise penis/urethra 21.62 NA NA 12.24 12.10 2.18 09054340 A Secondary urethral surgery 9.71 NA NA 5.99 6.56 0.96 09054344 A Secondary urethral surgery 17.06 NA NA 9.92 10.68 1.71 09054348 A Secondary urethral surgery 18.32 NA NA 16.54 14.40 1.34 09054352 A Reconstruct urethra/penis 26.13 NA NA 22.46 19.46 2.64 09054360 A Penis plastic surgery 12.78 NA NA 7.09 8.00 1.29 09054380 A Repair penis 14.18 NA NA 7.86 8.86 1.43 09054385 A Repair penis 16.56 NA NA 9.04 10.93 2.52 09054390 A Repair penis and bladder 22.77 NA NA 12.55 12.22 2.29 09054400 A Insert semi-rigid prosthesis 9.17 NA NA 5.43 6.07 0.92 09054401 A Insert self-contd prosthesis 10.44 NA NA 7.58 8.45 1.07 09054405 A Insert multi-comp penis pros 14.52 NA NA 7.80 8.67 1.47 090CMS-1503-P975**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**54406 A Remove muti-comp penis pros 12.89 NA NA 7.25 8.05 1.30 09054408 A Repair multi-comp penis pros 13.91 NA NA 7.89 8.73 1.43 09054410 A Remove/replace penis prosth 15.18 NA NA 8.53 9.51 1.54 09054411 A Remov/replc penis pros, comp 18.35 NA NA 9.98 11.02 1.85 09054415 A Remove self-contd penis pros 8.88 NA NA 5.66 6.28 0.89 09054416 A Remv/repl penis contain pros 12.08 NA NA 7.50 8.29 1.23 09054417 A Remv/replc penis pros, compl 16.10 NA NA 8.69 9.62 1.62 09054420 A Revision of penis 12.39 NA NA 7.04 7.88 1.26 09054430 A Revision of penis 11.06 NA NA 6.58 7.36 1.12 09054435 A Revision of penis 6.81 NA NA 4.66 5.20 0.68 09054440 C Repair of penis0.00 0.00 0.00 0.00 0.00 0.00 09054450 A Preputial stretching 1.12 0.80 0.94 0.47 0.54 0.10 00054500 A Biopsy of testis 1.31 NA NA 0.75 0.84 0.13 00054505 A Biopsy of testis 3.50 NA NA 2.28 2.57 0.35 01054512 A Excise lesion testis 9.33 NA NA 5.49 6.02 0.96 09054520 A Removal of testis 5.30 NA NA 3.65 3.98 0.64 09054522 A Orchiectomy, partial 10.25 NA NA 6.01 6.42 1.05 09054530 A Removal of testis 8.46 NA NA 5.43 6.04 0.90 09054535 A Extensive testis surgery 13.19 NA NA 7.33 7.91 1.33 09054550 A Exploration for testis 8.41 NA NA 5.15 5.63 0.85 09054560 A Exploration for testis 12.10 NA NA 6.83 7.16 1.23 09054600 A Reduce testis torsion 7.64 NA NA 4.84 5.35 0.76 09054620 A Suspension of testis 5.21 NA NA 3.06 3.43 0.52 01054640 A Suspension of testis 7.73 NA NA 5.44 5.80 0.90 09054650 A Orchiopexy (Fowler-Stephens) 12.39 NA NA 7.22 7.85 1.26 09054660 A Revision of testis 5.74 NA NA 4.09 4.50 0.57 090CMS-1503-P976**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**54670 A Repair testis injury 6.65 NA NA 4.50 4.97 0.66 09054680 A Relocation of testis(es) 14.04 NA NA 7.67 8.32 1.41 09054690 A Laparoscopy, orchiectomy 11.70 NA NA 6.43 6.58 2.57 09054692 A Laparoscopy, orchiopexy 13.74 NA NA 7.21 8.04 1.37 09054699 C Laparoscope proc, testis 0.00 0.00 0.00 0.00 0.00 0.00 YYY54700 A Drainage of scrotum 3.47 NA NA 2.38 2.58 0.41 01054800 A Biopsy of epididymis 2.33 NA NA 2.02 1.78 0.34 00054830 A Remove epididymis lesion 6.01 NA NA 4.24 4.64 0.65 09054840 A Remove epididymis lesion 5.27 NA NA 3.57 3.98 0.54 09054860 A Removal of epididymis 6.95 NA NA 4.58 5.07 0.71 09054861 A Removal of epididymis 9.70 NA NA 5.89 6.51 0.96 09054865 A Explore epididymis 5.77 NA NA 4.10 4.51 0.58 09054900 A Fusion of spermatic ducts 14.20 NA NA 7.87 7.93 1.06 09054901 A Fusion of spermatic ducts 19.10 NA NA 10.96 11.64 1.41 09055000 A Drainage of hydrocele 1.43 1.76 2.04 0.91 0.99 0.14 00055040 A Removal of hydrocele 5.45 NA NA 3.83 4.20 0.64 09055041 A Removal of hydroceles 8.54 NA NA 5.49 6.02 0.93 09055060 A Repair of hydrocele 6.15 NA NA 4.30 4.70 0.69 09055100 A Drainage of scrotum abscess 2.45 3.38 3.82 2.09 2.24 0.31 01055110 A Explore scrotum 6.33 NA NA 4.36 4.74 0.71 09055120 A Removal of scrotum lesion 5.72 NA NA 4.07 4.44 0.64 09055150 A Removal of scrotum 8.14 NA NA 5.37 5.86 0.89 09055175 A Revision of scrotum 5.87 NA NA 4.14 4.56 0.62 09055180 A Revision of scrotum 11.78 NA NA 7.28 7.88 1.34 09055200 A Incision of sperm duct 4.55 7.27 9.08 3.11 3.39 0.45 09055250 A Removal of sperm duct(s) 3.37 7.23 8.84 2.93 3.20 0.34 090CMS-1503-P977**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**55300 A Prepare, sperm duct x-ray 3.50 NA NA 1.68 1.71 0.35 00055400 A Repair of sperm duct 8.61 NA NA 5.13 5.74 0.86 09055450 A Ligation of sperm duct 4.43 5.33 6.38 2.66 2.90 0.44 01055500 A Removal of hydrocele 6.22 NA NA 4.62 4.73 0.92 09055520 A Removal of sperm cord lesion 6.66 NA NA 5.29 4.90 1.41 09055530 A Revise spermatic cord veins 5.75 NA NA 3.95 4.35 0.65 09055535 A Revise spermatic cord veins 7.19 NA NA 4.66 5.10 0.72 09055540 A Revise hernia & sperm veins 8.30 NA NA 6.01 5.58 1.71 09055550 A Laparo ligate spermatic vein 7.20 NA NA 4.60 4.95 0.72 09055559 C Laparo proc, spermatic cord 0.00 0.00 0.00 0.00 0.00 0.00 YYY55600 A Incise sperm duct pouch 7.01 NA NA 4.60 5.11 0.71 09055605 A Incise sperm duct pouch 8.76 NA NA 6.08 6.11 0.88 09055650 A Remove sperm duct pouch 12.65 NA NA 7.13 7.78 1.27 09055680 A Remove sperm pouch lesion 5.67 NA NA 3.86 4.12 0.57 09055700 A Biopsy of prostate 2.58 3.33 3.98 1.27 1.37 0.27 00055705 A Biopsy of prostate 4.61 NA NA 2.74 3.07 0.47 01055706 A Prostate saturation sampling 6.28 NA NA 4.00 4.64 0.45 01055720 A Drainage of prostate abscess 7.73 NA NA 4.73 5.22 0.76 09055725 A Drainage of prostate abscess 10.05 NA NA 6.29 6.88 1.02 09055801 A Removal of prostate 19.80 NA NA 10.38 11.35 1.99 09055810 A Extensive prostate surgery 24.29 NA NA 12.03 13.23 2.57 09055812 A Extensive prostate surgery 29.89 NA NA 14.55 16.10 3.02 09055815 A Extensive prostate surgery 32.95 NA NA 15.76 17.48 3.32 09055821 A Removal of prostate 15.76 NA NA 8.36 9.26 1.61 09055831 A Removal of prostate 17.19 NA NA 8.92 9.89 1.72 09055840 A Extensive prostate surgery 24.63 NA NA 12.31 13.64 2.50 090CMS-1503-P978**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**55842 A Extensive prostate surgery 26.49 NA NA 13.04 14.48 2.70 09055845 A Extensive prostate surgery 30.67 NA NA 14.50 16.07 3.15 09055860 A Surgical exposure, prostate 15.84 NA NA 8.29 9.22 1.58 09055862 A Extensive prostate surgery 20.04 NA NA 10.24 11.43 2.01 09055865 A Extensive prostate surgery 24.57 NA NA 12.27 13.67 2.47 09055866 A Laparo radical prostatectomy 32.46 NA NA 15.60 17.28 3.31 09055870 A Electroejaculation 2.58 2.22 2.48 1.35 1.52 0.27 00055873 A Cryoablate prostate 13.60 169.57 169.57 7.47 10.45 1.41 09055875 A Transperi needle place, pros 13.46 NA NA 7.66 8.43 1.34 09055876 A Place rt device/marker, pros 1.73 1.99 2.25 1.06 1.19 0.17 00055899 C Genital surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY55920 A Place needles pelvic for rt 8.31 NA NA 4.40 4.26 0.83 00055970 N Sex transformation, M to F 0.00 0.00 0.00 0.00 0.00 0.00 XXX55980 N Sex transformation, F to M 0.00 0.00 0.00 0.00 0.00 0.00 XXX56405 A I & D of vulva/perineum 1.49 1.45 1.46 1.43 1.41 0.27 01056420 A Drainage of gland abscess 1.44 1.82 1.94 1.02 1.02 0.25 01056440 A Surgery for vulva lesion 2.89 NA NA 2.05 2.01 0.51 01056441 A Lysis of labial lesion(s) 2.02 1.88 1.99 1.74 1.80 0.30 01056442 A Hymenotomy 0.68 NA NA 0.61 0.63 0.11 00056501 A Destroy, vulva lesions, sim 1.58 1.94 1.98 1.52 1.51 0.28 01056515 A Destroy vulva lesion/s compl 3.08 3.00 2.98 2.35 2.26 0.52 01056605 A Biopsy of vulva/perineum 1.10 1.11 1.14 0.54 0.50 0.18 00056606 A Biopsy of vulva/perineum 0.55 0.46 0.47 0.25 0.23 0.08 ZZZ56620 A Partial removal of vulva 7.53 NA NA 6.10 5.91 1.31 09056625 A Complete removal of vulva 9.68 NA NA 6.66 6.36 1.68 09056630 A Extensive vulva surgery 14.80 NA NA 9.20 8.61 2.66 090CMS-1503-P979**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**56631 A Extensive vulva surgery 18.99 NA NA 11.45 10.71 3.33 09056632 A Extensive vulva surgery 21.86 NA NA 13.70 12.68 3.84 09056633 A Extensive vulva surgery 19.62 NA NA 11.62 10.82 3.45 09056634 A Extensive vulva surgery 20.66 NA NA 12.46 11.55 3.63 09056637 A Extensive vulva surgery 24.75 NA NA 14.09 13.08 4.34 09056640 A Extensive vulva surgery 24.78 NA NA 13.21 12.42 4.34 09056700 A Partial removal of hymen 2.84 NA NA 2.21 2.19 0.49 01056740 A Remove vagina gland lesion 4.88 NA NA 3.17 3.05 0.86 01056800 A Repair of vagina 3.93 NA NA 2.60 2.56 0.66 01056805 A Repair clitoris 19.88 NA NA 11.13 10.62 3.50 09056810 A Repair of perineum 4.29 NA NA 2.75 2.68 0.72 01056820 A Exam of vulva w/scope 1.50 1.47 1.48 0.80 0.75 0.27 00056821 A Exam/biopsy of vulva w/scope 2.05 1.89 1.91 1.05 0.99 0.35 00057000 A Exploration of vagina 3.02 NA NA 2.09 2.08 0.52 01057010 A Drainage of pelvic abscess 6.84 NA NA 4.90 4.76 1.20 09057020 A Drainage of pelvic fluid 1.50 1.02 1.00 0.70 0.65 0.27 00057022 A I & d vaginal hematoma, pp 2.73 NA NA 1.82 1.76 0.47 01057023 A I & d vag hematoma, non-ob 5.18 NA NA 3.23 3.13 0.90 01057061 A Destroy vag lesions, simple 1.30 1.75 1.81 1.34 1.35 0.23 01057065 A Destroy vag lesions, complex 2.66 2.50 2.52 1.97 1.92 0.45 01057100 A Biopsy of vagina 1.20 1.17 1.18 0.58 0.54 0.21 00057105 A Biopsy of vagina 1.74 1.87 1.93 1.62 1.63 0.30 01057106 A Remove vagina wall, partial 7.50 NA NA 5.58 5.41 1.26 09057107 A Remove vagina tissue, part 24.56 NA NA 13.55 12.69 4.31 09057109 A Vaginectomy partial w/nodes 28.40 NA NA 15.90 14.47 4.99 09057110 A Remove vagina wall, complete 15.48 NA NA 8.80 8.42 2.68 090CMS-1503-P980**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**57111 A Remove vagina tissue, compl 28.40 NA NA 15.05 14.32 4.99 09057112 A Vaginectomy w/nodes, compl 30.52 NA NA 9.16 11.65 2.52 09057120 A Closure of vagina 8.28 NA NA 5.53 5.42 1.41 09057130 A Remove vagina lesion 2.46 2.31 2.38 1.84 1.84 0.42 01057135 A Remove vagina lesion 2.70 2.45 2.50 1.96 1.94 0.45 01057150 A Treat vagina infection 0.55 0.67 0.77 0.25 0.23 0.08 00057155 A Insert uteri tandems/ovoids 6.87 NA NA 4.77 4.70 0.62 09057160 A Insert pessary/other device 0.89 1.17 1.21 0.40 0.37 0.14 00057170 A Fitting of diaphragm/cap0.91 0.72 0.85 0.40 0.37 0.14 00057180 A Treat vaginal bleeding 1.63 2.13 2.23 1.21 1.23 0.28 01057200 A Repair of vagina 4.42 NA NA 3.66 3.63 0.73 09057210 A Repair vagina/perineum 5.71 NA NA 4.19 4.15 0.95 09057220 A Revision of urethra 4.85 NA NA 3.80 3.77 0.83 09057230 A Repair of urethral lesion 6.30 NA NA 4.39 4.42 1.10 09057240 A Repair bladder & vagina 11.50 NA NA 6.73 6.53 1.70 09057250 A Repair rectum & vagina 11.50 NA NA 6.85 6.35 1.94 09057260 A Repair of vagina 14.44 NA NA 8.15 7.58 2.43 09057265 A Extensive repair of vagina 15.94 NA NA 8.81 8.33 2.67 09057267 A Insert mesh/pelvic flr addon 4.88 NA NA 2.12 2.09 0.75 ZZZ57268 A Repair of bowel bulge 7.57 NA NA 5.49 5.39 1.27 09057270 A Repair of bowel pouch 13.67 NA NA 7.96 7.62 2.33 09057280 A Suspension of vagina 16.72 NA NA 9.18 8.96 2.70 09057282 A Colpopexy, extraperitoneal 7.97 NA NA 5.63 5.60 1.29 09057283 A Colpopexy, intraperitoneal 11.66 NA NA 7.01 6.80 1.99 09057284 A Repair paravag defect,open 14.33 NA NA 7.85 7.83 2.25 09057285 A Repair paravag defect, vag 11.60 NA NA 6.75 6.61 1.87 090CMS-1503-P981**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**57287 A Revise/remove sling repair 11.15 NA NA 7.38 7.70 1.53 09057288 A Repair bladder defect12.13 NA NA 7.05 7.38 1.65 09057289 A Repair bladder & vagina 12.80 NA NA 7.29 7.63 1.29 09057291 A Construction of vagina 8.64 NA NA 8.95 7.39 1.53 09057292 A Construct vagina with graft 14.01 NA NA 8.11 7.93 2.43 09057295 A Revise vag graft via vagina 7.82 NA NA 5.17 5.22 1.24 09057296 A Revise vag graft, open abd 16.56 NA NA 9.14 8.72 2.90 09057300 A Repair rectum-vagina fistula 8.71 NA NA 6.36 5.90 1.58 09057305 A Repair rectum-vagina fistula 15.35 NA NA 9.45 8.61 3.08 09057307 A Fistula repair & colostomy 17.17 NA NA 10.85 9.76 3.82 09057308 A Fistula repair, transperine 10.59 NA NA 7.29 6.70 1.87 09057310 A Repair urethrovaginal lesion 7.65 NA NA 5.02 5.43 0.76 09057311 A Repair urethrovaginal lesion 8.91 NA NA 5.52 5.97 0.89 09057320 A Repair bladder-vagina lesion 8.88 NA NA 5.67 6.01 1.09 09057330 A Repair bladder-vagina lesion 13.21 NA NA 7.17 7.67 1.33 09057335 A Repair vagina 20.02 NA NA 11.29 11.00 3.52 09057400 A Dilation of vagina 2.27 NA NA 1.33 1.31 0.40 00057410 A Pelvic examination 1.75 NA NA 1.15 1.11 0.30 00057415 A Remove vaginal foreign body 2.49 NA NA 1.85 1.84 0.38 01057420 A Exam of vagina w/scope 1.60 1.52 1.53 0.84 0.79 0.27 00057421 A Exam/biopsy of vag w/scope 2.20 1.98 2.00 1.12 1.05 0.38 00057423 A Repair paravag defect, lap 16.08 NA NA 8.66 8.44 2.83 09057425 A Laparoscopy, surg, colpopexy 17.03 NA NA 9.38 8.98 2.77 09057426 A Revise prosth vag graft lap 14.30 NA NA 8.93 8.93 2.50 09057452 A Exam of cervix w/scope 1.50 1.42 1.44 0.99 0.95 0.25 00057454 A Bx/curett of cervix w/scope 2.33 1.80 1.79 1.36 1.30 0.40 000CMS-1503-P982**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**57455 A Biopsy of cervix w/scope 1.99 1.85 1.87 1.01 0.95 0.34 00057456 A Endocerv curettage w/scope 1.85 1.77 1.80 0.95 0.90 0.32 00057460 A Bx of cervix w/scope, leep 2.83 4.75 5.18 1.58 1.52 0.49 00057461 A Conz of cervix w/scope, leep 3.43 5.13 5.55 1.65 1.56 0.61 00057500 A Biopsy of cervix 1.20 2.22 2.40 0.85 0.82 0.21 00057505 A Endocervical curettage 1.19 1.54 1.59 1.28 1.29 0.21 01057510 A Cauterization of cervix 1.90 1.64 1.65 1.23 1.19 0.32 01057511 A Cryocautery of cervix 1.95 1.96 1.99 1.62 1.60 0.34 01057513 A Laser surgery of cervix 1.95 1.91 1.93 1.62 1.61 0.34 01057520 A Conization of cervix 4.11 4.09 4.18 3.24 3.21 0.71 09057522 A Conization of cervix 3.67 3.40 3.44 2.89 2.85 0.65 09057530 A Removal of cervix 5.27 NA NA 4.04 3.98 0.90 09057531 A Removal of cervix, radical 29.95 NA NA 16.83 15.51 5.26 09057540 A Removal of residual cervix 13.29 NA NA 7.79 7.43 2.32 09057545 A Remove cervix/repair pelvis 14.10 NA NA 8.16 7.78 2.44 09057550 A Removal of residual cervix 6.34 NA NA 4.67 4.60 1.12 09057555 A Remove cervix/repair vagina 9.94 NA NA 6.32 6.08 1.72 09057556 A Remove cervix, repair bowel 9.36 NA NA 5.98 5.91 1.51 09057558 A D&c of cervical stump 1.72 1.64 1.66 1.35 1.33 0.30 01057700 A Revision of cervix 4.35 NA NA 4.04 4.05 0.75 09057720 A Revision of cervix 4.61 NA NA 3.70 3.66 0.79 09057800 A Dilation of cervical canal 0.77 0.85 0.87 0.55 0.53 0.13 00058100 A Biopsy of uterus lining 1.53 1.41 1.43 0.84 0.80 0.27 00058110 A Bx done w/colposcopy add-on 0.77 0.53 0.53 0.35 0.32 0.13 ZZZ58120 A Dilation and curettage 3.59 3.33 3.25 2.29 2.20 0.64 01058140 A Myomectomy abdom method 15.79 NA NA 8.98 8.47 2.91 090CMS-1503-P983**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**58145 A Myomectomy vag method 8.91 NA NA 5.79 5.60 1.55 09058146 A Myomectomy abdom complex 20.34 NA NA 10.89 10.35 3.57 09058150 A Total hysterectomy 17.31 NA NA 9.64 9.05 3.05 09058152 A Total hysterectomy 21.86 NA NA 11.83 11.19 3.89 09058180 A Partial hysterectomy 16.60 NA NA 9.27 8.77 2.91 09058200 A Extensive hysterectomy 23.10 NA NA 12.53 11.66 4.04 09058210 A Extensive hysterectomy 30.91 NA NA 16.73 15.49 5.47 09058240 A Removal of pelvis contents 49.33 NA NA 26.31 24.38 8.65 09058260 A Vaginal hysterectomy 14.15 NA NA 8.23 7.85 2.47 09058262 A Vag hyst including t/o 15.94 NA NA 9.01 8.58 2.80 09058263 A Vag hyst w/t/o & vag repair 17.23 NA NA 9.59 9.14 3.02 09058267 A Vag hyst w/urinary repair 18.36 NA NA 10.17 9.66 3.24 09058270 A Vag hyst w/enterocele repair 15.30 NA NA 8.55 8.15 2.67 09058275 A Hysterectomy/revise vagina 17.03 NA NA 9.54 9.09 3.01 09058280 A Hysterectomy/revise vagina 18.33 NA NA 10.18 9.63 3.19 09058285 A Extensive hysterectomy 23.38 NA NA 12.12 11.43 4.08 09058290 A Vag hyst complex 20.27 NA NA 10.87 10.31 3.56 09058291 A Vag hyst incl t/o, complex 22.06 NA NA 11.68 11.10 3.87 09058292 A Vag hyst t/o & repair, compl 23.35 NA NA 12.24 11.59 4.08 09058293 A Vag hyst w/uro repair, compl 24.33 NA NA 12.68 11.96 4.27 09058294 A Vag hyst w/enterocele, compl 21.55 NA NA 11.43 10.79 3.80 09058300 N Insert intrauterine device 1.01 0.92 1.03 0.44 0.43 0.07 XXX58301 A Remove intrauterine device 1.27 1.28 1.32 0.57 0.53 0.23 00058321 A Artificial insemination 0.92 1.15 1.21 0.41 0.39 0.06 00058322 A Artificial insemination 1.10 1.21 1.25 0.49 0.46 0.18 00058323 A Sperm washing 0.23 0.19 0.24 0.10 0.10 0.04 000CMS-1503-P984**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**58340 A Catheter for hysterography 0.88 2.26 2.57 0.69 0.71 0.13 00058345 A Reopen fallopian tube 4.70 NA NA 2.85 2.77 0.81 01058346 A Insert heyman uteri capsule 7.56 NA NA 5.23 4.96 0.65 09058350 A Reopen fallopian tube1.06 1.52 1.59 1.06 1.07 0.18 01058353 A Endometr ablate, thermal 3.60 23.15 27.05 2.32 2.27 0.64 01058356 A Endometrial cryoablation 6.41 43.89 50.40 2.96 2.78 1.12 01058400 A Suspension of uterus 7.14 NA NA 4.81 4.80 1.12 09058410 A Suspension of uterus 13.80 NA NA 7.96 7.57 2.40 09058520 A Repair of ruptured uterus 13.48 NA NA 7.82 7.39 3.01 09058540 A Revision of uterus 15.71 NA NA 8.88 8.41 2.76 09058541 A Lsh, uterus 250 g or less 14.70 NA NA 8.69 8.19 2.56 09058542 A Lsh w/t/o ut250 g or less 16.56 NA NA 9.54 8.95 2.91 09058543 A Lsh uterus above 250 g 16.87 NA NA 9.69 9.07 2.97 09058544 A Lsh w/t/o uterus above250 g 18.37 NA NA 10.35 9.65 3.24 09058545 A Laparoscopic myomectomy 15.55 NA NA 8.64 8.17 2.77 09058546 A Laparo-myomectomy, complex 19.94 NA NA 10.53 9.97 3.52 09058548 A Lap radical hyst 31.63 NA NA 17.37 15.75 5.52 09058550 A Laparo-asst vag hysterectomy 15.10 NA NA 8.77 8.38 2.66 09058552 A Laparo-vag hyst incl t/o 16.91 NA NA 9.58 9.11 2.98 09058553 A Laparo-vag hyst, complex 20.06 NA NA 10.66 10.05 3.53 09058554 A Laparo-vag hyst w/t/o, compl 23.11 NANA 12.47 11.73 4.08 09058555 A Hysteroscopy, dx, sep proc 3.33 4.81 4.00 1.81 1.72 0.58 00058558 A Hysteroscopy, biopsy 4.74 5.89 4.93 2.47 2.35 0.83 00058559 A Hysteroscopy, lysis 6.16 NA NA 3.11 2.95 1.09 00058560 A Hysteroscopy, resect septum 6.99 NA NA 3.48 3.30 1.23 00058561 A Hysteroscopy, remove myoma 9.99 NA NA 4.83 4.55 1.74 000CMS-1503-P985**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**58562 A Hysteroscopy, remove fb 5.20 5.82 4.89 2.64 2.52 0.90 00058563 A Hysteroscopy, ablation 6.16 37.97 43.95 3.11 2.95 1.09 00058565 A Hysteroscopy, sterilization 7.12 42.54 47.36 4.60 4.47 1.24 09058570 A Tlh, uterus 250 g or less 15.88 NA NA 9.27 8.69 2.80 09058571 A Tlh w/t/o 250 g or less 17.69 NA NA 10.28 9.52 3.12 09058572 A Tlh, uterus over 250 g 20.09 NA NA 11.20 10.39 3.53 09058573 A Tlh w/t/o uterus over250 g 23.11 NA NA 12.74 11.69 4.04 09058578 C Laparo proc, uterus 0.00 0.00 0.00 0.00 0.00 0.00 YYY58579 C Hysteroscope procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY58600 A Division of fallopian tube 5.91 NA NA 3.94 3.80 1.05 09058605 A Division of fallopian tube 5.28 NA NA 3.62 3.53 0.92 09058611 A Ligate oviduct(s) add-on 1.45 NA NA 0.65 0.60 0.25 ZZZ58615 A Occlude fallopian tube(s) 3.94 NA NA 2.65 2.65 0.69 01058660 A Laparoscopy, lysis 11.59 NA NA 6.54 6.19 2.12 09058661 A Laparoscopy, remove adnexa 11.35 NA NA 6.03 5.69 2.01 01058662 A Laparoscopy, excise lesions 12.15 NA NA 6.89 6.56 2.15 09058670 A Laparoscopy, tubal cautery 5.91 NA NA 3.96 3.85 1.05 09058671 A Laparoscopy, tubal block 5.91 NA NA 3.96 3.84 1.05 09058672 A Laparoscopy, fimbrioplasty 12.91 NA NA 7.00 6.64 2.26 09058673 A Laparoscopy, salpingostomy 14.04 NA NA 7.60 7.24 2.44 09058679 C Laparo proc, oviduct-ovary 0.00 0.00 0.00 0.00 0.00 0.00 YYY58700 A Removal of fallopian tube 12.95 NA NA 7.90 7.42 2.50 09058720 A Removal of ovary/tube(s) 12.16 NA NA 7.31 6.92 2.23 09058740 A Adhesiolysis tube, ovary 14.90 NA NA 8.66 8.27 2.74 09058750 A Repair oviduct 15.64 NA NA 8.75 8.35 2.74 09058752 A Revise ovarian tube(s) 15.64 NA NA 8.69 8.44 1.14 090CMS-1503-P986**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**58760 A Fimbrioplasty 13.93 NA NA 7.98 7.68 2.43 09058770 A Create new tubal opening 14.77 NA NA 8.30 7.68 2.57 09058800 A Drainage of ovarian cyst(s) 4.62 3.95 4.02 3.44 3.43 0.79 09058805 A Drainage of ovarian cyst(s) 6.42 NA NA 4.36 4.35 1.13 09058820 A Drain ovary abscess, open 4.70 NA NA 4.54 4.12 0.81 09058822 A Drain ovary abscess, percut 11.81 NA NA 7.13 6.96 2.61 09058823 A Drain pelvic abscess, percut 3.37 20.70 22.52 1.19 1.35 0.40 00058825 A Transposition, ovary(s)11.78 NA NA 7.39 6.91 2.05 09058900 A Biopsy of ovary(s) 6.59 NA NA 5.35 4.87 1.46 09058920 A Partial removal of ovary(s) 11.95 NA NA 6.99 6.64 2.08 09058925 A Removal of ovarian cyst(s) 12.43 NA NA 7.51 7.09 2.32 09058940 A Removal of ovary(s) 8.22 NA NA 5.72 5.36 1.60 09058943 A Removal of ovary(s) 19.52 NA NA 10.92 10.18 3.66 09058950 A Resect ovarian malignancy 18.37 NA NA 10.82 10.11 3.38 09058951 A Resect ovarian malignancy 24.26 NA NA 13.30 12.34 4.34 09058952 A Resect ovarian malignancy 27.29 NA NA 15.09 13.99 4.92 09058953 A Tah, rad dissect for debulk 34.13 NA NA 18.30 16.94 6.10 09058954 A Tah rad debulk/lymph remove 37.13 NA NA 19.69 18.23 6.60 09058956 A Bso, omentectomy w/tah 22.80 NA NA 12.96 12.12 4.14 09058957 A Resect recurrent gyn mal 26.22 NA NA 14.65 13.38 4.99 09058958 A Resect recur gyn mal w/lym 29.22 NA NA 15.98 14.65 5.13 09058960 A Exploration of abdomen 15.79 NA NA 9.28 8.74 2.87 09058970 A Retrieval of oocyte 3.52 2.49 2.45 1.92 1.79 0.27 00058974 C Transfer of embryo 0.00 0.00 0.00 0.00 0.00 0.00 00058976 A Transfer of embryo 3.82 2.99 3.01 2.06 2.04 0.28 00058999 C Genital surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYYCMS-1503-P987**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**59000 A Amniocentesis, diagnostic 1.30 1.95 2.08 0.77 0.74 0.38 00059001 A Amniocentesis, therapeutic 3.00 NA NA 1.58 1.59 0.89 00059012 A Fetal cord puncture,prenatal 3.44 NA NA 1.73 1.64 1.03 00059015 A Chorion biopsy 2.20 1.79 1.79 1.17 1.12 0.65 00059020 A Fetal contract stress test 0.66 1.19 1.18 NA NA 0.18 00059020 TC A Fetal contract stress test 0.00 0.89 0.91 NA NA 0.01 00059020 26 A Fetal contract stress test 0.66 0.30 0.27 0.30 0.27 0.17 00059025 A Fetal non-stress test 0.53 0.72 0.71 NA NA 0.14 00059025 TC A Fetal non-stress test 0.00 0.48 0.49 NA NA 0.01 00059025 26 A Fetal non-stress test 0.53 0.24 0.22 0.24 0.22 0.13 00059030 A Fetal scalp blood sample 1.99 NA NA 0.86 0.81 0.13 00059050 A Fetal monitor w/report 0.89 NA NA 0.40 0.37 0.27 XXX59051 A Fetal monitor/interpret only 0.74 NA NA 0.33 0.31 0.23 XXX59070 A Transabdom amnioinfus w/us 5.24 5.63 5.70 2.66 2.60 1.57 00059072 A Umbilical cord occlud w/us 8.99 NA NA 4.28 4.14 2.68 00059074 A Fetal fluid drainage w/us 5.24 5.75 5.44 2.93 2.70 1.57 00059076 A Fetal shunt placement, w/us 8.99 NA NA 4.28 3.97 2.68 00059100 A Remove uterus lesion 13.37 NA NA 7.92 7.51 3.98 09059120 A Treat ectopic pregnancy 12.67 NA NA 7.60 7.29 3.80 09059121 A Treat ectopic pregnancy 12.74 NA NA 7.55 7.25 3.82 09059130 A Treat ectopic pregnancy 15.08 NA NA 8.60 8.16 1.12 09059135 A Treat ectopic pregnancy 14.92 NA NA 8.49 8.41 1.10 09059136 A Treat ectopic pregnancy 14.25 NA NA 8.16 7.77 4.25 09059140 A Treat ectopic pregnancy 5.94 NA NA 4.32 4.16 0.42 09059150 A Treat ectopic pregnancy 12.29 NA NA 7.35 7.03 3.67 09059151 A Treat ectopic pregnancy 12.11 NA NA 6.99 6.70 3.62 090CMS-1503-P988**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**59160 A D & c after delivery 2.76 2.48 2.65 1.67 1.72 0.81 01059200 A Insert cervical dilator 0.79 1.07 1.14 0.36 0.33 0.24 00059300 A Episiotomy or vaginal repair 2.41 2.56 2.58 1.39 1.29 0.71 00059320 A Revision of cervix 2.48 NA NA 1.42 1.37 0.72 00059325 A Revision of cervix 4.06 NA NA 2.13 2.03 0.30 00059350 A Repair of uterus 4.94 NA NA 2.22 1.99 1.47 00059400 A Obstetrical care 27.48 NA NA 19.18 18.46 7.94 MMM59409 A Obstetrical care 13.48 NA NA 6.10 5.64 3.87 MMM59410 A Obstetrical care 15.37 NA NA 7.66 7.14 4.42 MMM59412 A Antepartum manipulation 1.71 NA NA 0.93 0.89 0.51 MMM59414 A Deliver placenta 1.61 NA NA 0.72 0.67 0.47 MMM59425 A Antepartum care only 6.50 5.56 5.36 2.92 2.56 1.87 MMM59426 A Antepartum care only 11.57 10.13 9.77 5.19 4.54 3.25 MMM59430 A Care after delivery 2.13 1.47 1.42 1.09 1.02 0.61 MMM59510 A Cesarean delivery 31.07 NA NA 21.51 20.79 9.20 MMM59514 A Cesarean delivery only 15.95 NA NA 7.23 6.69 4.71 MMM59515 A Cesarean delivery 18.39 NA NA 9.40 8.83 5.41 MMM59525 A Remove uterus after cesarean 8.53 NA NA 3.83 3.56 2.53 ZZZ59610 A Vbac delivery 28.86 NA NA 19.78 19.20 8.62 MMM59612 A Vbac delivery only 15.04 NA NA 6.82 6.35 4.49 MMM59614 A Vbac care after delivery 16.64 NA NA 8.00 7.51 4.96 MMM59618 A Attempted vbac delivery 32.51 NA NA 22.22 21.56 9.71 MMM59620 A Attempted vbac delivery only 17.50 NA NA 7.92 7.35 5.23 MMM59622 A Attempted vbac after care 19.83 NA NA 10.19 9.62 5.92 MMM59812 A Treatment of miscarriage 4.44 3.73 3.67 3.14 3.05 1.30 09059820 A Care of miscarriage 4.84 4.91 4.98 4.31 4.28 1.44 090CMS-1503-P989**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**59821 A Treatment of miscarriage 5.09 4.71 4.76 4.06 4.01 1.53 09059830 A Treat uterus infection 6.59 NA NA 4.57 4.48 1.96 09059840 R Abortion 3.01 2.58 2.54 2.34 2.32 0.83 01059841 R Abortion 5.65 4.13 4.03 3.56 3.42 1.68 01059850 R Abortion 5.90 NA NA 3.89 3.87 0.42 09059851 R Abortion 5.92 NA NA 4.28 4.22 1.75 09059852 R Abortion 8.23 NA NA 5.90 5.91 0.61 09059855 R Abortion 6.43 NA NA 4.18 4.06 1.92 09059856 R Abortion 7.79 NA NA 4.65 4.50 2.32 09059857 R Abortion 9.33 NA NA 5.25 5.25 0.68 09059866 R Abortion (mpr) 3.99 NA NA 2.12 2.04 0.30 00059870 A Evacuate mole of uterus 6.57 NA NA 5.54 5.56 1.96 09059871 A Remove cerclage suture 2.13 NA NA 1.30 1.25 0.64 00059897 C Fetal invas px w/us 0.00 0.00 0.00 0.00 0.00 0.00 YYY59898 C Laparo proc, ob care/deliver 0.00 0.00 0.00 0.00 0.00 0.00 YYY59899 C Maternity care procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY60000 A Drain thyroid/tongue cyst 1.81 2.78 2.67 2.30 2.23 0.25 01060100 A Biopsy of thyroid 1.56 1.41 1.53 0.58 0.62 0.17 00060200 A Remove thyroid lesion 10.02 NA NA 8.06 7.50 1.77 09060210 A Partial thyroid excision 11.23 NA NA 7.97 7.30 2.15 09060212 A Partial thyroid excision 16.43 NA NA 11.17 10.08 3.18 09060220 A Partial removal of thyroid 12.37 NA NA 8.71 7.96 2.23 09060225 A Partial removal of thyroid 14.79 NA NA 10.50 9.62 2.74 09060240 A Removal of thyroid 16.22 NA NA 10.11 9.24 3.07 09060252 A Removal of thyroid 22.01 NA NA 13.85 12.64 4.03 09060254 A Extensive thyroid surgery 28.42 NA NA 18.00 16.45 4.71 090CMS-1503-P990**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**60260 A Repeat thyroid surgery 18.26 NA NA 11.67 10.66 3.25 09060270 A Removal of thyroid 23.20 NA NA 13.73 12.88 4.55 09060271 A Removal of thyroid 17.62 NA NA 11.18 10.32 3.12 09060280 A Remove thyroid duct lesion 6.16 NA NA 6.36 5.95 0.88 09060281 A Remove thyroid duct lesion 8.82 NA NA 8.00 7.31 1.19 09060300 A Aspir/inj thyroid cyst 0.97 2.09 2.13 0.36 0.38 0.11 00060500 A Explore parathyroid glands 16.78 NA NA 10.62 9.67 3.36 09060502 A Re-explore parathyroids 21.15 NA NA 13.16 12.01 4.31 09060505 A Explore parathyroid glands 23.06 NA NA 14.42 13.33 4.49 09060512 A Autotransplant parathyroid 4.44 NA NA 2.06 1.86 0.86 ZZZ60520 A Removal of thymus gland 17.16 NA NA 10.34 9.68 3.60 09060521 A Removal of thymus gland 19.18 NA NA 10.21 10.46 4.71 09060522 A Removal of thymus gland 23.48 NA NA 12.27 12.45 5.67 09060540 A Explore adrenal gland 18.02 NA NA 10.09 10.09 3.15 09060545 A Explore adrenal gland 20.93 NA NA 11.46 11.16 3.83 09060600 A Remove carotid body lesion 25.09 NA NA 12.79 12.31 5.51 09060605 A Remove carotid body lesion 31.96 NA NA 18.48 16.53 4.27 09060650 A Laparoscopy adrenalectomy 20.73 NA NA 11.00 10.56 3.89 09060659 C Laparo proc, endocrine0.00 0.00 0.00 0.00 0.00 0.00 YYY60699 C Endocrine surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY6070F I Pt asked/cnsld aed effects 0.00 0.00 0.00 0.00 0.00 0.00 XXX61000 A Remove cranial cavity fluid 1.58 NA NA 1.29 1.32 0.14 00061001 A Remove cranial cavity fluid 1.49 NA NA 1.30 1.34 0.55 00061020 A Remove brain cavity fluid 1.51 NA NA 2.03 1.94 0.52 00061026 A Injection into brain canal 1.69 NA NA 1.63 1.63 0.40 00061050 A Remove brain canal fluid 1.51 NA NA 1.32 1.38 0.13 000CMS-1503-P991**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**61055 A Injection into brain canal 2.10 NA NA 1.49 1.57 0.30 00061070 A Brain canal shunt procedure 0.89 NA NA 1.36 1.33 0.21 00061105 A Twist drill hole 5.45 NA NA 6.17 5.77 1.99 09061107 A Drill skull for implantation 4.99 NA NA 2.71 2.62 1.85 00061108 A Drill skull for drainage 11.64 NA NA 10.96 10.32 4.30 09061120 A Burr hole for puncture 9.60 NA NA 8.99 8.44 3.59 09061140 A Pierce skull for biopsy 17.23 NA NA 13.89 13.24 6.34 09061150 A Pierce skull for drainage 18.90 NA NA 14.54 13.73 7.04 09061151 A Pierce skull for drainage 13.49 NA NA 11.12 10.41 5.03 09061154 A Pierce skull & remove clot 17.07 NA NA 14.31 13.55 6.33 09061156 A Pierce skull for drainage 17.45 NA NA 13.18 12.65 6.50 09061210 A Pierce skull, implant device 5.83 NA NA 3.16 3.05 2.16 00061215 A Insert brain-fluid device 5.85 NA NA 6.85 6.48 2.15 09061250 A Pierce skull & explore 11.49 NA NA 10.02 9.34 4.28 09061253 A Pierce skull & explore 13.49 NA NA 9.91 9.38 1.78 09061304 A Open skull for exploration 23.41 NA NA 17.19 16.33 8.46 09061305 A Open skull for exploration 28.64 NA NA 20.86 19.80 10.67 09061312 A Open skull for drainage 30.17 NA NA 20.88 19.84 11.21 09061313 A Open skull for drainage 28.09 NA NA 20.74 19.69 10.41 09061314 A Open skull for drainage 25.90 NA NA 19.09 18.10 9.62 09061315 A Open skull for drainage 29.65 NA NA 21.17 20.21 11.06 09061316 A Implt cran bone flap to abdo 1.39 NA NA 0.76 0.72 0.51 ZZZ61320 A Open skull for drainage 27.42 NA NA 19.34 18.56 10.06 09061321 A Open skull for drainage 30.53 NA NA 21.90 20.46 11.39 09061322 A Decompressive craniotomy 34.26 NA NA 24.09 22.53 12.70 09061323 A Decompressive lobectomy 35.06 NA NA 23.79 22.29 12.93 090CMS-1503-P992**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**61330 A Decompress eye socket 25.30 NA NA 18.97 17.17 9.44 09061332 A Explore/biopsy eye socket 28.60 NA NA 20.23 18.55 10.65 09061333 A Explore orbit/remove lesion 29.27 NA NA 23.34 20.36 10.91 09061334 A Explore orbit/remove object 19.60 NA NA 15.31 13.27 7.29 09061340 A Subtemporal decompression 20.11 NA NA 15.59 14.66 7.50 09061343 A Incise skull (press relief) 31.86 NA NA 22.10 21.09 11.78 09061345 A Relieve cranial pressure 29.23 NA NA 20.99 19.96 10.89 09061440 A Incise skull for surgery 28.66 NA NA 20.67 19.58 10.67 09061450 A Incise skull for surgery 27.69 NA NA 19.62 18.52 10.31 09061458 A Incise skull for brain wound 28.84 NA NA 20.55 19.65 10.64 09061460 A Incise skull for surgery 30.24 NA NA 21.54 20.10 11.26 09061470 A Incise skull for surgery 27.62 NA NA 19.58 18.58 10.29 09061480 A Incise skull for surgery 28.05 NA NA 14.21 14.49 2.05 09061490 A Incise skull for surgery 27.22 NA NA 19.36 18.47 10.16 09061500 A Removal of skull lesion 19.18 NA NA 14.99 14.11 6.01 09061501 A Remove infected skull bone 16.35 NA NA 13.41 12.56 4.85 09061510 A Removal of brain lesion 30.83 NA NA 22.92 21.87 11.43 09061512 A Remove brain lining lesion 37.14 NA NA 25.43 24.33 13.79 09061514 A Removal of brain abscess 27.23 NA NA 19.45 18.64 10.09 09061516 A Removal of brain lesion 26.58 NA NA 19.18 18.30 9.58 09061517 A Implt brain chemotx add-on 1.38 NA NA 0.75 0.72 0.51 ZZZ61518 A Removal of brain lesion 39.89 NA NA 27.81 26.52 14.85 09061519 A Remove brain lining lesion 43.43 NA NA 28.94 27.63 16.08 09061520 A Removal of brain lesion 57.09 NA NA 37.02 35.34 18.65 09061521 A Removal of brain lesion 46.99 NA NA 31.16 29.53 17.51 09061522 A Removal of brain abscess 31.54 NA NA 22.25 21.21 11.76 090CMS-1503-P993**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**61524 A Removal of brain lesion 29.89 NA NA 21.35 20.15 11.15 09061526 A Removal of brain lesion 54.08 NA NA 35.46 32.91 20.15 09061530 A Removal of brain lesion 45.56 NA NA 29.93 28.01 17.00 09061531 A Implant brain electrodes 16.41 NA NA 13.86 13.16 6.12 09061533 A Implant brain electrodes 21.46 NA NA 16.12 15.30 7.98 09061534 A Removal of brain lesion 23.01 NA NA 17.58 16.70 8.58 09061535 A Remove brain electrodes 13.15 NA NA 11.66 11.05 4.90 09061536 A Removal of brain lesion 37.72 NA NA 25.63 24.52 14.06 09061537 A Removal of brain tissue 36.45 NA NA 24.07 22.39 13.51 09061538 A Removal of brain tissue 39.45 NA NA 26.06 24.10 14.72 09061539 A Removal of brain tissue 34.28 NA NA 23.75 22.41 12.77 09061540 A Removal of brain tissue 31.43 NA NA 22.28 21.26 11.71 09061541 A Incision of brain tissue 30.94 NA NA 21.92 20.77 11.53 09061542 A Removal of brain tissue 33.16 NA NA 19.78 20.41 12.35 09061543 A Removal of brain tissue 31.31 NA NA 22.12 20.68 11.66 09061544 A Remove & treat brain lesion 27.36 NA NA 19.44 16.85 10.20 09061545 A Excision of brain tumor 46.43 NA NA 31.82 30.11 17.30 09061546 A Removal of pituitary gland 33.44 NA NA 23.29 22.07 12.45 09061548 A Removal of pituitary gland 23.37 NA NA 16.50 15.63 6.92 09061550 A Release of skull seams 15.59 NA NA 10.26 10.36 1.14 09061552 A Release of skull seams 20.40 NA NA 11.23 12.57 1.51 09061556 A Incise skull/sutures24.09 NA NA 15.47 15.35 8.99 09061557 A Incise skull/sutures23.31 NA NA 18.19 17.46 8.69 09061558 A Excision of skull/sutures 26.50 NA NA 14.01 15.94 9.88 09061559 A Excision of skull/sutures 34.02 NA NA 24.88 23.90 2.50 09061563 A Excision of skull tumor 28.44 NA NA 20.28 19.32 10.60 090CMS-1503-P994**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**61564 A Excision of skull tumor 34.74 NA NA 24.45 23.34 12.93 09061566 A Removal of brain tissue 32.45 NA NA 22.84 21.91 12.08 09061567 A Incision of brain tissue 37.00 NA NA 26.04 25.04 13.81 09061570 A Remove foreign body, brain 26.51 NA NA 19.50 18.29 9.88 09061571 A Incise skull for brain wound 28.42 NA NA 20.54 19.60 10.58 09061575 A Skull base/brainstem surgery 36.56 NA NA 25.00 23.08 13.62 09061576 A Skull base/brainstem surgery 55.31 NA NA 42.57 41.30 7.38 09061580 A Craniofacial approach, skull 34.51 NA NA 33.30 31.09 6.12 09061581 A Craniofacial approach, skull 39.13 NA NA 37.56 34.73 5.23 09061582 A Craniofacial approach, skull 35.14 NA NA 41.57 38.86 13.10 09061583 A Craniofacial approach, skull 38.50 NA NA 34.13 32.69 13.44 09061584 A Orbitocranial approach/skull 37.70 NA NA 33.83 32.33 13.18 09061585 A Orbitocranial approach/skull 42.57 NA NA 37.91 34.39 15.87 09061586 A Resect nasopharynx, skull 27.48 NA NA 34.26 30.56 10.24 09061590 A Infratemporal approach/skull 47.04 NA NA 37.61 34.85 8.77 09061591 A Infratemporal approach/skull 47.02 NA NA 37.26 34.86 9.96 09061592 A Orbitocranial approach/skull 43.08 NA NA 36.12 34.66 15.06 09061595 A Transtemporal approach/skull 33.74 NA NA 29.98 28.29 7.42 09061596 A Transcochlear approach/skull 39.43 NA NA 30.77 28.94 5.26 09061597 A Transcondylar approach/skull 40.82 NA NA 30.65 29.43 15.22 09061598 A Transpetrosal approach/skull 36.53 NA NA 34.01 30.24 13.61 09061600 A Resect/excise cranial lesion 30.01 NA NA 28.14 26.20 6.46 09061601 A Resect/excise cranial lesion 31.14 NA NA 29.07 27.71 10.56 09061605 A Resect/excise cranial lesion 32.57 NA NA 28.98 26.94 5.14 09061606 A Resect/excise cranial lesion 42.05 NA NA 33.00 31.91 14.20 09061607 A Resect/excise cranial lesion 40.93 NA NA 31.20 29.31 15.25 090CMS-1503-P995**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**61608 A Resect/excise cranial lesion 45.54 NA NA 35.17 33.65 15.97 09061609 A Transect artery, sinus 9.88 0.00 2.21 0.00 2.21 3.69 ZZZ61610 A Transect artery, sinus 29.63 NA NA 13.96 14.27 11.05 ZZZ61611 A Transect artery, sinus 7.41 NA NA 3.20 3.50 0.54 ZZZ61612 A Transect artery, sinus 27.84 NA NA 12.04 12.60 2.03 ZZZ61613 A Remove aneurysm, sinus 45.03 NA NA 36.15 34.05 16.79 09061615 A Resect/excise lesion, skull 35.77 NA NA 28.81 27.78 4.78 09061616 A Resect/excise lesion, skull 46.74 NA NA 37.41 35.54 14.96 09061618 A Repair dura 18.69 NA NA 14.40 13.56 5.98 09061619 A Repair dura 22.10 NA NA 16.25 15.24 6.57 09061623 A Endovasc tempory vessel occl 9.95 NA NA 4.32 4.56 1.92 00061624 A Transcath occlusion, cns 20.12 NA NA 8.43 8.87 3.91 00061626 A Transcath occlusion, non-cns 16.60 NA NA 6.13 6.87 2.22 00061630 R Intracranial angioplasty 22.07 NA NA 10.81 11.31 4.34 XXX61635 R Intracran angioplsty w/stent 24.28 NA NA 11.73 12.26 4.22 XXX61640 N Dilate ic vasospasm, init 12.32 NA NA 5.33 5.15 0.90 00061641 N Dilate ic vasospasm add-on 4.33 NA NA 1.87 1.81 0.32 ZZZ61642 N Dilate ic vasospasm add-on 8.66 NA NA 3.74 3.62 0.64 ZZZ61680 A Intracranial vessel surgery 32.55 NA NA 22.98 22.00 12.12 09061682 A Intracranial vessel surgery 63.41 NA NA 38.93 37.35 23.63 09061684 A Intracranial vessel surgery 41.64 NA NA 28.23 26.53 15.51 09061686 A Intracranial vessel surgery 67.50 NA NA 42.81 40.96 25.17 09061690 A Intracranial vessel surgery 31.34 NA NA 22.46 21.27 11.69 09061692 A Intracranial vessel surgery 54.59 NA NA 35.19 33.38 20.35 09061697 A Brain aneurysm repr, complx 63.40 NA NA 40.27 37.93 23.39 09061698 A Brain aneurysm repr, complx 69.63 NA NA 43.98 40.81 25.94 090CMS-1503-P996**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**61700 A Brain aneurysm repr, simple 50.62 NA NA 33.28 32.04 18.75 09061702 A Inner skull vessel surgery 60.04 NA NA 38.72 36.14 22.37 09061703 A Clamp neck artery 18.80 NA NA 14.75 14.07 7.01 09061705 A Revise circulation to head 38.10 NA NA 25.84 24.06 14.20 09061708 A Revise circulation to head 37.20 NA NA 21.81 20.09 3.19 09061710 A Revise circulation to head 31.29 NA NA 15.61 16.75 6.77 09061711 A Fusion of skull arteries 38.23 NA NA 25.84 24.47 14.24 09061720 A Incise skull/brain surgery 17.62 NA NA 13.74 12.30 6.57 09061735 A Incise skull/brain surgery 22.35 NA NA 14.50 13.76 8.32 09061750 A Incise skull/brain biopsy 19.83 NA NA 14.86 14.14 7.33 09061751 A Brain biopsy w/ct/mr guide 18.79 NA NA 15.21 14.52 6.95 09061760 A Implant brain electrodes 22.39 NA NA 16.55 15.24 8.34 09061770 A Incise skull for treatment 23.19 NA NA 16.79 15.32 8.51 09061790 A Treat trigeminal nerve 11.60 NA NA 10.20 9.45 4.22 09061791 A Treat trigeminal tract 15.41 NA NA 12.38 11.67 5.40 09061795 A Brain surgery using computer 4.03 NA NA 2.24 2.12 1.10 ZZZ61796 A Srs, cranial lesion simple 13.93 NA NA 11.15 9.71 4.80 09061797 A Srs, cran les simple, addl 3.48 NA NA 1.90 1.76 1.20 ZZZ61798 A Srs, cranial lesion complex 19.85 NA NA 14.36 11.34 6.85 09061799 A Srs, cran les complex, addl 4.81 NA NA 2.62 2.43 1.65 ZZZ61800 A Apply srs headframe add-on 2.25 NA NA 1.55 1.44 0.76 ZZZ61850 A Implant neuroelectrodes 13.34 NA NA 8.09 9.01 4.99 09061860 A Implant neuroelectrodes 22.26 NA NA 16.28 15.52 8.29 09061863 A Implant neuroelectrode 20.71 NA NA 16.30 15.63 7.69 09061864 A Implant neuroelectrde, addl 4.49 NA NA 2.46 2.37 1.67 ZZZ61867 A Implant neuroelectrode 33.03 NA NA 23.09 22.06 12.28 090CMS-1503-P997**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**61868 A Implant neuroelectrde, addl 7.91 NA NA 4.32 4.17 2.95 ZZZ61870 A Implant neuroelectrodes 16.34 NA NA 12.89 12.38 6.09 09061875 A Implant neuroelectrodes 16.46 NA NA 12.95 12.27 1.22 09061880 A Revise/remove neuroelectrode 6.95 NA NA 7.26 6.79 2.56 09061885 A Insrt/redo neurostim 1 array 7.57 NA NA 9.59 8.94 2.68 09061886 A Implant neurostim arrays 9.93 NA NA 11.31 10.63 3.66 09061888 A Revise/remove neuroreceiver 5.23 NA NA 4.57 4.44 1.78 01062000 A Treat skull fracture 13.93 NA NA 11.57 9.87 5.20 09062005 A Treat skull fracture 17.63 NA NA 13.74 12.85 6.57 09062010 A Treatment of head injury 21.43 NA NA 16.35 15.37 7.98 09062100 A Repair brain fluid leakage 23.53 NA NA 16.82 15.89 7.80 09062115 A Reduction of skull defect 22.91 NA NA 12.75 11.39 1.68 09062116 A Reduction of skull defect 25.02 NA NA 18.69 17.80 9.33 09062117 A Reduction of skull defect 28.35 NA NA 19.91 19.08 3.80 09062120 A Repair skull cavity lesion 24.59 NA NA 23.11 22.29 3.29 09062121 A Incise skull repair 23.03 NA NA 19.09 18.36 8.59 09062140 A Repair of skull defect 14.55 NA NA 11.66 11.03 4.93 09062141 A Repair of skull defect 16.07 NA NA 12.57 11.95 5.51 09062142 A Remove skull plate/flap 11.83 NA NA 10.33 9.81 4.24 09062143 A Replace skull plate/flap 14.15 NA NA 11.57 10.96 5.20 09062145 A Repair of skull & brain 20.09 NA NA 14.67 14.03 7.49 09062146 A Repair of skull with graft 17.28 NA NA 13.55 12.61 6.44 09062147 A Repair of skull with graft 20.67 NA NA 15.41 14.52 7.69 09062148 A Retr bone flap to fix skull 2.00 NA NA 1.10 1.03 0.73 ZZZ62160 A Neuroendoscopy add-on 3.00 NA NA 1.63 1.58 1.12 ZZZ62161 A Dissect brain w/scope 21.23 NA NA 16.17 15.39 7.91 090CMS-1503-P998**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**62162 A Remove colloid cyst w/scope 26.80 NA NA 19.77 18.93 9.98 09062163 A Neuroendoscopy w/fb removal 16.53 NA NA 13.78 13.20 6.15 09062164 A Remove brain tumor w/scope 29.43 NA NA 22.08 20.55 10.98 09062165 A Remove pituit tumor w/scope 23.23 NA NA 16.94 16.08 6.61 09062180 A Establish brain cavity shunt 22.58 NA NA 16.87 16.07 8.42 09062190 A Establish brain cavity shunt 12.17 NA NA 10.75 10.16 4.54 09062192 A Establish brain cavity shunt 13.35 NA NA 10.97 10.34 4.80 09062194 A Replace/irrigate catheter 5.78 NA NA 6.40 5.15 0.47 01062200 A Establish brain cavity shunt 19.29 NA NA 14.65 13.93 7.19 09062201 A Brain cavity shunt w/scope 16.04 NA NA 13.80 13.05 5.95 09062220 A Establish brain cavity shunt 14.10 NA NA 11.23 10.60 5.02 09062223 A Establish brain cavity shunt 14.05 NA NA 12.22 11.63 5.03 09062225 A Replace/irrigate catheter 6.19 NA NA 6.86 6.43 2.29 09062230 A Replace/revise brain shunt 11.43 NA NA 9.48 9.02 4.13 09062252 A Csf shunt reprogram 0.74 2.03 2.01 NA NA 0.26 XXX62252 TC A Csf shunt reprogram 0.00 1.63 1.62 NA NA 0.01 XXX62252 26 A Csf shunt reprogram 0.74 0.40 0.39 0.40 0.39 0.25 XXX62256 A Remove brain cavity shunt 7.38 NA NA 7.59 7.19 2.73 09062258 A Replace brain cavity shunt 15.64 NA NA 12.15 11.62 5.64 09062263 A Epidural lysis mult sessions 6.54 15.52 13.65 5.73 4.66 0.54 01062264 A Epidural lysis on single day 4.42 7.97 7.27 2.52 2.04 0.37 01062267 A Interdiscal perq aspir, dx 3.00 3.61 3.84 1.29 1.34 0.31 00062268 A Drain spinal cord cyst 4.73 6.91 7.60 2.45 2.40 0.47 00062269 A Needle biopsy, spinal cord 5.01 6.54 7.87 2.20 2.20 0.58 00062270 A Spinal fluid tap, diagnostic 1.37 2.74 2.89 0.68 0.69 0.24 00062272 A Drain cerebro spinal fluid 1.35 3.94 3.89 0.81 0.80 0.34 000CMS-1503-P999**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**62273 A Inject epidural patch 2.15 2.69 2.52 1.05 0.91 0.21 00062280 A Treat spinal cord lesion 2.63 6.65 6.30 1.91 1.62 0.52 01062281 A Treat spinal cord lesion 2.66 6.16 5.74 1.72 1.47 0.28 01062282 A Treat spinal canal lesion 2.33 5.77 5.91 1.67 1.47 0.30 01062284 A Injection for myelogram 1.54 4.00 4.45 0.76 0.83 0.18 00062287 A Percutaneous diskectomy 9.03 NA NA 6.78 6.22 0.85 09062290 A Inject for spine disk x-ray 3.00 6.54 6.37 1.90 1.70 0.31 00062291 A Inject for spine disk x-ray 2.91 6.22 5.94 1.86 1.63 0.28 00062292 A Injection into disk lesion 9.24 NA NA 8.59 6.05 0.78 09062294 A Injection into spinal artery 12.87 NA NA 4.41 6.16 1.06 09062310 A Inject spine c/t 1.91 5.07 4.64 1.19 0.96 0.17 00062311 A Inject spine l/s (cd) 1.54 4.28 4.09 0.97 0.82 0.13 00062318 A Inject spine w/cath, c/t 2.04 4.82 4.66 0.81 0.70 0.17 00062319 A Inject spine w/cath l/s (cd) 1.87 4.48 4.27 0.84 0.72 0.17 00062350 A Implant spinal canal cath 6.05 NA NA 4.89 4.31 1.09 01062351 A Implant spinal canal cath 11.66 NA NA 10.63 9.88 3.52 09062355 A Remove spinal canal catheter 4.35 NA NA 3.97 3.53 0.76 01062360 A Insert spine infusion device 4.33 NA NA 4.10 3.59 0.90 01062361 A Implant spine infusion pump 5.65 NA NA 4.86 4.60 1.14 01062362 A Implant spine infusion pump 6.10 NA NA 5.03 4.59 1.27 01062365 A Remove spine infusion device 4.65 NA NA 4.37 3.96 0.92 01062367 A Analyze spine infusion pump 0.48 0.71 0.65 0.23 0.19 0.06 XXX62368 A Analyze spine infusion pump 0.75 1.00 0.87 0.37 0.30 0.07 XXX63001 A Removal of spinal lamina 17.61 NA NA 13.39 12.68 5.91 09063003 A Removal of spinal lamina 17.74 NA NA 13.46 12.76 5.85 09063005 A Removal of spinal lamina 16.43 NA NA 13.39 12.78 5.27 090CMS-1503-P1000**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**63011 A Removal of spinal lamina 15.91 NA NA 12.46 11.66 4.17 09063012 A Removal of spinal lamina 16.85 NA NA 13.20 12.67 5.30 09063015 A Removal of spinal lamina 20.85 NA NA 16.09 15.34 7.28 09063016 A Removal of spinal lamina 22.03 NA NA 16.26 15.39 7.04 09063017 A Removal of spinal lamina 17.33 NA NA 14.06 13.40 5.78 09063020 A Neck spine disk surgery 16.20 NA NA 13.29 12.69 5.26 09063030 A Low back disk surgery 13.18 NA NA 11.60 11.04 4.01 09063035 A Spinal disk surgery add-on 3.15 NA NA 1.76 1.70 0.92 ZZZ63040 A Laminotomy, single cervical 20.31 NA NA 15.13 14.42 6.51 09063042 A Laminotomy, single lumbar 18.76 NA NA 14.61 13.95 5.40 09063043 C Laminotomy, addl cervical 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ63044 C Laminotomy, addl lumbar 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ63045 A Removal of spinal lamina 17.95 NA NA 14.01 13.35 5.95 09063046 A Removal of spinal lamina 17.25 NA NA 13.50 12.87 5.34 09063047 A Removal of spinal lamina 15.37 NA NA 12.78 12.22 4.58 09063048 A Remove spinal lamina add-on 3.47 NA NA 1.94 1.85 1.05 ZZZ63050 A Cervical laminoplasty 22.01 NA NA 17.01 15.91 8.21 09063051 A C-laminoplasty w/graft/plate 25.51 NA NA 18.33 17.36 7.52 09063055 A Decompress spinal cord 23.55 NA NA 17.14 16.38 7.96 09063056 A Decompress spinal cord 21.86 NA NA 15.96 15.18 6.43 09063057 A Decompress spine cord add-on 5.25 NA NA 2.93 2.82 1.57 ZZZ63064 A Decompress spinal cord 26.22 NA NA 18.48 17.52 8.25 09063066 A Decompress spine cord add-on 3.26 NA NA 1.79 1.74 1.22 ZZZ63075 A Neck spine disk surgery 19.60 NA NA 15.04 14.46 6.34 09063076 A Neck spine disk surgery 4.04 NA NA 2.24 2.16 1.30 ZZZ63077 A Spine disk surgery, thorax 22.88 NA NA 15.93 15.17 6.09 090CMS-1503-P1001**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**63078 A Spine disk surgery, thorax 3.28 NA NA 1.82 1.74 0.78 ZZZ63081 A Removal of vertebral body 26.10 NA NA 18.73 17.85 8.20 09063082 A Remove vertebral body add-on 4.36 NA NA 2.42 2.34 1.36 ZZZ63085 A Removal of vertebral body 29.47 NA NA 19.12 18.26 8.24 09063086 A Remove vertebral body add-on 3.19 NA NA 1.68 1.64 0.90 ZZZ63087 A Removal of vertebral body 37.53 NA NA 24.00 22.96 10.10 09063088 A Remove vertebral body add-on 4.32 NA NA 2.42 2.33 1.10 ZZZ63090 A Removal of vertebral body 30.93 NA NA 20.65 19.54 7.47 09063091 A Remove vertebral body add-on 3.03 NA NA 1.66 1.60 0.71 ZZZ63101 A Removal of vertebral body 34.10 NA NA 24.43 23.22 11.04 09063102 A Removal of vertebral body 34.10 NA NA 24.11 22.92 8.93 09063103 A Remove vertebral body add-on 4.82 NA NA 2.69 2.61 1.34 ZZZ63170 A Incise spinal cord tract(s) 22.21 NA NA 17.09 15.89 8.28 09063172 A Drainage of spinal cyst 19.76 NA NA 14.97 14.19 7.35 09063173 A Drainage of spinal cyst 24.31 NA NA 18.24 17.35 9.09 09063180 A Revise spinal cord ligaments 20.53 NA NA 16.17 14.66 7.64 09063182 A Revise spinal cord ligaments 22.82 NA NA 17.43 14.81 8.51 09063185 A Incise spinal column/nerves 16.49 NA NA 13.02 12.18 6.15 09063190 A Incise spinal column/nerves 18.89 NA NA 14.54 13.80 4.45 09063191 A Incise spinal column/nerves 18.92 NA NA 15.14 11.94 3.89 09063194 A Incise spinal column & cord 22.10 NA NA 15.75 15.07 2.95 09063195 A Incise spinal column & cord 21.64 NA NA 16.26 15.20 8.07 09063196 A Incise spinal column & cord 25.27 NA NA 13.24 15.02 1.87 09063197 A Incise spinal column & cord 24.08 NA NA 18.12 17.15 8.99 09063198 A Incise spinal column & cord 29.90 NA NA 15.46 14.55 2.20 09063199 A Incise spinal column & cord 31.47 NA NA 16.14 17.62 2.32 090CMS-1503-P1002**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**63200 A Release of spinal cord 21.44 NA NA 16.21 15.35 7.87 09063250 A Revise spinal cord vessels 43.86 NA NA 29.00 27.33 16.35 09063251 A Revise spinal cord vessels 44.64 NA NA 29.87 28.36 16.65 09063252 A Revise spinal cord vessels 44.63 NA NA 29.86 28.31 16.65 09063265 A Excise intraspinal lesion 23.82 NA NA 17.63 16.80 8.39 09063266 A Excise intraspinal lesion 24.68 NA NA 17.98 17.09 8.72 09063267 A Excise intraspinal lesion 19.45 NA NA 15.06 14.38 6.50 09063268 A Excise intraspinal lesion 20.02 NA NA 15.94 14.83 7.46 09063270 A Excise intraspinal lesion 29.80 NA NA 21.30 20.11 11.12 09063271 A Excise intraspinal lesion 29.92 NA NA 21.09 20.08 10.98 09063272 A Excise intraspinal lesion 27.50 NA NA 19.57 18.68 9.83 09063273 A Excise intraspinal lesion 26.47 NA NA 19.47 17.88 9.86 09063275 A Biopsy/excise spinal tumor 25.86 NA NA 18.68 17.75 9.16 09063276 A Biopsy/excise spinal tumor 25.69 NA NA 18.65 17.73 9.04 09063277 A Biopsy/excise spinal tumor 22.39 NA NA 16.73 15.90 7.26 09063278 A Biopsy/excise spinal tumor 22.12 NA NA 17.09 15.95 8.25 09063280 A Biopsy/excise spinal tumor 30.29 NA NA 21.64 20.77 11.25 09063281 A Biopsy/excise spinal tumor 29.99 NA NA 21.59 20.62 11.08 09063282 A Biopsy/excise spinal tumor 28.15 NA NA 20.48 19.61 10.33 09063283 A Biopsy/excise spinal tumor 26.76 NA NA 20.08 18.93 9.96 09063285 A Biopsy/excise spinal tumor 38.05 NA NA 25.98 24.55 14.19 09063286 A Biopsy/excise spinal tumor 37.62 NA NA 25.68 24.51 13.71 09063287 A Biopsy/excise spinal tumor 40.08 NA NA 27.37 25.89 14.95 09063290 A Biopsy/excise spinal tumor 40.82 NA NA 27.36 26.06 15.22 09063295 A Repair of laminectomy defect 5.25 NA NA 2.87 2.68 1.95 ZZZ63300 A Removal of vertebral body 26.80 NA NA 19.01 18.10 9.01 090CMS-1503-P1003**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**63301 A Removal of vertebral body 31.57 NA NA 22.71 20.61 11.77 09063302 A Removal of vertebral body 31.15 NA NA 22.48 20.50 11.60 09063303 A Removal of vertebral body 33.55 NA NA 23.35 21.18 12.49 09063304 A Removal of vertebral body 33.85 NA NA 23.96 22.57 12.60 09063305 A Removal of vertebral body 36.24 NA NA 25.12 22.68 13.51 09063306 A Removal of vertebral body 35.55 NA NA 15.92 19.10 13.25 09063307 A Removal of vertebral body 34.96 NA NA 24.11 22.52 13.04 09063308 A Remove vertebral body add-on 5.24 NA NA 2.84 2.76 1.62 ZZZ63600 A Remove spinal cord lesion 15.12 NA NA 10.55 8.17 1.64 09063610 A Stimulation of spinal cord 8.72 17.25 23.43 2.29 2.25 0.71 00063615 A Remove lesion of spinal cord 17.32 NA NA 13.20 11.98 6.44 09063620 A Srs, spinal lesion 15.60 NA NA 11.93 10.11 5.38 09063621 A Srs, spinal lesion, addl 4.00 NA NA 2.19 2.02 1.37 ZZZ63650 A Implant neuroelectrodes 7.20 NA NA 5.25 4.34 0.66 01063655 A Implant neuroelectrodes 11.56 NA NA 10.49 9.82 3.76 09063661 A Remove spine eltrd perq aray 5.08 11.66 11.66 3.90 3.90 0.73 01063662 A Remove spine eltrd plate 11.00 NA NA 8.48 8.48 1.61 09063663 A Revise spine eltrd perq aray 7.75 16.11 16.11 5.24 5.24 1.13 01063664 A Revise spine eltrd plate 11.52 NA NA 8.75 8.75 1.67 09063685 A Insrt/redo spine n generator 6.05 NA NA 5.04 4.47 1.14 01063688 A Revise/remove neuroreceiver 5.30 NA NA 4.68 4.18 1.05 01063700 A Repair of spinal herniation 17.47 NA NA 14.67 13.55 6.50 09063702 A Repair of spinal herniation 19.41 NA NA 15.73 14.92 7.23 09063704 A Repair of spinal herniation 22.43 NA NA 18.36 16.58 8.35 09063706 A Repair of spinal herniation 25.35 NA NA 19.96 18.68 9.47 09063707 A Repair spinal fluid leakage 12.65 NA NA 10.80 10.19 3.63 090CMS-1503-P1004**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**63709 A Repair spinal fluid leakage 15.65 NA NA 12.43 11.83 4.68 09063710 A Graft repair of spine defect 15.40 NA NA 12.48 11.86 5.04 09063740 A Install spinal shunt 12.63 NA NA 10.80 10.43 4.42 09063741 A Install spinal shunt 9.12 NA NA 7.40 6.53 2.27 09063744 A Revision of spinal shunt 8.94 NA NA 7.92 7.24 3.18 09063746 A Removal of spinal shunt 7.33 NA NA 7.65 7.04 2.73 09064400 A N block inj, trigeminal 1.11 2.14 2.00 0.77 0.66 0.18 00064402 A N block inj, facial 1.25 1.96 1.85 0.78 0.70 0.18 00064405 A N block inj, occipital 1.32 1.91 1.70 0.88 0.74 0.27 00064408 A N block inj, vagus 1.41 2.15 2.00 1.21 1.08 0.17 00064410 A N block inj, phrenic 1.43 2.68 2.55 0.74 0.68 0.34 00064412 A N block inj, spinal accessor 1.18 3.20 2.96 0.91 0.79 0.21 00064413 A N block inj, cervical plexus 1.40 1.97 1.85 0.82 0.71 0.21 00064415 A N block inj, brachial plexus 1.48 2.15 2.13 0.53 0.48 0.11 00064416 A N block cont infuse, b plex 1.81 NA NA 0.41 0.42 0.14 00064417 A N block inj, axillary1.44 2.17 2.17 0.54 0.49 0.11 00064418 A N block inj, suprascapular 1.32 2.64 2.54 0.82 0.71 0.13 00064420 A N block inj, intercost,sng 1.18 1.97 2.67 0.75 0.65 0.13 00064421 A N block inj, intercost,mlt 1.68 2.60 3.82 0.95 0.81 0.21 00064425 A N block inj, ilio-ing/hypogi 1.75 2.04 1.87 0.95 0.81 0.21 00064430 A N block inj, pudendal1.46 2.22 2.57 0.78 0.84 0.14 00064435 A N block inj, paracervical 1.45 2.28 2.41 0.77 0.75 0.25 00064445 A N block inj, sciatic, sng 1.48 2.23 2.24 0.74 0.68 0.17 00064446 A N blk inj, sciatic, cont inf 1.81 NA NA 0.42 0.47 0.14 00064447 A N block inj fem, single 1.50 NA NA 0.34 0.32 0.11 00064448 A N block inj fem, cont inf 1.63 NA NA 0.37 0.40 0.13 000CMS-1503-P1005**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**64449 A N block inj, lumbar plexus 1.81 NA NA 0.49 0.51 0.14 00064450 A N block, other peripheral 1.27 1.69 1.60 0.67 0.63 0.11 00064455 A N block inj, plantar digit 0.75 0.58 0.60 0.23 0.26 0.08 00064479 A Inj foramen epidural c/t 2.20 5.94 5.81 1.48 1.26 0.27 00064480 A Inj foramen epidural add-on 1.54 2.66 2.48 0.81 0.67 0.24 ZZZ64483 A Inj foramen epidural l/s 1.90 5.97 5.89 1.34 1.15 0.17 00064484 A Inj foramen epidural add-on 1.33 2.71 2.60 0.69 0.56 0.11 ZZZ64490 A Inj paravert f jnt c/t1 lev 1.82 3.72 3.72 1.25 1.25 0.21 00064491 A Inj paravert f jnt c/t 2lev 1.16 1.57 1.57 0.58 0.58 0.11 ZZZ64492 A Inj paravert f jnt c/t 3lev 1.16 1.61 1.61 0.61 0.61 0.11 ZZZ64493 A Inj paravert f jnt l/s 1 lev 1.52 3.45 3.45 1.09 1.09 0.14 00064494 A Inj paravert f jnt l/s 2 lev 1.00 1.49 1.49 0.48 0.48 0.08 ZZZ64495 A Inj paravert f jnt l/s 3 lev 1.00 1.53 1.53 0.51 0.51 0.08 ZZZ64505 A N block, spenopalatine gangl 1.36 1.42 1.40 1.00 0.93 0.10 00064508 A N block, carotid sinus s/p 1.12 3.54 3.23 0.98 0.86 0.25 00064510 A N block, stellate ganglion 1.22 2.46 2.61 0.89 0.73 0.10 00064517 A N block inj, hypogas plxs 2.20 2.95 2.69 1.34 1.13 0.18 00064520 A N block, lumbar/thoracic 1.35 4.26 4.10 1.00 0.83 0.11 00064530 A N block inj, celiac pelus 1.58 3.99 3.91 1.05 0.92 0.14 00064550 A Apply neurostimulator 0.18 0.29 0.27 0.08 0.07 0.01 00064553 A Implant neuroelectrodes 2.36 3.34 3.27 1.98 1.93 0.40 01064555 A Implant neuroelectrodes 2.32 2.97 3.29 1.70 1.77 0.27 01064560 A Implant neuroelectrodes 2.41 4.68 4.06 2.41 2.14 0.17 01064561 A Implant neuroelectrodes 7.15 17.71 22.09 3.84 4.11 0.81 01064565 A Implant neuroelectrodes 1.81 3.23 3.07 1.76 1.58 0.25 01064573 A Implant neuroelectrodes 8.25 NA NA 7.48 6.94 2.53 090CMS-1503-P1006**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**64575 A Implant neuroelectrodes 4.42 NA NA 4.17 3.53 0.45 09064577 A Implant neuroelectrodes 4.69 NA NA 2.79 3.52 1.74 09064580 A Implant neuroelectrodes 4.19 NA NA 3.85 3.75 0.92 09064581 A Implant neuroelectrodes 14.23 NA NA 6.86 7.39 1.64 09064585 A Revise/remove neuroelectrode 2.11 4.67 6.12 1.86 2.06 0.28 01064590 A Insrt/redo pn/gastr stimul 2.45 4.68 5.61 1.94 2.19 0.30 01064595 A Revise/rmv pn/gastr stimul 1.78 4.89 6.27 1.68 1.89 0.23 01064600 A Injection treatment of nerve 3.49 8.04 7.90 2.75 2.41 0.55 01064605 A Injection treatment of nerve 5.65 15.54 12.68 4.73 3.84 0.45 01064610 A Injection treatment of nerve 7.20 12.76 11.87 5.16 4.90 2.23 01064612 A Destroy nerve, face muscle 2.01 2.49 2.35 2.16 1.90 0.68 01064613 A Destroy nerve, neck muscle 2.01 2.23 2.18 1.87 1.64 0.61 01064614 A Destroy nerve, extrem musc 2.20 2.53 2.48 2.04 1.82 0.44 01064620 A Injection treatment of nerve 2.89 3.02 3.80 2.10 1.79 0.30 01064622 A Destr paravertebrl nerve l/s 3.05 6.90 6.48 2.50 2.05 0.27 01064623 A Destr paravertebral n add-on 0.99 2.74 2.58 0.51 0.39 0.08 ZZZ64626 A Destr paravertebrl nerve c/t 3.92 8.08 7.38 3.64 3.00 0.35 01064627 A Destr paravertebral n add-on 1.16 3.92 3.73 0.60 0.47 0.10 ZZZ64630 A Injection treatment of nerve 3.05 3.11 3.20 2.13 2.11 0.35 01064632 A N block inj, common digit 1.23 1.16 1.15 0.71 0.73 0.10 01064640 A Injection treatment of nerve 2.81 3.23 3.32 1.92 1.88 0.25 01064650 A Chemodenerv eccrine glands 0.70 1.32 1.23 0.41 0.37 0.11 00064653 A Chemodenerv eccrine glands 0.88 1.49 1.37 0.46 0.43 0.25 00064680 A Injection treatment of nerve 2.67 6.33 6.16 1.99 1.80 0.31 01064681 A Injection treatment of nerve 3.78 6.26 6.74 1.63 1.74 0.31 01064702 A Revise finger/toe nerve 6.26 NA NA 7.35 6.64 1.10 090CMS-1503-P1007**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**64704 A Revise hand/foot nerve 4.69 NA NA 4.25 4.16 0.57 09064708 A Revise arm/leg nerve 6.36 NA NA 6.95 6.49 1.20 09064712 A Revision of sciatic nerve 8.07 NA NA 7.08 6.56 1.38 09064713 A Revision of arm nerve(s) 11.40 NA NA 8.88 8.39 2.43 09064714 A Revise low back nerve(s) 10.55 NA NA 8.57 7.33 1.78 09064716 A Revision of cranial nerve 6.99 NA NA 7.80 7.33 1.17 09064718 A Revise ulnar nerve at elbow 7.26 NA NA 8.68 8.10 1.54 09064719 A Revise ulnar nerve at wrist 4.97 NA NA 5.84 5.51 0.96 09064721 A Carpal tunnel surgery 4.97 6.57 6.25 6.50 6.19 1.02 09064722 A Relieve pressure on nerve(s) 4.82 NA NA 4.72 4.31 0.88 09064726 A Release foot/toe nerve 4.27 NA NA 3.50 3.40 0.41 09064727 A Internal nerve revision 3.10 NA NA 1.85 1.74 0.62 ZZZ64732 A Incision of brow nerve 4.89 NA NA 6.17 5.52 1.84 09064734 A Incision of cheek nerve 5.55 NA NA 6.98 6.03 0.73 09064736 A Incision of chin nerve 5.23 NA NA 5.85 5.47 1.95 09064738 A Incision of jaw nerve 6.36 NA NA 7.42 6.41 2.36 09064740 A Incision of tongue nerve 6.22 NA NA 6.83 6.33 0.83 09064742 A Incision of facial nerve 6.85 NA NA 7.10 6.23 0.90 09064744 A Incise nerve, back of head 5.72 NA NA 6.62 5.64 2.12 09064746 A Incise diaphragm nerve 6.56 NA NA 4.67 4.77 1.60 09064752 A Incision of vagus nerve 7.69 NA NA 5.95 5.57 1.88 09064755 A Incision of stomach nerves 15.05 NA NA 8.97 8.13 3.33 09064760 A Incision of vagus nerve 7.59 NA NA 5.91 5.24 1.67 09064761 A Incision of pelvis nerve 7.04 NA NA 5.33 5.01 1.05 09064763 A Incise hip/thigh nerve 7.56 NA NA 5.80 6.19 1.67 09064766 A Incise hip/thigh nerve 9.47 NA NA 6.96 6.83 0.95 090CMS-1503-P1008**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**64771 A Sever cranial nerve 8.15 NA NA 7.35 7.18 1.09 09064772 A Incision of spinal nerve 7.84 NA NA 7.49 7.02 1.88 09064774 A Remove skin nerve lesion 5.80 NA NA 5.51 5.16 1.09 09064776 A Remove digit nerve lesion 5.60 NA NA 5.19 4.86 0.88 09064778 A Digit nerve surgery add-on 3.11 NA NA 2.21 1.90 0.64 ZZZ64782 A Remove limb nerve lesion 6.86 NA NA 5.64 5.34 0.95 09064783 A Limb nerve surgery add-on 3.71 NA NA 2.52 2.23 0.47 ZZZ64784 A Remove nerve lesion 10.62 NA NA 9.29 8.57 2.08 09064786 A Remove sciatic nerve lesion 16.25 NA NA 12.74 11.82 3.33 09064787 A Implant nerve end 4.29 NA NA 2.24 2.21 0.71 ZZZ64788 A Remove skin nerve lesion 5.24 NA NA 5.57 5.16 1.12 09064790 A Removal of nerve lesion 12.10 NA NA 10.10 9.35 2.85 09064792 A Removal of nerve lesion 15.86 NA NA 11.96 11.53 5.91 09064795 A Biopsy of nerve 3.01 NA NA 2.10 1.96 0.85 00064802 A Remove sympathetic nerves 10.37 NA NA 8.63 6.72 0.85 09064804 A Remove sympathetic nerves 15.91 NA NA 6.76 6.83 1.31 09064809 A Remove sympathetic nerves 14.71 NA NA 10.45 8.82 1.22 09064818 A Remove sympathetic nerves 11.34 NA NA 6.73 6.14 2.15 09064820 A Remove sympathetic nerves 10.74 NA NA 10.27 9.44 1.98 09064821 A Remove sympathetic nerves 9.33 NA NA 9.21 8.79 1.91 09064822 A Remove sympathetic nerves 9.33 NA NA 9.21 8.64 1.91 09064823 A Remove sympathetic nerves 10.94 NA NA 10.16 9.40 2.23 09064831 A Repair of digit nerve 9.16 NA NA 9.57 8.92 1.70 09064832 A Repair nerve add-on 5.65 NA NA 3.63 3.37 1.05 ZZZ64834 A Repair of hand or foot nerve 10.81 NA NA 9.60 8.92 1.92 09064835 A Repair of hand or foot nerve 11.73 NA NA 10.10 9.50 2.39 090CMS-1503-P1009**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**64836 A Repair of hand or foot nerve 11.73 NA NA 10.10 9.51 2.39 09064837 A Repair nerve add-on 6.25 NA NA 3.65 3.55 0.79 ZZZ64840 A Repair of leg nerve 14.02 NA NA 10.83 10.30 1.12 09064856 A Repair/transpose nerve 15.07 NA NA 12.51 11.66 2.95 09064857 A Repair arm/leg nerve 15.82 NA NA 12.87 12.04 3.02 09064858 A Repair sciatic nerve 17.82 NA NA 15.65 14.23 3.65 09064859 A Nerve surgery 4.25 NA NA 3.03 2.67 0.86 ZZZ64861 A Repair of arm nerves 20.89 NA NA 12.26 12.71 4.28 09064862 A Repair of low back nerves 21.09 NA NA 16.46 14.20 7.86 09064864 A Repair of facial nerve 13.41 NA NA 10.87 10.13 1.77 09064865 A Repair of facial nerve 16.09 NA NA 15.69 15.13 2.12 09064866 A Fusion of facial/other nerve 16.83 NA NA 14.44 14.52 2.25 09064868 A Fusion of facial/other nerve 14.90 NA NA 14.20 13.52 1.98 09064870 A Fusion of facial/other nerve 17.08 NA NA 12.11 10.84 4.15 09064872 A Subsequent repair of nerve 1.99 NA NA 1.16 1.14 0.27 ZZZ64874 A Repair & revise nerve add-on 2.98 NA NA 2.03 1.80 0.38 ZZZ64876 A Repair nerve/shorten bone 3.37 NA NA 1.85 1.70 0.68 ZZZ64885 A Nerve graft, head or neck 17.60 NA NA 13.54 12.78 2.33 09064886 A Nerve graft, head or neck 20.82 NA NA 15.44 14.82 2.77 09064890 A Nerve graft, hand or foot 16.24 NA NA 12.74 12.17 3.32 09064891 A Nerve graft, hand or foot 17.35 NA NA 15.32 13.59 3.56 09064892 A Nerve graft, arm or leg 15.74 NA NA 12.44 11.81 3.24 09064893 A Nerve graft, arm or leg 16.87 NA NA 13.85 12.62 3.48 09064895 A Nerve graft, hand or foot 20.39 NA NA 17.48 15.24 4.17 09064896 A Nerve graft, hand or foot 21.96 NA NA 15.55 15.13 8.20 09064897 A Nerve graft, arm or leg 19.38 NA NA 15.22 14.09 3.97 090CMS-1503-P1010**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**64898 A Nerve graft, arm or leg 20.97 NA NA 15.93 15.14 4.30 09064901 A Nerve graft add-on 10.20 NA NA 7.26 6.29 2.08 ZZZ64902 A Nerve graft add-on 11.81 NA NA 8.41 7.22 2.40 ZZZ64905 A Nerve pedicle transfer 15.11 NA NA 12.74 11.82 3.09 09064907 A Nerve pedicle transfer 20.03 NA NA 10.82 12.21 1.47 09064910 A Nerve repair w/allograft 11.39 NA NA 11.23 10.47 2.05 09064911 A Neurorraphy w/vein autograft 14.39 NA NA 14.06 12.54 2.95 09064999 C Nervous system surgery 0.00 0.00 0.00 0.00 0.00 0.00 YYY65091 A Revise eye 7.26 NA NA 10.40 9.58 1.50 09065093 A Revise eye with implant 7.04 NA NA 10.39 9.67 1.44 09065101 A Removal of eye 8.30 NA NA 12.22 11.24 1.70 09065103 A Remove eye/insert implant 8.84 NA NA 12.59 11.54 1.81 09065105 A Remove eye/attach implant 9.93 NA NA 13.72 12.54 2.02 09065110 A Removal of eye 15.70 NA NA 18.28 16.56 2.08 09065112 A Remove eye/revise socket 18.51 NA NA 21.22 19.20 2.44 09065114 A Remove eye/revise socket 19.65 NA NA 22.03 19.82 2.61 09065125 A Revise ocular implant 3.27 9.11 8.89 4.82 4.41 0.66 09065130 A Insert ocular implant 8.42 NA NA 11.95 10.93 1.71 09065135 A Insert ocular implant 8.60 NA NA 12.08 11.06 1.74 09065140 A Attach ocular implant 9.46 NA NA 13.04 11.94 1.27 09065150 A Revise ocular implant 6.43 NA NA 9.61 8.95 0.47 09065155 A Reinsert ocular implant 10.10 NA NA 13.50 12.36 2.05 09065175 A Removal of ocular implant 7.40 NA NA 10.90 10.02 0.99 09065205 A Remove foreign body from eye 0.71 0.82 0.76 0.51 0.45 0.10 00065210 A Remove foreign body from eye 0.84 1.08 0.99 0.67 0.58 0.13 00065220 A Remove foreign body from eye 0.71 0.86 0.80 0.45 0.40 0.11 000CMS-1503-P1011**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**65222 A Remove foreign body from eye 0.93 1.18 1.08 0.71 0.62 0.14 00065235 A Remove foreign body from eye 9.01 NA NA 10.93 9.67 1.29 09065260 A Remove foreign body from eye 12.54 NA NA 14.36 12.77 0.92 09065265 A Remove foreign body from eye 14.34 NA NA 15.96 14.14 3.19 09065270 A Repair of eye wound 1.95 5.28 5.16 1.99 1.77 0.28 01065272 A Repair of eye wound 4.62 9.22 8.68 5.25 4.63 0.34 09065273 A Repair of eye wound 5.16 NA NA 5.57 4.92 0.38 09065275 A Repair of eye wound 6.29 9.78 8.76 6.74 5.81 0.89 09065280 A Repair of eye wound 9.10 NA NA 9.64 8.54 1.87 09065285 A Repair of eye wound 14.71 NA NA 14.50 12.67 2.70 09065286 A Repair of eye wound 6.63 12.79 12.09 7.31 6.44 0.93 09065290 A Repair of eye socket wound 6.53 NA NA 7.27 6.45 1.33 09065400 A Removal of eye lesion 7.50 11.41 10.42 9.40 8.37 1.07 09065410 A Biopsy of cornea 1.47 2.48 2.33 1.47 1.29 0.32 00065420 A Removal of eye lesion 4.36 9.81 9.38 6.16 5.60 0.58 09065426 A Removal of eye lesion 6.05 11.94 11.26 7.37 6.58 0.86 09065430 A Corneal smear 1.47 1.73 1.57 1.44 1.28 0.23 00065435 A Curette/treat cornea 0.92 1.31 1.20 1.04 0.93 0.17 00065436 A Curette/treat cornea 4.82 6.03 5.40 5.61 4.98 0.88 09065450 A Treatment of corneal lesion 3.47 5.57 5.10 5.48 5.00 0.49 09065600 A Revision of cornea 4.20 6.77 6.20 5.45 4.83 0.62 09065710 A Corneal transplant 14.45 NA NA 16.67 14.82 2.05 09065730 A Corneal transplant 16.35 NA NA 18.20 16.11 2.32 09065750 A Corneal transplant 16.90 NA NA 17.87 15.80 2.25 09065755 A Corneal transplant 16.79 NA NA 17.80 15.73 2.37 09065756 A Corneal trnspl, endothelial 16.84 NA NA 16.58 14.42 1.24 090CMS-1503-P1012**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**65757 C Prep corneal endo allograft 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ65760 N Revision of cornea 0.00 0.00 0.00 0.00 0.00 0.00 XXX65765 N Revision of cornea 0.00 0.00 0.00 0.00 0.00 0.00 XXX65767 N Corneal tissue transplant 0.00 0.00 0.00 0.00 0.00 0.00 XXX65770 A Revise cornea with implant 19.74 NA NA 19.87 17.50 7.35 09065771 N Radial keratotomy 0.00 0.00 0.00 0.00 0.00 0.00 XXX65772 A Correction of astigmatism 5.09 7.48 6.83 6.31 5.62 0.68 09065775 A Correction of astigmatism 6.91 NA NA 8.57 7.68 0.51 09065780 A Ocular reconst, transplant 10.73 NA NA 14.14 12.80 1.44 09065781 A Ocular reconst, transplant 18.14 NA NA 19.42 17.29 1.33 09065782 A Ocular reconst, transplant 15.43 NA NA 16.97 15.14 3.18 09065800 A Drainage of eye 1.91 2.24 2.05 1.77 1.56 0.28 00065805 A Drainage of eye 1.91 2.63 2.44 1.78 1.56 0.35 00065810 A Drainage of eye 5.82 NA NA 7.44 6.63 0.88 09065815 A Drainage of eye 6.00 11.59 10.95 7.39 6.57 1.10 09065820 A Relieve inner eye pressure 8.91 NA NA 11.99 10.92 0.65 09065850 A Incision of eye 11.39 NA NA 12.23 10.88 2.06 09065855 A Laser surgery of eye 3.99 5.47 5.02 4.38 3.91 0.65 01065860 A Incise inner eye adhesions 3.59 5.04 4.65 3.55 3.15 1.37 09065865 A Incise inner eye adhesions 5.77 NA NA 7.45 6.78 0.41 09065870 A Incise inner eye adhesions 7.39 NA NA 9.17 8.23 1.34 09065875 A Incise inner eye adhesions 7.81 NA NA 9.84 8.83 1.12 09065880 A Incise inner eye adhesions 8.36 NA NA 10.22 9.14 0.62 09065900 A Remove eye lesion 12.51 NA NA 14.56 13.01 0.92 09065920 A Remove implant of eye 9.99 NA NA 12.12 10.81 1.34 09065930 A Remove blood clot from eye 8.39 NA NA 9.50 8.51 1.54 090CMS-1503-P1013**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**66020 A Injection treatment of eye 1.64 3.49 3.32 2.04 1.84 0.11 01066030 A Injection treatment of eye 1.30 3.25 3.12 1.80 1.63 0.18 01066130 A Remove eye lesion 7.83 11.54 10.72 8.20 7.27 1.72 09066150 A Glaucoma surgery 10.53 NA NA 13.99 12.55 0.76 09066155 A Glaucoma surgery 10.52 NA NA 13.99 12.53 0.76 09066160 A Glaucoma surgery 12.39 NA NA 15.31 13.66 0.90 09066165 A Glaucoma surgery 10.24 NA NA 13.79 12.37 0.75 09066170 A Glaucoma surgery 15.02 NA NA 18.64 16.60 1.99 09066172 A Incision of eye 18.86 NA NA 23.61 20.99 2.50 09066180 A Implant eye shunt 16.30 NA NA 16.54 14.53 2.20 09066185 A Revise eye shunt 9.58 NA NA 11.46 10.17 1.74 09066220 A Repair eye lesion 9.21 NA NA 11.63 10.25 1.31 09066225 A Repair/graft eye lesion 12.63 NA NA 13.58 11.97 2.57 09066250 A Follow-up surgery of eye 7.10 13.56 12.80 8.53 7.57 1.46 09066500 A Incision of iris 3.83 NA NA 6.01 5.53 0.28 09066505 A Incision of iris 4.22 NA NA 6.56 6.03 0.31 09066600 A Remove iris and lesion 10.12 NA NA 13.16 11.71 0.79 09066605 A Removal of iris 14.22 NA NA 15.52 13.65 1.06 09066625 A Removal of iris 5.30 NA NA 6.72 6.05 0.75 09066630 A Removal of iris 7.28 NA NA 8.70 7.73 1.27 09066635 A Removal of iris 7.37 NA NA 8.77 7.79 0.54 09066680 A Repair iris & ciliary body 6.39 NA NA 8.08 7.21 1.41 09066682 A Repair iris & ciliary body 7.33 NA NA 10.44 9.35 1.51 09066700 A Destruction, ciliarybody 5.14 7.42 6.74 5.91 5.25 0.51 09066710 A Ciliary transsleral therapy 5.14 7.17 6.51 5.90 5.24 1.06 09066711 A Ciliary endoscopic ablation 7.93 NA NA 10.10 8.99 0.58 090CMS-1503-P1014**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**66720 A Destruction, ciliarybody 5.00 8.11 7.39 6.77 6.10 0.71 09066740 A Destruction, ciliarybody 5.14 7.07 6.42 5.91 5.26 0.37 09066761 A Revision of iris 5.02 7.69 7.02 6.65 5.94 0.78 09066762 A Revision of iris 5.38 7.88 7.17 6.58 5.85 0.71 09066770 A Removal of inner eye lesion 6.13 8.60 7.80 7.42 6.60 0.44 09066820 A Incision, secondary cataract 4.01 NA NA 6.88 6.46 0.69 09066821 A After cataract laser surgery 3.42 5.75 5.26 5.24 4.76 0.55 09066825 A Reposition intraocular lens 9.01 NA NA 12.20 11.10 1.22 09066830 A Removal of lens lesion 9.47 NA NA 10.60 9.37 0.69 09066840 A Removal of lens material 9.18 NA NA 10.40 9.19 1.88 09066850 A Removal of lens material 10.55 NA NA 11.74 10.38 1.51 09066852 A Removal of lens material 11.41 NA NA 12.36 10.92 2.08 09066920 A Extraction of lens 10.13 NA NA 11.09 9.80 0.73 09066930 A Extraction of lens 11.61 NA NA 12.51 11.04 0.85 09066940 A Extraction of lens 10.37 NA NA 11.61 10.27 1.81 09066982 A Cataract surgery, complex 15.02 NA NA 14.70 12.95 2.42 09066983 A Cataract surg w/iol, 1 stage 10.43 NA NA 10.42 9.20 0.86 09066984 A Cataract surg w/iol, 1 stage 10.52 NA NA 10.86 9.63 1.71 09066985 A Insert lens prosthesis 9.98 NA NA 11.66 10.32 1.34 09066986 A Exchange lens prosthesis 12.26 NA NA 13.31 11.87 1.62 09066990 A Ophthalmic endoscope add-on 1.51 NA NA 1.07 0.91 0.10 ZZZ66999 C Eye surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY67005 A Partial removal of eye fluid 5.89 NA NA 7.34 6.56 1.30 09067010 A Partial removal of eye fluid 7.06 NA NA 8.16 7.26 1.02 09067015 A Release of eye fluid 7.14 NA NA 9.09 8.19 1.03 09067025 A Replace eye fluid 8.11 12.10 11.10 9.65 8.55 1.50 090CMS-1503-P1015**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**67027 A Implant eye drug system 11.62 NA NA 12.30 10.86 2.11 09067028 A Injection eye drug 2.52 3.36 3.10 2.21 1.93 0.38 00067030 A Incise inner eye strands 6.11 NA NA 8.74 7.87 0.44 09067031 A Laser surgery, eye strands 4.47 6.37 5.79 5.53 4.93 0.61 09067036 A Removal of inner eye fluid 13.32 NA NA 13.71 12.08 1.89 09067039 A Laser treatment of retina 16.74 NA NA 17.97 15.92 3.08 09067040 A Laser treatment of retina 19.61 NA NA 20.39 17.99 2.80 09067041 A Vit for macular pucker 19.25 NA NA 18.17 15.73 2.74 09067042 A Vit for macular hole 22.38 NA NA 20.38 17.58 3.21 09067043 A Vit for membrane dissect 23.24 NA NA 21.70 18.77 4.25 09067101 A Repair detached retina 8.80 13.07 11.86 10.15 8.98 1.61 09067105 A Repair detached retina 8.53 11.63 10.50 9.58 8.46 1.22 09067107 A Repair detached retina 16.71 NA NA 17.53 15.41 3.07 09067108 A Repair detached retina 22.89 NA NA 22.41 19.59 3.26 09067110 A Repair detached retina 10.25 14.01 12.73 11.54 10.19 1.36 09067112 A Rerepair detached retina 18.75 NA NA 18.65 16.31 2.67 09067113 A Repair retinal detach, cplx 25.35 NA NA 23.93 20.72 3.62 09067115 A Release encircling material 6.11 NA NA 7.87 7.02 0.81 09067120 A Remove eye implant material 7.10 11.18 10.30 8.57 7.61 1.46 09067121 A Remove eye implant material 12.25 NA NA 13.32 11.73 2.25 09067141 A Treatment of retina 6.15 8.48 7.65 7.53 6.69 1.13 09067145 A Treatment of retina 6.32 8.44 7.58 7.65 6.79 0.89 09067208 A Treatment of retinal lesion 7.65 9.16 8.17 8.60 7.60 0.55 09067210 A Treatment of retinal lesion 9.45 9.95 8.79 9.35 8.17 1.46 09067218 A Treatment of retinal lesion 20.36 NA NA 18.74 16.33 1.51 09067220 A Treatment of choroid lesion 14.39 15.43 13.68 14.10 12.33 2.64 090CMS-1503-P1016**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**67221 R Ocular photodynamic ther 3.45 4.57 4.31 2.63 2.27 0.49 00067225 A Eye photodynamic ther add-on 0.47 0.38 0.33 0.33 0.28 0.03 ZZZ67227 A Treatment of retinal lesion 7.53 9.57 8.60 8.51 7.53 0.55 09067228 A Treatment of retinal lesion 13.82 18.48 17.29 15.99 14.10 2.18 09067229 A Tr retinal les preterm inf 16.30 NA NA 15.57 13.82 1.22 09067250 A Reinforce eye wall 9.61 NA NA 12.22 11.10 1.68 09067255 A Reinforce/graft eye wall 10.17 NA NA 13.33 12.11 2.06 09067299 C Eye surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY67311 A Revise eye muscle 7.77 NA NA 9.02 8.03 1.36 09067312 A Revise two eye muscles 9.66 NA NA 10.35 9.14 1.98 09067314 A Revise eye muscle 8.79 NA NA 10.10 8.95 1.54 09067316 A Revise two eye muscles 10.93 NA NA 11.58 10.18 2.23 09067318 A Revise eye muscle(s) 9.12 NA NA 10.69 9.47 0.66 09067320 A Revise eye muscle(s) add-on 5.40 NA NA 3.79 3.16 0.40 ZZZ67331 A Eye surgery follow-up add-on 5.13 NA NA 3.57 2.97 0.89 ZZZ67332 A Rerevise eye muscles add-on 5.56 NA NA 3.92 3.26 0.96 ZZZ67334 A Revise eye muscle w/suture 5.05 NA NA 3.58 2.96 0.37 ZZZ67335 A Eye suture during surgery 2.49 NA NA 1.75 1.49 0.42 ZZZ67340 A Revise eye muscle add-on 6.00 NA NA 4.25 3.53 0.44 ZZZ67343 A Release eye tissue 8.47 NA NA 9.85 8.76 1.72 09067345 A Destroy nerve of eye muscle 3.01 3.54 3.18 2.92 2.57 0.83 01067346 A Biopsy, eye muscle 2.87 NA NA 2.79 2.46 0.64 00067399 C Eye muscle surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY67400 A Explore/biopsy eye socket 11.20 NA NA 14.76 13.48 2.15 09067405 A Explore/drain eye socket 9.20 NA NA 12.85 11.84 1.23 09067412 A Explore/treat eye socket 10.30 NA NA 13.45 12.38 1.94 090CMS-1503-P1017**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**67413 A Explore/treat eye socket 10.24 NA NA 13.60 12.50 2.08 09067414 A Explr/decompress eye socket 17.94 NA NA 19.30 17.01 2.37 09067415 A Aspiration, orbital contents 1.76 NA NA 1.25 1.04 0.25 00067420 A Explore/treat eye socket 21.87 NA NA 23.51 21.13 4.48 09067430 A Explore/treat eye socket 15.29 NA NA 19.56 17.79 1.13 09067440 A Explore/drain eye socket 14.84 NA NA 18.87 17.15 1.98 09067445 A Explr/decompress eye socket 19.12 NA NA 20.26 18.03 3.91 09067450 A Explore/biopsy eye socket 15.41 NA NA 19.65 17.84 2.05 09067500 A Inject/treat eye socket1.44 0.87 0.82 0.69 0.61 0.11 00067505 A Inject/treat eye socket1.27 1.24 1.08 1.04 0.85 0.27 00067515 A Inject/treat eye socket1.40 1.34 1.13 1.13 0.92 0.27 00067550 A Insert eye socket implant 11.77 NA NA 15.17 13.84 2.39 09067560 A Revise eye socket implant 12.18 NA NA 15.49 14.04 1.62 09067570 A Decompress optic nerve 14.40 NA NA 17.43 16.01 5.36 09067599 C Orbit surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY67700 A Drainage of eyelid abscess 1.40 5.81 5.76 1.84 1.66 0.24 01067710 A Incision of eyelid 1.07 4.95 4.96 1.64 1.50 0.23 01067715 A Incision of eyelid fold 1.27 5.11 5.08 1.77 1.61 0.27 01067800 A Remove eyelid lesion 1.41 2.13 1.96 1.50 1.34 0.25 01067801 A Remove eyelid lesions 1.91 2.61 2.39 1.86 1.64 0.38 01067805 A Remove eyelid lesions 2.27 3.35 3.08 2.38 2.11 0.45 01067808 A Remove eyelid lesion(s) 4.60 NA NA 5.72 5.11 0.93 09067810 A Biopsy of eyelid 1.48 4.42 4.48 1.06 0.96 0.23 00067820 A Revise eyelashes 0.71 0.70 0.65 0.79 0.71 0.11 00067825 A Revise eyelashes 1.43 2.14 1.98 1.96 1.79 0.28 01067830 A Revise eyelashes 1.75 5.49 5.39 2.12 1.91 0.35 010CMS-1503-P1018**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**67835 A Revise eyelashes 5.70 NA NA 6.62 5.93 1.17 09067840 A Remove eyelid lesion 2.09 5.43 5.32 2.36 2.12 0.35 01067850 A Treat eyelid lesion 1.74 4.18 4.16 2.07 1.97 0.25 01067875 A Closure of eyelid by suture 1.35 3.33 3.25 1.39 1.23 0.25 00067880 A Revision of eyelid 4.60 8.08 7.54 5.72 5.12 0.85 09067882 A Revision of eyelid 6.02 9.62 8.92 7.24 6.45 1.23 09067900 A Repair brow defect 6.82 10.93 10.23 7.48 6.71 1.27 09067901 A Repair eyelid defect7.59 13.26 11.59 8.58 7.59 1.55 09067902 A Repair eyelid defect 9.82 NA NA 10.55 9.13 2.01 09067903 A Repair eyelid defect6.51 9.98 9.49 7.10 6.43 1.31 09067904 A Repair eyelid defect7.97 12.35 11.41 8.83 7.75 1.58 09067906 A Repair eyelid defect 6.93 NA NA 7.38 6.57 0.51 09067908 A Repair eyelid defect5.30 8.41 7.78 6.60 6.05 1.09 09067909 A Revise eyelid defect 5.57 9.24 8.69 6.70 6.06 1.14 09067911 A Revise eyelid defect 7.50 NA NA 8.30 7.26 1.46 09067912 A Correction eyelid w/implant 6.36 17.83 17.71 7.41 6.76 0.96 09067914 A Repair eyelid defect3.75 6.94 6.61 4.34 3.90 0.71 09067915 A Repair eyelid defect3.26 6.24 6.00 3.84 3.48 0.47 09067916 A Repair eyelid defect5.48 9.42 8.86 6.63 5.98 0.99 09067917 A Repair eyelid defect6.19 10.05 9.41 7.14 6.42 1.20 09067921 A Repair eyelid defect3.47 6.73 6.42 4.13 3.71 0.71 09067922 A Repair eyelid defect3.14 6.04 5.82 3.69 3.35 0.44 09067923 A Repair eyelid defect6.05 9.70 9.05 7.04 6.31 1.17 09067924 A Repair eyelid defect5.93 10.27 9.68 6.67 5.97 1.17 09067930 A Repair eyelid wound 3.65 6.43 6.10 3.15 2.77 0.73 01067935 A Repair eyelid wound 6.36 10.11 9.47 6.12 5.44 1.30 090CMS-1503-P1019**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**67938 A Remove eyelid foreign body 1.38 5.21 5.15 1.86 1.69 0.23 01067950 A Revision of eyelid 5.99 9.88 9.31 7.01 6.35 1.14 09067961 A Revision of eyelid 5.86 10.06 9.48 6.91 6.24 1.14 09067966 A Revision of eyelid 8.97 12.45 11.35 9.54 8.34 1.77 09067971 A Reconstruction of eyelid 10.01 NA NA 10.38 9.23 2.03 09067973 A Reconstruction of eyelid 13.13 NA NA 13.14 11.68 2.68 09067974 A Reconstruction of eyelid 13.10 NA NA 13.12 11.63 2.68 09067975 A Reconstruction of eyelid 9.35 NA NA 9.93 8.85 1.91 09067999 C Revision of eyelid 0.00 0.00 0.00 0.00 0.00 0.00 YYY68020 A Incise/drain eyelid lining 1.42 1.92 1.75 1.68 1.52 0.21 01068040 A Treatment of eyelid lesions 0.85 0.97 0.88 0.65 0.56 0.17 00068100 A Biopsy of eyelid lining 1.35 3.27 3.20 1.41 1.25 0.21 00068110 A Remove eyelid lining lesion 1.82 4.35 4.20 2.34 2.11 0.37 01068115 A Remove eyelid lining lesion 2.41 6.09 5.91 2.76 2.46 0.32 01068130 A Remove eyelid lining lesion 5.10 9.76 9.26 6.45 5.82 0.37 09068135 A Remove eyelid lining lesion 1.89 2.48 2.25 2.34 2.11 0.27 01068200 A Treat eyelid by injection 0.49 0.69 0.64 0.49 0.43 0.08 00068320 A Revise/graft eyelid lining 6.64 13.34 12.59 8.47 7.57 1.34 09068325 A Revise/graft eyelid lining 8.63 NA NA 9.89 8.79 1.75 09068326 A Revise/graft eyelid lining 8.42 NA NA 9.73 8.63 1.71 09068328 A Revise/graft eyelid lining 9.45 NA NA 10.52 9.36 1.94 09068330 A Revise eyelid lining 5.78 10.89 10.28 7.15 6.38 1.19 09068335 A Revise/graft eyelid lining 8.46 NA NA 9.72 8.63 1.72 09068340 A Separate eyelid adhesions 4.97 10.02 9.50 6.22 5.54 1.03 09068360 A Revise eyelid lining 5.17 9.44 8.90 6.33 5.66 1.06 09068362 A Revise eyelid lining 8.61 NA NA 9.85 8.72 1.75 090CMS-1503-P1020**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**68371 A Harvest eye tissue, alograft 5.09 NA NA 6.49 5.86 0.37 01068399 C Eyelid lining surgery 0.00 0.00 0.00 0.00 0.00 0.00 YYY68400 A Incise/drain tear gland 1.74 5.91 5.81 1.95 1.81 0.35 01068420 A Incise/drain tear sac 2.35 6.38 6.21 2.39 2.19 0.31 01068440 A Incise tear duct opening 0.99 1.84 1.81 1.76 1.62 0.21 01068500 A Removal of tear gland 12.77 NA NA 14.64 12.99 3.11 09068505 A Partial removal, tear gland 12.69 NA NA 14.58 13.09 2.57 09068510 A Biopsy of tear gland 4.60 7.72 7.37 3.71 3.16 0.93 00068520 A Removal of tear sac 8.78 NA NA 10.45 9.41 1.19 09068525 A Biopsy of tear sac 4.42 NA NA 3.12 2.65 0.89 00068530 A Clearance of tear duct 3.70 8.00 7.80 3.56 3.17 0.75 01068540 A Remove tear gland lesion 12.18 NA NA 13.93 12.40 1.62 09068550 A Remove tear gland lesion 15.16 NA NA 16.87 14.94 2.01 09068700 A Repair tear ducts 7.87 NA NA 9.10 8.08 1.60 09068705 A Revise tear duct opening 2.11 4.38 4.21 2.55 2.29 0.42 01068720 A Create tear sac drain 9.96 NA NA 11.29 10.09 1.72 09068745 A Create tear duct drain 9.90 NA NA 11.45 10.23 2.02 09068750 A Create tear duct drain 10.10 NA NA 11.98 10.73 2.05 09068760 A Close tear duct opening 1.78 3.73 3.58 2.30 2.08 0.35 01068761 A Close tear duct opening 1.41 2.66 2.52 1.92 1.74 0.23 01068770 A Close tear system fistula 8.29 NA NA 9.40 7.88 1.68 09068801 A Dilate tear duct opening 1.00 2.44 2.32 1.99 1.86 0.17 01068810 A Probe nasolacrimal duct 2.15 4.52 4.24 3.08 2.87 0.41 01068811 A Probe nasolacrimal duct 2.45 NA NA 3.33 3.02 0.49 01068815 A Probe nasolacrimal duct 3.30 8.94 8.64 3.92 3.53 0.61 01068816 A Probe nl duct w/balloon 3.06 16.92 16.10 3.98 3.56 0.62 010CMS-1503-P1021**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**68840 A Explore/irrigate tear ducts 1.30 2.25 2.06 1.95 1.74 0.25 01068850 A Injection for tear sac x-ray 0.80 0.80 0.87 0.68 0.72 0.07 00068899 C Tear duct system surgery 0.00 0.00 0.00 0.00 0.00 0.00 YYY69000 A Drain external ear lesion 1.50 3.70 3.58 1.84 1.74 0.23 01069005 A Drain external ear lesion 2.16 3.90 3.75 2.29 2.17 0.30 01069020 A Drain outer ear canal lesion 1.53 5.10 5.00 2.54 2.45 0.21 01069090 N Pierce earlobes 0.00 0.00 0.00 0.00 0.00 0.00 XXX69100 A Biopsy of external ear 0.81 1.98 2.07 0.58 0.54 0.11 00069105 A Biopsy of external ear canal 0.85 3.17 3.12 0.97 0.93 0.10 00069110 A Remove external ear, partial 3.53 9.35 9.23 5.64 5.53 0.55 09069120 A Removal of external ear 4.14 NA NA 7.33 7.04 0.62 09069140 A Remove ear canal lesion(s) 8.14 NA NA 16.86 16.41 1.09 09069145 A Remove ear canal lesion(s) 2.70 8.65 8.33 4.44 4.25 0.37 09069150 A Extensive ear canal surgery 13.61 NA NA 15.83 15.24 2.02 09069155 A Extensive ear/neck surgery 23.35 NA NA 24.32 23.08 3.12 09069200 A Clear outer ear canal 0.77 2.72 2.68 0.86 0.79 0.10 00069205 A Clear outer ear canal 1.21 NA NA 1.68 1.61 0.17 01069210 A Remove impacted ear wax 0.61 0.83 0.77 0.31 0.27 0.07 00069220 A Clean out mastoid cavity 0.83 3.12 3.06 0.94 0.89 0.10 00069222 A Clean out mastoid cavity 1.45 4.85 4.78 2.48 2.41 0.18 01069300 R Revise external ear 6.69 13.06 11.92 6.91 6.44 0.89 YYY69310 A Rebuild outer ear canal 10.97 NA NA 20.03 19.45 1.50 09069320 A Rebuild outer ear canal 17.18 NA NA 26.50 25.69 2.29 09069399 C Outer ear surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY69400 A Inflate middle ear canal 0.83 3.40 3.28 0.94 0.89 0.10 00069401 A Inflate middle ear canal 0.63 1.85 1.76 0.78 0.74 0.07 000CMS-1503-P1022**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**69405 A Catheterize middle ear canal 2.68 4.79 4.58 2.82 2.67 0.35 01069420 A Incision of eardrum 1.38 4.10 4.01 2.07 1.98 0.18 01069421 A Incision of eardrum 1.78 NA NA 2.50 2.42 0.24 01069424 A Remove ventilating tube0.85 2.82 2.78 0.93 0.87 0.10 00069433 A Create eardrum opening 1.57 4.14 4.02 2.15 2.05 0.23 01069436 A Create eardrum opening 2.01 NA NA 2.59 2.51 0.27 01069440 A Exploration of middle ear 7.71 NA NA 12.05 11.48 1.03 09069450 A Eardrum revision 5.69 NA NA 9.93 9.48 0.75 09069501 A Mastoidectomy 9.21 NA NA 11.76 11.13 1.23 09069502 A Mastoidectomy 12.56 NA NA 15.18 14.38 1.75 09069505 A Remove mastoid structures 13.17 NA NA 21.24 20.50 1.77 09069511 A Extensive mastoid surgery 13.70 NA NA 21.54 20.83 1.84 09069530 A Extensive mastoid surgery 20.38 NA NA 26.87 25.77 2.71 09069535 A Remove part of temporal bone 37.42 NA NA 38.53 36.48 5.43 09069540 A Remove ear lesion 1.25 4.75 4.67 2.40 2.33 0.17 01069550 A Remove ear lesion 11.15 NA NA 18.61 18.00 1.50 09069552 A Remove ear lesion 19.81 NA NA 25.06 23.97 2.64 09069554 A Remove ear lesion 35.97 NA NA 36.15 33.35 4.79 09069601 A Mastoid surgery revision 13.45 NA NA 16.54 15.66 1.78 09069602 A Mastoid surgery revision 13.76 NA NA 17.43 16.53 1.84 09069603 A Mastoid surgery revision 14.20 NA NA 21.83 21.18 1.89 09069604 A Mastoid surgery revision 14.20 NA NA 17.68 16.90 1.89 09069605 A Mastoid surgery revision 18.69 NA NA 25.90 24.90 2.49 09069610 A Repair of eardrum 4.47 6.53 6.34 3.86 3.63 0.61 01069620 A Repair of eardrum 6.03 13.75 13.45 7.92 7.57 0.79 09069631 A Repair eardrum structures 10.05 NA NA 15.30 14.58 1.34 090CMS-1503-P1023**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**69632 A Rebuild eardrum structures 12.96 NA NA 17.94 17.08 1.72 09069633 A Rebuild eardrum structures 12.31 NA NA 17.52 16.69 1.65 09069635 A Repair eardrum structures 13.51 NA NA 21.44 20.65 1.81 09069636 A Rebuild eardrum structures 15.43 NA NA 24.03 23.18 2.05 09069637 A Rebuild eardrum structures 15.32 NA NA 24.02 23.16 2.08 09069641 A Revise middle ear & mastoid 12.89 NA NA 16.89 16.07 1.74 09069642 A Revise middle ear & mastoid 17.06 NA NA 21.24 20.18 2.27 09069643 A Revise middle ear & mastoid 15.59 NA NA 19.43 18.44 2.08 09069644 A Revise middle ear & mastoid 17.23 NA NA 24.99 24.11 2.30 09069645 A Revise middle ear & mastoid 16.71 NA NA 24.77 23.88 2.26 09069646 A Revise middle ear & mastoid 18.37 NA NA 25.67 24.66 2.44 09069650 A Release middle ear bone 9.80 NA NA 13.24 12.44 1.30 09069660 A Revise middle ear bone 12.03 NA NA 14.52 13.77 1.61 09069661 A Revise middle ear bone 15.92 NA NA 18.67 17.74 2.08 09069662 A Revise middle ear bone 15.60 NA NA 17.48 16.57 2.08 09069666 A Repair middle ear structures 9.89 NA NA 13.28 12.58 1.33 09069667 A Repair middle ear structures 9.90 NA NA 13.26 12.61 1.33 09069670 A Remove mastoid air cells 11.73 NA NA 15.32 14.51 1.57 09069676 A Remove middle ear nerve 9.69 NA NA 14.14 13.52 1.29 09069700 A Close mastoid fistula 8.37 NA NA 11.27 10.84 1.12 09069710 N Implant/replace hearingaid 0.00 0.00 0.00 0.00 0.00 0.00 XXX69711 A Remove/repair hearing aid 10.62 NA NA 14.10 13.48 1.41 09069714 A Implant temple bone w/stimul 14.45 NA NA 16.32 15.45 1.94 09069715 A Temple bne implnt w/stimulat 18.96 NA NA 19.11 17.99 2.52 09069717 A Temple bone implant revision 15.43 NA NA 16.93 16.19 2.05 09069718 A Revise temple bone implant 19.21 NA NA 19.25 18.15 2.54 090CMS-1503-P1024**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**69720 A Release facial nerve 14.71 NA NA 18.94 17.99 1.96 09069725 A Release facial nerve 27.64 NA NA 26.23 24.54 3.69 09069740 A Repair facial nerve 16.27 NA NA 17.17 16.21 2.16 09069745 A Repair facial nerve 17.02 NA NA 18.57 17.63 2.26 09069799 C Middle ear surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY69801 A Incise inner ear 8.70 NA NA 12.82 12.21 1.17 09069802 A Incise inner ear 13.50 NA NA 16.33 15.47 1.78 09069805 A Explore inner ear 14.71 NA NA 15.50 14.55 1.96 09069806 A Explore inner ear 12.63 NA NA 14.41 13.65 1.70 09069820 A Establish inner ear window 10.52 NA NA 14.04 13.45 1.41 09069840 A Revise inner ear window 10.44 NA NA 12.47 13.41 0.76 09069905 A Remove inner ear 11.26 NA NA 15.05 14.35 1.51 09069910 A Remove inner ear & mastoid 13.91 NA NA 15.23 14.43 1.87 09069915 A Incise inner ear nerve 22.77 NA NA 21.30 19.87 3.08 09069930 A Implant cochlear device 17.73 NA NA 17.27 16.41 2.36 09069949 C Inner ear surgery procedure 0.00 0.00 0.00 0.00 0.00 0.00 YYY69950 A Incise inner ear nerve 27.63 NA NA 28.17 24.54 3.69 09069955 A Release facial nerve 29.42 NA NA 27.27 25.54 3.93 09069960 A Release inner ear canal 29.42 NA NA 25.72 23.95 3.93 09069970 A Remove inner ear lesion 32.41 NA NA 28.97 27.13 4.32 09069979 C Temporal bone surgery 0.00 0.00 0.00 0.00 0.00 0.00 YYY69990 R Microsurgery add-on 3.46 NA NA 1.89 1.83 1.20 ZZZ70010 A Contrast x-ray of brain 1.19 2.75 3.34 NA NA 0.22 XXX70010 TC A Contrast x-ray of brain 0.00 2.34 2.88 NA NA 0.01 XXX70010 26 A Contrast x-ray of brain 1.19 0.41 0.46 0.41 0.46 0.21 XXX70015 A Contrast x-ray of brain 1.19 2.87 2.99 NA NA 0.08 XXXCMS-1503-P1025**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**70015 TC A Contrast x-ray of brain 0.00 2.45 2.51 NA NA 0.01 XXX70015 26 A Contrast x-ray of brain 1.19 0.42 0.48 0.42 0.48 0.07 XXX70030 A X-ray eye for foreign body 0.17 0.60 0.65 NA NA 0.02 XXX70030 TC A X-ray eye for foreign body 0.00 0.54 0.58 NA NA 0.01 XXX70030 26 A X-ray eye for foreign body 0.17 0.06 0.07 0.06 0.07 0.01 XXX70100 A X-ray exam of jaw 0.18 0.78 0.77 NA NA 0.02 XXX70100 TC A X-ray exam of jaw 0.00 0.70 0.69 NA NA 0.01 XXX70100 26 A X-ray exam of jaw 0.18 0.08 0.08 0.08 0.08 0.01 XXX70110 A X-ray exam of jaw 0.25 0.82 0.88 NA NA 0.02 XXX70110 TC A X-ray exam of jaw 0.00 0.73 0.78 NA NA 0.01 XXX70110 26 A X-ray exam of jaw 0.25 0.09 0.10 0.09 0.10 0.01 XXX70120 A X-ray exam of mastoids 0.18 0.82 0.82 NA NA 0.02 XXX70120 TC A X-ray exam of mastoids 0.00 0.74 0.74 NA NA 0.01 XXX70120 26 A X-ray exam of mastoids 0.18 0.08 0.08 0.08 0.08 0.01 XXX70130 A X-ray exam of mastoids 0.34 1.23 1.27 NA NA 0.02 XXX70130 TC A X-ray exam of mastoids 0.00 1.10 1.13 NA NA 0.01 XXX70130 26 A X-ray exam of mastoids 0.34 0.13 0.14 0.13 0.14 0.01 XXX70134 A X-ray exam of middle ear 0.34 0.90 0.98 NA NA 0.02 XXX70134 TC A X-ray exam of middle ear 0.00 0.78 0.85 NA NA 0.01 XXX70134 26 A X-ray exam of middle ear 0.34 0.12 0.13 0.12 0.13 0.01 XXX70140 A X-ray exam of facial bones 0.19 0.66 0.68 NA NA 0.02 XXX70140 TC A X-ray exam of facial bones 0.00 0.56 0.59 NA NA 0.01 XXX70140 26 A X-ray exam of facial bones 0.19 0.10 0.09 0.10 0.09 0.01 XXX70150 A X-ray exam of facial bones 0.26 0.92 0.97 NA NA 0.02 XXX70150 TC A X-ray exam of facial bones 0.00 0.81 0.86 NA NA 0.01 XXX70150 26 A X-ray exam of facial bones 0.26 0.11 0.11 0.11 0.11 0.01 XXXCMS-1503-P1026**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**70160 A X-ray exam of nasal bones 0.17 0.74 0.77 NA NA 0.02 XXX70160 TC A X-ray exam of nasal bones 0.00 0.67 0.70 NA NA 0.01 XXX70160 26 A X-ray exam of nasal bones 0.17 0.07 0.07 0.07 0.07 0.01 XXX70170 C X-ray exam of tear duct 0.00 0.00 0.00 NA NA 0.00 XXX70170 TC C X-ray exam of tear duct 0.00 0.00 0.00 NA NA 0.00 XXX70170 26 A X-ray exam of tear duct 0.30 0.10 0.12 0.10 0.12 0.03 XXX70190 A X-ray exam of eye sockets 0.21 0.78 0.82 NA NA 0.02 XXX70190 TC A X-ray exam of eye sockets 0.00 0.69 0.73 NA NA 0.01 XXX70190 26 A X-ray exam of eye sockets 0.21 0.09 0.09 0.09 0.09 0.01 XXX70200 A X-ray exam of eye sockets 0.28 0.92 0.99 NA NA 0.02 XXX70200 TC A X-ray exam of eye sockets 0.00 0.81 0.87 NA NA 0.01 XXX70200 26 A X-ray exam of eye sockets 0.28 0.11 0.12 0.11 0.12 0.01 XXX70210 A X-ray exam of sinuses 0.17 0.69 0.70 NA NA 0.02 XXX70210 TC A X-ray exam of sinuses 0.00 0.61 0.63 NA NA 0.01 XXX70210 26 A X-ray exam of sinuses 0.17 0.08 0.07 0.08 0.07 0.01 XXX70220 A X-ray exam of sinuses 0.25 0.82 0.87 NA NA 0.02 XXX70220 TC A X-ray exam of sinuses 0.00 0.72 0.77 NA NA 0.01 XXX70220 26 A X-ray exam of sinuses 0.25 0.10 0.10 0.10 0.10 0.01 XXX70240 A X-ray exam, pituitary saddle 0.19 0.62 0.66 NA NA 0.02 XXX70240 TC A X-ray exam, pituitary saddle 0.00 0.54 0.58 NA NA 0.01 XXX70240 26 A X-ray exam, pituitary saddle 0.19 0.08 0.08 0.08 0.08 0.01 XXX70250 A X-ray exam of skull 0.24 0.81 0.83 NA NA 0.02 XXX70250 TC A X-ray exam of skull 0.00 0.70 0.72 NA NA 0.01 XXX70250 26 A X-ray exam of skull 0.24 0.11 0.11 0.11 0.11 0.01 XXX70260 A X-ray exam of skull 0.34 0.98 1.03 NA NA 0.02 XXX70260 TC A X-ray exam of skull 0.00 0.83 0.89 NA NA 0.01 XXXCMS-1503-P1027**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**70260 26 A X-ray exam of skull 0.34 0.15 0.14 0.15 0.14 0.01 XXX70300 A X-ray exam of teeth 0.10 0.30 0.31 NA NA 0.02 XXX70300 TC A X-ray exam of teeth 0.00 0.23 0.25 NA NA 0.01 XXX70300 26 A X-ray exam of teeth 0.10 0.07 0.06 0.07 0.06 0.01 XXX70310 A X-ray exam of teeth 0.16 0.94 0.91 NA NA 0.02 XXX70310 TC A X-ray exam of teeth 0.00 0.84 0.82 NA NA 0.01 XXX70310 26 A X-ray exam of teeth 0.16 0.10 0.09 0.10 0.09 0.01 XXX70320 A Full mouth x-ray of teeth 0.22 1.22 1.22 NA NA 0.02 XXX70320 TC A Full mouth x-ray of teeth 0.00 1.09 1.11 NA NA 0.01 XXX70320 26 A Full mouth x-ray of teeth 0.22 0.13 0.11 0.13 0.11 0.01 XXX70328 A X-ray exam of jaw joint 0.18 0.67 0.69 NA NA 0.02 XXX70328 TC A X-ray exam of jaw joint 0.00 0.60 0.62 NA NA 0.01 XXX70328 26 A X-ray exam of jaw joint 0.18 0.07 0.07 0.07 0.07 0.01 XXX70330 A X-ray exam of jaw joints 0.24 1.09 1.14 NA NA 0.02 XXX70330 TC A X-ray exam of jaw joints 0.00 0.98 1.03 NA NA 0.01 XXX70330 26 A X-ray exam of jaw joints 0.24 0.11 0.11 0.11 0.11 0.01 XXX70332 A X-ray exam of jaw joint 0.54 1.82 1.90 NA NA 0.04 XXX70332 TC A X-ray exam of jaw joint 0.00 1.52 1.64 NA NA 0.01 XXX70332 26 A X-ray exam of jaw joint 0.54 0.30 0.26 0.30 0.26 0.03 XXX70336 A Magnetic image, jaw joint 1.48 8.61 11.50 NA NA 0.09 XXX70336 TC A Magnetic image, jaw joint 0.00 8.10 10.92 NA NA 0.01 XXX70336 26 A Magnetic image, jaw joint 1.48 0.51 0.58 0.51 0.58 0.08 XXX70350 A X-ray head for orthodontia 0.17 0.43 0.43 NA NA 0.02 XXX70350 TC A X-ray head for orthodontia 0.00 0.31 0.34 NA NA 0.01 XXX70350 26 A X-ray head for orthodontia 0.17 0.12 0.09 0.12 0.09 0.01 XXX70355 A Panoramic x-ray of jaws 0.20 0.38 0.42 NA NA 0.02 XXXCMS-1503-P1028**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**70355 TC A Panoramic x-ray of jaws 0.00 0.26 0.32 NA NA 0.01 XXX70355 26 A Panoramic x-ray of jaws 0.20 0.12 0.10 0.12 0.10 0.01 XXX70360 A X-ray exam of neck 0.17 0.57 0.61 NA NA 0.02 XXX70360 TC A X-ray exam of neck 0.00 0.51 0.54 NA NA 0.01 XXX70360 26 A X-ray exam of neck 0.17 0.06 0.07 0.06 0.07 0.01 XXX70370 A Throat x-ray & fluoroscopy 0.32 2.07 2.01 NA NA 0.02 XXX70370 TC A Throat x-ray & fluoroscopy 0.00 1.94 1.88 NA NA 0.01 XXX70370 26 A Throat x-ray & fluoroscopy 0.32 0.13 0.13 0.13 0.13 0.01 XXX70371 A Speech evaluation, complex 0.84 1.70 1.86 NA NA 0.04 XXX70371 TC A Speech evaluation, complex 0.00 1.36 1.53 NA NA 0.01 XXX70371 26 A Speech evaluation, complex 0.84 0.34 0.33 0.34 0.33 0.03 XXX70373 A Contrast x-ray of larynx 0.44 1.88 1.92 NA NA 0.02 XXX70373 TC A Contrast x-ray of larynx 0.00 1.70 1.76 NA NA 0.01 XXX70373 26 A Contrast x-ray of larynx 0.44 0.18 0.16 0.18 0.16 0.01 XXX70380 A X-ray exam of salivary gland 0.17 0.98 0.96 NA NA 0.02 XXX70380 TC A X-ray exam of salivary gland 0.00 0.87 0.87 NA NA 0.01 XXX70380 26 A X-ray exam of salivary gland 0.17 0.11 0.09 0.11 0.09 0.01 XXX70390 A X-ray exam of salivary duct 0.38 2.37 2.51 NA NA 0.04 XXX70390 TC A X-ray exam of salivary duct 0.00 2.23 2.36 NA NA 0.01 XXX70390 26 A X-ray exam of salivary duct 0.38 0.14 0.15 0.14 0.15 0.03 XXX70450 A Ct head/brain w/o dye 0.85 3.67 4.79 NA NA 0.05 XXX70450 TC A Ct head/brain w/o dye 0.00 3.38 4.45 NA NA 0.01 XXX70450 26 A Ct head/brain w/o dye 0.85 0.29 0.34 0.29 0.34 0.04 XXX70460 A Ct head/brain w/dye 1.13 4.85 6.23 NA NA 0.07 XXX70460 TC A Ct head/brain w/dye 0.00 4.45 5.78 NA NA 0.01 XXX70460 26 A Ct head/brain w/dye 1.13 0.40 0.45 0.40 0.45 0.06 XXXCMS-1503-P1029**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**70470 A Ct head/brain w/o & w/dye 1.27 5.92 7.63 NA NA 0.08 XXX70470 TC A Ct head/brain w/o & w/dye 0.00 5.47 7.12 NA NA 0.01 XXX70470 26 A Ct head/brain w/o & w/dye 1.27 0.45 0.51 0.45 0.51 0.07 XXX70480 A Ct orbit/ear/fossa w/o dye 1.28 6.39 7.75 NA NA 0.08 XXX70480 TC A Ct orbit/ear/fossa w/o dye 0.00 5.93 7.24 NA NA 0.01 XXX70480 26 A Ct orbit/ear/fossa w/o dye 1.28 0.46 0.51 0.46 0.51 0.07 XXX70481 A Ct orbit/ear/fossa w/dye 1.38 7.45 9.10 NA NA 0.09 XXX70481 TC A Ct orbit/ear/fossa w/dye 0.00 6.97 8.55 NA NA 0.01 XXX70481 26 A Ct orbit/ear/fossa w/dye 1.38 0.48 0.55 0.48 0.55 0.08 XXX70482 A Ct orbit/ear/fossa w/o&w/dye 1.45 8.38 10.41 NA NA 0.09 XXX70482 TC A Ct orbit/ear/fossa w/o&w/dye 0.00 7.87 9.84 NA NA 0.01 XXX70482 26 A Ct orbit/ear/fossa w/o&w/dye 1.45 0.51 0.57 0.51 0.57 0.08 XXX70486 A Ct maxillofacial w/o dye 1.14 5.18 6.39 NA NA 0.07 XXX70486 TC A Ct maxillofacial w/o dye 0.00 4.76 5.93 NA NA 0.01 XXX70486 26 A Ct maxillofacial w/odye 1.14 0.42 0.46 0.42 0.46 0.06 XXX70487 A Ct maxillofacial w/dye 1.30 6.23 7.77 NA NA 0.08 XXX70487 TC A Ct maxillofacial w/dye 0.00 5.78 7.25 NA NA 0.01 XXX70487 26 A Ct maxillofacial w/dye 1.30 0.45 0.52 0.45 0.52 0.07 XXX70488 A Ct maxillofacial w/o & w/dye 1.42 7.71 9.62 NA NA 0.09 XXX70488 TC A Ct maxillofacial w/o & w/dye 0.00 7.21 9.06 NA NA 0.01 XXX70488 26 A Ct maxillofacial w/o &w/dye 1.42 0.50 0.56 0.50 0.56 0.08 XXX70490 A Ct soft tissue neck w/o dye 1.28 4.84 6.09 NA NA 0.08 XXX70490 TC A Ct soft tissue neck w/o dye 0.00 4.39 5.58 NA NA 0.01 XXX70490 26 A Ct soft tissue neck w/o dye 1.28 0.45 0.51 0.45 0.51 0.07 XXX70491 A Ct soft tissue neck w/dye 1.38 6.01 7.51 NA NA 0.08 XXX70491 TC A Ct soft tissue neck w/dye 0.00 5.52 6.96 NA NA 0.01 XXXCMS-1503-P1030**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**70491 26 A Ct soft tissue neck w/dye 1.38 0.49 0.55 0.49 0.55 0.07 XXX70492 A Ct sft tsue nck w/o & w/dye 1.45 7.38 9.30 NA NA 0.09 XXX70492 TC A Ct sft tsue nck w/o & w/dye 0.00 6.87 8.73 NA NA 0.01 XXX70492 26 A Ct sft tsue nck w/o & w/dye 1.45 0.51 0.57 0.51 0.57 0.08 XXX70496 A Ct angiography, head 1.75 12.06 15.32 NA NA 0.11 XXX70496 TC A Ct angiography, head 0.00 11.45 14.62 NA NA 0.01 XXX70496 26 A Ct angiography, head 1.75 0.61 0.70 0.61 0.70 0.10 XXX70498 A Ct angiography, neck 1.75 12.56 15.63 NA NA 0.11 XXX70498 TC A Ct angiography, neck 0.00 11.95 14.92 NA NA 0.01 XXX70498 26 A Ct angiography, neck 1.75 0.61 0.71 0.61 0.71 0.10 XXX70540 A Mri orbit/face/neck w/o dye 1.35 9.96 13.05 NA NA 0.09 XXX70540 TC A Mri orbit/face/neck w/o dye 0.00 9.49 12.52 NA NA 0.01 XXX70540 26 A Mri orbit/face/neck w/odye 1.35 0.47 0.53 0.47 0.53 0.08 XXX70542 A Mri orbit/face/neck w/dye 1.62 11.17 14.46 NA NA 0.11 XXX70542 TC A Mri orbit/face/neck w/dye 0.00 10.60 13.82 NA NA 0.01 XXX70542 26 A Mri orbit/face/neck w/dye 1.62 0.57 0.64 0.57 0.64 0.10 XXX70543 A Mri orbt/fac/nck w/o & w/dye 2.15 13.42 18.89 NA NA 0.14 XXX70543 TC A Mri orbt/fac/nck w/o & w/dye 0.00 12.67 18.05 NA NA 0.01 XXX70543 26 A Mri orbt/fac/nck w/o & w/dye 2.15 0.75 0.84 0.75 0.84 0.13 XXX70544 A Mr angiography head w/o dye 1.20 11.48 14.53 NA NA 0.08 XXX70544 TC A Mr angiography head w/o dye 0.00 11.06 14.06 NA NA 0.01 XXX70544 26 A Mr angiography head w/o dye 1.20 0.42 0.47 0.42 0.47 0.07 XXX70545 A Mr angiography head w/dye 1.20 11.38 14.44 NA NA 0.08 XXX70545 TC A Mr angiography head w/dye 0.00 10.96 13.97 NA NA 0.01 XXX70545 26 A Mr angiography head w/dye 1.20 0.42 0.47 0.42 0.47 0.07 XXX70546 A Mr angiograph head w/o&w/dye 1.80 17.39 22.84 NA NA 0.12 XXXCMS-1503-P1031**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**70546 TC A Mr angiograph head w/o&w/dye 0.00 16.76 22.13 NA NA 0.01 XXX70546 26 A Mr angiograph head w/o&w/dye 1.80 0.63 0.71 0.63 0.71 0.11 XXX70547 A Mr angiography neck w/o dye 1.20 11.48 14.51 NA NA 0.08 XXX70547 TC A Mr angiography neck w/o dye 0.00 11.06 14.03 NA NA 0.01 XXX70547 26 A Mr angiography neck w/o dye 1.20 0.42 0.48 0.42 0.48 0.07 XXX70548 A Mr angiography neck w/dye 1.20 12.24 15.28 NA NA 0.08 XXX70548 TC A Mr angiography neck w/dye 0.00 11.82 14.80 NA NA 0.01 XXX70548 26 A Mr angiography neck w/dye 1.20 0.42 0.48 0.42 0.48 0.07 XXX70549 A Mr angiograph neck w/o&w/dye 1.80 17.40 22.85 NA NA 0.11 XXX70549 TC A Mr angiograph neck w/o&w/dye 0.00 16.77 22.14 NA NA 0.01 XXX70549 26 A Mr angiograph neck w/o&w/dye 1.80 0.63 0.71 0.63 0.71 0.10 XXX70551 A Mri brain w/o dye 1.48 10.40 13.39 NA NA 0.09 XXX70551 TC A Mri brain w/o dye 0.00 9.88 12.81 NA NA 0.01 XXX70551 26 A Mri brain w/o dye 1.48 0.52 0.58 0.52 0.58 0.08 XXX70552 A Mri brain w/dye 1.78 11.48 14.80 NA NA 0.12 XXX70552 TC A Mri brain w/dye 0.00 10.85 14.09 NA NA 0.01 XXX70552 26 A Mri brain w/dye 1.78 0.63 0.71 0.63 0.71 0.11 XXX70553 A Mri brain w/o & w/dye 2.36 13.18 18.51 NA NA 0.15 XXX70553 TC A Mri brain w/o & w/dye 0.00 12.35 17.57 NA NA 0.01 XXX70553 26 A Mri brain w/o & w/dye 2.36 0.83 0.94 0.83 0.94 0.14 XXX70554 A Fmri brain by tech 2.11 11.55 14.26 NA NA 0.14 XXX70554 TC A Fmri brain by tech 0.00 10.79 13.40 NA NA 0.01 XXX70554 26 A Fmri brain by tech2.11 0.76 0.86 0.76 0.86 0.13 XXX70555 C Fmri brain by phys/psych 0.00 0.00 0.00 NA NA 0.00 XXX70555 TC C Fmri brain by phys/psych 0.00 0.00 0.00 NA NA 0.00 XXX70555 26 A Fmri brain by phys/psych 2.54 0.86 1.02 0.86 1.02 0.25 XXXCMS-1503-P1032**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**70557 C Mri brain w/o dye 0.00 0.00 0.00 NA NA 0.00 XXX70557 TC C Mri brain w/o dye 0.00 0.00 0.00 NA NA 0.00 XXX70557 26 A Mri brain w/o dye 2.90 1.59 1.48 1.59 1.48 1.09 XXX70558 C Mri brain w/dye 0.00 0.00 0.00 NA NA 0.00 XXX70558 TC C Mri brain w/dye 0.00 0.00 0.00 NA NA 0.00 XXX70558 26 A Mri brain w/dye 3.20 1.12 1.28 1.12 1.28 0.31 XXX70559 C Mri brain w/o & w/dye 0.00 0.00 0.00 NA NA 0.00 XXX70559 TC C Mri brain w/o & w/dye 0.00 0.00 0.00 NA NA 0.00 XXX70559 26 A Mri brain w/o & w/dye 3.20 1.16 1.33 1.16 1.33 0.31 XXX71010 A Chest x-ray 0.18 0.45 0.49 NA NA 0.02 XXX71010 TC A Chest x-ray 0.00 0.38 0.42 NA NA 0.01 XXX71010 26 A Chest x-ray 0.18 0.07 0.07 0.07 0.07 0.01 XXX71015 A Chest x-ray 0.21 0.60 0.64 NA NA 0.02 XXX71015 TC A Chest x-ray 0.00 0.52 0.56 NA NA 0.01 XXX71015 26 A Chest x-ray 0.21 0.08 0.08 0.08 0.08 0.01 XXX71020 A Chest x-ray 0.22 0.59 0.66 NA NA 0.02 XXX71020 TC A Chest x-ray 0.00 0.51 0.57 NA NA 0.01 XXX71020 26 A Chest x-ray 0.22 0.08 0.09 0.08 0.09 0.01 XXX71021 A Chest x-ray 0.27 0.78 0.83 NA NA 0.02 XXX71021 TC A Chest x-ray 0.00 0.66 0.72 NA NA 0.01 XXX71021 26 A Chest x-ray 0.27 0.12 0.11 0.12 0.11 0.01 XXX71022 A Chest x-ray 0.31 0.96 1.03 NA NA 0.02 XXX71022 TC A Chest x-ray 0.00 0.84 0.90 NA NA 0.01 XXX71022 26 A Chest x-ray 0.31 0.12 0.13 0.12 0.13 0.01 XXX71023 A Chest x-ray and fluoroscopy 0.38 1.56 1.61 NA NA 0.02 XXX71023 TC A Chest x-ray and fluoroscopy 0.00 1.41 1.45 NA NA 0.01 XXXCMS-1503-P1033**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**71023 26 A Chest x-ray and fluoroscopy 0.38 0.15 0.16 0.15 0.16 0.01 XXX71030 A Chest x-ray 0.31 0.92 1.00 NA NA 0.02 XXX71030 TC A Chest x-ray 0.00 0.81 0.88 NA NA 0.01 XXX71030 26 A Chest x-ray 0.31 0.11 0.12 0.11 0.12 0.01 XXX71034 A Chest x-ray and fluoroscopy 0.46 1.85 2.10 NA NA 0.02 XXX71034 TC A Chest x-ray and fluoroscopy 0.00 1.68 1.89 NA NA 0.01 XXX71034 26 A Chest x-ray and fluoroscopy 0.46 0.17 0.21 0.17 0.21 0.01 XXX71035 A Chest x-ray 0.18 0.77 0.82 NA NA 0.02 XXX71035 TC A Chest x-ray 0.00 0.71 0.75 NA NA 0.01 XXX71035 26 A Chest x-ray 0.18 0.06 0.07 0.06 0.07 0.01 XXX71040 A Contrast x-ray of bronchi 0.58 2.06 2.20 NA NA 0.02 XXX71040 TC A Contrast x-ray of bronchi 0.00 1.86 1.97 NA NA 0.01 XXX71040 26 A Contrast x-ray of bronchi 0.58 0.20 0.23 0.20 0.23 0.01 XXX71060 A Contrast x-ray of bronchi 0.74 3.06 3.29 NA NA 0.05 XXX71060 TC A Contrast x-ray of bronchi 0.00 2.80 3.00 NA NA 0.01 XXX71060 26 A Contrast x-ray of bronchi 0.74 0.26 0.29 0.26 0.29 0.04 XXX71090 C X-ray & pacemaker insertion 0.00 0.00 0.00 NA NA 0.00 XXX71090 TC C X-ray & pacemaker insertion 0.00 0.00 0.00 NA NA 0.00 XXX71090 26 A X-ray & pacemaker insertion 0.54 0.21 0.26 0.21 0.26 0.04 XXX71100 A X-ray exam of ribs 0.22 0.67 0.71 NA NA 0.02 XXX71100 TC A X-ray exam of ribs 0.00 0.58 0.62 NA NA 0.01 XXX71100 26 A X-ray exam of ribs 0.22 0.09 0.09 0.09 0.09 0.01 XXX71101 A X-ray exam of ribs/chest 0.27 0.80 0.86 NA NA 0.02 XXX71101 TC A X-ray exam of ribs/chest 0.00 0.70 0.75 NA NA 0.01 XXX71101 26 A X-ray exam of ribs/chest 0.27 0.10 0.11 0.10 0.11 0.01 XXX71110 A X-ray exam of ribs 0.27 0.85 0.90 NA NA 0.02 XXXCMS-1503-P1034**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**71110 TC A X-ray exam of ribs 0.00 0.74 0.79 NA NA 0.01 XXX71110 26 A X-ray exam of ribs 0.27 0.11 0.11 0.11 0.11 0.01 XXX71111 A X-ray exam of ribs/chest 0.32 1.15 1.20 NA NA 0.02 XXX71111 TC A X-ray exam of ribs/chest 0.00 1.02 1.07 NA NA 0.01 XXX71111 26 A X-ray exam of ribs/chest 0.32 0.13 0.13 0.13 0.13 0.01 XXX71120 A X-ray exam of breastbone 0.20 0.64 0.71 NA NA 0.02 XXX71120 TC A X-ray exam of breastbone 0.00 0.57 0.63 NA NA 0.01 XXX71120 26 A X-ray exam of breastbone 0.20 0.07 0.08 0.07 0.08 0.01 XXX71130 A X-ray exam of breastbone 0.22 0.79 0.85 NA NA 0.02 XXX71130 TC A X-ray exam of breastbone 0.00 0.70 0.76 NA NA 0.01 XXX71130 26 A X-ray exam of breastbone 0.22 0.09 0.09 0.09 0.09 0.01 XXX71250 A Ct thorax w/o dye 1.16 4.81 6.23 NA NA 0.08 XXX71250 TC A Ct thorax w/o dye 0.00 4.40 5.77 NA NA 0.01 XXX71250 26 A Ct thorax w/o dye 1.16 0.41 0.46 0.41 0.46 0.07 XXX71260 A Ct thorax w/dye 1.24 5.98 7.68 NA NA 0.08 XXX71260 TC A Ct thorax w/dye 0.00 5.54 7.18 NA NA 0.01 XXX71260 26 A Ct thorax w/dye 1.24 0.44 0.50 0.44 0.50 0.07 XXX71270 A Ct thorax w/o & w/dye 1.38 7.41 9.60 NA NA 0.08 XXX71270 TC A Ct thorax w/o & w/dye 0.00 6.93 9.05 NA NA 0.01 XXX71270 26 A Ct thorax w/o & w/dye 1.38 0.48 0.55 0.48 0.55 0.07 XXX71275 A Ct angiography, chest 1.92 9.04 11.72 NA NA 0.12 XXX71275 TC A Ct angiography, chest 0.00 8.37 10.95 NA NA 0.01 XXX71275 26 A Ct angiography, chest 1.92 0.67 0.77 0.67 0.77 0.11 XXX71550 A Mri chest w/o dye 1.46 11.56 14.81 NA NA 0.09 XXX71550 TC A Mri chest w/o dye 0.00 11.05 14.24 NA NA 0.01 XXX71550 26 A Mri chest w/o dye 1.46 0.51 0.57 0.51 0.57 0.08 XXXCMS-1503-P1035**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**71551 A Mri chest w/dye 1.73 13.10 16.62 NA NA 0.11 XXX71551 TC A Mri chest w/dye 0.00 12.49 15.94 NA NA 0.01 XXX71551 26 A Mri chest w/dye 1.73 0.61 0.68 0.61 0.68 0.10 XXX71552 A Mri chest w/o & w/dye 2.26 16.05 21.90 NA NA 0.14 XXX71552 TC A Mri chest w/o & w/dye 0.00 15.26 21.00 NA NA 0.01 XXX71552 26 A Mri chest w/o & w/dye 2.26 0.79 0.90 0.79 0.90 0.13 XXX71555 R Mri angio chest w or w/o dye 1.81 11.18 14.18 NA NA 0.11 XXX71555 TC R Mri angio chest w or w/o dye 0.00 10.54 13.44 NA NA 0.01 XXX71555 26 R Mri angio chest w or w/o dye 1.81 0.64 0.74 0.64 0.74 0.10 XXX72010 A X-ray exam of spine 0.45 1.71 1.67 NA NA 0.04 XXX72010 TC A X-ray exam of spine 0.00 1.51 1.49 NA NA 0.01 XXX72010 26 A X-ray exam of spine 0.45 0.20 0.18 0.20 0.18 0.03 XXX72020 A X-ray exam of spine 0.15 0.48 0.52 NA NA 0.02 XXX72020 TC A X-ray exam of spine 0.00 0.42 0.46 NA NA 0.01 XXX72020 26 A X-ray exam of spine 0.15 0.06 0.06 0.06 0.06 0.01 XXX72040 A X-ray exam of neck spine 0.22 0.86 0.88 NA NA 0.04 XXX72040 TC A X-ray exam of neck spine 0.00 0.76 0.78 NA NA 0.01 XXX72040 26 A X-ray exam of neck spine 0.22 0.10 0.10 0.10 0.10 0.03 XXX72050 A X-ray exam of neck spine 0.31 1.12 1.19 NA NA 0.04 XXX72050 TC A X-ray exam of neck spine 0.00 1.00 1.06 NA NA 0.01 XXX72050 26 A X-ray exam of neck spine 0.31 0.12 0.13 0.12 0.13 0.03 XXX72052 A X-ray exam of neck spine 0.36 1.48 1.55 NA NA 0.04 XXX72052 TC A X-ray exam of neck spine 0.00 1.34 1.40 NA NA 0.01 XXX72052 26 A X-ray exam of neck spine 0.36 0.14 0.15 0.14 0.15 0.03 XXX72069 A X-ray exam of trunk spine 0.22 0.81 0.82 NA NA 0.04 XXX72069 TC A X-ray exam of trunk spine 0.00 0.72 0.73 NA NA 0.01 XXXCMS-1503-P1036**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**72069 26 A X-ray exam of trunk spine 0.22 0.09 0.09 0.09 0.09 0.03 XXX72070 A X-ray exam of thoracic spine 0.22 0.70 0.74 NA NA 0.02 XXX72070 TC A X-ray exam of thoracic spine 0.00 0.61 0.65 NA NA 0.01 XXX72070 26 A X-ray exam of thoracic spine 0.22 0.09 0.09 0.09 0.09 0.01 XXX72072 A X-ray exam of thoracic spine 0.22 0.78 0.86 NA NA 0.02 XXX72072 TC A X-ray exam of thoracic spine 0.00 0.70 0.77 NA NA 0.01 XXX72072 26 A X-ray exam of thoracic spine 0.22 0.08 0.09 0.08 0.09 0.01 XXX72074 A X-ray exam of thoracic spine 0.22 0.96 1.05 NA NA 0.02 XXX72074 TC A X-ray exam of thoracic spine 0.00 0.88 0.96 NA NA 0.01 XXX72074 26 A X-ray exam of thoracic spine 0.22 0.08 0.09 0.08 0.09 0.01 XXX72080 A X-ray exam of trunk spine 0.22 0.78 0.81 NA NA 0.04 XXX72080 TC A X-ray exam of trunk spine 0.00 0.68 0.71 NA NA 0.01 XXX72080 26 A X-ray exam of trunk spine 0.22 0.10 0.10 0.10 0.10 0.03 XXX72090 A X-ray exam of trunk spine 0.28 1.10 1.12 NA NA 0.05 XXX72090 TC A X-ray exam of trunk spine 0.00 0.98 0.99 NA NA 0.01 XXX72090 26 A X-ray exam of trunk spine 0.28 0.12 0.13 0.12 0.13 0.04 XXX72100 A X-ray exam of lower spine 0.22 0.91 0.93 NA NA 0.04 XXX72100 TC A X-ray exam of lower spine 0.00 0.81 0.83 NA NA 0.01 XXX72100 26 A X-ray exam of lower spine 0.22 0.10 0.10 0.10 0.10 0.03 XXX72110 A X-ray exam of lower spine 0.31 1.20 1.27 NA NA 0.04 XXX72110 TC A X-ray exam of lower spine 0.00 1.08 1.14 NA NA 0.01 XXX72110 26 A X-ray exam of lower spine 0.31 0.12 0.13 0.12 0.13 0.03 XXX72114 A X-ray exam of lower spine 0.36 1.71 1.76 NA NA 0.05 XXX72114 TC A X-ray exam of lower spine 0.00 1.56 1.60 NA NA 0.01 XXX72114 26 A X-ray exam of lower spine 0.36 0.15 0.16 0.15 0.16 0.04 XXX72120 A X-ray exam of lower spine 0.22 1.24 1.25 NA NA 0.04 XXXCMS-1503-P1037**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**72120 TC A X-ray exam of lower spine 0.00 1.14 1.15 NA NA 0.01 XXX72120 26 A X-ray exam of lower spine 0.22 0.10 0.10 0.10 0.10 0.03 XXX72125 A Ct neck spine w/o dye 1.16 4.85 6.27 NA NA 0.08 XXX72125 TC A Ct neck spine w/o dye 0.00 4.45 5.81 NA NA 0.01 XXX72125 26 A Ct neck spine w/o dye 1.16 0.40 0.46 0.40 0.46 0.07 XXX72126 A Ct neck spine w/dye 1.22 5.99 7.68 NA NA 0.08 XXX72126 TC A Ct neck spine w/dye 0.00 5.56 7.20 NA NA 0.01 XXX72126 26 A Ct neck spine w/dye 1.22 0.43 0.48 0.43 0.48 0.07 XXX72127 A Ct neck spine w/o & w/dye 1.27 7.38 9.54 NA NA 0.08 XXX72127 TC A Ct neck spine w/o & w/dye 0.00 6.94 9.04 NA NA 0.01 XXX72127 26 A Ct neck spine w/o & w/dye 1.27 0.44 0.50 0.44 0.50 0.07 XXX72128 A Ct chest spine w/o dye 1.16 4.85 6.25 NA NA 0.08 XXX72128 TC A Ct chest spine w/o dye 0.00 4.44 5.79 NA NA 0.01 XXX72128 26 A Ct chest spine w/o dye 1.16 0.41 0.46 0.41 0.46 0.07 XXX72129 A Ct chest spine w/dye 1.22 6.01 7.70 NA NA 0.08 XXX72129 TC A Ct chest spine w/dye 0.00 5.58 7.21 NA NA 0.01 XXX72129 26 A Ct chest spine w/dye 1.22 0.43 0.49 0.43 0.49 0.07 XXX72130 A Ct chest spine w/o & w/dye 1.27 7.39 9.55 NA NA 0.08 XXX72130 TC A Ct chest spine w/o & w/dye 0.00 6.95 9.05 NA NA 0.01 XXX72130 26 A Ct chest spine w/o & w/dye 1.27 0.44 0.50 0.44 0.50 0.07 XXX72131 A Ct lumbar spine w/o dye 1.16 4.83 6.24 NA NA 0.08 XXX72131 TC A Ct lumbar spine w/o dye 0.00 4.42 5.78 NA NA 0.01 XXX72131 26 A Ct lumbar spine w/o dye 1.16 0.41 0.46 0.41 0.46 0.07 XXX72132 A Ct lumbar spine w/dye 1.22 5.97 7.68 NA NA 0.08 XXX72132 TC A Ct lumbar spine w/dye 0.00 5.55 7.19 NA NA 0.01 XXX72132 26 A Ct lumbar spine w/dye 1.22 0.42 0.49 0.42 0.49 0.07 XXXCMS-1503-P1038**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**72133 A Ct lumbar spine w/o & w/dye 1.27 7.38 9.54 NA NA 0.08 XXX72133 TC A Ct lumbar spine w/o & w/dye 0.00 6.94 9.04 NA NA 0.01 XXX72133 26 A Ct lumbar spine w/o & w/dye 1.27 0.44 0.50 0.44 0.50 0.07 XXX72141 A Mri neck spine w/o dye 1.60 9.00 11.82 NA NA 0.11 XXX72141 TC A Mri neck spine w/o dye 0.00 8.43 11.19 NA NA 0.01 XXX72141 26 A Mri neck spine w/o dye 1.60 0.57 0.63 0.57 0.63 0.10 XXX72142 A Mri neck spine w/dye 1.92 11.59 14.88 NA NA 0.12 XXX72142 TC A Mri neck spine w/dye 0.00 10.90 14.11 NA NA 0.01 XXX72142 26 A Mri neck spine w/dye 1.92 0.69 0.77 0.69 0.77 0.11 XXX72146 A Mri chest spine w/o dye 1.60 9.01 12.02 NA NA 0.11 XXX72146 TC A Mri chest spine w/o dye 0.00 8.44 11.38 NA NA 0.01 XXX72146 26 A Mri chest spine w/o dye 1.60 0.57 0.64 0.57 0.64 0.10 XXX72147 A Mri chest spine w/dye 1.92 10.08 13.22 NA NA 0.12 XXX72147 TC A Mri chest spine w/dye 0.00 9.40 12.45 NA NA 0.01 XXX72147 26 A Mri chest spine w/dye 1.92 0.68 0.77 0.68 0.77 0.11 XXX72148 A Mri lumbar spine w/o dye 1.48 8.96 11.96 NA NA 0.11 XXX72148 TC A Mri lumbar spine w/o dye 0.00 8.43 11.37 NA NA 0.01 XXX72148 26 A Mri lumbar spine w/o dye 1.48 0.53 0.59 0.53 0.59 0.10 XXX72149 A Mri lumbar spine w/dye 1.78 11.38 14.74 NA NA 0.12 XXX72149 TC A Mri lumbar spine w/dye 0.00 10.74 14.02 NA NA 0.01 XXX72149 26 A Mri lumbar spine w/dye 1.78 0.64 0.72 0.64 0.72 0.11 XXX72156 A Mri neck spine w/o & w/dye 2.57 13.00 18.29 NA NA 0.18 XXX72156 TC A Mri neck spine w/o & w/dye 0.00 12.09 17.27 NA NA 0.01 XXX72156 26 A Mri neck spine w/o & w/dye 2.57 0.91 1.02 0.91 1.02 0.17 XXX72157 A Mri chest spine w/o & w/dye 2.57 11.91 17.04 NA NA 0.18 XXX72157 TC A Mri chest spine w/o & w/dye 0.00 11.01 16.02 NA NA 0.01 XXXCMS-1503-P1039**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**72157 26 A Mri chest spine w/o & w/dye 2.57 0.90 1.02 0.90 1.02 0.17 XXX72158 A Mri lumbar spine w/o & w/dye 2.36 12.89 18.18 NA NA 0.18 XXX72158 TC A Mri lumbar spine w/o & w/dye 0.00 12.05 17.24 NA NA 0.01 XXX72158 26 A Mri lumbar spine w/o & w/dye 2.36 0.84 0.94 0.84 0.94 0.17 XXX72159 N Mr angio spine w/o&w/dye 1.80 13.41 15.99 NA NA 0.08 XXX72159 TC N Mr angio spine w/o&w/dye 0.00 12.63 15.22 NA NA 0.01 XXX72159 26 N Mr angio spine w/o&w/dye 1.80 0.78 0.77 0.78 0.77 0.07 XXX72170 A X-ray exam of pelvis 0.17 0.55 0.58 NA NA 0.04 XXX72170 TC A X-ray exam of pelvis 0.00 0.48 0.51 NA NA 0.01 XXX72170 26 A X-ray exam of pelvis 0.17 0.07 0.07 0.07 0.07 0.03 XXX72190 A X-ray exam of pelvis 0.21 0.95 0.97 NA NA 0.04 XXX72190 TC A X-ray exam of pelvis 0.00 0.86 0.88 NA NA 0.01 XXX72190 26 A X-ray exam of pelvis 0.21 0.09 0.09 0.09 0.09 0.03 XXX72191 A Ct angiograph pelv w/o&w/dye 1.81 8.61 11.26 NA NA 0.14 XXX72191 TC A Ct angiograph pelv w/o&w/dye 0.00 7.98 10.54 NA NA 0.01 XXX72191 26 A Ct angiograph pelv w/o&w/dye 1.81 0.63 0.72 0.63 0.72 0.13 XXX72192 A Ct pelvis w/o dye 1.09 4.49 5.89 NA NA 0.07 XXX72192 TC A Ct pelvis w/o dye 0.00 4.11 5.45 NA NA 0.01 XXX72192 26 A Ct pelvis w/o dye 1.09 0.38 0.44 0.38 0.44 0.06 XXX72193 A Ct pelvis w/dye 1.16 5.63 7.27 NA NA 0.08 XXX72193 TC A Ct pelvis w/dye 0.00 5.22 6.81 NA NA 0.01 XXX72193 26 A Ct pelvis w/dye 1.16 0.41 0.46 0.41 0.46 0.07 XXX72194 A Ct pelvis w/o & w/dye 1.22 7.47 9.60 NA NA 0.08 XXX72194 TC A Ct pelvis w/o & w/dye 0.00 7.04 9.11 NA NA 0.01 XXX72194 26 A Ct pelvis w/o & w/dye 1.22 0.43 0.49 0.43 0.49 0.07 XXX72195 A Mri pelvis w/o dye 1.46 10.31 13.34 NA NA 0.11 XXXCMS-1503-P1040**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**72195 TC A Mri pelvis w/o dye 0.00 9.79 12.76 NA NA 0.01 XXX72195 26 A Mri pelvis w/o dye 1.46 0.52 0.58 0.52 0.58 0.10 XXX72196 A Mri pelvis w/dye 1.73 11.32 14.64 NA NA 0.11 XXX72196 TC A Mri pelvis w/dye 0.00 10.71 13.95 NA NA 0.01 XXX72196 26 A Mri pelvis w/dye 1.73 0.61 0.69 0.61 0.69 0.10 XXX72197 A Mri pelvis w/o & w/dye 2.26 13.64 19.11 NA NA 0.14 XXX72197 TC A Mri pelvis w/o & w/dye 0.00 12.86 18.22 NA NA 0.01 XXX72197 26 A Mri pelvis w/o & w/dye 2.26 0.78 0.89 0.78 0.89 0.13 XXX72198 A Mr angio pelvis w/o & w/dye 1.80 11.12 14.08 NA NA 0.11 XXX72198 TC A Mr angio pelvis w/o & w/dye 0.00 10.50 13.37 NA NA 0.01 XXX72198 26 A Mr angio pelvis w/o & w/dye 1.80 0.62 0.71 0.62 0.71 0.10 XXX72200 A X-ray exam sacroiliac joints 0.17 0.63 0.67 NA NA 0.02 XXX72200 TC A X-ray exam sacroiliac joints 0.00 0.56 0.60 NA NA 0.01 XXX72200 26 A X-ray exam sacroiliac joints 0.17 0.07 0.07 0.07 0.07 0.01 XXX72202 A X-ray exam sacroiliac joints 0.19 0.74 0.80 NA NA 0.02 XXX72202 TC A X-ray exam sacroiliac joints 0.00 0.67 0.72 NA NA 0.01 XXX72202 26 A X-ray exam sacroiliac joints 0.19 0.07 0.08 0.07 0.08 0.01 XXX72220 A X-ray exam of tailbone 0.17 0.62 0.66 NA NA 0.02 XXX72220 TC A X-ray exam of tailbone 0.00 0.55 0.59 NA NA 0.01 XXX72220 26 A X-ray exam of tailbone 0.17 0.07 0.07 0.07 0.07 0.01 XXX72240 A Contrast x-ray of neck spine 0.91 2.62 3.22 NA NA 0.07 XXX72240 TC A Contrast x-ray of neck spine 0.00 2.29 2.86 NA NA 0.01 XXX72240 26 A Contrast x-ray of neck spine 0.91 0.33 0.36 0.33 0.36 0.06 XXX72255 A Contrast x-ray, thorax spine 0.91 2.55 2.99 NA NA 0.05 XXX72255 TC A Contrast x-ray, thorax spine 0.00 2.20 2.63 NA NA 0.01 XXX72255 26 A Contrast x-ray, thorax spine 0.91 0.35 0.36 0.35 0.36 0.04 XXXCMS-1503-P1041**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**72265 A Contrast x-ray, lower spine 0.83 2.63 3.11 NA NA 0.05 XXX72265 TC A Contrast x-ray, lower spine 0.00 2.32 2.78 NA NA 0.01 XXX72265 26 A Contrast x-ray, lower spine 0.83 0.31 0.33 0.31 0.33 0.04 XXX72270 A Contrast x-ray, spine 1.33 4.06 4.81 NA NA 0.08 XXX72270 TC A Contrast x-ray, spine 0.00 3.58 4.28 NA NA 0.01 XXX72270 26 A Contrast x-ray, spine 1.33 0.48 0.53 0.48 0.53 0.07 XXX72275 A Epidurography 0.76 2.65 2.46 NA NA 0.05 XXX72275 TC A Epidurography 0.00 2.27 2.14 NA NA 0.01 XXX72275 26 A Epidurography 0.76 0.38 0.32 0.38 0.32 0.04 XXX72285 A X-ray c/t spine disk 1.16 2.23 3.09 NA NA 0.07 XXX72285 TC A X-ray c/t spine disk 0.00 1.63 2.59 NA NA 0.01 XXX72285 26 A X-ray c/t spine disk 1.16 0.60 0.50 0.60 0.50 0.06 XXX72291 C Perq verte/sacroplsty, fluor 0.00 0.00 0.00 NA NA 0.00 XXX72291 TC C Perq verte/sacroplsty, fluor 0.00 0.00 0.00 NA NA 0.00 XXX72291 26 A Perq verte/sacroplsty,fluor 1.31 0.57 0.59 0.57 0.59 0.23 XXX72292 C Perq verte/sacroplsty,ct 0.00 0.00 0.00 NA NA 0.00 XXX72292 TC C Perq verte/sacroplsty,ct 0.00 0.00 0.00 NA NA 0.00 XXX72292 26 A Perq verte/sacroplsty,ct 1.38 0.56 0.60 0.56 0.60 0.21 XXX72295 A X-ray of lower spine disk 0.83 2.09 2.92 NA NA 0.05 XXX72295 TC A X-ray of lower spine disk 0.00 1.67 2.55 NA NA 0.01 XXX72295 26 A X-ray of lower spine disk 0.83 0.42 0.37 0.42 0.37 0.04 XXX73000 A X-ray exam of collar bone 0.16 0.63 0.65 NA NA 0.02 XXX73000 TC A X-ray exam of collar bone 0.00 0.56 0.58 NA NA 0.01 XXX73000 26 A X-ray exam of collar bone 0.16 0.07 0.07 0.07 0.07 0.01 XXX73010 A X-ray exam of shoulder blade 0.17 0.69 0.69 NA NA 0.04 XXX73010 TC A X-ray exam of shoulder blade 0.00 0.61 0.61 NA NA 0.01 XXXCMS-1503-P1042**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**73010 26 A X-ray exam of shoulder blade 0.17 0.08 0.08 0.08 0.08 0.03 XXX73020 A X-ray exam of shoulder 0.15 0.50 0.52 NA NA 0.02 XXX73020 TC A X-ray exam of shoulder 0.00 0.43 0.46 NA NA 0.01 XXX73020 26 A X-ray exam of shoulder 0.15 0.07 0.06 0.07 0.06 0.01 XXX73030 A X-ray exam of shoulder 0.18 0.65 0.68 NA NA 0.04 XXX73030 TC A X-ray exam of shoulder 0.00 0.57 0.60 NA NA 0.01 XXX73030 26 A X-ray exam of shoulder 0.18 0.08 0.08 0.08 0.08 0.03 XXX73040 A Contrast x-ray of shoulder 0.54 2.37 2.55 NA NA 0.05 XXX73040 TC A Contrast x-ray of shoulder 0.00 2.16 2.32 NA NA 0.01 XXX73040 26 A Contrast x-ray of shoulder 0.54 0.21 0.23 0.21 0.23 0.04 XXX73050 A X-ray exam of shoulders 0.20 0.89 0.89 NA NA 0.04 XXX73050 TC A X-ray exam of shoulders 0.00 0.79 0.79 NA NA 0.01 XXX73050 26 A X-ray exam of shoulders 0.20 0.10 0.10 0.10 0.10 0.03 XXX73060 A X-ray exam of humerus 0.17 0.64 0.66 NA NA 0.02 XXX73060 TC A X-ray exam of humerus 0.00 0.56 0.59 NA NA 0.01 XXX73060 26 A X-ray exam of humerus 0.17 0.08 0.07 0.08 0.07 0.01 XXX73070 A X-ray exam of elbow 0.15 0.64 0.66 NA NA 0.02 XXX73070 TC A X-ray exam of elbow 0.00 0.57 0.59 NA NA 0.01 XXX73070 26 A X-ray exam of elbow 0.15 0.07 0.07 0.07 0.07 0.01 XXX73080 A X-ray exam of elbow 0.17 0.82 0.84 NA NA 0.02 XXX73080 TC A X-ray exam of elbow 0.00 0.75 0.77 NA NA 0.01 XXX73080 26 A X-ray exam of elbow 0.17 0.07 0.07 0.07 0.07 0.01 XXX73085 A Contrast x-ray of elbow 0.54 2.14 2.26 NA NA 0.04 XXX73085 TC A Contrast x-ray of elbow 0.00 1.90 2.02 NA NA 0.01 XXX73085 26 A Contrast x-ray of elbow 0.54 0.24 0.24 0.24 0.24 0.03 XXX73090 A X-ray exam of forearm 0.16 0.61 0.63 NA NA 0.02 XXXCMS-1503-P1043**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**73090 TC A X-ray exam of forearm 0.00 0.54 0.57 NA NA 0.01 XXX73090 26 A X-ray exam of forearm 0.16 0.07 0.06 0.07 0.06 0.01 XXX73092 A X-ray exam of arm, infant 0.16 0.74 0.72 NA NA 0.02 XXX73092 TC A X-ray exam of arm, infant 0.00 0.67 0.65 NA NA 0.01 XXX73092 26 A X-ray exam of arm, infant 0.16 0.07 0.07 0.07 0.07 0.01 XXX73100 A X-ray exam of wrist 0.16 0.71 0.71 NA NA 0.04 XXX73100 TC A X-ray exam of wrist 0.00 0.63 0.63 NA NA 0.01 XXX73100 26 A X-ray exam of wrist 0.16 0.08 0.08 0.08 0.08 0.03 XXX73110 A X-ray exam of wrist 0.17 0.87 0.86 NA NA 0.02 XXX73110 TC A X-ray exam of wrist 0.00 0.79 0.79 NA NA 0.01 XXX73110 26 A X-ray exam of wrist 0.17 0.08 0.07 0.08 0.07 0.01 XXX73115 A Contrast x-ray of wrist 0.54 2.57 2.57 NA NA 0.05 XXX73115 TC A Contrast x-ray of wrist 0.00 2.33 2.33 NA NA 0.01 XXX73115 26 A Contrast x-ray of wrist 0.54 0.24 0.24 0.24 0.24 0.04 XXX73120 A X-ray exam of hand 0.16 0.61 0.63 NA NA 0.02 XXX73120 TC A X-ray exam of hand 0.00 0.54 0.56 NA NA 0.01 XXX73120 26 A X-ray exam of hand 0.16 0.07 0.07 0.07 0.07 0.01 XXX73130 A X-ray exam of hand 0.17 0.72 0.74 NA NA 0.02 XXX73130 TC A X-ray exam of hand 0.00 0.65 0.67 NA NA 0.01 XXX73130 26 A X-ray exam of hand 0.17 0.07 0.07 0.07 0.07 0.01 XXX73140 A X-ray exam of finger(s) 0.13 0.79 0.77 NA NA 0.02 XXX73140 TC A X-ray exam of finger(s) 0.00 0.73 0.71 NA NA 0.01 XXX73140 26 A X-ray exam of finger(s) 0.13 0.06 0.06 0.06 0.06 0.01 XXX73200 A Ct upper extremity w/o dye 1.09 4.77 6.04 NA NA 0.08 XXX73200 TC A Ct upper extremity w/o dye 0.00 4.39 5.61 NA NA 0.01 XXX73200 26 A Ct upper extremity w/o dye 1.09 0.38 0.43 0.38 0.43 0.07 XXXCMS-1503-P1044**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**73201 A Ct upper extremity w/dye 1.16 5.92 7.43 NA NA 0.08 XXX73201 TC A Ct upper extremity w/dye 0.00 5.51 6.97 NA NA 0.01 XXX73201 26 A Ct upper extremity w/dye 1.16 0.41 0.46 0.41 0.46 0.07 XXX73202 A Ct uppr extremity w/o&w/dye 1.22 7.80 9.80 NA NA 0.08 XXX73202 TC A Ct uppr extremity w/o&w/dye 0.00 7.37 9.32 NA NA 0.01 XXX73202 26 A Ct uppr extremity w/o&w/dye 1.22 0.43 0.48 0.43 0.48 0.07 XXX73206 A Ct angio upr extrm w/o&w/dye 1.81 8.19 10.70 NA NA 0.09 XXX73206 TC A Ct angio upr extrm w/o&w/dye 0.00 7.55 9.96 NA NA 0.01 XXX73206 26 A Ct angio upr extrm w/o&w/dye 1.81 0.64 0.74 0.64 0.74 0.08 XXX73218 A Mri upper extremity w/o dye 1.35 10.66 13.60 NA NA 0.08 XXX73218 TC A Mri upper extremity w/o dye 0.00 10.15 13.06 NA NA 0.01 XXX73218 26 A Mri upper extremity w/o dye 1.35 0.51 0.54 0.51 0.54 0.07 XXX73219 A Mri upper extremity w/dye 1.62 11.04 14.50 NA NA 0.11 XXX73219 TC A Mri upper extremity w/dye 0.00 10.46 13.86 NA NA 0.01 XXX73219 26 A Mri upper extremity w/dye 1.62 0.58 0.64 0.58 0.64 0.10 XXX73220 A Mri uppr extremity w/o&w/dye 2.15 13.70 19.16 NA NA 0.14 XXX73220 TC A Mri uppr extremity w/o&w/dye 0.00 12.94 18.31 NA NA 0.01 XXX73220 26 A Mri uppr extremity w/o&w/dye 2.15 0.76 0.85 0.76 0.85 0.13 XXX73221 A Mri joint upr extrem w/o dye 1.35 9.81 12.68 NA NA 0.11 XXX73221 TC A Mri joint upr extrem w/o dye 0.00 9.30 12.13 NA NA 0.01 XXX73221 26 A Mri joint upr extrem w/o dye 1.35 0.51 0.55 0.51 0.55 0.10 XXX73222 A Mri joint upr extrem w/dye 1.62 10.39 13.67 NA NA 0.11 XXX73222 TC A Mri joint upr extrem w/dye 0.00 9.81 13.03 NA NA 0.01 XXX73222 26 A Mri joint upr extrem w/dye 1.62 0.58 0.64 0.58 0.64 0.10 XXX73223 A Mri joint upr extr w/o&w/dye 2.15 12.79 18.09 NA NA 0.14 XXX73223 TC A Mri joint upr extr w/o&w/dye 0.00 12.02 17.24 NA NA 0.01 XXXCMS-1503-P1045**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**73223 26 A Mri joint upr extr w/o&w/dye 2.15 0.77 0.85 0.77 0.85 0.13 XXX73225 N Mr angio upr extr w/o&w/dye 1.73 13.38 15.78 NA NA 0.08 XXX73225 TC N Mr angio upr extr w/o&w/dye 0.00 12.63 15.04 NA NA 0.01 XXX73225 26 N Mr angio upr extr w/o&w/dye 1.73 0.75 0.74 0.75 0.74 0.07 XXX73500 A X-ray exam of hip 0.17 0.56 0.58 NA NA 0.04 XXX73500 TC A X-ray exam of hip 0.00 0.48 0.50 NA NA 0.01 XXX73500 26 A X-ray exam of hip 0.17 0.08 0.08 0.08 0.08 0.03 XXX73510 A X-ray exam of hip 0.21 0.86 0.88 NA NA 0.04 XXX73510 TC A X-ray exam of hip 0.00 0.77 0.78 NA NA 0.01 XXX73510 26 A X-ray exam of hip 0.21 0.09 0.10 0.09 0.10 0.03 XXX73520 A X-ray exam of hips 0.26 0.87 0.90 NA NA 0.04 XXX73520 TC A X-ray exam of hips 0.00 0.75 0.79 NA NA 0.01 XXX73520 26 A X-ray exam of hips 0.26 0.12 0.11 0.12 0.11 0.03 XXX73525 A Contrast x-ray of hip 0.54 2.31 2.34 NA NA 0.05 XXX73525 TC A Contrast x-ray of hip 0.00 2.05 2.09 NA NA 0.01 XXX73525 26 A Contrast x-ray of hip 0.54 0.26 0.25 0.26 0.25 0.04 XXX73530 C X-ray exam of hip 0.00 0.00 0.00 NA NA 0.00 XXX73530 TC C X-ray exam of hip 0.00 0.00 0.00 NA NA 0.00 XXX73530 26 A X-ray exam of hip 0.29 0.10 0.12 0.10 0.12 0.03 XXX73540 A X-ray exam of pelvis & hips 0.20 1.01 0.95 NA NA 0.04 XXX73540 TC A X-ray exam of pelvis & hips 0.00 0.91 0.86 NA NA 0.01 XXX73540 26 A X-ray exam of pelvis & hips 0.20 0.10 0.09 0.10 0.09 0.03 XXX73542 A X-ray exam, sacroiliac joint 0.59 1.83 1.78 NA NA 0.04 XXX73542 TC A X-ray exam, sacroiliac joint 0.00 1.54 1.54 NA NA 0.01 XXX73542 26 A X-ray exam, sacroiliac joint 0.59 0.29 0.24 0.29 0.24 0.03 XXX73550 A X-ray exam of thigh 0.17 0.59 0.63 NA NA 0.04 XXXCMS-1503-P1046**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**73550 TC A X-ray exam of thigh 0.00 0.52 0.56 NA NA 0.01 XXX73550 26 A X-ray exam of thigh 0.17 0.07 0.07 0.07 0.07 0.03 XXX73560 A X-ray exam of knee, 1 or 2 0.17 0.67 0.68 NA NA 0.04 XXX73560 TC A X-ray exam of knee, 1 or 2 0.00 0.59 0.60 NA NA 0.01 XXX73560 26 A X-ray exam of knee, 1 or 2 0.17 0.08 0.08 0.08 0.08 0.03 XXX73562 A X-ray exam of knee, 3 0.18 0.85 0.85 NA NA 0.04 XXX73562 TC A X-ray exam of knee, 3 0.00 0.76 0.76 NA NA 0.01 XXX73562 26 A X-ray exam of knee, 3 0.18 0.09 0.09 0.09 0.09 0.03 XXX73564 A X-ray exam, knee, 4 or more 0.22 0.97 0.97 NA NA 0.04 XXX73564 TC A X-ray exam, knee, 4 or more 0.00 0.87 0.87 NA NA 0.01 XXX73564 26 A X-ray exam, knee, 4 or more 0.22 0.10 0.10 0.10 0.10 0.03 XXX73565 A X-ray exam of knees 0.17 0.81 0.78 NA NA 0.04 XXX73565 TC A X-ray exam of knees 0.00 0.72 0.69 NA NA 0.01 XXX73565 26 A X-ray exam of knees 0.17 0.09 0.09 0.09 0.09 0.03 XXX73580 A Contrast x-ray of knee joint 0.54 3.36 3.25 NA NA 0.07 XXX73580 TC A Contrast x-ray of knee joint 0.00 3.07 2.98 NA NA 0.01 XXX73580 26 A Contrast x-ray of knee joint 0.54 0.29 0.27 0.29 0.27 0.06 XXX73590 A X-ray exam of lower leg 0.17 0.59 0.62 NA NA 0.02 XXX73590 TC A X-ray exam of lower leg 0.00 0.52 0.55 NA NA 0.01 XXX73590 26 A X-ray exam of lower leg 0.17 0.07 0.07 0.07 0.07 0.01 XXX73592 A X-ray exam of leg, infant 0.16 0.77 0.73 NA NA 0.02 XXX73592 TC A X-ray exam of leg, infant 0.00 0.69 0.66 NA NA 0.01 XXX73592 26 A X-ray exam of leg, infant 0.16 0.08 0.07 0.08 0.07 0.01 XXX73600 A X-ray exam of ankle 0.16 0.64 0.65 NA NA 0.02 XXX73600 TC A X-ray exam of ankle 0.00 0.57 0.58 NA NA 0.01 XXX73600 26 A X-ray exam of ankle 0.16 0.07 0.07 0.07 0.07 0.01 XXXCMS-1503-P1047**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**73610 A X-ray exam of ankle 0.17 0.75 0.76 NA NA 0.02 XXX73610 TC A X-ray exam of ankle 0.00 0.68 0.69 NA NA 0.01 XXX73610 26 A X-ray exam of ankle 0.17 0.07 0.07 0.07 0.07 0.01 XXX73615 A Contrast x-ray of ankle 0.54 2.45 2.45 NA NA 0.05 XXX73615 TC A Contrast x-ray of ankle 0.00 2.19 2.20 NA NA 0.01 XXX73615 26 A Contrast x-ray of ankle 0.54 0.26 0.25 0.26 0.25 0.04 XXX73620 A X-ray exam of foot 0.16 0.62 0.62 NA NA 0.02 XXX73620 TC A X-ray exam of foot 0.00 0.56 0.56 NA NA 0.01 XXX73620 26 A X-ray exam of foot 0.16 0.06 0.06 0.06 0.06 0.01 XXX73630 A X-ray exam of foot 0.17 0.73 0.75 NA NA 0.02 XXX73630 TC A X-ray exam of foot 0.00 0.67 0.68 NA NA 0.01 XXX73630 26 A X-ray exam of foot 0.17 0.06 0.07 0.06 0.07 0.01 XXX73650 A X-ray exam of heel 0.16 0.64 0.63 NA NA 0.02 XXX73650 TC A X-ray exam of heel 0.00 0.57 0.57 NA NA 0.01 XXX73650 26 A X-ray exam of heel 0.16 0.07 0.06 0.07 0.06 0.01 XXX73660 A X-ray exam of toe(s) 0.13 0.71 0.70 NA NA 0.02 XXX73660 TC A X-ray exam of toe(s) 0.00 0.66 0.65 NA NA 0.01 XXX73660 26 A X-ray exam of toe(s) 0.13 0.05 0.05 0.05 0.05 0.01 XXX73700 A Ct lower extremity w/o dye 1.09 4.78 6.05 NA NA 0.08 XXX73700 TC A Ct lower extremity w/o dye 0.00 4.40 5.62 NA NA 0.01 XXX73700 26 A Ct lower extremity w/o dye 1.09 0.38 0.43 0.38 0.43 0.07 XXX73701 A Ct lower extremity w/dye 1.16 5.98 7.51 NA NA 0.08 XXX73701 TC A Ct lower extremity w/dye 0.00 5.58 7.04 NA NA 0.01 XXX73701 26 A Ct lower extremity w/dye 1.16 0.40 0.47 0.40 0.47 0.07 XXX73702 A Ct lwr extremity w/o&w/dye 1.22 7.87 9.85 NA NA 0.08 XXX73702 TC A Ct lwr extremity w/o&w/dye 0.00 7.44 9.36 NA NA 0.01 XXXCMS-1503-P1048**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**73702 26 A Ct lwr extremity w/o&w/dye 1.22 0.43 0.49 0.43 0.49 0.07 XXX73706 A Ct angio lwr extr w/o&w/dye 1.90 9.22 11.85 NA NA 0.12 XXX73706 TC A Ct angio lwr extr w/o&w/dye 0.00 8.55 11.07 NA NA 0.01 XXX73706 26 A Ct angio lwr extr w/o&w/dye 1.90 0.67 0.78 0.67 0.78 0.11 XXX73718 A Mri lower extremity w/o dye 1.35 10.31 13.27 NA NA 0.09 XXX73718 TC A Mri lower extremity w/o dye 0.00 9.83 12.73 NA NA 0.01 XXX73718 26 A Mri lower extremity w/o dye 1.35 0.48 0.54 0.48 0.54 0.08 XXX73719 A Mri lower extremity w/dye 1.62 11.13 14.44 NA NA 0.11 XXX73719 TC A Mri lower extremity w/dye 0.00 10.56 13.80 NA NA 0.01 XXX73719 26 A Mri lower extremity w/dye 1.62 0.57 0.64 0.57 0.64 0.10 XXX73720 A Mri lwr extremity w/o&w/dye 2.15 13.74 19.17 NA NA 0.14 XXX73720 TC A Mri lwr extremity w/o&w/dye 0.00 12.99 18.32 NA NA 0.01 XXX73720 26 A Mri lwr extremity w/o&w/dye 2.15 0.75 0.85 0.75 0.85 0.13 XXX73721 A Mri jnt of lwr extre w/o dye 1.35 10.05 12.96 NA NA 0.11 XXX73721 TC A Mri jnt of lwr extre w/o dye 0.00 9.55 12.41 NA NA 0.01 XXX73721 26 A Mri jnt of lwr extre w/o dye 1.35 0.50 0.55 0.50 0.55 0.10 XXX73722 A Mri joint of lwr extr w/dye 1.62 10.70 13.90 NA NA 0.12 XXX73722 TC A Mri joint of lwr extr w/dye 0.00 10.11 13.25 NA NA 0.01 XXX73722 26 A Mri joint of lwr extr w/dye 1.62 0.59 0.65 0.59 0.65 0.11 XXX73723 A Mri joint lwr extr w/o&w/dye 2.15 12.77 18.05 NA NA 0.14 XXX73723 TC A Mri joint lwr extr w/o&w/dye 0.00 12.01 17.20 NA NA 0.01 XXX73723 26 A Mri joint lwr extr w/o&w/dye 2.15 0.76 0.85 0.76 0.85 0.13 XXX73725 R Mr ang lwr ext w or w/o dye 1.82 11.15 14.10 NA NA 0.11 XXX73725 TC R Mr ang lwr ext w or w/o dye 0.00 10.52 13.38 NA NA 0.01 XXX73725 26 R Mr ang lwr ext w or w/o dye 1.82 0.63 0.72 0.63 0.72 0.10 XXX74000 A X-ray exam of abdomen 0.18 0.48 0.53 NA NA 0.02 XXXCMS-1503-P1049**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**74000 TC A X-ray exam of abdomen 0.00 0.41 0.46 NA NA 0.01 XXX74000 26 A X-ray exam of abdomen 0.18 0.07 0.07 0.07 0.07 0.01 XXX74010 A X-ray exam of abdomen 0.23 0.82 0.86 NA NA 0.02 XXX74010 TC A X-ray exam of abdomen 0.00 0.73 0.77 NA NA 0.01 XXX74010 26 A X-ray exam of abdomen 0.23 0.09 0.09 0.09 0.09 0.01 XXX74020 A X-ray exam of abdomen 0.27 0.81 0.88 NA NA 0.02 XXX74020 TC A X-ray exam of abdomen 0.00 0.71 0.77 NA NA 0.01 XXX74020 26 A X-ray exam of abdomen 0.27 0.10 0.11 0.10 0.11 0.01 XXX74022 A X-ray exam series, abdomen 0.32 0.98 1.06 NA NA 0.02 XXX74022 TC A X-ray exam series, abdomen 0.00 0.87 0.93 NA NA 0.01 XXX74022 26 A X-ray exam series, abdomen 0.32 0.11 0.13 0.11 0.13 0.01 XXX74150 A Ct abdomen w/o dye 1.19 4.53 5.89 NA NA 0.08 XXX74150 TC A Ct abdomen w/o dye 0.00 4.11 5.42 NA NA 0.01 XXX74150 26 A Ct abdomen w/o dye 1.19 0.42 0.47 0.42 0.47 0.07 XXX74160 A Ct abdomen w/dye 1.27 6.57 8.32 NA NA 0.08 XXX74160 TC A Ct abdomen w/dye 0.00 6.12 7.81 NA NA 0.01 XXX74160 26 A Ct abdomen w/dye 1.27 0.45 0.51 0.45 0.51 0.07 XXX74170 A Ct abdomen w/o & w/dye 1.40 9.02 11.29 NA NA 0.09 XXX74170 TC A Ct abdomen w/o & w/dye 0.00 8.52 10.73 NA NA 0.01 XXX74170 26 A Ct abdomen w/o & w/dye 1.40 0.50 0.56 0.50 0.56 0.08 XXX74175 A Ct angio abdom w/o & w/dye 1.90 9.22 11.99 NA NA 0.14 XXX74175 TC A Ct angio abdom w/o & w/dye 0.00 8.56 11.23 NA NA 0.01 XXX74175 26 A Ct angio abdom w/o & w/dye 1.90 0.66 0.76 0.66 0.76 0.13 XXX74181 A Mri abdomen w/o dye 1.46 8.95 11.78 NA NA 0.09 XXX74181 TC A Mri abdomen w/o dye 0.00 8.44 11.20 NA NA 0.01 XXX74181 26 A Mri abdomen w/o dye 1.46 0.51 0.58 0.51 0.58 0.08 XXXCMS-1503-P1050**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**74182 A Mri abdomen w/dye 1.73 12.63 16.17 NA NA 0.11 XXX74182 TC A Mri abdomen w/dye 0.00 12.03 15.49 NA NA 0.01 XXX74182 26 A Mri abdomen w/dye 1.73 0.60 0.68 0.60 0.68 0.10 XXX74183 A Mri abdomen w/o & w/dye 2.26 13.69 19.15 NA NA 0.14 XXX74183 TC A Mri abdomen w/o & w/dye 0.00 12.91 18.26 NA NA 0.01 XXX74183 26 A Mri abdomen w/o & w/dye 2.26 0.78 0.89 0.78 0.89 0.13 XXX74185 R Mri angio, abdom w orw/o dye 1.80 11.10 14.05 NA NA 0.11 XXX74185 TC R Mri angio, abdom w orw/o dye 0.00 10.48 13.34 NA NA 0.01 XXX74185 26 R Mri angio, abdom w orw/o dye 1.80 0.62 0.71 0.62 0.71 0.10 XXX74190 C X-ray exam of peritoneum 0.00 0.00 0.00 NA NA 0.00 XXX74190 TC C X-ray exam of peritoneum 0.00 0.00 0.00 NA NA 0.00 XXX74190 26 A X-ray exam of peritoneum 0.48 0.17 0.19 0.17 0.19 0.04 XXX74210 A Contrst x-ray exam of throat 0.36 1.77 1.88 NA NA 0.02 XXX74210 TC A Contrst x-ray exam of throat 0.00 1.64 1.73 NA NA 0.01 XXX74210 26 A Contrst x-ray exam of throat 0.36 0.13 0.15 0.13 0.15 0.01 XXX74220 A Contrast x-ray, esophagus 0.46 2.00 2.11 NA NA 0.04 XXX74220 TC A Contrast x-ray, esophagus 0.00 1.84 1.93 NA NA 0.01 XXX74220 26 A Contrast x-ray, esophagus 0.46 0.16 0.18 0.16 0.18 0.03 XXX74230 A Cine/vid x-ray, throat/esoph 0.53 1.96 2.07 NA NA 0.04 XXX74230 TC A Cine/vid x-ray, throat/esoph 0.00 1.77 1.86 NA NA 0.01 XXX74230 26 A Cine/vid x-ray, throat/esoph 0.53 0.19 0.21 0.19 0.21 0.03 XXX74235 C Remove esophagus obstruction 0.00 0.00 0.00 NA NA 0.00 XXX74235 TC C Remove esophagus obstruction 0.00 0.00 0.00 NA NA 0.00 XXX74235 26 A Remove esophagus obstruction 1.19 0.65 0.62 0.65 0.62 0.10 XXX74240 A X-ray exam, upper gi tract 0.69 2.42 2.50 NA NA 0.05 XXX74240 TC A X-ray exam, upper gi tract 0.00 2.17 2.22 NA NA 0.01 XXXCMS-1503-P1051**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**74240 26 A X-ray exam, upper gi tract 0.69 0.25 0.28 0.25 0.28 0.04 XXX74241 A X-ray exam, upper gi tract 0.69 2.58 2.70 NA NA 0.04 XXX74241 TC A X-ray exam, upper gi tract 0.00 2.34 2.43 NA NA 0.01 XXX74241 26 A X-ray exam, upper gi tract 0.69 0.24 0.27 0.24 0.27 0.03 XXX74245 A X-ray exam, upper gi tract 0.91 3.92 4.14 NA NA 0.07 XXX74245 TC A X-ray exam, upper gi tract 0.00 3.60 3.78 NA NA 0.01 XXX74245 26 A X-ray exam, upper gi tract 0.91 0.32 0.36 0.32 0.36 0.06 XXX74246 A Contrst x-ray uppr gi tract 0.69 2.78 2.93 NA NA 0.05 XXX74246 TC A Contrst x-ray uppr gi tract 0.00 2.54 2.65 NA NA 0.01 XXX74246 26 A Contrst x-ray uppr gi tract 0.69 0.24 0.28 0.24 0.28 0.04 XXX74247 A Contrst x-ray uppr gi tract 0.69 3.20 3.34 NA NA 0.05 XXX74247 TC A Contrst x-ray uppr gi tract 0.00 2.96 3.06 NA NA 0.01 XXX74247 26 A Contrst x-ray uppr gi tract 0.69 0.24 0.28 0.24 0.28 0.04 XXX74249 A Contrst x-ray uppr gi tract 0.91 4.32 4.54 NA NA 0.07 XXX74249 TC A Contrst x-ray uppr gi tract 0.00 4.00 4.18 NA NA 0.01 XXX74249 26 A Contrst x-ray uppr gi tract 0.91 0.32 0.36 0.32 0.36 0.06 XXX74250 A X-ray exam of small bowel 0.47 2.46 2.56 NA NA 0.04 XXX74250 TC A X-ray exam of small bowel 0.00 2.30 2.38 NA NA 0.01 XXX74250 26 A X-ray exam of small bowel 0.47 0.16 0.18 0.16 0.18 0.03 XXX74251 A X-ray exam of small bowel 0.69 10.09 9.76 NA NA 0.05 XXX74251 TC A X-ray exam of small bowel 0.00 9.85 9.48 NA NA 0.01 XXX74251 26 A X-ray exam of small bowel 0.69 0.24 0.28 0.24 0.28 0.04 XXX74260 A X-ray exam of small bowel 0.50 8.33 8.14 NA NA 0.04 XXX74260 TC A X-ray exam of small bowel 0.00 8.16 7.94 NA NA 0.01 XXX74260 26 A X-ray exam of small bowel 0.50 0.17 0.20 0.17 0.20 0.03 XXX74261 A Ct colonography, w/o dye 2.28 12.18 12.18 NA NA 0.14 XXXCMS-1503-P1052**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**74261 TC A Ct colonography, w/o dye 0.00 11.38 11.38 NA NA 0.01 XXX74261 26 A Ct colonography, w/o dye 2.28 0.80 0.80 0.80 0.80 0.13 XXX74262 A Ct colonography, w/dye 2.50 13.73 13.73 NA NA 0.15 XXX74262 TC A Ct colonography, w/dye 0.00 12.85 12.85 NA NA 0.01 XXX74262 26 A Ct colonography, w/dye 2.50 0.88 0.88 0.88 0.88 0.14 XXX74263 N Ct colonography, screen 2.28 19.72 19.72 NA NA 0.14 XXX74263 TC N Ct colonography, screen 0.00 18.73 18.73 NA NA 0.01 XXX74263 26 N Ct colonography, screen 2.28 0.99 0.99 0.99 0.99 0.13 XXX74270 A Contrast x-ray exam of colon 0.69 3.56 3.68 NA NA 0.05 XXX74270 TC A Contrast x-ray exam of colon 0.00 3.32 3.40 NA NA 0.01 XXX74270 26 A Contrast x-ray exam of colon 0.69 0.24 0.28 0.24 0.28 0.04 XXX74280 A Contrast x-ray exam of colon 0.99 4.92 5.07 NA NA 0.07 XXX74280 TC A Contrast x-ray exam of colon 0.00 4.58 4.68 NA NA 0.01 XXX74280 26 A Contrast x-ray exam of colon 0.99 0.34 0.39 0.34 0.39 0.06 XXX74283 A Contrast x-ray exam of colon 2.02 3.59 3.87 NA NA 0.07 XXX74283 TC A Contrast x-ray exam of colon 0.00 2.86 3.06 NA NA 0.01 XXX74283 26 A Contrast x-ray exam of colon 2.02 0.73 0.81 0.73 0.81 0.06 XXX74290 A Contrast x-ray, gallbladder 0.32 1.58 1.63 NA NA 0.02 XXX74290 TC A Contrast x-ray, gallbladder 0.00 1.47 1.50 NA NA 0.01 XXX74290 26 A Contrast x-ray, gallbladder 0.32 0.11 0.13 0.11 0.13 0.01 XXX74291 A Contrast x-rays, gallbladder 0.20 1.71 1.63 NA NA 0.02 XXX74291 TC A Contrast x-rays, gallbladder 0.00 1.63 1.55 NA NA 0.01 XXX74291 26 A Contrast x-rays, gallbladder 0.20 0.08 0.08 0.08 0.08 0.01 XXX74300 C X-ray bile ducts/pancreas 0.00 0.00 0.00 NA NA 0.00 XXX74300 TC C X-ray bile ducts/pancreas 0.00 0.00 0.00 NA NA 0.00 XXX74300 26 A X-ray bile ducts/pancreas 0.36 0.13 0.14 0.13 0.14 0.03 XXXCMS-1503-P1053**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**74301 C X-rays at surgery add-on 0.00 0.00 0.00 NA NA 0.00 ZZZ74301 TC C X-rays at surgery add-on 0.00 0.00 0.00 NA NA 0.00 ZZZ74301 26 A X-rays at surgery add-on 0.21 0.08 0.09 0.08 0.09 0.03 ZZZ74305 C X-ray bile ducts/pancreas 0.00 0.00 0.00 NA NA 0.00 XXX74305 TC C X-ray bile ducts/pancreas 0.00 0.00 0.00 NA NA 0.00 XXX74305 26 A X-ray bile ducts/pancreas 0.42 0.14 0.17 0.14 0.17 0.04 XXX74320 A Contrast x-ray of bile ducts 0.54 2.15 2.55 NA NA 0.04 XXX74320 TC A Contrast x-ray of bile ducts 0.00 1.97 2.33 NA NA 0.01 XXX74320 26 A Contrast x-ray of bile ducts 0.54 0.18 0.22 0.18 0.22 0.03 XXX74327 A X-ray bile stone removal 0.70 3.03 3.16 NA NA 0.14 XXX74327 TC A X-ray bile stone removal 0.00 2.79 2.88 NA NA 0.01 XXX74327 26 A X-ray bile stone removal 0.70 0.24 0.28 0.24 0.28 0.13 XXX74328 C X-ray bile duct endoscopy 0.00 0.00 0.00 NA NA 0.00 XXX74328 TC C X-ray bile duct endoscopy 0.00 0.00 0.00 NA NA 0.00 XXX74328 26 A X-ray bile duct endoscopy 0.70 0.27 0.30 0.27 0.30 0.06 XXX74329 C X-ray for pancreas endoscopy 0.00 0.00 0.00 NA NA 0.00 XXX74329 TC C X-ray for pancreas endoscopy 0.00 0.00 0.00 NA NA 0.00 XXX74329 26 A X-ray for pancreas endoscopy 0.70 0.28 0.30 0.28 0.30 0.06 XXX74330 C X-ray bile/panc endoscopy 0.00 0.00 0.00 NA NA 0.00 XXX74330 TC C X-ray bile/panc endoscopy 0.00 0.00 0.00 NA NA 0.00 XXX74330 26 A X-ray bile/panc endoscopy 0.90 0.34 0.37 0.34 0.37 0.07 XXX74340 C X-ray guide for GI tube 0.00 0.00 0.00 NA NA 0.00 XXX74340 TC C X-ray guide for GI tube 0.00 0.00 0.00 NA NA 0.00 XXX74340 26 A X-ray guide for GI tube 0.54 0.19 0.22 0.19 0.22 0.04 XXX74355 C X-ray guide, intestinal tube 0.00 0.00 0.00 NA NA 0.00 XXX74355 TC C X-ray guide, intestinal tube 0.00 0.00 0.00 NA NA 0.00 XXXCMS-1503-P1054**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**74355 26 A X-ray guide, intestinal tube 0.76 0.30 0.32 0.30 0.32 0.07 XXX74360 C X-ray guide, GI dilation 0.00 0.00 0.00 NA NA 0.00 XXX74360 TC C X-ray guide, GI dilation 0.00 0.00 0.00 NA NA 0.00 XXX74360 26 A X-ray guide, GI dilation 0.54 0.27 0.27 0.27 0.27 0.04 XXX74363 C X-ray, bile duct dilation 0.00 0.00 0.00 NA NA 0.00 XXX74363 TC C X-ray, bile duct dilation 0.00 0.00 0.00 NA NA 0.00 XXX74363 26 A X-ray, bile duct dilation 0.88 0.30 0.35 0.30 0.35 0.08 XXX74400 A Contrst x-ray, urinary tract 0.49 2.53 2.70 NA NA 0.04 XXX74400 TC A Contrst x-ray, urinary tract 0.00 2.36 2.51 NA NA 0.01 XXX74400 26 A Contrst x-ray, urinary tract 0.49 0.17 0.19 0.17 0.19 0.03 XXX74410 A Contrst x-ray, urinary tract 0.49 2.57 2.81 NA NA 0.04 XXX74410 TC A Contrst x-ray, urinary tract 0.00 2.39 2.61 NA NA 0.01 XXX74410 26 A Contrst x-ray, urinary tract 0.49 0.18 0.20 0.18 0.20 0.03 XXX74415 A Contrst x-ray, urinary tract 0.49 3.21 3.41 NA NA 0.04 XXX74415 TC A Contrst x-ray, urinary tract 0.00 3.04 3.22 NA NA 0.01 XXX74415 26 A Contrst x-ray, urinary tract 0.49 0.17 0.19 0.17 0.19 0.03 XXX74420 C Contrst x-ray, urinary tract 0.00 0.00 0.00 NA NA 0.00 XXX74420 TC C Contrst x-ray, urinary tract 0.00 0.00 0.00 NA NA 0.00 XXX74420 26 A Contrst x-ray, urinary tract 0.36 0.13 0.15 0.13 0.15 0.03 XXX74425 C Contrst x-ray, urinary tract 0.00 0.00 0.00 NA NA 0.00 XXX74425 TC C Contrst x-ray, urinary tract 0.00 0.00 0.00 NA NA 0.00 XXX74425 26 A Contrst x-ray, urinary tract 0.36 0.12 0.15 0.12 0.15 0.03 XXX74430 A Contrast x-ray, bladder 0.32 1.91 2.01 NA NA 0.02 XXX74430 TC A Contrast x-ray, bladder 0.00 1.79 1.88 NA NA 0.01 XXX74430 26 A Contrast x-ray, bladder 0.32 0.12 0.13 0.12 0.13 0.01 XXX74440 A X-ray, male genital tract 0.38 2.00 2.11 NA NA 0.04 XXXCMS-1503-P1055**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**74440 TC A X-ray, male genital tract 0.00 1.85 1.95 NA NA 0.01 XXX74440 26 A X-ray, male genital tract 0.38 0.15 0.16 0.15 0.16 0.03 XXX74445 C X-ray exam of penis 0.00 0.00 0.00 NA NA 0.00 XXX74445 TC C X-ray exam of penis 0.00 0.00 0.00 NA NA 0.00 XXX74445 26 A X-ray exam of penis 1.14 0.45 0.50 0.45 0.50 0.10 XXX74450 C X-ray, urethra/bladder 0.00 0.00 0.00 NA NA 0.00 XXX74450 TC C X-ray, urethra/bladder 0.00 0.00 0.00 NA NA 0.00 XXX74450 26 A X-ray, urethra/bladder 0.33 0.12 0.14 0.12 0.14 0.03 XXX74455 A X-ray, urethra/bladder 0.33 2.05 2.26 NA NA 0.02 XXX74455 TC A X-ray, urethra/bladder 0.00 1.93 2.12 NA NA 0.01 XXX74455 26 A X-ray, urethra/bladder 0.33 0.12 0.14 0.12 0.14 0.01 XXX74470 C X-ray exam of kidney lesion 0.00 0.00 0.00 NA NA 0.00 XXX74470 TC C X-ray exam of kidney lesion 0.00 0.00 0.00 NA NA 0.00 XXX74470 26 A X-ray exam of kidney lesion 0.54 0.19 0.22 0.19 0.22 0.04 XXX74475 A X-ray control, cath insert 0.54 2.13 2.66 NA NA 0.04 XXX74475 TC A X-ray control, cath insert 0.00 1.95 2.44 NA NA 0.01 XXX74475 26 A X-ray control, cath insert 0.54 0.18 0.22 0.18 0.22 0.03 XXX74480 A X-ray control, cath insert 0.54 2.14 2.67 NA NA 0.04 XXX74480 TC A X-ray control, cath insert 0.00 1.95 2.45 NA NA 0.01 XXX74480 26 A X-ray control, cath insert 0.54 0.19 0.22 0.19 0.22 0.03 XXX74485 A X-ray guide, GU dilation 0.54 2.21 2.63 NA NA 0.04 XXX74485 TC A X-ray guide, GU dilation 0.00 2.02 2.41 NA NA 0.01 XXX74485 26 A X-ray guide, GU dilation 0.54 0.19 0.22 0.19 0.22 0.03 XXX74710 A X-ray measurement of pelvis 0.34 0.64 0.80 NA NA 0.02 XXX74710 TC A X-ray measurement of pelvis 0.00 0.52 0.66 NA NA 0.01 XXX74710 26 A X-ray measurement of pelvis 0.34 0.12 0.14 0.12 0.14 0.01 XXXCMS-1503-P1056**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**74740 A X-ray, female genital tract 0.38 1.77 1.89 NA NA 0.02 XXX74740 TC A X-ray, female genital tract 0.00 1.63 1.74 NA NA 0.01 XXX74740 26 A X-ray, female genital tract 0.38 0.14 0.15 0.14 0.15 0.01 XXX74742 C X-ray, fallopian tube 0.00 0.00 0.00 NA NA 0.00 XXX74742 TC C X-ray, fallopian tube 0.00 0.00 0.00 NA NA 0.00 XXX74742 26 A X-ray, fallopian tube0.61 0.27 0.27 0.27 0.27 0.06 XXX74775 C X-ray exam of perineum 0.00 0.00 0.00 NA NA 0.00 XXX74775 TC C X-ray exam of perineum 0.00 0.00 0.00 NA NA 0.00 XXX74775 26 A X-ray exam of perineum 0.62 0.22 0.25 0.22 0.25 0.06 XXX75557 A Cardiac mri for morph 2.35 7.92 10.58 NA NA 0.11 XXX75557 TC A Cardiac mri for morph 0.00 7.06 9.55 NA NA 0.01 XXX75557 26 A Cardiac mri for morph 2.35 0.86 1.03 0.86 1.03 0.10 XXX75559 A Cardiac mri w/stress img 2.95 11.55 15.86 NA NA 0.14 XXX75559 TC A Cardiac mri w/stress img 0.00 10.42 14.49 NA NA 0.01 XXX75559 26 A Cardiac mri w/stress img 2.95 1.13 1.37 1.13 1.37 0.13 XXX75561 A Cardiac mri for morph w/dye 2.60 11.11 14.93 NA NA 0.12 XXX75561 TC A Cardiac mri for morph w/dye 0.00 10.15 13.79 NA NA 0.01 XXX75561 26 A Cardiac mri for morph w/dye 2.60 0.96 1.14 0.96 1.14 0.11 XXX75563 A Card mri w/stress img & dye 3.00 13.37 18.43 NA NA 0.12 XXX75563 TC A Card mri w/stress img & dye 0.00 12.21 16.99 NA NA 0.01 XXX75563 26 A Card mri w/stress img & dye 3.00 1.16 1.44 1.16 1.44 0.11 XXX75565 A Card mri vel flw map add-on 0.25 1.89 1.89 NA NA 0.02 ZZZ75565 TC A Card mri vel flw map add-on 0.00 1.78 1.78 NA NA 0.01 ZZZ75565 26 A Card mri vel flw map add-on 0.25 0.11 0.11 0.11 0.11 0.01 ZZZ75571 A Ct hrt w/o dye w/ca test 0.58 2.50 2.50 NA NA 0.02 XXX75571 TC A Ct hrt w/o dye w/ca test 0.00 2.29 2.29 NA NA 0.01 XXXCMS-1503-P1057**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**75571 26 A Ct hrt w/o dye w/ca test 0.58 0.21 0.21 0.21 0.21 0.01 XXX75572 A Ct hrt w/3d image 1.75 6.71 6.71 NA NA 0.07 XXX75572 TC A Ct hrt w/3d image 0.00 6.05 6.05 NA NA 0.01 XXX75572 26 A Ct hrt w/3d image 1.75 0.66 0.66 0.66 0.66 0.06 XXX75573 A Ct hrt w/3d image, congen 2.55 9.05 9.05 NA NA 0.09 XXX75573 TC A Ct hrt w/3d image, congen 0.00 8.05 8.05 NA NA 0.01 XXX75573 26 A Ct hrt w/3d image, congen 2.55 1.00 1.00 1.00 1.00 0.08 XXX75574 A Ct angio hrt w/3d image 2.40 10.45 10.45 NA NA 0.09 XXX75574 TC A Ct angio hrt w/3d image 0.00 9.55 9.55 NA NA 0.01 XXX75574 26 A Ct angio hrt w/3d image 2.40 0.90 0.90 0.90 0.90 0.08 XXX75600 A Contrast x-ray exam of aorta 0.49 5.38 7.36 NA NA 0.04 XXX75600 TC A Contrast x-ray exam of aorta 0.00 5.19 7.13 NA NA 0.01 XXX75600 26 A Contrast x-ray exam of aorta 0.49 0.19 0.23 0.19 0.23 0.03 XXX75605 A Contrast x-ray exam of aorta 1.14 3.14 5.07 NA NA 0.08 XXX75605 TC A Contrast x-ray exam of aorta 0.00 2.72 4.57 NA NA 0.01 XXX75605 26 A Contrast x-ray exam of aorta 1.14 0.42 0.50 0.42 0.50 0.07 XXX75625 A Contrast x-ray exam of aorta 1.14 3.22 5.04 NA NA 0.11 XXX75625 TC A Contrast x-ray exam of aorta 0.00 2.81 4.58 NA NA 0.01 XXX75625 26 A Contrast x-ray exam of aorta 1.14 0.41 0.46 0.41 0.46 0.10 XXX75630 A X-ray aorta, leg arteries 1.79 3.47 5.46 NA NA 0.11 XXX75630 TC A X-ray aorta, leg arteries 0.00 2.81 4.70 NA NA 0.01 XXX75630 26 A X-ray aorta, leg arteries 1.79 0.66 0.76 0.66 0.76 0.10 XXX75635 A Ct angio abdominal arteries 2.40 9.83 13.19 NA NA 0.16 XXX75635 TC A Ct angio abdominal arteries 0.00 8.98 12.19 NA NA 0.03 XXX75635 26 A Ct angio abdominal arteries 2.40 0.85 1.00 0.85 1.00 0.13 XXX75650 A Artery x-rays, head & neck 1.49 3.37 5.23 NA NA 0.11 XXXCMS-1503-P1058**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**75650 TC A Artery x-rays, head & neck 0.00 2.83 4.61 NA NA 0.01 XXX75650 26 A Artery x-rays, head & neck 1.49 0.54 0.62 0.54 0.62 0.10 XXX75658 A Artery x-rays, arm 1.31 3.96 5.58 NA NA 0.09 XXX75658 TC A Artery x-rays, arm 0.00 3.51 5.08 NA NA 0.01 XXX75658 26 A Artery x-rays, arm 1.31 0.45 0.50 0.45 0.50 0.08 XXX75660 A Artery x-rays, head & neck 1.31 4.03 5.70 NA NA 0.05 XXX75660 TC A Artery x-rays, head & neck 0.00 3.52 5.14 NA NA 0.01 XXX75660 26 A Artery x-rays, head & neck 1.31 0.51 0.56 0.51 0.56 0.04 XXX75662 A Artery x-rays, head & neck 1.66 4.94 6.65 NA NA 0.10 XXX75662 TC A Artery x-rays, head & neck 0.00 4.28 5.91 NA NA 0.03 XXX75662 26 A Artery x-rays, head & neck 1.66 0.66 0.74 0.66 0.74 0.07 XXX75665 A Artery x-rays, head & neck 1.31 4.27 5.94 NA NA 0.12 XXX75665 TC A Artery x-rays, head & neck 0.00 3.76 5.38 NA NA 0.01 XXX75665 26 A Artery x-rays, head & neck 1.31 0.51 0.56 0.51 0.56 0.11 XXX75671 A Artery x-rays, head & neck 1.66 5.10 6.81 NA NA 0.13 XXX75671 TC A Artery x-rays, head & neck 0.00 4.47 6.10 NA NA 0.03 XXX75671 26 A Artery x-rays, head & neck 1.66 0.63 0.71 0.63 0.71 0.10 XXX75676 A Artery x-rays, neck 1.31 3.93 5.65 NA NA 0.12 XXX75676 TC A Artery x-rays, neck 0.00 3.43 5.10 NA NA 0.01 XXX75676 26 A Artery x-rays, neck 1.31 0.50 0.55 0.50 0.55 0.11 XXX75680 A Artery x-rays, neck 1.66 4.46 6.26 NA NA 0.11 XXX75680 TC A Artery x-rays, neck 0.00 3.83 5.55 NA NA 0.01 XXX75680 26 A Artery x-rays, neck 1.66 0.63 0.71 0.63 0.71 0.10 XXX75685 A Artery x-rays, spine 1.31 4.02 5.71 NA NA 0.09 XXX75685 TC A Artery x-rays, spine 0.00 3.51 5.15 NA NA 0.01 XXX75685 26 A Artery x-rays, spine 1.31 0.51 0.56 0.51 0.56 0.08 XXXCMS-1503-P1059**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**75705 A Artery x-rays, spine 2.18 4.22 5.99 NA NA 0.08 XXX75705 TC A Artery x-rays, spine 0.00 3.42 5.08 NA NA 0.01 XXX75705 26 A Artery x-rays, spine 2.18 0.80 0.91 0.80 0.91 0.07 XXX75710 A Artery x-rays, arm/leg 1.14 3.84 5.60 NA NA 0.07 XXX75710 TC A Artery x-rays, arm/leg 0.00 3.43 5.14 NA NA 0.01 XXX75710 26 A Artery x-rays, arm/leg 1.14 0.41 0.46 0.41 0.46 0.06 XXX75716 A Artery x-rays, arms/legs 1.31 4.63 6.44 NA NA 0.13 XXX75716 TC A Artery x-rays, arms/legs 0.00 4.16 5.90 NA NA 0.03 XXX75716 26 A Artery x-rays, arms/legs 1.31 0.47 0.54 0.47 0.54 0.10 XXX75722 A Artery x-rays, kidney 1.14 3.47 5.38 NA NA 0.08 XXX75722 TC A Artery x-rays, kidney 0.00 3.06 4.89 NA NA 0.01 XXX75722 26 A Artery x-rays, kidney 1.14 0.41 0.49 0.41 0.49 0.07 XXX75724 A Artery x-rays, kidneys 1.49 4.17 6.27 NA NA 0.09 XXX75724 TC A Artery x-rays, kidneys 0.00 3.60 5.56 NA NA 0.03 XXX75724 26 A Artery x-rays, kidneys 1.49 0.57 0.71 0.57 0.71 0.06 XXX75726 A Artery x-rays, abdomen 1.14 3.70 5.49 NA NA 0.09 XXX75726 TC A Artery x-rays, abdomen 0.00 3.31 5.03 NA NA 0.01 XXX75726 26 A Artery x-rays, abdomen 1.14 0.39 0.46 0.39 0.46 0.08 XXX75731 A Artery x-rays, adrenal gland 1.14 3.63 5.61 NA NA 0.05 XXX75731 TC A Artery x-rays, adrenal gland 0.00 3.23 5.10 NA NA 0.01 XXX75731 26 A Artery x-rays, adrenal gland 1.14 0.40 0.51 0.40 0.51 0.04 XXX75733 A Artery x-rays, adrenals 1.31 4.41 6.54 NA NA 0.07 XXX75733 TC A Artery x-rays, adrenals 0.00 3.90 5.91 NA NA 0.03 XXX75733 26 A Artery x-rays, adrenals 1.31 0.51 0.63 0.51 0.63 0.04 XXX75736 A Artery x-rays, pelvis 1.14 3.69 5.52 NA NA 0.07 XXX75736 TC A Artery x-rays, pelvis 0.00 3.28 5.05 NA NA 0.01 XXXCMS-1503-P1060**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**75736 26 A Artery x-rays, pelvis 1.14 0.41 0.47 0.41 0.47 0.06 XXX75741 A Artery x-rays, lung 1.31 3.14 4.96 NA NA 0.09 XXX75741 TC A Artery x-rays, lung 0.00 2.69 4.43 NA NA 0.01 XXX75741 26 A Artery x-rays, lung 1.31 0.45 0.53 0.45 0.53 0.08 XXX75743 A Artery x-rays, lungs 1.66 3.52 5.36 NA NA 0.11 XXX75743 TC A Artery x-rays, lungs 0.00 2.95 4.68 NA NA 0.01 XXX75743 26 A Artery x-rays, lungs 1.66 0.57 0.68 0.57 0.68 0.10 XXX75746 A Artery x-rays, lung 1.14 3.46 5.27 NA NA 0.08 XXX75746 TC A Artery x-rays, lung 0.00 3.06 4.81 NA NA 0.01 XXX75746 26 A Artery x-rays, lung 1.14 0.40 0.46 0.40 0.46 0.07 XXX75756 A Artery x-rays, chest 1.14 3.75 5.69 NA NA 0.24 XXX75756 TC A Artery x-rays, chest 0.00 3.34 5.16 NA NA 0.01 XXX75756 26 A Artery x-rays, chest 1.14 0.41 0.53 0.41 0.53 0.23 XXX75774 A Artery x-ray, each vessel 0.36 2.45 4.24 NA NA 0.04 ZZZ75774 TC A Artery x-ray, each vessel 0.00 2.32 4.09 NA NA 0.01 ZZZ75774 26 A Artery x-ray, each vessel 0.36 0.13 0.15 0.13 0.15 0.03 ZZZ75791 A Av dialysis shunt imaging 1.71 7.59 7.59 NA NA 0.11 XXX75791 TC A Av dialysis shunt imaging 0.00 6.99 6.99 NA NA 0.01 XXX75791 26 A Av dialysis shunt imaging 1.71 0.60 0.60 0.60 0.60 0.10 XXX75801 C Lymph vessel x-ray, arm/leg 0.00 0.00 0.00 NA NA 0.00 XXX75801 TC C Lymph vessel x-ray, arm/leg 0.00 0.00 0.00 NA NA 0.00 XXX75801 26 A Lymph vessel x-ray, arm/leg 0.81 0.35 0.33 0.35 0.33 0.18 XXX75803 C Lymph vessel x-ray,arms/legs 0.00 0.00 0.00 NA NA 0.00 XXX75803 TC C Lymph vessel x-ray,arms/legs 0.00 0.00 0.00 NA NA 0.00 XXX75803 26 A Lymph vessel x-ray,arms/legs 1.17 0.41 0.47 0.41 0.47 0.10 XXX75805 C Lymph vessel x-ray, trunk 0.00 0.00 0.00 NA NA 0.00 XXXCMS-1503-P1061**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**75805 TC C Lymph vessel x-ray, trunk 0.00 0.00 0.00 NA NA 0.00 XXX75805 26 A Lymph vessel x-ray, trunk 0.81 0.28 0.33 0.28 0.33 0.07 XXX75807 C Lymph vessel x-ray, trunk 0.00 0.00 0.00 NA NA 0.00 XXX75807 TC C Lymph vessel x-ray, trunk 0.00 0.00 0.00 NA NA 0.00 XXX75807 26 A Lymph vessel x-ray, trunk 1.17 0.42 0.48 0.42 0.48 0.10 XXX75809 A Nonvascular shunt, x-ray 0.47 2.41 2.33 NA NA 0.04 XXX75809 TC A Nonvascular shunt, x-ray 0.00 2.22 2.13 NA NA 0.01 XXX75809 26 A Nonvascular shunt, x-ray 0.47 0.19 0.20 0.19 0.20 0.03 XXX75810 C Vein x-ray, spleen/liver 0.00 0.00 0.00 NA NA 0.00 XXX75810 TC C Vein x-ray, spleen/liver 0.00 0.00 0.00 NA NA 0.00 XXX75810 26 A Vein x-ray, spleen/liver 1.14 0.40 0.47 0.40 0.47 0.10 XXX75820 A Vein x-ray, arm/leg 0.70 2.83 2.91 NA NA 0.05 XXX75820 TC A Vein x-ray, arm/leg 0.00 2.57 2.61 NA NA 0.01 XXX75820 26 A Vein x-ray, arm/leg 0.70 0.26 0.30 0.26 0.30 0.04 XXX75822 A Vein x-ray, arms/legs 1.06 3.24 3.32 NA NA 0.08 XXX75822 TC A Vein x-ray, arms/legs 0.00 2.87 2.90 NA NA 0.01 XXX75822 26 A Vein x-ray, arms/legs 1.06 0.37 0.42 0.37 0.42 0.07 XXX75825 A Vein x-ray, trunk 1.14 3.00 4.77 NA NA 0.09 XXX75825 TC A Vein x-ray, trunk 0.00 2.61 4.33 NA NA 0.01 XXX75825 26 A Vein x-ray, trunk 1.14 0.39 0.44 0.39 0.44 0.08 XXX75827 A Vein x-ray, chest 1.14 3.17 4.86 NA NA 0.08 XXX75827 TC A Vein x-ray, chest 0.00 2.78 4.43 NA NA 0.01 XXX75827 26 A Vein x-ray, chest 1.14 0.39 0.43 0.39 0.43 0.07 XXX75831 A Vein x-ray, kidney 1.14 3.10 4.88 NA NA 0.26 XXX75831 TC A Vein x-ray, kidney 0.00 2.71 4.43 NA NA 0.01 XXX75831 26 A Vein x-ray, kidney 1.14 0.39 0.45 0.39 0.45 0.25 XXXCMS-1503-P1062**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**75833 A Vein x-ray, kidneys 1.49 3.75 5.47 NA NA 0.09 XXX75833 TC A Vein x-ray, kidneys 0.00 3.25 4.91 NA NA 0.01 XXX75833 26 A Vein x-ray, kidneys 1.49 0.50 0.56 0.50 0.56 0.08 XXX75840 A Vein x-ray, adrenal gland 1.14 3.01 4.79 NA NA 0.26 XXX75840 TC A Vein x-ray, adrenal gland 0.00 2.63 4.37 NA NA 0.01 XXX75840 26 A Vein x-ray, adrenal gland 1.14 0.38 0.42 0.38 0.42 0.25 XXX75842 A Vein x-ray, adrenal glands 1.49 3.61 5.45 NA NA 0.09 XXX75842 TC A Vein x-ray, adrenal glands 0.00 3.09 4.85 NA NA 0.01 XXX75842 26 A Vein x-ray, adrenal glands 1.49 0.52 0.60 0.52 0.60 0.08 XXX75860 A Vein x-ray, neck 1.14 3.12 4.98 NA NA 0.09 XXX75860 TC A Vein x-ray, neck 0.00 2.70 4.49 NA NA 0.01 XXX75860 26 A Vein x-ray, neck 1.14 0.42 0.49 0.42 0.49 0.08 XXX75870 A Vein x-ray, skull 1.14 3.00 4.87 NA NA 0.08 XXX75870 TC A Vein x-ray, skull 0.00 2.60 4.42 NA NA 0.01 XXX75870 26 A Vein x-ray, skull 1.14 0.40 0.45 0.40 0.45 0.07 XXX75872 A Vein x-ray, skull 1.14 6.55 7.03 NA NA 0.08 XXX75872 TC A Vein x-ray, skull 0.00 5.93 6.45 NA NA 0.01 XXX75872 26 A Vein x-ray, skull 1.14 0.62 0.58 0.62 0.58 0.07 XXX75880 A Vein x-ray, eye socket 0.70 5.35 4.21 NA NA 0.05 XXX75880 TC A Vein x-ray, eye socket 0.00 5.02 3.90 NA NA 0.01 XXX75880 26 A Vein x-ray, eye socket 0.70 0.33 0.31 0.33 0.31 0.04 XXX75885 A Vein x-ray, liver 1.44 3.15 5.00 NA NA 0.09 XXX75885 TC A Vein x-ray, liver 0.00 2.66 4.42 NA NA 0.01 XXX75885 26 A Vein x-ray, liver 1.44 0.49 0.58 0.49 0.58 0.08 XXX75887 A Vein x-ray, liver 1.44 3.24 5.08 NA NA 0.07 XXX75887 TC A Vein x-ray, liver 0.00 2.74 4.49 NA NA 0.01 XXXCMS-1503-P1063**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**75887 26 A Vein x-ray, liver 1.44 0.50 0.59 0.50 0.59 0.06 XXX75889 A Vein x-ray, liver 1.14 3.08 4.88 NA NA 0.08 XXX75889 TC A Vein x-ray, liver 0.00 2.69 4.42 NA NA 0.01 XXX75889 26 A Vein x-ray, liver 1.14 0.39 0.46 0.39 0.46 0.07 XXX75891 A Vein x-ray, liver 1.14 3.08 4.88 NA NA 0.08 XXX75891 TC A Vein x-ray, liver 0.00 2.69 4.42 NA NA 0.01 XXX75891 26 A Vein x-ray, liver 1.14 0.39 0.46 0.39 0.46 0.07 XXX75893 A Venous sampling by catheter 0.54 2.82 4.59 NA NA 0.02 XXX75893 TC A Venous sampling by catheter 0.00 2.63 4.38 NA NA 0.01 XXX75893 26 A Venous sampling by catheter 0.54 0.19 0.21 0.19 0.21 0.01 XXX75894 C X-rays, transcath therapy 0.00 0.00 0.00 NA NA 0.00 XXX75894 TC C X-rays, transcath therapy 0.00 0.00 0.00 NA NA 0.00 XXX75894 26 A X-rays, transcath therapy 1.31 0.46 0.52 0.46 0.52 0.17 XXX75896 C X-rays, transcath therapy 0.00 0.00 0.00 NA NA 0.00 XXX75896 TC C X-rays, transcath therapy 0.00 0.00 0.00 NA NA 0.00 XXX75896 26 A X-rays, transcath therapy 1.31 0.47 0.55 0.47 0.55 0.17 XXX75898 C Follow-up angiography 0.00 0.00 0.00 NA NA 0.00 XXX75898 TC C Follow-up angiography 0.00 0.00 0.00 NA NA 0.00 XXX75898 26 A Follow-up angiography 1.65 0.60 0.69 0.60 0.69 0.21 XXX75900 C Intravascular cath exchange 0.00 0.00 0.00 NA NA 0.00 XXX75900 TC C Intravascular cath exchange 0.00 0.00 0.00 NA NA 0.00 XXX75900 26 A Intravascular cath exchange 0.49 0.17 0.19 0.17 0.19 0.06 XXX75901 A Remove cva device obstruct 0.49 4.39 4.29 NA NA 0.04 XXX75901 TC A Remove cva device obstruct 0.00 4.22 4.10 NA NA 0.01 XXX75901 26 A Remove cva device obstruct 0.49 0.17 0.19 0.17 0.19 0.03 XXX75902 A Remove cva lumen obstruct 0.39 1.70 1.80 NA NA 0.05 XXXCMS-1503-P1064**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**75902 TC A Remove cva lumen obstruct 0.00 1.57 1.65 NA NA 0.01 XXX75902 26 A Remove cva lumen obstruct 0.39 0.13 0.15 0.13 0.15 0.04 XXX75940 C X-ray placement, vein filter 0.00 0.00 0.00 NA NA 0.00 XXX75940 TC C X-ray placement, vein filter 0.00 0.00 0.00 NA NA 0.00 XXX75940 26 A X-ray placement, vein filter 0.54 0.19 0.21 0.19 0.21 0.07 XXX75945 C Intravascular us 0.00 0.00 0.00 NA NA 0.00 XXX75945 TC C Intravascular us 0.00 0.00 0.00 NA NA 0.00 XXX75945 26 A Intravascular us 0.40 0.14 0.16 0.14 0.16 0.06 XXX75946 C Intravascular us add-on 0.00 0.00 0.00 NA NA 0.00 ZZZ75946 TC C Intravascular us add-on 0.00 0.00 0.00 NA NA 0.00 ZZZ75946 26 A Intravascular us add-on 0.40 0.13 0.15 0.13 0.15 0.07 ZZZ75952 C Endovasc repair abdom aorta 0.00 0.00 0.00 NA NA 0.00 XXX75952 TC C Endovasc repair abdom aorta 0.00 0.00 0.00 NA NA 0.00 XXX75952 26 A Endovasc repair abdom aorta 4.49 1.54 1.62 1.54 1.62 0.89 XXX75953 C Abdom aneurysm endovas rpr 0.00 0.00 0.00 NA NA 0.00 XXX75953 TC C Abdom aneurysm endovas rpr 0.00 0.00 0.00 NA NA 0.00 XXX75953 26 A Abdom aneurysm endovas rpr 1.36 0.47 0.49 0.47 0.49 0.28 XXX75954 C Iliac aneurysm endovas rpr 0.00 0.00 0.00 NA NA 0.00 XXX75954 TC C Iliac aneurysm endovas rpr 0.00 0.00 0.00 NA NA 0.00 XXX75954 26 A Iliac aneurysm endovas rpr 2.25 0.79 0.82 0.79 0.82 0.42 XXX75956 C Xray, endovasc thor ao repr 0.00 0.00 0.00 NA NA 0.00 XXX75956 TC C Xray, endovasc thor ao repr 0.00 0.00 0.00 NA NA 0.00 XXX75956 26 A Xray, endovasc thor ao repr 7.00 2.33 2.52 2.33 2.52 1.50 XXX75957 C Xray, endovasc thor ao repr 0.00 0.00 0.00 NA NA 0.00 XXX75957 TC C Xray, endovasc thor ao repr 0.00 0.00 0.00 NA NA 0.00 XXX75957 26 A Xray, endovasc thor ao repr 6.00 2.02 2.17 2.02 2.17 1.26 XXXCMS-1503-P1065**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**75958 C Xray, place prox ext thor ao 0.00 0.00 0.00 NA NA 0.00 XXX75958 TC C Xray, place prox ext thor ao 0.00 0.00 0.00 NA NA 0.00 XXX75958 26 A Xray, place prox ext thor ao 4.00 1.34 1.41 1.34 1.41 0.85 XXX75959 C Xray, place dist ext thor ao 0.00 0.00 0.00 NA NA 0.00 XXX75959 TC C Xray, place dist ext thor ao 0.00 0.00 0.00 NA NA 0.00 XXX75959 26 A Xray, place dist ext thor ao 3.50 1.08 1.20 1.08 1.20 0.86 XXX75960 A Transcath iv stent rs&i 0.82 2.64 4.79 NA NA 0.07 XXX75960 TC A Transcath iv stent rs&i 0.00 2.35 4.45 NA NA 0.01 XXX75960 26 A Transcath iv stent rs&i 0.82 0.29 0.34 0.29 0.34 0.06 XXX75961 A Retrieval, broken catheter 4.24 4.62 6.26 NA NA 0.29 XXX75961 TC A Retrieval, broken catheter 0.00 3.16 4.57 NA NA 0.01 XXX75961 26 A Retrieval, broken catheter 4.24 1.46 1.69 1.46 1.69 0.28 XXX75962 A Repair arterial blockage 0.54 3.39 5.62 NA NA 0.04 XXX75962 TC A Repair arterial blockage 0.00 3.20 5.40 NA NA 0.01 XXX75962 26 A Repair arterial blockage 0.54 0.19 0.22 0.19 0.22 0.03 XXX75964 A Repair artery blockage, each 0.36 2.31 3.46 NA NA 0.05 ZZZ75964 TC A Repair artery blockage, each 0.00 2.18 3.32 NA NA 0.01 ZZZ75964 26 A Repair artery blockage,each 0.36 0.13 0.14 0.13 0.14 0.04 ZZZ75966 A Repair arterial blockage 1.31 3.66 6.07 NA NA 0.08 XXX75966 TC A Repair arterial blockage 0.00 3.18 5.50 NA NA 0.01 XXX75966 26 A Repair arterial blockage 1.31 0.48 0.57 0.48 0.57 0.07 XXX75968 A Repair artery blockage, each 0.36 2.17 3.41 NA NA 0.02 ZZZ75968 TC A Repair artery blockage, each 0.00 2.04 3.25 NA NA 0.01 ZZZ75968 26 A Repair artery blockage,each 0.36 0.13 0.16 0.13 0.16 0.01 ZZZ75970 C Vascular biopsy 0.00 0.00 0.00 NA NA 0.00 XXX75970 TC C Vascular biopsy 0.00 0.00 0.00 NA NA 0.00 XXXCMS-1503-P1066**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**75970 26 A Vascular biopsy 0.83 0.29 0.33 0.29 0.33 0.07 XXX75978 A Repair venous blockage 0.54 3.50 5.60 NA NA 0.04 XXX75978 TC A Repair venous blockage 0.00 3.31 5.39 NA NA 0.01 XXX75978 26 A Repair venous blockage 0.54 0.19 0.21 0.19 0.21 0.03 XXX75980 C Contrast xray exam bile duct 0.00 0.00 0.00 NA NA 0.00 XXX75980 TC C Contrast xray exam bile duct 0.00 0.00 0.00 NA NA 0.00 XXX75980 26 A Contrast xray exam bile duct 1.44 0.49 0.58 0.49 0.58 0.13 XXX75982 C Contrast xray exam bile duct 0.00 0.00 0.00 NA NA 0.00 XXX75982 TC C Contrast xray exam bile duct 0.00 0.00 0.00 NA NA 0.00 XXX75982 26 A Contrast xray exam bile duct 1.44 0.49 0.58 0.49 0.58 0.13 XXX75984 A Xray control catheter change 0.72 2.35 2.56 NA NA 0.05 XXX75984 TC A Xray control catheter change 0.00 2.10 2.27 NA NA 0.01 XXX75984 26 A Xray control catheter change 0.72 0.25 0.29 0.25 0.29 0.04 XXX75989 A Abscess drainage under x-ray 1.19 2.26 2.69 NA NA 0.07 XXX75989 TC A Abscess drainage under x-ray 0.00 1.85 2.21 NA NA 0.01 XXX75989 26 A Abscess drainage underx-ray 1.19 0.41 0.48 0.41 0.48 0.06 XXX75992 C Atherectomy, x-ray exam 0.00 0.00 0.00 NA NA 0.00 XXX75992 TC C Atherectomy, x-ray exam 0.00 0.00 0.00 NA NA 0.00 XXX75992 26 A Atherectomy, x-ray exam 0.54 0.20 0.23 0.20 0.23 0.07 XXX75993 C Atherectomy, x-ray exam 0.00 0.00 0.00 NA NA 0.00 ZZZ75993 TC C Atherectomy, x-ray exam 0.00 0.00 0.00 NA NA 0.00 ZZZ75993 26 A Atherectomy, x-ray exam 0.36 0.13 0.15 0.13 0.15 0.04 ZZZ75994 C Atherectomy, x-ray exam 0.00 0.00 0.00 NA NA 0.00 XXX75994 TC C Atherectomy, x-ray exam 0.00 0.00 0.00 NA NA 0.00 XXX75994 26 A Atherectomy, x-ray exam 1.31 0.40 0.42 0.40 0.42 0.11 XXX75995 C Atherectomy, x-ray exam 0.00 0.00 0.00 NA NA 0.00 XXXCMS-1503-P1067**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**75995 TC C Atherectomy, x-ray exam 0.00 0.00 0.00 NA NA 0.00 XXX75995 26 A Atherectomy, x-ray exam 1.31 0.51 0.54 0.51 0.54 0.08 XXX75996 C Atherectomy, x-ray exam 0.00 0.00 0.00 NA NA 0.00 ZZZ75996 TC C Atherectomy, x-ray exam 0.00 0.00 0.00 NA NA 0.00 ZZZ75996 26 A Atherectomy, x-ray exam 0.36 0.14 0.15 0.14 0.15 0.08 ZZZ76000 A Fluoroscope examination 0.17 2.93 2.90 NA NA 0.02 XXX76000 TC A Fluoroscope examination 0.00 2.86 2.83 NA NA 0.01 XXX76000 26 A Fluoroscope examination 0.17 0.07 0.07 0.07 0.07 0.01 XXX76001 C Fluoroscope exam, extensive 0.00 0.00 0.00 NA NA 0.00 XXX76001 TC C Fluoroscope exam, extensive 0.00 0.00 0.00 NA NA 0.00 XXX76001 26 A Fluoroscope exam, extensive 0.67 0.29 0.30 0.29 0.30 0.08 XXX76010 A X-ray, nose to rectum 0.18 0.53 0.60 NA NA 0.02 XXX76010 TC A X-ray, nose to rectum 0.00 0.47 0.53 NA NA 0.01 XXX76010 26 A X-ray, nose to rectum 0.18 0.06 0.07 0.06 0.07 0.01 XXX76080 A X-ray exam of fistula 0.54 1.10 1.23 NA NA 0.04 XXX76080 TC A X-ray exam of fistula 0.00 0.91 1.01 NA NA 0.01 XXX76080 26 A X-ray exam of fistula 0.54 0.19 0.22 0.19 0.22 0.03 XXX76098 A X-ray exam, breast specimen 0.16 0.32 0.37 NA NA 0.02 XXX76098 TC A X-ray exam, breast specimen 0.00 0.26 0.31 NA NA 0.01 XXX76098 26 A X-ray exam, breast specimen 0.16 0.06 0.06 0.06 0.06 0.01 XXX76100 A X-ray exam of body section 0.58 2.27 2.94 NA NA 0.07 XXX76100 TC A X-ray exam of body section 0.00 1.97 2.66 NA NA 0.01 XXX76100 26 A X-ray exam of body section 0.58 0.30 0.28 0.30 0.28 0.06 XXX76101 A Complex body section x-ray 0.58 3.65 4.47 NA NA 0.09 XXX76101 TC A Complex body section x-ray 0.00 3.24 4.15 NA NA 0.01 XXX76101 26 A Complex body section x-ray 0.58 0.41 0.32 0.41 0.32 0.08 XXXCMS-1503-P1068**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**76102 A Complex body section x-rays 0.58 5.09 6.22 NA NA 0.11 XXX76102 TC A Complex body section x-rays 0.00 4.68 5.90 NA NA 0.01 XXX76102 26 A Complex body section x-rays 0.58 0.41 0.32 0.41 0.32 0.10 XXX76120 A Cine/video x-rays 0.38 1.69 1.82 NA NA 0.04 XXX76120 TC A Cine/video x-rays 0.00 1.55 1.67 NA NA 0.01 XXX76120 26 A Cine/video x-rays 0.38 0.14 0.15 0.14 0.15 0.03 XXX76125 C Cine/video x-rays add-on 0.00 0.00 0.00 NA NA 0.00 ZZZ76125 TC C Cine/video x-rays add-on 0.00 0.00 0.00 NA NA 0.00 ZZZ76125 26 A Cine/video x-rays add-on 0.27 0.11 0.13 0.11 0.13 0.03 ZZZ76140 I X-ray consultation 0.00 0.00 0.00 0.00 0.00 0.00 XXX76150 A X-ray exam, dry process 0.00 0.64 0.61 NA NA 0.01 XXX76350 C Special x-ray contraststudy 0.00 0.00 0.00 0.00 0.00 0.00 XXX76376 A 3d render w/o postprocess 0.20 1.39 1.84 NA NA 0.02 XXX76376 TC A 3d render w/o postprocess 0.00 1.32 1.76 NA NA 0.01 XXX76376 26 A 3d render w/o postprocess 0.20 0.07 0.08 0.07 0.08 0.01 XXX76377 A 3d rendering w/postprocess 0.79 1.36 1.87 NA NA 0.05 XXX76377 TC A 3d rendering w/postprocess 0.00 1.08 1.55 NA NA 0.01 XXX76377 26 A 3d rendering w/postprocess 0.79 0.28 0.32 0.28 0.32 0.04 XXX76380 A CAT scan follow-up study 0.98 3.58 4.48 NA NA 0.05 XXX76380 TC A CAT scan follow-up study 0.00 3.22 4.08 NA NA 0.01 XXX76380 26 A CAT scan follow-up study 0.98 0.36 0.40 0.36 0.40 0.04 XXX76390 N Mr spectroscopy 1.40 11.68 12.30 NA NA 0.07 XXX76390 TC N Mr spectroscopy 0.00 11.07 11.71 NA NA 0.01 XXX76390 26 N Mr spectroscopy 1.40 0.61 0.59 0.61 0.59 0.06 XXX76496 C Fluoroscopic procedure 0.00 0.00 0.00 NA NA 0.00 XXX76496 TC C Fluoroscopic procedure 0.00 0.00 0.00 NA NA 0.00 XXXCMS-1503-P1069**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**76496 26 C Fluoroscopic procedure 0.00 0.00 0.00 0.00 0.00 0.00 XXX76497 C Ct procedure 0.00 0.00 0.00 NA NA 0.00 XXX76497 TC C Ct procedure 0.00 0.00 0.00 NA NA 0.00 XXX76497 26 C Ct procedure 0.00 0.00 0.00 0.00 0.00 0.00 XXX76498 C Mri procedure 0.00 0.00 0.00 NA NA 0.00 XXX76498 TC C Mri procedure 0.00 0.00 0.00 NA NA 0.00 XXX76498 26 C Mri procedure 0.00 0.00 0.00 0.00 0.00 0.00 XXX76499 C Radiographic procedure 0.00 0.00 0.00 NA NA 0.00 XXX76499 TC C Radiographic procedure 0.00 0.00 0.00 NA NA 0.00 XXX76499 26 C Radiographic procedure 0.00 0.00 0.00 0.00 0.00 0.00 XXX76506 A Echo exam of head 0.63 2.73 2.82 NA NA 0.05 XXX76506 TC A Echo exam of head 0.00 2.50 2.57 NA NA 0.01 XXX76506 26 A Echo exam of head 0.63 0.23 0.25 0.23 0.25 0.04 XXX76510 A Ophth us, b & quant a 1.55 3.24 3.08 NA NA 0.28 XXX76510 TC A Ophth us, b & quant a 0.00 2.15 2.16 NA NA 0.01 XXX76510 26 A Ophth us, b & quant a 1.55 1.09 0.92 1.09 0.92 0.27 XXX76511 A Ophth us, quant a only 0.94 1.94 1.95 NA NA 0.02 XXX76511 TC A Ophth us, quant a only 0.00 1.30 1.41 NA NA 0.01 XXX76511 26 A Ophth us, quant a only 0.94 0.64 0.54 0.64 0.54 0.01 XXX76512 A Ophth us, b w/non-quant a 0.94 1.69 1.72 NA NA 0.05 XXX76512 TC A Ophth us, b w/non-quant a 0.00 1.05 1.17 NA NA 0.01 XXX76512 26 A Ophth us, b w/non-quant a 0.94 0.64 0.55 0.64 0.55 0.04 XXX76513 A Echo exam of eye, water bath 0.66 1.95 1.90 NA NA 0.02 XXX76513 TC A Echo exam of eye, water bath 0.00 1.57 1.57 NA NA 0.01 XXX76513 26 A Echo exam of eye, water bath 0.66 0.38 0.33 0.38 0.33 0.01 XXX76514 A Echo exam of eye, thickness 0.17 0.24 0.22 NA NA 0.02 XXXCMS-1503-P1070**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**76514 TC A Echo exam of eye, thickness 0.00 0.13 0.12 NA NA 0.01 XXX76514 26 A Echo exam of eye, thickness 0.17 0.11 0.10 0.11 0.10 0.01 XXX76516 A Echo exam of eye 0.54 1.62 1.55 NA NA 0.02 XXX76516 TC A Echo exam of eye 0.00 1.25 1.24 NA NA 0.01 XXX76516 26 A Echo exam of eye 0.54 0.37 0.31 0.37 0.31 0.01 XXX76519 A Echo exam of eye 0.54 1.77 1.70 NA NA 0.04 XXX76519 TC A Echo exam of eye 0.00 1.39 1.38 NA NA 0.01 XXX76519 26 A Echo exam of eye 0.54 0.38 0.32 0.38 0.32 0.03 XXX76529 A Echo exam of eye 0.57 1.62 1.54 NA NA 0.04 XXX76529 TC A Echo exam of eye 0.00 1.22 1.21 NA NA 0.01 XXX76529 26 A Echo exam of eye 0.57 0.40 0.33 0.40 0.33 0.03 XXX76536 A Us exam of head and neck 0.56 2.78 2.82 NA NA 0.04 XXX76536 TC A Us exam of head and neck 0.00 2.57 2.60 NA NA 0.01 XXX76536 26 A Us exam of head and neck 0.56 0.21 0.22 0.21 0.22 0.03 XXX76604 A Us exam, chest 0.55 1.82 1.96 NA NA 0.04 XXX76604 TC A Us exam, chest 0.00 1.63 1.74 NA NA 0.01 XXX76604 26 A Us exam, chest 0.55 0.19 0.22 0.19 0.22 0.03 XXX76645 A Us exam, breast(s) 0.54 2.11 2.20 NA NA 0.05 XXX76645 TC A Us exam, breast(s) 0.00 1.92 1.98 NA NA 0.01 XXX76645 26 A Us exam, breast(s) 0.54 0.19 0.22 0.19 0.22 0.04 XXX76700 A Us exam, abdom, complete 0.81 3.04 3.21 NA NA 0.05 XXX76700 TC A Us exam, abdom, complete 0.00 2.75 2.89 NA NA 0.01 XXX76700 26 A Us exam, abdom, complete 0.81 0.29 0.32 0.29 0.32 0.04 XXX76705 A Echo exam of abdomen 0.59 2.33 2.47 NA NA 0.04 XXX76705 TC A Echo exam of abdomen 0.00 2.12 2.23 NA NA 0.01 XXX76705 26 A Echo exam of abdomen 0.59 0.21 0.24 0.21 0.24 0.03 XXXCMS-1503-P1071**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**76770 A Us exam abdo back wall, comp 0.74 2.88 3.09 NA NA 0.05 XXX76770 TC A Us exam abdo back wall, comp 0.00 2.61 2.79 NA NA 0.01 XXX76770 26 A Us exam abdo back wall, comp 0.74 0.27 0.30 0.27 0.30 0.04 XXX76775 A Us exam abdo back wall, lim 0.58 2.36 2.61 NA NA 0.04 XXX76775 TC A Us exam abdo back wall, lim 0.00 2.15 2.37 NA NA 0.01 XXX76775 26 A Us exam abdo back wall, lim 0.58 0.21 0.24 0.21 0.24 0.03 XXX76776 A Us exam k transpl w/doppler 0.76 3.38 3.56 NA NA 0.05 XXX76776 TC A Us exam k transpl w/doppler 0.00 3.12 3.26 NA NA 0.01 XXX76776 26 A Us exam k transpl w/doppler 0.76 0.26 0.30 0.26 0.30 0.04 XXX76800 A Us exam, spinal canal 1.13 2.84 2.71 NA NA 0.05 XXX76800 TC A Us exam, spinal canal 0.00 2.35 2.27 NA NA 0.01 XXX76800 26 A Us exam, spinal canal 1.13 0.49 0.44 0.49 0.44 0.04 XXX76801 A Ob us < 14 wks, single fetus 0.99 2.52 2.74 NA NA 0.04 XXX76801 TC A Ob us < 14 wks, single fetus 0.00 2.13 2.34 NA NA 0.01 XXX76801 26 A Ob us < 14 wks, single fetus 0.99 0.39 0.40 0.39 0.40 0.03 XXX76802 A Ob us < 14 wks, addl fetus 0.83 1.05 1.17 NA NA 0.04 ZZZ76802 TC A Ob us < 14 wks, addl fetus 0.00 0.71 0.83 NA NA 0.01 ZZZ76802 26 A Ob us < 14 wks, addl fetus 0.83 0.34 0.34 0.34 0.34 0.03 ZZZ76805 A Ob us >/= 14 wks, sngl fetus 0.99 3.12 3.29 NA NA 0.04 XXX76805 TC A Ob us >/= 14 wks, sngl fetus 0.00 2.72 2.89 NA NA 0.01 XXX76805 26 A Ob us >/= 14 wks, sngl fetus 0.99 0.40 0.40 0.40 0.40 0.03 XXX76810 A Ob us >/= 14 wks, addl fetus 0.98 1.74 1.82 NA NA 0.04 ZZZ76810 TC A Ob us >/= 14 wks, addl fetus 0.00 1.34 1.42 NA NA 0.01 ZZZ76810 26 A Ob us >/= 14 wks, addl fetus 0.98 0.40 0.40 0.40 0.40 0.03 ZZZ76811 A Ob us, detailed, sngl fetus 1.90 3.32 3.66 NA NA 0.07 XXX76811 TC A Ob us, detailed, sngl fetus 0.00 2.49 2.88 NA NA 0.01 XXXCMS-1503-P1072**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**76811 26 A Ob us, detailed, sngl fetus 1.90 0.83 0.78 0.83 0.78 0.06 XXX76812 A Ob us, detailed, addl fetus 1.78 4.19 4.12 NA NA 0.07 ZZZ76812 TC A Ob us, detailed, addl fetus 0.00 3.41 3.39 NA NA 0.01 ZZZ76812 26 A Ob us, detailed, addl fetus 1.78 0.78 0.73 0.78 0.73 0.06 ZZZ76813 A Ob us nuchal meas, 1 gest 1.18 2.33 2.47 NA NA 0.05 XXX76813 TC A Ob us nuchal meas, 1 gest 0.00 1.81 1.99 NA NA 0.01 XXX76813 26 A Ob us nuchal meas, 1 gest 1.18 0.52 0.48 0.52 0.48 0.04 XXX76814 A Ob us nuchal meas, add-on 0.99 1.30 1.33 NA NA 0.04 XXX76814 TC A Ob us nuchal meas, add-on 0.00 0.86 0.93 NA NA 0.01 XXX76814 26 A Ob us nuchal meas, add-on 0.99 0.44 0.40 0.44 0.40 0.03 XXX76815 A Ob us, limited, fetus(s) 0.65 1.85 1.98 NA NA 0.02 XXX76815 TC A Ob us, limited, fetus(s) 0.00 1.59 1.72 NA NA 0.01 XXX76815 26 A Ob us, limited, fetus(s) 0.65 0.26 0.26 0.26 0.26 0.01 XXX76816 A Ob us, follow-up, per fetus 0.85 2.48 2.51 NA NA 0.04 XXX76816 TC A Ob us, follow-up, per fetus 0.00 2.11 2.16 NA NA 0.01 XXX76816 26 A Ob us, follow-up, per fetus 0.85 0.37 0.35 0.37 0.35 0.03 XXX76817 A Transvaginal us, obstetric 0.75 2.07 2.21 NA NA 0.04 XXX76817 TC A Transvaginal us, obstetric 0.00 1.77 1.91 NA NA 0.01 XXX76817 26 A Transvaginal us, obstetric 0.75 0.30 0.30 0.30 0.30 0.03 XXX76818 A Fetal biophys profile w/nst 1.05 2.37 2.48 NA NA 0.04 XXX76818 TC A Fetal biophys profile w/nst 0.00 1.91 2.04 NA NA 0.01 XXX76818 26 A Fetal biophys profile w/nst 1.05 0.46 0.44 0.46 0.44 0.03 XXX76819 A Fetal biophys profil w/o nst 0.77 1.70 1.87 NA NA 0.04 XXX76819 TC A Fetal biophys profil w/o nst 0.00 1.38 1.55 NA NA 0.01 XXX76819 26 A Fetal biophys profil w/o nst 0.77 0.32 0.32 0.32 0.32 0.03 XXX76820 A Umbilical artery echo 0.50 0.64 0.85 NA NA 0.02 XXXCMS-1503-P1073**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**76820 TC A Umbilical artery echo 0.00 0.42 0.64 NA NA 0.01 XXX76820 26 A Umbilical artery echo 0.50 0.22 0.21 0.22 0.21 0.01 XXX76821 A Middle cerebral artery echo 0.70 1.96 2.09 NA NA 0.04 XXX76821 TC A Middle cerebral artery echo 0.00 1.65 1.80 NA NA 0.01 XXX76821 26 A Middle cerebral arteryecho 0.70 0.31 0.29 0.31 0.29 0.03 XXX76825 A Echo exam of fetal heart 1.67 4.52 4.61 NA NA 0.05 XXX76825 TC A Echo exam of fetal heart 0.00 3.81 3.92 NA NA 0.01 XXX76825 26 A Echo exam of fetal heart 1.67 0.71 0.69 0.71 0.69 0.04 XXX76826 A Echo exam of fetal heart 0.83 2.83 2.77 NA NA 0.04 XXX76826 TC A Echo exam of fetal heart 0.00 2.48 2.44 NA NA 0.01 XXX76826 26 A Echo exam of fetal heart 0.83 0.35 0.33 0.35 0.33 0.03 XXX76827 A Echo exam of fetal heart 0.58 1.14 1.34 NA NA 0.02 XXX76827 TC A Echo exam of fetal heart 0.00 0.89 1.10 NA NA 0.01 XXX76827 26 A Echo exam of fetal heart 0.58 0.25 0.24 0.25 0.24 0.01 XXX76828 A Echo exam of fetal heart 0.56 0.72 0.84 NA NA 0.02 XXX76828 TC A Echo exam of fetal heart 0.00 0.47 0.61 NA NA 0.01 XXX76828 26 A Echo exam of fetal heart 0.56 0.25 0.23 0.25 0.23 0.01 XXX76830 A Transvaginal us, non-ob 0.69 2.78 2.89 NA NA 0.04 XXX76830 TC A Transvaginal us, non-ob 0.00 2.51 2.61 NA NA 0.01 XXX76830 26 A Transvaginal us, non-ob 0.69 0.27 0.28 0.27 0.28 0.03 XXX76831 A Echo exam, uterus 0.72 2.81 2.88 NA NA 0.04 XXX76831 TC A Echo exam, uterus 0.00 2.50 2.59 NA NA 0.01 XXX76831 26 A Echo exam, uterus 0.72 0.31 0.29 0.31 0.29 0.03 XXX76856 A Us exam, pelvic, complete 0.69 2.75 2.89 NA NA 0.04 XXX76856 TC A Us exam, pelvic, complete 0.00 2.49 2.61 NA NA 0.01 XXX76856 26 A Us exam, pelvic, complete 0.69 0.26 0.28 0.26 0.28 0.03 XXXCMS-1503-P1074**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**76857 A Us exam, pelvic, limited 0.38 2.29 2.53 NA NA 0.04 XXX76857 TC A Us exam, pelvic, limited 0.00 2.14 2.37 NA NA 0.01 XXX76857 26 A Us exam, pelvic, limited 0.38 0.15 0.16 0.15 0.16 0.03 XXX76870 A Us exam, scrotum 0.64 2.75 2.90 NA NA 0.05 XXX76870 TC A Us exam, scrotum 0.00 2.52 2.64 NA NA 0.01 XXX76870 26 A Us exam, scrotum 0.64 0.23 0.26 0.23 0.26 0.04 XXX76872 A Us, transrectal 0.69 3.01 3.37 NA NA 0.05 XXX76872 TC A Us, transrectal 0.00 2.74 3.07 NA NA 0.01 XXX76872 26 A Us, transrectal 0.69 0.27 0.30 0.27 0.30 0.04 XXX76873 A Echograp trans r, pros study 1.55 3.49 3.65 NA NA 0.09 XXX76873 TC A Echograp trans r, pros study 0.00 2.79 2.96 NA NA 0.01 XXX76873 26 A Echograp trans r, pros study 1.55 0.70 0.69 0.70 0.69 0.08 XXX76880 A Us exam, extremity 0.59 3.44 3.38 NA NA 0.04 XXX76880 TC A Us exam, extremity 0.00 3.23 3.16 NA NA 0.01 XXX76880 26 A Us exam, extremity 0.59 0.21 0.22 0.21 0.22 0.03 XXX76885 A Us exam infant hips, dynamic 0.74 3.36 3.42 NA NA 0.05 XXX76885 TC A Us exam infant hips, dynamic 0.00 3.09 3.12 NA NA 0.01 XXX76885 26 A Us exam infant hips, dynamic 0.74 0.27 0.30 0.27 0.30 0.04 XXX76886 A Us exam infant hips, static 0.62 2.95 2.71 NA NA 0.02 XXX76886 TC A Us exam infant hips, static 0.00 2.66 2.44 NA NA 0.01 XXX76886 26 A Us exam infant hips, static 0.62 0.29 0.27 0.29 0.27 0.01 XXX76930 A Echo guide, cardiocentesis 0.67 1.61 1.96 NA NA 0.02 XXX76930 TC A Echo guide, cardiocentesis 0.00 1.35 1.64 NA NA 0.01 XXX76930 26 A Echo guide, cardiocentesis 0.67 0.26 0.32 0.26 0.32 0.01 XXX76932 C Echo guide for heart biopsy 0.00 0.00 0.00 NA NA 0.00 XXX76932 TC C Echo guide for heart biopsy 0.00 0.00 0.00 NA NA 0.00 XXXCMS-1503-P1075**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**76932 26 A Echo guide for heart biopsy 0.67 0.26 0.32 0.26 0.32 0.04 XXX76936 A Echo guide for artery repair 1.99 6.13 6.83 NA NA 0.25 XXX76936 TC A Echo guide for artery repair 0.00 5.43 6.04 NA NA 0.01 XXX76936 26 A Echo guide for artery repair 1.99 0.70 0.79 0.70 0.79 0.24 XXX76937 A Us guide, vascular access 0.30 0.65 0.68 NA NA 0.04 ZZZ76937 TC A Us guide, vascular access 0.00 0.54 0.56 NA NA 0.01 ZZZ76937 26 A Us guide, vascular access 0.30 0.11 0.12 0.11 0.12 0.03 ZZZ76940 C Us guide, tissue ablation 0.00 0.00 0.00 NA NA 0.00 XXX76940 TC C Us guide, tissue ablation 0.00 0.00 0.00 NA NA 0.00 XXX76940 26 A Us guide, tissue ablation 2.00 0.77 0.80 0.77 0.80 0.30 XXX76941 C Echo guide for transfusion 0.00 0.00 0.00 NA NA 0.00 XXX76941 TC C Echo guide for transfusion 0.00 0.00 0.00 NA NA 0.00 XXX76941 26 A Echo guide for transfusion 1.34 0.60 0.57 0.60 0.57 0.11 XXX76942 A Echo guide for biopsy 0.67 4.81 5.00 NA NA 0.05 XXX76942 TC A Echo guide for biopsy 0.00 4.56 4.72 NA NA 0.01 XXX76942 26 A Echo guide for biopsy 0.67 0.25 0.28 0.25 0.28 0.04 XXX76945 C Echo guide, villus sampling 0.00 0.00 0.00 NA NA 0.00 XXX76945 TC C Echo guide, villus sampling 0.00 0.00 0.00 NA NA 0.00 XXX76945 26 A Echo guide, villus sampling 0.67 0.30 0.28 0.30 0.28 0.04 XXX76946 A Echo guide for amniocentesis 0.38 0.51 0.71 NA NA 0.02 XXX76946 TC A Echo guide for amniocentesis 0.00 0.34 0.55 NA NA 0.01 XXX76946 26 A Echo guide for amniocentesis 0.38 0.17 0.16 0.17 0.16 0.01 XXX76948 A Echo guide, ova aspiration 0.38 0.52 0.71 NA NA 0.04 XXX76948 TC A Echo guide, ova aspiration 0.00 0.35 0.55 NA NA 0.01 XXX76948 26 A Echo guide, ova aspiration 0.38 0.17 0.16 0.17 0.16 0.03 XXX76950 A Echo guidance radiotherapy 0.58 1.34 1.44 NA NA 0.04 XXXCMS-1503-P1076**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**76950 TC A Echo guidance radiotherapy 0.00 1.06 1.18 NA NA 0.01 XXX76950 26 A Echo guidance radiotherapy 0.58 0.28 0.26 0.28 0.26 0.03 XXX76965 A Echo guidance radiotherapy 1.34 1.23 2.06 NA NA 0.09 XXX76965 TC A Echo guidance radiotherapy 0.00 0.65 1.46 NA NA 0.01 XXX76965 26 A Echo guidance radiotherapy 1.34 0.58 0.60 0.58 0.60 0.08 XXX76970 A Ultrasound exam follow-up 0.40 2.52 2.35 NA NA 0.05 XXX76970 TC A Ultrasound exam follow-up 0.00 2.35 2.19 NA NA 0.01 XXX76970 26 A Ultrasound exam follow-up 0.40 0.17 0.16 0.17 0.16 0.04 XXX76975 C GI endoscopic ultrasound 0.00 0.00 0.00 NA NA 0.00 XXX76975 TC C GI endoscopic ultrasound 0.00 0.00 0.00 NA NA 0.00 XXX76975 26 A GI endoscopic ultrasound 0.81 0.39 0.38 0.39 0.38 0.08 XXX76977 A Us bone density measure 0.05 0.13 0.24 NA NA 0.02 XXX76977 TC A Us bone density measure 0.00 0.11 0.22 NA NA 0.01 XXX76977 26 A Us bone density measure 0.05 0.02 0.02 0.02 0.02 0.01 XXX76998 C Us guide, intraop 0.00 0.00 0.00 NA NA 0.00 XXX76998 TC C Us guide, intraop 0.00 0.00 0.00 NA NA 0.00 XXX76998 26 A Us guide, intraop 1.20 0.46 0.47 0.46 0.47 0.27 XXX76999 C Echo examination procedure 0.00 0.00 0.00 NA NA 0.00 XXX76999 TC C Echo examination procedure 0.00 0.00 0.00 NA NA 0.00 XXX76999 26 C Echo examination procedure 0.00 0.00 0.00 0.00 0.00 0.00 XXX77001 A Fluoroguide for vein device 0.38 2.89 2.88 NA NA 0.04 ZZZ77001 TC A Fluoroguide for vein device 0.00 2.75 2.73 NA NA 0.01 ZZZ77001 26 A Fluoroguide for vein device 0.38 0.14 0.15 0.14 0.15 0.03 ZZZ77002 A Needle localization by xray 0.54 1.62 1.61 NA NA 0.04 XXX77002 TC A Needle localization by xray 0.00 1.37 1.38 NA NA 0.01 XXX77002 26 A Needle localization byxray 0.54 0.25 0.23 0.25 0.23 0.03 XXXCMS-1503-P1077**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**77003 A Fluoroguide for spine inject 0.60 1.23 1.19 NA NA 0.04 XXX77003 TC A Fluoroguide for spine inject 0.00 0.94 0.95 NA NA 0.01 XXX77003 26 A Fluoroguide for spine inject 0.60 0.29 0.24 0.29 0.24 0.03 XXX77011 A Ct scan for localization 1.21 21.33 20.94 NA NA 0.05 XXX77011 TC A Ct scan for localization 0.00 20.78 20.40 NA NA 0.01 XXX77011 26 A Ct scan for localization 1.21 0.55 0.54 0.55 0.54 0.04 XXX77012 A Ct scan for needle biopsy 1.16 2.34 3.53 NA NA 0.05 XXX77012 TC A Ct scan for needle biopsy 0.00 1.94 3.06 NA NA 0.01 XXX77012 26 A Ct scan for needle biopsy 1.16 0.40 0.47 0.40 0.47 0.04 XXX77013 C Ct guide for tissue ablation 0.00 0.00 0.00 NA NA 0.00 XXX77013 TC C Ct guide for tissue ablation 0.00 0.00 0.00 NA NA 0.00 XXX77013 26 A Ct guide for tissue ablation 3.99 1.37 1.60 1.37 1.60 0.38 XXX77014 A Ct scan for therapy guide 0.85 4.69 4.79 NA NA 0.05 XXX77014 TC A Ct scan for therapy guide 0.00 4.27 4.41 NA NA 0.01 XXX77014 26 A Ct scan for therapy guide 0.85 0.42 0.38 0.42 0.38 0.04 XXX77021 A Mr guidance for needle place 1.50 9.40 10.88 NA NA 0.14 XXX77021 TC A Mr guidance for needle place 0.00 8.87 10.28 NA NA 0.01 XXX77021 26 A Mr guidance for needle place 1.50 0.53 0.60 0.53 0.60 0.13 XXX77022 C Mri for tissue ablation 0.00 0.00 0.00 NA NA 0.00 XXX77022 TC C Mri for tissue ablation 0.00 0.00 0.00 NA NA 0.00 XXX77022 26 A Mri for tissue ablation 4.24 1.53 1.66 1.53 1.66 0.40 XXX77031 A Stereotact guide for brst bx 1.59 1.92 2.97 NA NA 0.14 XXX77031 TC A Stereotact guide for brst bx 0.00 1.35 2.34 NA NA 0.01 XXX77031 26 A Stereotact guide for brstbx 1.59 0.57 0.63 0.57 0.63 0.13 XXX77032 A Guidance for needle, breast 0.56 0.82 1.02 NA NA 0.04 XXX77032 TC A Guidance for needle, breast 0.00 0.63 0.80 NA NA 0.01 XXXCMS-1503-P1078**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**77032 26 A Guidance for needle, breast 0.56 0.19 0.22 0.19 0.22 0.03 XXX77051 A Computer dx mammogram add-on 0.06 0.19 0.25 NA NA 0.02 ZZZ77051 TC A Computer dx mammogram add-on 0.00 0.17 0.23 NA NA 0.01 ZZZ77051 26 A Computer dx mammogram add-on 0.06 0.02 0.02 0.02 0.02 0.01 ZZZ77052 A Comp screen mammogram add-on 0.06 0.19 0.25 NA NA 0.02 ZZZ77052 TC A Comp screen mammogram add-on 0.00 0.17 0.23 NA NA 0.01 ZZZ77052 26 A Comp screen mammogram add-on 0.06 0.02 0.02 0.02 0.02 0.01 ZZZ77053 A X-ray of mammary duct 0.36 1.20 1.57 NA NA 0.02 XXX77053 TC A X-ray of mammary duct 0.00 1.08 1.43 NA NA 0.01 XXX77053 26 A X-ray of mammary duct 0.36 0.12 0.14 0.12 0.14 0.01 XXX77054 A X-ray of mammary ducts 0.45 1.67 2.16 NA NA 0.04 XXX77054 TC A X-ray of mammary ducts 0.00 1.51 1.98 NA NA 0.01 XXX77054 26 A X-ray of mammary ducts 0.45 0.16 0.18 0.16 0.18 0.03 XXX77055 A Mammogram, one breast 0.70 1.63 1.75 NA NA 0.05 XXX77055 TC A Mammogram, one breast 0.00 1.38 1.47 NA NA 0.01 XXX77055 26 A Mammogram, one breast 0.70 0.25 0.28 0.25 0.28 0.04 XXX77056 A Mammogram, both breasts 0.87 2.11 2.26 NA NA 0.07 XXX77056 TC A Mammogram, both breasts 0.00 1.81 1.92 NA NA 0.01 XXX77056 26 A Mammogram, both breasts 0.87 0.30 0.34 0.30 0.34 0.06 XXX77057 A Mammogram, screening 0.70 1.44 1.60 NA NA 0.05 XXX77057 TC A Mammogram, screening 0.00 1.19 1.32 NA NA 0.01 XXX77057 26 A Mammogram, screening 0.70 0.25 0.28 0.25 0.28 0.04 XXX77058 A Mri, one breast 1.63 15.45 20.13 NA NA 0.11 XXX77058 TC A Mri, one breast 0.00 14.89 19.49 NA NA 0.01 XXX77058 26 A Mri, one breast 1.63 0.56 0.64 0.56 0.64 0.10 XXX77059 A Mri, both breasts 1.63 15.36 20.97 NA NA 0.11 XXXCMS-1503-P1079**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**77059 TC A Mri, both breasts 0.00 14.80 20.33 NA NA 0.01 XXX77059 26 A Mri, both breasts 1.63 0.56 0.64 0.56 0.64 0.10 XXX77071 A X-ray stress view 0.41 1.00 0.88 1.00 0.88 0.07 XXX77072 A X-rays for bone age 0.19 0.44 0.48 NA NA 0.02 XXX77072 TC A X-rays for bone age 0.00 0.37 0.40 NA NA 0.01 XXX77072 26 A X-rays for bone age 0.19 0.07 0.08 0.07 0.08 0.01 XXX77073 A X-rays, bone length studies 0.27 0.78 0.82 NA NA 0.05 XXX77073 TC A X-rays, bone length studies 0.00 0.65 0.69 NA NA 0.01 XXX77073 26 A X-rays, bone length studies 0.27 0.13 0.13 0.13 0.13 0.04 XXX77074 A X-rays, bone survey, limited 0.45 1.42 1.53 NA NA 0.04 XXX77074 TC A X-rays, bone survey, limited 0.00 1.26 1.35 NA NA 0.01 XXX77074 26 A X-rays, bone survey, limited 0.45 0.16 0.18 0.16 0.18 0.03 XXX77075 A X-rays, bone survey complete 0.54 2.25 2.40 NA NA 0.04 XXX77075 TC A X-rays, bone survey complete 0.00 2.06 2.18 NA NA 0.01 XXX77075 26 A X-rays, bone survey complete 0.54 0.19 0.22 0.19 0.22 0.03 XXX77076 A X-rays, bone survey, infant 0.70 2.15 2.15 NA NA 0.05 XXX77076 TC A X-rays, bone survey, infant 0.00 1.90 1.89 NA NA 0.01 XXX77076 26 A X-rays, bone survey, infant 0.70 0.25 0.26 0.25 0.26 0.04 XXX77077 A Joint survey, single view 0.31 0.80 0.88 NA NA 0.05 XXX77077 TC A Joint survey, single view 0.00 0.65 0.74 NA NA 0.01 XXX77077 26 A Joint survey, single view 0.31 0.15 0.14 0.15 0.14 0.04 XXX77078 A Ct bone density, axial 0.25 3.42 4.29 NA NA 0.02 XXX77078 TC A Ct bone density, axial 0.00 3.33 4.19 NA NA 0.01 XXX77078 26 A Ct bone density, axial 0.25 0.09 0.10 0.09 0.10 0.01 XXX77079 A Ct bone density, peripheral 0.22 0.91 1.24 NA NA 0.02 XXX77079 TC A Ct bone density, peripheral 0.00 0.81 1.15 NA NA 0.01 XXXCMS-1503-P1080**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**77079 26 A Ct bone density, peripheral 0.22 0.10 0.09 0.10 0.09 0.01 XXX77080 A Dxa bone density, axial 0.32 3.46 3.46 NA NA 0.19 XXX77080 TC A Dxa bone density, axial 0.00 3.35 3.35 NA NA 0.18 XXX77080 26 A Dxa bone density, axial 0.32 0.11 0.11 0.11 0.11 0.01 XXX77081 A Dxa bone density/peripheral 0.22 0.61 0.61 NA NA 0.02 XXX77081 TC A Dxa bone density/peripheral 0.00 0.55 0.55 NA NA 0.01 XXX77081 26 A Dxa bone density/peripheral 0.22 0.06 0.06 0.06 0.06 0.01 XXX77082 A Dxa bone density, vert fx 0.18 0.87 0.87 NA NA 0.06 XXX77082 TC A Dxa bone density, vert fx 0.00 0.81 0.81 NA NA 0.05 XXX77082 26 A Dxa bone density, vert fx 0.18 0.06 0.06 0.06 0.06 0.01 XXX77083 A Radiographic absorptiometry 0.20 0.46 0.52 NA NA 0.02 XXX77083 TC A Radiographic absorptiometry 0.00 0.37 0.44 NA NA 0.01 XXX77083 26 A Radiographic absorptiometry 0.20 0.09 0.08 0.09 0.08 0.01 XXX77084 A Magnetic image, bone marrow 1.60 10.57 13.56 NA NA 0.11 XXX77084 TC A Magnetic image, bone marrow 0.00 10.00 12.92 NA NA 0.01 XXX77084 26 A Magnetic image, bone marrow 1.60 0.57 0.64 0.57 0.64 0.10 XXX77261 A Radiation therapy planning 1.39 0.72 0.67 0.72 0.67 0.10 XXX77262 A Radiation therapy planning 2.11 1.05 0.97 1.05 0.97 0.18 XXX77263 A Radiation therapy planning 3.14 1.56 1.44 1.56 1.44 0.27 XXX77280 A Set radiation therapy field 0.70 4.71 4.88 NA NA 0.04 XXX77280 TC A Set radiation therapy field 0.00 4.36 4.56 NA NA 0.01 XXX77280 26 A Set radiation therapy field 0.70 0.35 0.32 0.35 0.32 0.03 XXX77285 A Set radiation therapy field 1.05 8.52 8.71 NA NA 0.07 XXX77285 TC A Set radiation therapy field 0.00 8.00 8.24 NA NA 0.01 XXX77285 26 A Set radiation therapy field 1.05 0.52 0.47 0.52 0.47 0.06 XXX77290 A Set radiation therapy field 1.56 14.18 14.10 NA NA 0.08 XXXCMS-1503-P1081**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**77290 TC A Set radiation therapy field 0.00 13.40 13.39 NA NA 0.01 XXX77290 26 A Set radiation therapy field 1.56 0.78 0.71 0.78 0.71 0.07 XXX77295 A Set radiation therapy field 4.56 8.42 11.95 NA NA 0.29 XXX77295 TC A Set radiation therapy field 0.00 6.15 9.88 NA NA 0.04 XXX77295 26 A Set radiation therapy field 4.56 2.27 2.07 2.27 2.07 0.25 XXX77299 C Radiation therapy planning 0.00 0.00 0.00 NA NA 0.00 XXX77299 TC C Radiation therapy planning 0.00 0.00 0.00 NA NA 0.00 XXX77299 26 C Radiation therapy planning 0.00 0.00 0.00 0.00 0.00 0.00 XXX77300 A Radiation therapy dose plan 0.62 1.33 1.42 NA NA 0.04 XXX77300 TC A Radiation therapy dose plan 0.00 1.02 1.14 NA NA 0.01 XXX77300 26 A Radiation therapy dose plan 0.62 0.31 0.28 0.31 0.28 0.03 XXX77301 A Radiotherapy dose plan,imrt 7.99 60.71 60.43 NA NA 0.65 XXX77301 TC A Radiotherapy dose plan,imrt 0.00 56.74 56.80 NA NA 0.23 XXX77301 26 A Radiotherapy dose plan,imrt 7.99 3.97 3.63 3.97 3.63 0.42 XXX77305 A Teletx isodose plan simple 0.70 1.04 1.24 NA NA 0.04 XXX77305 TC A Teletx isodose plan simple 0.00 0.69 0.92 NA NA 0.01 XXX77305 26 A Teletx isodose plan simple 0.70 0.35 0.32 0.35 0.32 0.03 XXX77310 A Teletx isodose plan intermed 1.05 1.46 1.70 NA NA 0.07 XXX77310 TC A Teletx isodose plan intermed 0.00 0.94 1.22 NA NA 0.01 XXX77310 26 A Teletx isodose plan intermed 1.05 0.52 0.48 0.52 0.48 0.06 XXX77315 A Teletx isodose plan complex 1.56 2.41 2.62 NA NA 0.08 XXX77315 TC A Teletx isodose plan complex 0.00 1.63 1.91 NA NA 0.01 XXX77315 26 A Teletx isodose plan complex 1.56 0.78 0.71 0.78 0.71 0.07 XXX77321 A Special teletx port plan 0.95 1.71 2.19 NA NA 0.05 XXX77321 TC A Special teletx port plan 0.00 1.24 1.76 NA NA 0.01 XXX77321 26 A Special teletx port plan 0.95 0.47 0.43 0.47 0.43 0.04 XXXCMS-1503-P1082**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**77326 A Brachytx isodose calc simp 0.93 3.25 3.34 NA NA 0.07 XXX77326 TC A Brachytx isodose calc simp 0.00 2.78 2.92 NA NA 0.03 XXX77326 26 A Brachytx isodose calc simp 0.93 0.47 0.42 0.47 0.42 0.04 XXX77327 A Brachytx isodose calc interm 1.39 4.47 4.64 NA NA 0.10 XXX77327 TC A Brachytx isodose calc interm 0.00 3.78 4.01 NA NA 0.03 XXX77327 26 A Brachytx isodose calc interm 1.39 0.69 0.63 0.69 0.63 0.07 XXX77328 A Brachytx isodose plan compl 2.09 5.75 6.05 NA NA 0.14 XXX77328 TC A Brachytx isodose plan compl 0.00 4.71 5.10 NA NA 0.04 XXX77328 26 A Brachytx isodose plan compl 2.09 1.04 0.95 1.04 0.95 0.10 XXX77331 A Special radiation dosimetry 0.87 0.97 0.97 NA NA 0.05 XXX77331 TC A Special radiation dosimetry 0.00 0.54 0.57 NA NA 0.01 XXX77331 26 A Special radiation dosimetry 0.87 0.43 0.40 0.43 0.40 0.04 XXX77332 A Radiation treatment aid(s) 0.54 1.69 1.76 NA NA 0.04 XXX77332 TC A Radiation treatment aid(s) 0.00 1.42 1.52 NA NA 0.01 XXX77332 26 A Radiation treatment aid(s) 0.54 0.27 0.24 0.27 0.24 0.03 XXX77333 A Radiation treatment aid(s) 0.84 0.67 0.89 NA NA 0.05 XXX77333 TC A Radiation treatment aid(s) 0.00 0.25 0.51 NA NA 0.01 XXX77333 26 A Radiation treatment aid(s) 0.84 0.42 0.38 0.42 0.38 0.04 XXX77334 A Radiation treatment aid(s) 1.24 3.02 3.27 NA NA 0.07 XXX77334 TC A Radiation treatment aid(s) 0.00 2.40 2.71 NA NA 0.01 XXX77334 26 A Radiation treatment aid(s) 1.24 0.62 0.56 0.62 0.56 0.06 XXX77336 A Radiation physics consult 0.00 1.18 1.54 NA NA 0.01 XXX77338 A Design mlc device for imrt 4.29 10.10 10.10 NA NA 0.28 XXX77338 TC A Design mlc device for imrt 0.00 7.96 7.96 NA NA 0.04 XXX77338 26 A Design mlc device for imrt 4.29 2.14 2.14 2.14 2.14 0.24 XXX77370 A Radiation physics consult 0.00 3.16 3.44 NA NA 0.04 XXXCMS-1503-P1083**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**77371 C Srs, multisource 0.00 0.00 0.00 0.00 0.00 0.00 XXX77372 A Srs, linear based 0.00 23.63 25.23 NA NA 0.06 XXX77373 A Sbrt delivery 0.00 44.40 47.10 NA NA 0.07 XXX77399 C External radiation dosimetry 0.00 0.00 0.00 NA NA 0.00 XXX77399 TC C External radiation dosimetry 0.00 0.00 0.00 NA NA 0.00 XXX77399 26 C External radiation dosimetry 0.00 0.00 0.00 0.00 0.00 0.00 XXX77401 A Radiation treatment delivery 0.00 0.54 0.74 NA NA 0.01 XXX77402 A Radiation treatment delivery 0.00 5.74 5.08 NA NA 0.01 XXX77403 A Radiation treatment delivery 0.00 3.89 3.88 NA NA 0.01 XXX77404 A Radiation treatment delivery 0.00 4.37 4.31 NA NA 0.01 XXX77406 A Radiation treatment delivery 0.00 4.39 4.34 NA NA 0.01 XXX77407 A Radiation treatment delivery 0.00 7.82 7.38 NA NA 0.01 XXX77408 A Radiation treatment delivery 0.00 5.37 5.28 NA NA 0.01 XXX77409 A Radiation treatment delivery 0.00 6.01 5.87 NA NA 0.01 XXX77411 A Radiation treatment delivery 0.00 5.99 5.85 NA NA 0.01 XXX77412 A Radiation treatment delivery 0.00 7.09 6.90 NA NA 0.01 XXX77413 A Radiation treatment delivery 0.00 7.11 6.94 NA NA 0.01 XXX77414 A Radiation treatment delivery 0.00 8.01 7.77 NA NA 0.01 XXX77416 A Radiation treatment delivery 0.00 8.05 7.80 NA NA 0.01 XXX77417 A Radiology port film(s) 0.00 0.38 0.44 NA NA 0.01 XXX77418 A Radiation tx delivery, imrt 0.00 13.68 15.38 NA NA 0.01 XXX77421 A Stereoscopic x-ray guidance 0.39 2.54 2.86 NA NA 0.02 XXX77421 TC A Stereoscopic x-ray guidance 0.00 2.35 2.68 NA NA 0.01 XXX77421 26 A Stereoscopic x-ray guidance 0.39 0.19 0.18 0.19 0.18 0.01 XXX77422 A Neutron beam tx, simple 0.00 5.50 5.90 NA NA 0.01 XXX77423 A Neutron beam tx, complex 0.00 7.77 7.52 NA NA 0.01 XXXCMS-1503-P1084**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**77427 A Radiation tx management, x5 3.70 2.02 1.83 2.02 1.83 0.31 XXX77431 A Radiation therapy management 1.81 1.08 1.01 1.08 1.01 0.14 XXX77432 A Stereotactic radiationtrmt 7.92 3.97 3.66 3.97 3.66 0.68 XXX77435 A Sbrt management13.00 6.67 6.21 6.67 6.21 1.12 XXX77470 A Special radiation treatment 2.09 2.33 3.81 NA NA 0.11 XXX77470 TC A Special radiation treatment 0.00 1.29 2.86 NA NA 0.01 XXX77470 26 A Special radiation treatment 2.09 1.04 0.95 1.04 0.95 0.10 XXX77499 C Radiation therapy management 0.00 0.00 0.00 NA NA 0.00 XXX77499 TC C Radiation therapy management 0.00 0.00 0.00 NA NA 0.00 XXX77499 26 C Radiation therapy management 0.00 0.00 0.00 0.00 0.00 0.00 XXX77520 C Proton trmt, simple w/o comp 0.00 0.00 0.00 0.00 0.00 0.00 XXX77522 C Proton trmt, simple w/comp 0.00 0.00 0.00 0.00 0.00 0.00 XXX77523 C Proton trmt, intermediate 0.00 0.00 0.00 0.00 0.00 0.00 XXX77525 C Proton treatment, complex 0.00 0.00 0.00 0.00 0.00 0.00 XXX77600 R Hyperthermia treatment 1.56 10.84 10.50 NA NA 0.10 XXX77600 TC R Hyperthermia treatment 0.00 10.05 9.78 NA NA 0.03 XXX77600 26 R Hyperthermia treatment 1.56 0.79 0.72 0.79 0.72 0.07 XXX77605 R Hyperthermia treatment 2.09 29.52 24.33 NA NA 0.43 XXX77605 TC R Hyperthermia treatment 0.00 28.62 23.52 NA NA 0.03 XXX77605 26 R Hyperthermia treatment 2.09 0.90 0.81 0.90 0.81 0.40 XXX77610 R Hyperthermia treatment 1.56 18.12 18.24 NA NA 0.10 XXX77610 TC R Hyperthermia treatment 0.00 17.35 17.57 NA NA 0.03 XXX77610 26 R Hyperthermia treatment 1.56 0.77 0.67 0.77 0.67 0.07 XXX77615 R Hyperthermia treatment 2.09 27.27 26.70 NA NA 0.17 XXX77615 TC R Hyperthermia treatment 0.00 26.22 25.75 NA NA 0.07 XXX77615 26 R Hyperthermia treatment 2.09 1.05 0.95 1.05 0.95 0.10 XXXCMS-1503-P1085**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**77620 R Hyperthermia treatment 1.56 13.94 12.29 NA NA 0.08 XXX77620 TC R Hyperthermia treatment 0.00 13.27 11.68 NA NA 0.04 XXX77620 26 R Hyperthermia treatment 1.56 0.67 0.61 0.67 0.61 0.04 XXX77750 A Infuse radioactive materials 5.00 5.51 5.25 NA NA 0.30 09077750 TC A Infuse radioactive materials 0.00 3.04 3.00 NA NA 0.03 09077750 26 A Infuse radioactive materials 5.00 2.47 2.25 2.47 2.25 0.27 09077761 A Apply intrcav radiat simple 3.85 7.05 6.90 NA NA 0.25 09077761 TC A Apply intrcav radiat simple 0.00 5.17 5.20 NA NA 0.04 09077761 26 A Apply intrcav radiat simple 3.85 1.88 1.70 1.88 1.70 0.21 09077762 A Apply intrcav radiat interm 5.76 8.78 8.65 NA NA 0.37 09077762 TC A Apply intrcav radiat interm 0.00 5.97 6.07 NA NA 0.06 09077762 26 A Apply intrcav radiat interm 5.76 2.81 2.58 2.81 2.58 0.31 09077763 A Apply intrcav radiat compl 8.66 11.99 11.74 NA NA 0.52 09077763 TC A Apply intrcav radiat compl 0.00 7.76 7.86 NA NA 0.07 09077763 26 A Apply intrcav radiat compl 8.66 4.23 3.88 4.23 3.88 0.45 09077776 A Apply interstit radiat simpl 4.70 7.61 7.57 NA NA 0.38 09077776 TC A Apply interstit radiat simpl 0.00 5.24 5.44 NA NA 0.06 09077776 26 A Apply interstit radiat simpl 4.70 2.37 2.13 2.37 2.13 0.32 09077777 A Apply interstit radiat inter 7.52 9.25 9.33 NA NA 0.57 09077777 TC A Apply interstit radiat inter 0.00 5.62 5.91 NA NA 0.06 09077777 26 A Apply interstit radiat inter 7.52 3.63 3.42 3.63 3.42 0.51 09077778 A Apply interstit radiat compl 11.32 13.39 13.14 NA NA 0.70 09077778 TC A Apply interstit radiat compl 0.00 7.87 8.06 NA NA 0.08 09077778 26 A Apply interstit radiat compl 11.32 5.52 5.08 5.52 5.08 0.62 09077785 A Hdr brachytx, 1 channel 1.42 5.81 5.05 NA NA 0.10 XXX77785 TC A Hdr brachytx, 1 channel 0.00 5.11 4.40 NA NA 0.03 XXXCMS-1503-P1086**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**77785 26 A Hdr brachytx, 1 channel 1.42 0.70 0.65 0.70 0.65 0.07 XXX77786 A Hdr brachytx, 2-12 channel 3.25 12.94 13.55 NA NA 0.23 XXX77786 TC A Hdr brachytx, 2-12 channel 0.00 11.32 12.11 NA NA 0.06 XXX77786 26 A Hdr brachytx, 2-12 channel 3.25 1.62 1.44 1.62 1.44 0.17 XXX77787 A Hdr brachytx over 12 chan 4.89 22.87 21.94 NA NA 0.35 XXX77787 TC A Hdr brachytx over 12 chan 0.00 20.42 19.68 NA NA 0.08 XXX77787 26 A Hdr brachytx over 12 chan 4.89 2.45 2.26 2.45 2.26 0.27 XXX77789 A Apply surface radiation 1.14 2.23 2.12 NA NA 0.07 00077789 TC A Apply surface radiation 0.00 1.64 1.59 NA NA 0.01 00077789 26 A Apply surface radiation 1.14 0.59 0.53 0.59 0.53 0.06 00077790 A Radiation handling 1.05 1.68 1.62 NA NA 0.05 XXX77790 TC A Radiation handling 0.00 1.17 1.15 NA NA 0.01 XXX77790 26 A Radiation handling 1.05 0.51 0.47 0.51 0.47 0.04 XXX77799 C Radium/radioisotope therapy 0.00 0.00 0.00 NA NA 0.00 XXX77799 TC C Radium/radioisotope therapy 0.00 0.00 0.00 NA NA 0.00 XXX77799 26 C Radium/radioisotope therapy 0.00 0.00 0.00 0.00 0.00 0.00 XXX78000 A Thyroid, single uptake 0.19 1.73 1.85 NA NA 0.02 XXX78000 TC A Thyroid, single uptake 0.00 1.67 1.78 NA NA 0.01 XXX78000 26 A Thyroid, single uptake 0.19 0.06 0.07 0.06 0.07 0.01 XXX78001 A Thyroid, multiple uptakes 0.26 2.22 2.35 NA NA 0.04 XXX78001 TC A Thyroid, multiple uptakes 0.00 2.13 2.25 NA NA 0.03 XXX78001 26 A Thyroid, multiple uptakes 0.26 0.09 0.10 0.09 0.10 0.01 XXX78003 A Thyroid suppress/stimul 0.33 1.85 1.95 NA NA 0.02 XXX78003 TC A Thyroid suppress/stimul 0.00 1.73 1.82 NA NA 0.01 XXX78003 26 A Thyroid suppress/stimul0.33 0.12 0.13 0.12 0.13 0.01 XXX78006 A Thyroid imaging with uptake 0.49 6.04 6.20 NA NA 0.06 XXXCMS-1503-P1087**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**78006 TC A Thyroid imaging with uptake 0.00 5.88 6.01 NA NA 0.03 XXX78006 26 A Thyroid imaging with uptake 0.49 0.16 0.19 0.16 0.19 0.03 XXX78007 A Thyroid image, mult uptakes 0.50 6.41 5.01 NA NA 0.06 XXX78007 TC A Thyroid image, mult uptakes 0.00 6.24 4.81 NA NA 0.03 XXX78007 26 A Thyroid image, mult uptakes 0.50 0.17 0.20 0.17 0.20 0.03 XXX78010 A Thyroid imaging 0.39 4.15 4.25 NA NA 0.04 XXX78010 TC A Thyroid imaging 0.00 4.02 4.10 NA NA 0.03 XXX78010 26 A Thyroid imaging 0.39 0.13 0.15 0.13 0.15 0.01 XXX78011 A Thyroid imaging with flow 0.45 4.40 4.66 NA NA 0.06 XXX78011 TC A Thyroid imaging with flow 0.00 4.24 4.48 NA NA 0.03 XXX78011 26 A Thyroid imaging with flow 0.45 0.16 0.18 0.16 0.18 0.03 XXX78015 A Thyroid met imaging 0.67 5.20 5.45 NA NA 0.07 XXX78015 TC A Thyroid met imaging 0.00 4.99 5.20 NA NA 0.03 XXX78015 26 A Thyroid met imaging 0.67 0.21 0.25 0.21 0.25 0.04 XXX78016 A Thyroid met imaging/studies 0.82 6.95 7.94 NA NA 0.06 XXX78016 TC A Thyroid met imaging/studies 0.00 6.81 7.69 NA NA 0.03 XXX78016 26 A Thyroid met imaging/studies 0.82 0.14 0.25 0.14 0.25 0.03 XXX78018 A Thyroid met imaging, body 0.86 7.57 8.22 NA NA 0.07 XXX78018 TC A Thyroid met imaging, body 0.00 7.31 7.90 NA NA 0.03 XXX78018 26 A Thyroid met imaging, body 0.86 0.26 0.32 0.26 0.32 0.04 XXX78020 A Thyroid met uptake 0.60 1.60 1.86 NA NA 0.04 ZZZ78020 TC A Thyroid met uptake 0.00 1.44 1.64 NA NA 0.01 ZZZ78020 26 A Thyroid met uptake 0.60 0.16 0.22 0.16 0.22 0.03 ZZZ78070 A Parathyroid nuclear imaging 0.82 3.24 3.88 NA NA 0.07 XXX78070 TC A Parathyroid nuclear imaging 0.00 2.98 3.56 NA NA 0.03 XXX78070 26 A Parathyroid nuclear imaging 0.82 0.26 0.32 0.26 0.32 0.04 XXXCMS-1503-P1088**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**78075 A Adrenal nuclear imaging 0.74 10.74 11.42 NA NA 0.08 XXX78075 TC A Adrenal nuclear imaging 0.00 10.53 11.14 NA NA 0.04 XXX78075 26 A Adrenal nuclear imaging 0.74 0.21 0.28 0.21 0.28 0.04 XXX78099 C Endocrine nuclear procedure 0.00 0.00 0.00 NA NA 0.00 XXX78099 TC C Endocrine nuclear procedure 0.00 0.00 0.00 NA NA 0.00 XXX78099 26 C Endocrine nuclear procedure 0.00 0.00 0.00 0.00 0.00 0.00 XXX78102 A Bone marrow imaging, ltd 0.55 3.90 4.18 NA NA 0.06 XXX78102 TC A Bone marrow imaging, ltd 0.00 3.74 3.97 NA NA 0.03 XXX78102 26 A Bone marrow imaging, ltd 0.55 0.16 0.21 0.16 0.21 0.03 XXX78103 A Bone marrow imaging, mult 0.75 5.03 5.49 NA NA 0.07 XXX78103 TC A Bone marrow imaging, mult 0.00 4.82 5.22 NA NA 0.03 XXX78103 26 A Bone marrow imaging, mult 0.75 0.21 0.27 0.21 0.27 0.04 XXX78104 A Bone marrow imaging, body 0.80 5.73 6.30 NA NA 0.07 XXX78104 TC A Bone marrow imaging, body 0.00 5.49 6.00 NA NA 0.03 XXX78104 26 A Bone marrow imaging, body 0.80 0.24 0.30 0.24 0.30 0.04 XXX78110 A Plasma volume, single 0.19 2.09 2.15 NA NA 0.04 XXX78110 TC A Plasma volume, single 0.00 2.02 2.07 NA NA 0.03 XXX78110 26 A Plasma volume, single 0.19 0.07 0.08 0.07 0.08 0.01 XXX78111 A Plasma volume, multiple 0.22 1.77 2.29 NA NA 0.04 XXX78111 TC A Plasma volume, multiple 0.00 1.73 2.21 NA NA 0.03 XXX78111 26 A Plasma volume, multiple0.22 0.04 0.08 0.04 0.08 0.01 XXX78120 A Red cell mass, single 0.23 2.02 2.24 NA NA 0.04 XXX78120 TC A Red cell mass, single 0.00 1.94 2.15 NA NA 0.03 XXX78120 26 A Red cell mass, single 0.23 0.08 0.09 0.08 0.09 0.01 XXX78121 A Red cell mass, multiple 0.32 2.13 2.53 NA NA 0.04 XXX78121 TC A Red cell mass, multiple 0.00 2.02 2.40 NA NA 0.03 XXXCMS-1503-P1089**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**78121 26 A Red cell mass, multiple 0.32 0.11 0.13 0.11 0.13 0.01 XXX78122 A Blood volume 0.45 2.01 2.75 NA NA 0.04 XXX78122 TC A Blood volume 0.00 1.88 2.59 NA NA 0.03 XXX78122 26 A Blood volume 0.45 0.13 0.16 0.13 0.16 0.01 XXX78130 A Red cell survival study 0.61 3.41 3.76 NA NA 0.08 XXX78130 TC A Red cell survival study 0.00 3.19 3.51 NA NA 0.04 XXX78130 26 A Red cell survival study 0.61 0.22 0.25 0.22 0.25 0.04 XXX78135 A Red cell survival kinetics 0.64 8.87 9.15 NA NA 0.07 XXX78135 TC A Red cell survival kinetics 0.00 8.64 8.89 NA NA 0.03 XXX78135 26 A Red cell survival kinetics 0.64 0.23 0.26 0.23 0.26 0.04 XXX78140 A Red cell sequestration 0.61 2.76 3.32 NA NA 0.07 XXX78140 TC A Red cell sequestration 0.00 2.55 3.08 NA NA 0.03 XXX78140 26 A Red cell sequestration 0.61 0.21 0.24 0.21 0.24 0.04 XXX78185 A Spleen imaging 0.40 5.16 5.31 NA NA 0.04 XXX78185 TC A Spleen imaging 0.00 5.02 5.15 NA NA 0.03 XXX78185 26 A Spleen imaging 0.40 0.14 0.16 0.14 0.16 0.01 XXX78190 A Platelet survival, kinetics 1.09 9.16 9.73 NA NA 0.07 XXX78190 TC A Platelet survival, kinetics 0.00 8.75 9.30 NA NA 0.03 XXX78190 26 A Platelet survival, kinetics 1.09 0.41 0.43 0.41 0.43 0.04 XXX78191 A Platelet survival0.61 3.43 4.41 NA NA 0.08 XXX78191 TC A Platelet survival0.00 3.21 4.17 NA NA 0.04 XXX78191 26 A Platelet survival0.61 0.22 0.24 0.22 0.24 0.04 XXX78195 A Lymph system imaging 1.20 8.47 8.82 NA NA 0.10 XXX78195 TC A Lymph system imaging 0.00 8.08 8.36 NA NA 0.03 XXX78195 26 A Lymph system imaging 1.20 0.39 0.46 0.39 0.46 0.07 XXX78199 C Blood/lymph nuclear exam 0.00 0.00 0.00 NA NA 0.00 XXXCMS-1503-P1090**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**78199 TC C Blood/lymph nuclear exam 0.00 0.00 0.00 NA NA 0.00 XXX78199 26 C Blood/lymph nuclear exam 0.00 0.00 0.00 0.00 0.00 0.00 XXX78201 A Liver imaging 0.44 4.72 4.83 NA NA 0.07 XXX78201 TC A Liver imaging 0.00 4.58 4.67 NA NA 0.03 XXX78201 26 A Liver imaging 0.44 0.14 0.16 0.14 0.16 0.04 XXX78202 A Liver imaging with flow 0.51 4.84 5.28 NA NA 0.04 XXX78202 TC A Liver imaging with flow 0.00 4.71 5.10 NA NA 0.03 XXX78202 26 A Liver imaging with flow 0.51 0.13 0.18 0.13 0.18 0.01 XXX78205 A Liver imaging (3D) 0.71 4.94 5.77 NA NA 0.07 XXX78205 TC A Liver imaging (3D) 0.00 4.73 5.50 NA NA 0.03 XXX78205 26 A Liver imaging (3D) 0.71 0.21 0.27 0.21 0.27 0.04 XXX78206 A Liver image (3d) with flow 0.96 8.34 8.97 NA NA 0.07 XXX78206 TC A Liver image (3d) with flow 0.00 8.04 8.60 NA NA 0.03 XXX78206 26 A Liver image (3d) with flow 0.96 0.30 0.37 0.30 0.37 0.04 XXX78215 A Liver and spleen imaging 0.49 4.65 4.96 NA NA 0.06 XXX78215 TC A Liver and spleen imaging 0.00 4.49 4.77 NA NA 0.03 XXX78215 26 A Liver and spleen imaging 0.49 0.16 0.19 0.16 0.19 0.03 XXX78216 A Liver & spleen image/flow 0.57 2.61 3.13 NA NA 0.06 XXX78216 TC A Liver & spleen image/flow 0.00 2.43 2.92 NA NA 0.03 XXX78216 26 A Liver & spleen image/flow 0.57 0.18 0.21 0.18 0.21 0.03 XXX78220 A Liver function study 0.49 2.86 3.41 NA NA 0.04 XXX78220 TC A Liver function study 0.00 2.71 3.22 NA NA 0.03 XXX78220 26 A Liver function study 0.49 0.15 0.19 0.15 0.19 0.01 XXX78223 A Hepatobiliary imaging 0.84 8.32 8.57 NA NA 0.07 XXX78223 TC A Hepatobiliary imaging 0.00 8.04 8.24 NA NA 0.03 XXX78223 26 A Hepatobiliary imaging 0.84 0.28 0.33 0.28 0.33 0.04 XXXCMS-1503-P1091**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**78230 A Salivary gland imaging 0.45 4.07 4.24 NA NA 0.06 XXX78230 TC A Salivary gland imaging 0.00 3.91 4.07 NA NA 0.03 XXX78230 26 A Salivary gland imaging 0.45 0.16 0.17 0.16 0.17 0.03 XXX78231 A Serial salivary imaging 0.52 2.71 3.13 NA NA 0.04 XXX78231 TC A Serial salivary imaging 0.00 2.53 2.93 NA NA 0.03 XXX78231 26 A Serial salivary imaging 0.52 0.18 0.20 0.18 0.20 0.01 XXX78232 A Salivary gland function exam 0.47 2.08 2.88 NA NA 0.06 XXX78232 TC A Salivary gland function exam 0.00 2.00 2.73 NA NA 0.03 XXX78232 26 A Salivary gland function exam 0.47 0.08 0.15 0.08 0.15 0.03 XXX78258 A Esophageal motility study 0.74 5.45 5.76 NA NA 0.06 XXX78258 TC A Esophageal motility study 0.00 5.20 5.46 NA NA 0.03 XXX78258 26 A Esophageal motility study 0.74 0.25 0.30 0.25 0.30 0.03 XXX78261 A Gastric mucosa imaging 0.69 5.99 6.40 NA NA 0.07 XXX78261 TC A Gastric mucosa imaging 0.00 5.75 6.12 NA NA 0.03 XXX78261 26 A Gastric mucosa imaging 0.69 0.24 0.28 0.24 0.28 0.04 XXX78262 A Gastroesophageal reflux exam 0.68 5.92 6.32 NA NA 0.04 XXX78262 TC A Gastroesophageal reflux exam 0.00 5.70 6.06 NA NA 0.03 XXX78262 26 A Gastroesophageal reflux exam 0.68 0.22 0.26 0.22 0.26 0.01 XXX78264 A Gastric emptying study 0.78 6.95 7.34 NA NA 0.07 XXX78264 TC A Gastric emptying study 0.00 6.69 7.04 NA NA 0.03 XXX78264 26 A Gastric emptying study 0.78 0.26 0.30 0.26 0.30 0.04 XXX78267 X Breath tst attain/anal c-14 0.00 0.00 0.00 0.00 0.00 0.00 XXX78268 X Breath test analysis, c-14 0.00 0.00 0.00 0.00 0.00 0.00 XXX78270 A Vit B-12 absorption exam 0.20 1.98 2.12 NA NA 0.02 XXX78270 TC A Vit B-12 absorption exam 0.00 1.91 2.04 NA NA 0.01 XXX78270 26 A Vit B-12 absorption exam 0.20 0.07 0.08 0.07 0.08 0.01 XXXCMS-1503-P1092**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**78271 A Vit b-12 absrp exam, int fac 0.20 2.25 2.26 NA NA 0.02 XXX78271 TC A Vit b-12 absrp exam, int fac 0.00 2.16 2.18 NA NA 0.01 XXX78271 26 A Vit b-12 absrp exam, int fac 0.20 0.09 0.08 0.09 0.08 0.01 XXX78272 A Vit B-12 absorp, combined 0.27 2.10 2.31 NA NA 0.04 XXX78272 TC A Vit B-12 absorp, combined 0.00 2.00 2.21 NA NA 0.03 XXX78272 26 A Vit B-12 absorp, combined 0.27 0.10 0.10 0.10 0.10 0.01 XXX78278 A Acute GI blood loss imaging 0.99 8.37 8.83 NA NA 0.09 XXX78278 TC A Acute GI blood loss imaging 0.00 8.05 8.45 NA NA 0.03 XXX78278 26 A Acute GI blood loss imaging 0.99 0.32 0.38 0.32 0.38 0.06 XXX78282 C GI protein loss exam 0.00 0.00 0.00 NA NA 0.00 XXX78282 TC C GI protein loss exam 0.00 0.00 0.00 NA NA 0.00 XXX78282 26 A GI protein loss exam0.38 0.13 0.15 0.13 0.15 0.03 XXX78290 A Meckels divert exam 0.68 8.28 8.45 NA NA 0.07 XXX78290 TC A Meckels divert exam 0.00 8.06 8.18 NA NA 0.03 XXX78290 26 A Meckels divert exam0.68 0.22 0.27 0.22 0.27 0.04 XXX78291 A Leveen/shunt patency exam 0.88 6.01 6.30 NA NA 0.09 XXX78291 TC A Leveen/shunt patency exam 0.00 5.73 5.96 NA NA 0.03 XXX78291 26 A Leveen/shunt patency exam 0.88 0.28 0.34 0.28 0.34 0.06 XXX78299 C GI nuclear procedure 0.00 0.00 0.00 NA NA 0.00 XXX78299 TC C GI nuclear procedure 0.00 0.00 0.00 NA NA 0.00 XXX78299 26 C GI nuclear procedure 0.00 0.00 0.00 0.00 0.00 0.00 XXX78300 A Bone imaging, limited area 0.62 4.16 4.38 NA NA 0.06 XXX78300 TC A Bone imaging, limited area 0.00 3.94 4.13 NA NA 0.03 XXX78300 26 A Bone imaging, limited area 0.62 0.22 0.25 0.22 0.25 0.03 XXX78305 A Bone imaging, multiple areas 0.83 5.47 5.78 NA NA 0.07 XXX78305 TC A Bone imaging, multiple areas 0.00 5.19 5.46 NA NA 0.03 XXXCMS-1503-P1093**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**78305 26 A Bone imaging, multiple areas 0.83 0.28 0.32 0.28 0.32 0.04 XXX78306 A Bone imaging, whole body 0.86 5.86 6.34 NA NA 0.07 XXX78306 TC A Bone imaging, whole body 0.00 5.58 6.01 NA NA 0.03 XXX78306 26 A Bone imaging, whole body 0.86 0.28 0.33 0.28 0.33 0.04 XXX78315 A Bone imaging, 3 phase 1.02 8.33 8.80 NA NA 0.09 XXX78315 TC A Bone imaging, 3 phase 0.00 8.00 8.41 NA NA 0.03 XXX78315 26 A Bone imaging, 3 phase 1.02 0.33 0.39 0.33 0.39 0.06 XXX78320 A Bone imaging (3D) 1.04 5.09 5.91 NA NA 0.09 XXX78320 TC A Bone imaging (3D) 0.00 4.77 5.52 NA NA 0.03 XXX78320 26 A Bone imaging (3D) 1.04 0.32 0.39 0.32 0.39 0.06 XXX78350 N Bone mineral, single photon 0.22 0.67 0.72 NA NA 0.02 XXX78350 TC N Bone mineral, single photon 0.00 0.57 0.63 NA NA 0.01 XXX78350 26 N Bone mineral, single photon 0.22 0.10 0.09 0.10 0.09 0.01 XXX78351 N Bone mineral, dual photon 0.30 0.13 0.13 0.13 0.13 0.01 XXX78399 C Musculoskeletal nuclear exam 0.00 0.00 0.00 NA NA 0.00 XXX78399 TC C Musculoskeletal nuclear exam 0.00 0.00 0.00 NA NA 0.00 XXX78399 26 C Musculoskeletal nuclear exam 0.00 0.00 0.00 0.00 0.00 0.00 XXX78414 C Non-imaging heart function 0.00 0.00 0.00 NA NA 0.00 XXX78414 TC C Non-imaging heart function 0.00 0.00 0.00 NA NA 0.00 XXX78414 26 A Non-imaging heart function 0.45 0.20 0.18 0.20 0.18 0.03 XXX78428 A Cardiac shunt imaging 0.78 4.28 4.79 NA NA 0.06 XXX78428 TC A Cardiac shunt imaging 0.00 4.01 4.45 NA NA 0.03 XXX78428 26 A Cardiac shunt imaging 0.78 0.27 0.34 0.27 0.34 0.03 XXX78445 A Vascular flow imaging 0.49 4.14 4.39 NA NA 0.04 XXX78445 TC A Vascular flow imaging 0.00 3.99 4.21 NA NA 0.03 XXX78445 26 A Vascular flow imaging 0.49 0.15 0.18 0.15 0.18 0.01 XXXCMS-1503-P1094**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**78451 A Ht muscle image spect, sing 1.38 8.42 8.42 NA NA 0.09 XXX78451 TC A Ht muscle image spect, sing 0.00 7.91 7.91 NA NA 0.03 XXX78451 26 A Ht muscle image spect,sing 1.38 0.51 0.51 0.51 0.51 0.06 XXX78452 A Ht muscle image spect, mult 1.62 12.17 12.17 NA NA 0.10 XXX78452 TC A Ht muscle image spect, mult 0.00 11.55 11.55 NA NA 0.04 XXX78452 26 A Ht muscle image spect, mult 1.62 0.62 0.62 0.62 0.62 0.06 XXX78453 A Ht muscle image,planar,sing 1.00 7.28 7.28 NA NA 0.09 XXX78453 TC A Ht muscle image,planar,sing 0.00 6.93 6.93 NA NA 0.03 XXX78453 26 A Ht muscle image,planar,sing 1.00 0.35 0.35 0.35 0.35 0.06 XXX78454 A Ht musc image, planar, mult 1.34 10.57 10.57 NA NA 0.10 XXX78454 TC A Ht musc image, planar, mult 0.00 10.10 10.10 NA NA 0.04 XXX78454 26 A Ht musc image, planar, mult 1.34 0.47 0.47 0.47 0.47 0.06 XXX78456 A Acute venous thrombus image 1.00 8.42 9.12 NA NA 0.06 XXX78456 TC A Acute venous thrombus image 0.00 8.07 8.67 NA NA 0.03 XXX78456 26 A Acute venous thrombus image 1.00 0.35 0.45 0.35 0.45 0.03 XXX78457 A Venous thrombosis imaging 0.77 4.59 4.83 NA NA 0.07 XXX78457 TC A Venous thrombosis imaging 0.00 4.32 4.53 NA NA 0.03 XXX78457 26 A Venous thrombosis imaging 0.77 0.27 0.30 0.27 0.30 0.04 XXX78458 A Ven thrombosis images, bilat 0.90 3.93 4.69 NA NA 0.09 XXX78458 TC A Ven thrombosis images, bilat 0.00 3.73 4.39 NA NA 0.03 XXX78458 26 A Ven thrombosis images, bilat 0.90 0.20 0.30 0.20 0.30 0.06 XXX78459 C Heart muscle imaging (PET) 0.00 0.00 0.00 NA NA 0.00 XXX78459 TC C Heart muscle imaging (PET) 0.00 0.00 0.00 NA NA 0.00 XXX78459 26 A Heart muscle imaging (PET) 1.50 0.43 0.61 0.43 0.61 0.10 XXX78466 A Heart infarct image 0.69 4.07 4.48 NA NA 0.06 XXX78466 TC A Heart infarct image 0.00 3.82 4.18 NA NA 0.03 XXXCMS-1503-P1095**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**78466 26 A Heart infarct image 0.69 0.25 0.30 0.25 0.30 0.03 XXX78468 A Heart infarct image (ef) 0.80 4.80 5.52 NA NA 0.06 XXX78468 TC A Heart infarct image (ef) 0.00 4.49 5.14 NA NA 0.03 XXX78468 26 A Heart infarct image (ef) 0.80 0.31 0.38 0.31 0.38 0.03 XXX78469 A Heart infarct image (3D) 0.92 5.92 6.48 NA NA 0.06 XXX78469 TC A Heart infarct image (3D) 0.00 5.53 6.04 NA NA 0.03 XXX78469 26 A Heart infarct image (3D) 0.92 0.39 0.44 0.39 0.44 0.03 XXX78472 A Gated heart, planar, single 0.98 5.38 6.24 NA NA 0.07 XXX78472 TC A Gated heart, planar, single 0.00 5.04 5.82 NA NA 0.03 XXX78472 26 A Gated heart, planar, single 0.98 0.34 0.42 0.34 0.42 0.04 XXX78473 A Gated heart, multiple 1.47 6.72 8.11 NA NA 0.09 XXX78473 TC A Gated heart, multiple 0.00 6.18 7.45 NA NA 0.03 XXX78473 26 A Gated heart, multiple1.47 0.54 0.66 0.54 0.66 0.06 XXX78481 A Heart first pass, single 0.98 4.15 5.10 NA NA 0.04 XXX78481 TC A Heart first pass, single 0.00 3.77 4.63 NA NA 0.01 XXX78481 26 A Heart first pass, single 0.98 0.38 0.47 0.38 0.47 0.03 XXX78483 A Heart first pass, multiple 1.47 5.48 6.95 NA NA 0.09 XXX78483 TC A Heart first pass, multiple 0.00 4.91 6.23 NA NA 0.03 XXX78483 26 A Heart first pass, multiple 1.47 0.57 0.72 0.57 0.72 0.06 XXX78491 C Heart image (pet), single 0.00 0.00 0.00 NA NA 0.00 XXX78491 TC C Heart image (pet), single 0.00 0.00 0.00 NA NA 0.00 XXX78491 26 A Heart image (pet), single 1.50 0.48 0.64 0.48 0.64 0.10 XXX78492 C Heart image (pet), multiple 0.00 0.00 0.00 NA NA 0.00 XXX78492 TC C Heart image (pet), multiple 0.00 0.00 0.00 NA NA 0.00 XXX78492 26 A Heart image (pet), multiple 1.87 0.64 0.84 0.64 0.84 0.13 XXX78494 A Heart image, spect 1.19 5.48 6.53 NA NA 0.07 XXXCMS-1503-P1096**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**78494 TC A Heart image, spect 0.00 5.01 5.99 NA NA 0.03 XXX78494 26 A Heart image, spect 1.19 0.47 0.54 0.47 0.54 0.04 XXX78496 A Heart first pass add-on 0.50 0.73 1.84 NA NA 0.02 ZZZ78496 TC A Heart first pass add-on 0.00 0.54 1.61 NA NA 0.01 ZZZ78496 26 A Heart first pass add-on0.50 0.19 0.23 0.19 0.23 0.01 ZZZ78499 C Cardiovascular nuclear exam 0.00 0.00 0.00 NA NA 0.00 XXX78499 TC C Cardiovascular nuclear exam 0.00 0.00 0.00 NA NA 0.00 XXX78499 26 C Cardiovascular nuclear exam 0.00 0.00 0.00 0.00 0.00 0.00 XXX78580 A Lung perfusion imaging 0.74 4.91 5.31 NA NA 0.06 XXX78580 TC A Lung perfusion imaging 0.00 4.67 5.02 NA NA 0.03 XXX78580 26 A Lung perfusion imaging 0.74 0.24 0.29 0.24 0.29 0.03 XXX78584 A Lung V/Q image single breath 0.99 2.87 3.32 NA NA 0.09 XXX78584 TC A Lung V/Q image single breath 0.00 2.53 2.93 NA NA 0.03 XXX78584 26 A Lung V/Q image singlebreath 0.99 0.34 0.39 0.34 0.39 0.06 XXX78585 A Lung V/Q imaging 1.09 8.36 8.96 NA NA 0.09 XXX78585 TC A Lung V/Q imaging 0.00 8.01 8.54 NA NA 0.03 XXX78585 26 A Lung V/Q imaging 1.09 0.35 0.42 0.35 0.42 0.06 XXX78586 A Aerosol lung image, single 0.40 4.12 4.33 NA NA 0.04 XXX78586 TC A Aerosol lung image, single 0.00 3.98 4.17 NA NA 0.03 XXX78586 26 A Aerosol lung image, single 0.40 0.14 0.16 0.14 0.16 0.01 XXX78587 A Aerosol lung image, multiple 0.49 5.12 5.45 NA NA 0.06 XXX78587 TC A Aerosol lung image, multiple 0.00 4.97 5.26 NA NA 0.03 XXX78587 26 A Aerosol lung image, multiple 0.49 0.15 0.19 0.15 0.19 0.03 XXX78588 A Perfusion lung image 1.09 8.44 8.66 NA NA 0.09 XXX78588 TC A Perfusion lung image 0.00 8.08 8.23 NA NA 0.03 XXX78588 26 A Perfusion lung image 1.09 0.36 0.43 0.36 0.43 0.06 XXXCMS-1503-P1097**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**78591 A Vent image, 1 breath, 1 proj 0.40 4.15 4.39 NA NA 0.04 XXX78591 TC A Vent image, 1 breath, 1 proj 0.00 4.01 4.23 NA NA 0.03 XXX78591 26 A Vent image, 1 breath, 1proj 0.40 0.14 0.16 0.14 0.16 0.01 XXX78593 A Vent image, 1 proj, gas 0.49 4.73 5.07 NA NA 0.06 XXX78593 TC A Vent image, 1 proj, gas 0.00 4.57 4.88 NA NA 0.03 XXX78593 26 A Vent image, 1 proj, gas 0.49 0.16 0.19 0.16 0.19 0.03 XXX78594 A Vent image, mult proj, gas 0.53 4.93 5.63 NA NA 0.06 XXX78594 TC A Vent image, mult proj, gas 0.00 4.78 5.44 NA NA 0.03 XXX78594 26 A Vent image, mult proj, gas 0.53 0.15 0.19 0.15 0.19 0.03 XXX78596 A Lung differential function 1.27 8.66 9.39 NA NA 0.07 XXX78596 TC A Lung differential function 0.00 8.25 8.92 NA NA 0.03 XXX78596 26 A Lung differential function 1.27 0.41 0.47 0.41 0.47 0.04 XXX78599 C Respiratory nuclear exam 0.00 0.00 0.00 NA NA 0.00 XXX78599 TC C Respiratory nuclear exam 0.00 0.00 0.00 NA NA 0.00 XXX78599 26 C Respiratory nuclear exam 0.00 0.00 0.00 0.00 0.00 0.00 XXX78600 A Brain image < 4 views 0.44 4.35 4.66 NA NA 0.04 XXX78600 TC A Brain image < 4 views 0.00 4.20 4.48 NA NA 0.03 XXX78600 26 A Brain image < 4 views 0.44 0.15 0.18 0.15 0.18 0.01 XXX78601 A Brain image w/flow < 4 views 0.51 5.18 5.55 NA NA 0.06 XXX78601 TC A Brain image w/flow < 4 views 0.00 5.02 5.35 NA NA 0.03 XXX78601 26 A Brain image w/flow < 4views 0.51 0.16 0.20 0.16 0.20 0.03 XXX78605 A Brain image 4+ views 0.53 4.66 5.06 NA NA 0.06 XXX78605 TC A Brain image 4+ views 0.00 4.48 4.84 NA NA 0.03 XXX78605 26 A Brain image 4+ views 0.53 0.18 0.22 0.18 0.22 0.03 XXX78606 A Brain image w/flow 4 + views 0.64 8.35 8.59 NA NA 0.04 XXX78606 TC A Brain image w/flow 4 + views 0.00 8.14 8.34 NA NA 0.03 XXXCMS-1503-P1098**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**78606 26 A Brain image w/flow 4 +views 0.64 0.21 0.25 0.21 0.25 0.01 XXX78607 A Brain imaging (3D) 1.23 8.34 9.14 NA NA 0.09 XXX78607 TC A Brain imaging (3D) 0.00 7.97 8.68 NA NA 0.03 XXX78607 26 A Brain imaging (3D) 1.23 0.37 0.46 0.37 0.46 0.06 XXX78608 C Brain imaging (PET) 0.00 0.00 0.00 NA NA 0.00 XXX78608 TC C Brain imaging (PET) 0.00 0.00 0.00 NA NA 0.00 XXX78608 26 A Brain imaging (PET) 1.50 0.45 0.56 0.45 0.56 0.11 XXX78609 N Brain imaging (PET) 1.50 0.65 0.62 NA NA 0.10 XXX78609 TC N Brain imaging (PET) 0.00 0.00 0.00 NA NA 0.00 XXX78609 26 N Brain imaging (PET) 1.50 0.65 0.62 0.65 0.62 0.10 XXX78610 A Brain flow imaging only 0.30 4.28 4.75 NA NA 0.04 XXX78610 TC A Brain flow imaging only 0.00 4.18 4.62 NA NA 0.03 XXX78610 26 A Brain flow imaging only 0.30 0.10 0.13 0.10 0.13 0.01 XXX78630 A Cerebrospinal fluid scan 0.68 8.45 8.90 NA NA 0.06 XXX78630 TC A Cerebrospinal fluid scan 0.00 8.22 8.63 NA NA 0.03 XXX78630 26 A Cerebrospinal fluid scan 0.68 0.23 0.27 0.23 0.27 0.03 XXX78635 A CSF ventriculography 0.61 8.43 8.52 NA NA 0.04 XXX78635 TC A CSF ventriculography 0.00 8.22 8.27 NA NA 0.03 XXX78635 26 A CSF ventriculography0.61 0.21 0.25 0.21 0.25 0.01 XXX78645 A CSF shunt evaluation 0.57 8.15 8.44 NA NA 0.06 XXX78645 TC A CSF shunt evaluation 0.00 7.97 8.22 NA NA 0.03 XXX78645 26 A CSF shunt evaluation 0.57 0.18 0.22 0.18 0.22 0.03 XXX78647 A Cerebrospinal fluid scan 0.90 8.43 9.01 NA NA 0.09 XXX78647 TC A Cerebrospinal fluid scan 0.00 8.16 8.68 NA NA 0.03 XXX78647 26 A Cerebrospinal fluid scan 0.90 0.27 0.33 0.27 0.33 0.06 XXX78650 A CSF leakage imaging 0.61 8.34 8.77 NA NA 0.07 XXXCMS-1503-P1099**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**78650 TC A CSF leakage imaging 0.00 8.15 8.54 NA NA 0.03 XXX78650 26 A CSF leakage imaging 0.61 0.19 0.23 0.19 0.23 0.04 XXX78660 A Nuclear exam of tear flow 0.53 4.49 4.52 NA NA 0.06 XXX78660 TC A Nuclear exam of tear flow 0.00 4.28 4.29 NA NA 0.03 XXX78660 26 A Nuclear exam of tear flow 0.53 0.21 0.23 0.21 0.23 0.03 XXX78699 C Nervous system nuclear exam 0.00 0.00 0.00 NA NA 0.00 XXX78699 TC C Nervous system nuclear exam 0.00 0.00 0.00 NA NA 0.00 XXX78699 26 C Nervous system nuclear exam 0.00 0.00 0.00 0.00 0.00 0.00 XXX78700 A Kidney imaging, morphol 0.45 4.24 4.56 NA NA 0.06 XXX78700 TC A Kidney imaging, morphol 0.00 4.08 4.38 NA NA 0.03 XXX78700 26 A Kidney imaging, morphol 0.45 0.16 0.18 0.16 0.18 0.03 XXX78701 A Kidney imaging with flow 0.49 5.19 5.56 NA NA 0.06 XXX78701 TC A Kidney imaging with flow 0.00 5.03 5.37 NA NA 0.03 XXX78701 26 A Kidney imaging with flow 0.49 0.16 0.19 0.16 0.19 0.03 XXX78707 A K flow/funct image w/o drug 0.96 5.22 5.81 NA NA 0.07 XXX78707 TC A K flow/funct image w/o drug 0.00 4.92 5.44 NA NA 0.03 XXX78707 26 A K flow/funct image w/o drug 0.96 0.30 0.37 0.30 0.37 0.04 XXX78708 A K flow/funct image w/drug 1.21 3.20 3.91 NA NA 0.09 XXX78708 TC A K flow/funct image w/drug 0.00 2.82 3.44 NA NA 0.03 XXX78708 26 A K flow/funct image w/drug 1.21 0.38 0.47 0.38 0.47 0.06 XXX78709 A K flow/funct image, multiple 1.41 8.55 9.03 NA NA 0.10 XXX78709 TC A K flow/funct image, multiple 0.00 8.10 8.49 NA NA 0.03 XXX78709 26 A K flow/funct image, multiple 1.41 0.45 0.54 0.45 0.54 0.07 XXX78710 A Kidney imaging (3D) 0.66 4.84 5.71 NA NA 0.04 XXX78710 TC A Kidney imaging (3D) 0.00 4.65 5.47 NA NA 0.03 XXX78710 26 A Kidney imaging (3D) 0.66 0.19 0.24 0.19 0.24 0.01 XXXCMS-1503-P1100**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**78725 A Kidney function study 0.38 2.38 2.52 NA NA 0.04 XXX78725 TC A Kidney function study 0.00 2.25 2.38 NA NA 0.03 XXX78725 26 A Kidney function study 0.38 0.13 0.14 0.13 0.14 0.01 XXX78730 A Urinary bladder retention 0.15 1.77 2.00 NA NA 0.02 ZZZ78730 TC A Urinary bladder retention 0.00 1.71 1.92 NA NA 0.01 ZZZ78730 26 A Urinary bladder retention 0.15 0.06 0.08 0.06 0.08 0.01 ZZZ78740 A Ureteral reflux study 0.57 5.72 5.77 NA NA 0.06 XXX78740 TC A Ureteral reflux study 0.00 5.50 5.53 NA NA 0.03 XXX78740 26 A Ureteral reflux study 0.57 0.22 0.24 0.22 0.24 0.03 XXX78761 A Testicular imaging w/flow 0.71 5.09 5.36 NA NA 0.07 XXX78761 TC A Testicular imaging w/flow 0.00 4.83 5.07 NA NA 0.03 XXX78761 26 A Testicular imaging w/flow 0.71 0.26 0.29 0.26 0.29 0.04 XXX78799 C Genitourinary nuclear exam 0.00 0.00 0.00 NA NA 0.00 XXX78799 TC C Genitourinary nuclear exam 0.00 0.00 0.00 NA NA 0.00 XXX78799 26 C Genitourinary nuclear exam 0.00 0.00 0.00 0.00 0.00 0.00 XXX78800 A Tumor imaging, limited area 0.66 4.34 4.65 NA NA 0.07 XXX78800 TC A Tumor imaging, limited area 0.00 4.11 4.40 NA NA 0.03 XXX78800 26 A Tumor imaging, limited area 0.66 0.23 0.25 0.23 0.25 0.04 XXX78801 A Tumor imaging, mult areas 0.79 6.03 6.41 NA NA 0.07 XXX78801 TC A Tumor imaging, mult areas 0.00 5.75 6.10 NA NA 0.03 XXX78801 26 A Tumor imaging, mult areas 0.79 0.28 0.31 0.28 0.31 0.04 XXX78802 A Tumor imaging, whole body 0.86 7.81 8.46 NA NA 0.07 XXX78802 TC A Tumor imaging, whole body 0.00 7.54 8.13 NA NA 0.03 XXX78802 26 A Tumor imaging, whole body 0.86 0.27 0.33 0.27 0.33 0.04 XXX78803 A Tumor imaging (3D) 1.09 8.03 8.93 NA NA 0.09 XXX78803 TC A Tumor imaging (3D) 0.00 7.72 8.53 NA NA 0.03 XXXCMS-1503-P1101**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**78803 26 A Tumor imaging (3D) 1.09 0.31 0.40 0.31 0.40 0.06 XXX78804 A Tumor imaging, whole body 1.07 14.18 15.50 NA NA 0.12 XXX78804 TC A Tumor imaging, whole body 0.00 13.86 15.09 NA NA 0.06 XXX78804 26 A Tumor imaging, whole body 1.07 0.32 0.41 0.32 0.41 0.06 XXX78805 A Abscess imaging, ltd area 0.73 4.11 4.51 NA NA 0.07 XXX78805 TC A Abscess imaging, ltd area 0.00 3.87 4.23 NA NA 0.03 XXX78805 26 A Abscess imaging, ltd area 0.73 0.24 0.28 0.24 0.28 0.04 XXX78806 A Abscess imaging, whole body 0.86 8.01 8.77 NA NA 0.07 XXX78806 TC A Abscess imaging, whole body 0.00 7.74 8.45 NA NA 0.03 XXX78806 26 A Abscess imaging, whole body 0.86 0.27 0.32 0.27 0.32 0.04 XXX78807 A Nuclear localization/abscess 1.09 8.01 8.94 NA NA 0.07 XXX78807 TC A Nuclear localization/abscess 0.00 7.71 8.54 NA NA 0.03 XXX78807 26 A Nuclear localization/abscess 1.09 0.30 0.40 0.30 0.40 0.04 XXX78808 A Iv inj ra drug dx study 0.18 0.85 1.03 NA NA 0.03 XXX78811 C Pet image, ltd area 0.00 0.00 0.00 NA NA 0.00 XXX78811 TC C Pet image, ltd area 0.00 0.00 0.00 NA NA 0.00 XXX78811 26 A Pet image, ltd area 1.54 0.51 0.60 0.51 0.60 0.18 XXX78812 C Pet image, skull-thigh 0.00 0.00 0.00 NA NA 0.00 XXX78812 TC C Pet image, skull-thigh 0.00 0.00 0.00 NA NA 0.00 XXX78812 26 A Pet image, skull-thigh 1.93 0.62 0.75 0.62 0.75 0.17 XXX78813 C Pet image, full body 0.00 0.00 0.00 NA NA 0.00 XXX78813 TC C Pet image, full body 0.00 0.00 0.00 NA NA 0.00 XXX78813 26 A Pet image, full body 2.00 0.67 0.79 0.67 0.79 0.18 XXX78814 C Pet image w/ct, lmtd 0.00 0.00 0.00 NA NA 0.00 XXX78814 TC C Pet image w/ct, lmtd 0.00 0.00 0.00 NA NA 0.00 XXX78814 26 A Pet image w/ct, lmtd 2.20 0.68 0.84 0.68 0.84 0.21 XXXCMS-1503-P1102**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**78815 C Pet image w/ct, skull-thigh 0.00 0.00 0.00 NA NA 0.00 XXX78815 TC C Pet image w/ct, skull-thigh 0.00 0.00 0.00 NA NA 0.00 XXX78815 26 A Pet image w/ct, skull-thigh 2.44 0.78 0.94 0.78 0.94 0.23 XXX78816 C Pet image w/ct, full body 0.00 0.00 0.00 NA NA 0.00 XXX78816 TC C Pet image w/ct, full body 0.00 0.00 0.00 NA NA 0.00 XXX78816 26 A Pet image w/ct, full body 2.50 0.75 0.94 0.75 0.94 0.23 XXX78999 C Nuclear diagnostic exam 0.00 0.00 0.00 NA NA 0.00 XXX78999 TC C Nuclear diagnostic exam 0.00 0.00 0.00 NA NA 0.00 XXX78999 26 C Nuclear diagnostic exam 0.00 0.00 0.00 0.00 0.00 0.00 XXX79005 A Nuclear rx, oral admin 1.80 1.85 2.27 NA NA 0.08 XXX79005 TC A Nuclear rx, oral admin 0.00 1.22 1.57 NA NA 0.01 XXX79005 26 A Nuclear rx, oral admin 1.80 0.63 0.70 0.63 0.70 0.07 XXX79101 A Nuclear rx, iv admin 1.96 2.21 2.67 NA NA 0.08 XXX79101 TC A Nuclear rx, iv admin 0.00 1.32 1.71 NA NA 0.01 XXX79101 26 A Nuclear rx, iv admin 1.96 0.89 0.96 0.89 0.96 0.07 XXX79200 A Nuclear rx, intracav admin 1.99 2.30 2.73 NA NA 0.12 XXX79200 TC A Nuclear rx, intracav admin 0.00 1.59 1.93 NA NA 0.01 XXX79200 26 A Nuclear rx, intracav admin 1.99 0.71 0.80 0.71 0.80 0.11 XXX79300 C Nuclr rx, interstit colloid 0.00 0.00 0.00 NA NA 0.00 XXX79300 TC C Nuclr rx, interstit colloid 0.00 0.00 0.00 NA NA 0.00 XXX79300 26 A Nuclr rx, interstit colloid 1.60 0.57 0.63 0.57 0.63 0.14 XXX79403 A Hematopoietic nuclear tx 2.25 2.91 3.61 NA NA 0.14 XXX79403 TC A Hematopoietic nuclear tx 0.00 2.08 2.67 NA NA 0.03 XXX79403 26 A Hematopoietic nucleartx 2.25 0.83 0.94 0.83 0.94 0.11 XXX79440 A Nuclear rx, intra-articular 1.99 2.32 2.53 NA NA 0.07 XXX79440 TC A Nuclear rx, intra-articular 0.00 1.42 1.63 NA NA 0.01 XXXCMS-1503-P1103**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**79440 26 A Nuclear rx, intra-articular 1.99 0.90 0.90 0.90 0.90 0.06 XXX79445 C Nuclear rx, intra-arterial 0.00 0.00 0.00 NA NA 0.00 XXX79445 TC C Nuclear rx, intra-arterial 0.00 0.00 0.00 NA NA 0.00 XXX79445 26 A Nuclear rx, intra-arterial 2.40 0.75 0.92 0.75 0.92 0.21 XXX79999 C Nuclear medicine therapy 0.00 0.00 0.00 NA NA 0.00 XXX79999 TC C Nuclear medicine therapy 0.00 0.00 0.00 NA NA 0.00 XXX79999 26 C Nuclear medicine therapy 0.00 0.00 0.00 0.00 0.00 0.00 XXX80500 A Lab pathology consultation 0.37 0.18 0.20 0.12 0.13 0.03 XXX80502 A Lab pathology consultation 1.33 0.44 0.47 0.39 0.42 0.07 XXX83020 26 A Hemoglobin electrophoresis 0.37 0.17 0.17 0.17 0.17 0.03 XXX83912 26 A Genetic examination 0.37 0.15 0.14 0.15 0.14 0.03 XXX84165 26 A Protein e-phoresis, serum 0.37 0.17 0.16 0.17 0.16 0.03 XXX84166 26 A Protein e-phoresis/urine/csf 0.37 0.17 0.16 0.17 0.16 0.03 XXX84181 26 A Western blot test0.37 0.17 0.16 0.17 0.16 0.03 XXX84182 26 A Protein, western blottest 0.37 0.16 0.16 0.16 0.16 0.03 XXX85060 A Blood smear interpretation 0.45 0.21 0.20 0.21 0.20 0.03 XXX85097 A Bone marrow interpretation 0.94 1.31 1.50 0.38 0.37 0.06 XXX85390 26 A Fibrinolysins screen 0.37 0.18 0.17 0.18 0.17 0.03 XXX85396 A Clotting assay, whole blood 0.37 NA NA 0.16 0.15 0.03 XXX85576 26 A Blood plateletaggregation 0.37 0.17 0.17 0.17 0.17 0.03 XXX86077 A Physician blood bank service 0.94 0.52 0.49 0.43 0.41 0.06 XXX86078 A Physician blood bank service 0.94 0.53 0.50 0.44 0.41 0.06 XXX86079 A Physician blood bank service 0.94 0.52 0.51 0.43 0.41 0.06 XXX86255 26 A Fluorescent antibody, screen 0.37 0.17 0.16 0.17 0.16 0.03 XXX86256 26 A Fluorescent antibody, titer 0.37 0.17 0.16 0.17 0.16 0.01 XXX86320 26 A Serum immunoelectrophoresis 0.37 0.17 0.16 0.17 0.16 0.01 XXXCMS-1503-P1104**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**86325 26 A Other immunoelectrophoresis 0.37 0.17 0.16 0.17 0.16 0.01 XXX86327 26 A Immunoelectrophoresis assay 0.42 0.20 0.19 0.20 0.19 0.03 XXX86334 26 A Immunofix e-phoresis, serum 0.37 0.17 0.16 0.17 0.16 0.03 XXX86335 26 A Immunfix e-phorsis/urine/csf 0.37 0.17 0.16 0.17 0.16 0.03 XXX86485 C Skin test, candida 0.00 0.00 0.00 0.00 0.00 0.00 XXX86486 A Skin test, nos antigen 0.00 0.12 0.13 NA NA 0.01 XXX86490 A Coccidioidomycosis skin test 0.00 0.16 0.18 NA NA 0.01 XXX86510 A Histoplasmosis skin test 0.00 0.16 0.18 NA NA 0.01 XXX86580 A TB intradermal test 0.00 0.20 0.21 NA NA 0.01 XXX87164 26 A Dark field examination 0.37 0.17 0.16 0.17 0.16 0.03 XXX87207 26 A Smear, special stain 0.37 0.18 0.17 0.18 0.17 0.03 XXX88104 A Cytopath fl nongyn, smears 0.56 1.31 1.31 NA NA 0.02 XXX88104 TC A Cytopath fl nongyn, smears 0.00 1.07 1.08 NA NA 0.01 XXX88104 26 A Cytopath fl nongyn, smears 0.56 0.24 0.23 0.24 0.23 0.01 XXX88106 A Cytopath fl nongyn, filter 0.56 1.66 1.73 NA NA 0.02 XXX88106 TC A Cytopath fl nongyn, filter 0.00 1.43 1.50 NA NA 0.01 XXX88106 26 A Cytopath fl nongyn, filter 0.56 0.23 0.23 0.23 0.23 0.01 XXX88107 A Cytopath fl nongyn, sm/fltr 0.76 1.98 2.09 NA NA 0.04 XXX88107 TC A Cytopath fl nongyn, sm/fltr 0.00 1.66 1.77 NA NA 0.01 XXX88107 26 A Cytopath fl nongyn, sm/fltr 0.76 0.32 0.32 0.32 0.32 0.03 XXX88108 A Cytopath, concentrate tech 0.56 1.52 1.59 NA NA 0.02 XXX88108 TC A Cytopath, concentrate tech 0.00 1.30 1.37 NA NA 0.01 XXX88108 26 A Cytopath, concentrate tech 0.56 0.22 0.22 0.22 0.22 0.01 XXX88112 A Cytopath, cell enhance tech 1.18 1.61 1.75 NA NA 0.05 XXX88112 TC A Cytopath, cell enhance tech 0.00 1.17 1.32 NA NA 0.01 XXX88112 26 A Cytopath, cell enhance tech 1.18 0.44 0.43 0.44 0.43 0.04 XXXCMS-1503-P1105**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**88125 A Forensic cytopathology 0.26 0.35 0.36 NA NA 0.02 XXX88125 TC A Forensic cytopathology 0.00 0.23 0.25 NA NA 0.01 XXX88125 26 A Forensic cytopathology0.26 0.12 0.11 0.12 0.11 0.01 XXX88141 A Cytopath, c/v, interpret 0.42 0.40 0.39 0.40 0.39 0.03 XXX88160 A Cytopath smear, other source 0.50 1.04 1.05 NA NA 0.02 XXX88160 TC A Cytopath smear, other source 0.00 0.83 0.85 NA NA 0.01 XXX88160 26 A Cytopath smear, other source 0.50 0.21 0.20 0.21 0.20 0.01 XXX88161 A Cytopath smear, other source 0.50 0.97 1.05 NA NA 0.02 XXX88161 TC A Cytopath smear, other source 0.00 0.79 0.87 NA NA 0.01 XXX88161 26 A Cytopath smear, other source 0.50 0.18 0.18 0.18 0.18 0.01 XXX88162 A Cytopath smear, other source 0.76 1.33 1.47 NA NA 0.04 XXX88162 TC A Cytopath smear, other source 0.00 1.05 1.18 NA NA 0.01 XXX88162 26 A Cytopath smear, other source 0.76 0.28 0.29 0.28 0.29 0.03 XXX88172 A Cytopathology eval offna 0.60 0.98 0.98 NA NA 0.02 XXX88172 TC A Cytopathology eval offna 0.00 0.71 0.72 NA NA 0.01 XXX88172 26 A Cytopathologyeval of fna 0.60 0.27 0.26 0.27 0.26 0.01 XXX88173 A Cytopath eval, fna, report 1.39 2.44 2.54 NA NA 0.05 XXX88173 TC A Cytopath eval, fna, report 0.00 1.87 1.98 NA NA 0.01 XXX88173 26 A Cytopath eval, fna, report 1.39 0.57 0.56 0.57 0.56 0.04 XXX88182 A Cell marker study 0.77 2.00 2.18 NA NA 0.06 XXX88182 TC A Cell marker study 0.00 1.80 1.97 NA NA 0.03 XXX88182 26 A Cell marker study 0.77 0.20 0.21 0.20 0.21 0.03 XXX88184 A Flowcytometry/ tc, 1 marker 0.00 2.24 2.41 NA NA 0.01 XXX88185 A Flowcytometry/tc, add-on 0.00 1.36 1.45 NA NA 0.01 ZZZ88187 A Flowcytometry/read, 2-8 1.36 0.56 0.53 0.56 0.53 0.08 XXX88188 A Flowcytometry/read, 9-15 1.69 0.72 0.66 0.72 0.66 0.10 XXXCMS-1503-P1106**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**88189 A Flowcytometry/read, 16 & > 2.23 0.67 0.67 0.67 0.67 0.13 XXX88199 C Cytopathology procedure 0.00 0.00 0.00 NA NA 0.00 XXX88199 TC C Cytopathology procedure 0.00 0.00 0.00 NA NA 0.00 XXX88199 26 C Cytopathology procedure 0.00 0.00 0.00 0.00 0.00 0.00 XXX88291 A Cyto/molecular report 0.52 0.29 0.30 0.29 0.30 0.03 XXX88299 C Cytogenetic study 0.00 0.00 0.00 0.00 0.00 0.00 XXX88300 A Surgical path, gross 0.08 0.62 0.64 NA NA 0.02 XXX88300 TC A Surgical path, gross 0.00 0.58 0.60 NA NA 0.01 XXX88300 26 A Surgical path, gross 0.08 0.04 0.04 0.04 0.04 0.01 XXX88302 A Tissue exam by pathologist 0.13 1.34 1.38 NA NA 0.02 XXX88302 TC A Tissue exam by pathologist 0.00 1.28 1.33 NA NA 0.01 XXX88302 26 A Tissue exam by pathologist 0.13 0.06 0.05 0.06 0.05 0.01 XXX88304 A Tissue exam by pathologist 0.22 1.56 1.66 NA NA 0.02 XXX88304 TC A Tissue exam by pathologist 0.00 1.47 1.57 NA NA 0.01 XXX88304 26 A Tissue exam by pathologist 0.22 0.09 0.09 0.09 0.09 0.01 XXX88305 A Tissue exam by pathologist 0.75 2.16 2.32 NA NA 0.02 XXX88305 TC A Tissue exam by pathologist 0.00 1.86 2.02 NA NA 0.01 XXX88305 26 A Tissue exam by pathologist 0.75 0.30 0.30 0.30 0.30 0.01 XXX88307 A Tissue exam by pathologist 1.59 4.87 4.87 NA NA 0.05 XXX88307 TC A Tissue exam by pathologist 0.00 4.16 4.19 NA NA 0.01 XXX88307 26 A Tissue exam by pathologist 1.59 0.71 0.68 0.71 0.68 0.04 XXX88309 A Tissue exam by pathologist 2.80 7.05 6.98 NA NA 0.11 XXX88309 TC A Tissue exam by pathologist 0.00 5.79 5.81 NA NA 0.03 XXX88309 26 A Tissue exam by pathologist 2.80 1.26 1.17 1.26 1.17 0.08 XXX88311 A Decalcify tissue 0.24 0.28 0.29 NA NA 0.02 XXX88311 TC A Decalcify tissue 0.00 0.18 0.19 NA NA 0.01 XXXCMS-1503-P1107**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**88311 26 A Decalcify tissue 0.24 0.10 0.10 0.10 0.10 0.01 XXX88312 A Special stains group 1 0.54 2.44 2.51 NA NA 0.02 XXX88312 TC A Special stains group 1 0.00 2.23 2.30 NA NA 0.01 XXX88312 26 A Special stains group1 0.54 0.21 0.21 0.21 0.21 0.01 XXX88313 A Special stains group 2 0.24 1.89 1.98 NA NA 0.02 XXX88313 TC A Special stains group 2 0.00 1.80 1.89 NA NA 0.01 XXX88313 26 A Special stains group2 0.24 0.09 0.09 0.09 0.09 0.01 XXX88314 A Histochemical stain add-on 0.45 1.93 2.12 NA NA 0.02 XXX88314 TC A Histochemical stain add-on 0.00 1.73 1.93 NA NA 0.01 XXX88314 26 A Histochemical stain add-on 0.45 0.20 0.19 0.20 0.19 0.01 XXX88318 A Chemical histochemistry 0.42 3.06 2.90 NA NA 0.02 XXX88318 TC A Chemical histochemistry 0.00 2.88 2.73 NA NA 0.01 XXX88318 26 A Chemical histochemistry 0.42 0.18 0.17 0.18 0.17 0.01 XXX88319 A Enzyme histochemistry 0.53 3.41 3.63 NA NA 0.04 XXX88319 TC A Enzyme histochemistry 0.00 3.19 3.42 NA NA 0.01 XXX88319 26 A Enzyme histochemistry 0.53 0.22 0.21 0.22 0.21 0.03 XXX88321 A Microslide consultation 1.63 0.92 0.91 0.68 0.64 0.10 XXX88323 A Microslide consultation 1.83 2.09 2.27 NA NA 0.05 XXX88323 TC A Microslide consultation 0.00 1.52 1.69 NA NA 0.01 XXX88323 26 A Microslide consultation 1.83 0.57 0.58 0.57 0.58 0.04 XXX88325 A Comprehensive review of data 2.50 3.18 3.18 1.23 1.11 0.13 XXX88329 A Path consult introp 0.67 0.80 0.80 0.30 0.29 0.04 XXX88331 A Path consult intraop, 1 bloc 1.19 1.45 1.44 NA NA 0.02 XXX88331 TC A Path consult intraop, 1 bloc 0.00 0.89 0.91 NA NA 0.01 XXX88331 26 A Path consult intraop, 1 bloc 1.19 0.56 0.53 0.56 0.53 0.01 XXX88332 A Path consult intraop, addl 0.59 0.57 0.56 NA NA 0.02 XXXCMS-1503-P1108**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**88332 TC A Path consult intraop, addl 0.00 0.30 0.31 NA NA 0.01 XXX88332 26 A Path consult intraop, addl 0.59 0.27 0.25 0.27 0.25 0.01 XXX88333 A Intraop cyto path consult, 1 1.20 1.53 1.52 NA NA 0.05 XXX88333 TC A Intraop cyto path consult, 1 0.00 0.99 1.00 NA NA 0.01 XXX88333 26 A Intraop cyto path consult, 1 1.20 0.54 0.52 0.54 0.52 0.04 XXX88334 A Intraop cyto path consult, 2 0.73 0.96 0.93 NA NA 0.04 XXX88334 TC A Intraop cyto path consult, 2 0.00 0.62 0.62 NA NA 0.01 XXX88334 26 A Intraop cyto path consult, 2 0.73 0.34 0.31 0.34 0.31 0.03 XXX88342 A Immunohistochemistry 0.85 2.04 2.12 NA NA 0.04 XXX88342 TC A Immunohistochemistry 0.00 1.71 1.80 NA NA 0.01 XXX88342 26 A Immunohistochemistry 0.85 0.33 0.32 0.33 0.32 0.03 XXX88346 A Immunofluorescent study 0.86 1.96 2.07 NA NA 0.02 XXX88346 TC A Immunofluorescent study 0.00 1.62 1.74 NA NA 0.01 XXX88346 26 A Immunofluorescent study 0.86 0.34 0.33 0.34 0.33 0.01 XXX88347 A Immunofluorescent study 0.86 1.23 1.37 NA NA 0.02 XXX88347 TC A Immunofluorescent study 0.00 1.00 1.12 NA NA 0.01 XXX88347 26 A Immunofluorescent study 0.86 0.23 0.25 0.23 0.25 0.01 XXX88348 A Electron microscopy 1.51 17.26 17.95 NA NA 0.12 XXX88348 TC A Electron microscopy 0.00 16.68 17.37 NA NA 0.08 XXX88348 26 A Electron microscopy1.51 0.58 0.58 0.58 0.58 0.04 XXX88349 A Scanning electron microscopy 0.76 10.10 9.46 NA NA 0.07 XXX88349 TC A Scanning electron microscopy 0.00 9.74 9.12 NA NA 0.04 XXX88349 26 A Scanning electron microscopy 0.76 0.36 0.34 0.36 0.34 0.03 XXX88355 A Analysis, skeletal muscle 1.85 3.13 4.30 NA NA 0.07 XXX88355 TC A Analysis, skeletal muscle 0.00 2.61 3.75 NA NA 0.01 XXX88355 26 A Analysis, skeletal muscle 1.85 0.52 0.55 0.52 0.55 0.06 XXXCMS-1503-P1109**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**88356 A Analysis, nerve 3.02 4.37 5.03 NA NA 0.18 XXX88356 TC A Analysis, nerve 0.00 3.83 4.35 NA NA 0.04 XXX88356 26 A Analysis, nerve 3.02 0.54 0.68 0.54 0.68 0.14 XXX88358 A Analysis, tumor 0.95 1.12 1.18 NA NA 0.04 XXX88358 TC A Analysis, tumor 0.00 0.89 0.93 NA NA 0.01 XXX88358 26 A Analysis, tumor 0.95 0.23 0.25 0.23 0.25 0.03 XXX88360 A Tumor immunohistochem/manual 1.10 2.32 2.43 NA NA 0.04 XXX88360 TC A Tumor immunohistochem/manual 0.00 1.92 2.03 NA NA 0.01 XXX88360 26 A Tumor immunohistochem/manual 1.10 0.40 0.40 0.40 0.40 0.03 XXX88361 A Tumor immunohistochem/comput 1.18 2.92 3.16 NA NA 0.05 XXX88361 TC A Tumor immunohistochem/comput 0.00 2.50 2.75 NA NA 0.01 XXX88361 26 A Tumor immunohistochem/comput 1.18 0.42 0.41 0.42 0.41 0.04 XXX88362 A Nerve teasing preparations 2.17 5.84 5.85 NA NA 0.14 XXX88362 TC A Nerve teasing preparations 0.00 4.94 4.99 NA NA 0.04 XXX88362 26 A Nerve teasing preparations 2.17 0.90 0.86 0.90 0.86 0.10 XXX88365 A Insitu hybridization (fish) 1.20 3.44 3.55 NA NA 0.04 XXX88365 TC A Insitu hybridization (fish) 0.00 3.00 3.11 NA NA 0.01 XXX88365 26 A Insitu hybridization (fish) 1.20 0.44 0.44 0.44 0.44 0.03 XXX88367 A Insitu hybridization, auto 1.30 5.90 6.06 NA NA 0.07 XXX88367 TC A Insitu hybridization, auto 0.00 5.47 5.63 NA NA 0.01 XXX88367 26 A Insitu hybridization, auto 1.30 0.43 0.43 0.43 0.43 0.06 XXX88368 A Insitu hybridization, manual 1.40 4.69 4.92 NA NA 0.05 XXX88368 TC A Insitu hybridization, manual 0.00 4.35 4.54 NA NA 0.01 XXX88368 26 A Insitu hybridization, manual 1.40 0.34 0.38 0.34 0.38 0.04 XXX88371 26 A Protein, western blottissue 0.37 0.17 0.16 0.17 0.16 0.03 XXX88372 26 A Protein analysis w/probe 0.37 0.17 0.16 0.17 0.16 0.03 XXXCMS-1503-P1110**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**88380 A Microdissection, laser 1.56 2.52 3.47 NA NA 0.05 XXX88380 TC A Microdissection, laser 0.00 2.09 2.96 NA NA 0.01 XXX88380 26 A Microdissection, laser 1.56 0.43 0.51 0.43 0.51 0.04 XXX88381 A Microdissection, manual 1.18 2.73 4.13 NA NA 0.04 XXX88381 TC A Microdissection, manual 0.00 2.49 3.78 NA NA 0.01 XXX88381 26 A Microdissection, manual1.18 0.24 0.35 0.24 0.35 0.03 XXX88384 C Eval molecular probes, 11-50 0.00 0.00 0.00 NA NA 0.00 XXX88384 TC C Eval molecular probes, 11-50 0.00 0.00 0.00 NA NA 0.00 XXX88384 26 C Eval molecular probes,11-50 0.00 0.00 0.00 0.00 0.00 0.00 XXX88385 A Eval molecul probes, 51-250 1.50 14.78 15.06 NA NA 0.07 XXX88385 TC A Eval molecul probes, 51-250 0.00 14.42 14.68 NA NA 0.03 XXX88385 26 A Eval molecul probes,51-250 1.50 0.36 0.38 0.36 0.38 0.04 XXX88386 A Eval molecul probes, 251-500 1.88 13.57 16.61 NA NA 0.09 XXX88386 TC A Eval molecul probes, 251-500 0.00 13.24 16.01 NA NA 0.03 XXX88386 26 A Eval molecul probes, 251-500 1.88 0.33 0.60 0.33 0.60 0.06 XXX88387 A Tiss exam molecular study 0.62 0.52 0.52 NA NA 0.02 XXX88387 TC A Tiss exam molecular study 0.00 0.24 0.24 NA NA 0.01 XXX88387 26 A Tiss exam molecular study 0.62 0.28 0.28 0.28 0.28 0.01 XXX88388 A Tiss ex molecul study add-on 0.45 0.20 0.20 NA NA 0.02 XXX88388 TC A Tiss ex molecul study add-on 0.00 0.11 0.11 NA NA 0.01 XXX88388 26 A Tiss ex molecul study add-on 0.45 0.09 0.09 0.09 0.09 0.01 XXX88399 C Surgical pathology procedure 0.00 0.00 0.00 NA NA 0.00 XXX88399 TC C Surgical pathology procedure 0.00 0.00 0.00 NA NA 0.00 XXX88399 26 C Surgical pathology procedure 0.00 0.00 0.00 0.00 0.00 0.00 XXX89049 A Chct for mal hyperthermia 1.40 5.63 5.87 0.38 0.44 0.10 XXX89060 26 A Exam,synovial fluid crystals 0.37 0.17 0.16 0.17 0.16 0.03 XXXCMS-1503-P1111**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**89100 A Sample intestinal contents 0.60 8.90 8.07 0.64 0.59 0.04 XXX89105 A Sample intestinal contents 0.50 7.79 7.68 0.51 0.49 0.03 XXX89130 A Sample stomach contents 0.45 7.19 6.79 0.46 0.42 0.03 XXX89132 A Sample stomach contents 0.19 7.26 7.46 0.34 0.35 0.01 XXX89135 A Sample stomach contents 0.79 8.70 8.57 0.71 0.71 0.06 XXX89136 A Sample stomach contents 0.21 7.23 6.84 0.35 0.33 0.01 XXX89140 A Sample stomach contents 0.94 7.70 7.19 0.67 0.61 0.06 XXX89141 A Sample stomach contents 0.85 8.21 7.64 0.67 0.62 0.06 XXX89220 A Sputum specimen collection 0.00 0.42 0.45 NA NA 0.01 XXX89230 A Collect sweat for test 0.00 0.05 0.08 NA NA 0.01 XXX89240 C Pathology lab procedure 0.00 0.00 0.00 0.00 0.00 0.00 XXX90281 I Human ig, im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90283 I Human ig, iv 0.00 0.00 0.00 0.00 0.00 0.00 XXX90284 X Human ig, sc 0.00 0.00 0.00 0.00 0.00 0.00 XXX90287 I Botulinum antitoxin 0.00 0.00 0.00 0.00 0.00 0.00 XXX90288 I Botulism ig, iv 0.00 0.00 0.00 0.00 0.00 0.00 XXX90291 I Cmv ig, iv 0.00 0.00 0.00 0.00 0.00 0.00 XXX90296 E Diphtheria antitoxin 0.00 0.00 0.00 0.00 0.00 0.00 XXX90371 E Hep b ig, im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90375 E Rabies ig, im/sc 0.00 0.00 0.00 0.00 0.00 0.00 XXX90376 E Rabies ig, heat treated 0.00 0.00 0.00 0.00 0.00 0.00 XXX90378 X Rsv, mab, im, 50mg 0.00 0.00 0.00 0.00 0.00 0.00 XXX90384 I Rh ig, full-dose, im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90385 E Rh ig, minidose, im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90386 I Rh ig, iv 0.00 0.00 0.00 0.00 0.00 0.00 XXX90389 I Tetanus ig, im 0.00 0.00 0.00 0.00 0.00 0.00 XXXCMS-1503-P1112**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**90393 E Vaccina ig, im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90396 E Varicella-zoster ig, im0.00 0.00 0.00 0.00 0.00 0.00 XXX90399 I Immune globulin 0.00 0.00 0.00 0.00 0.00 0.00 XXX90465 A Immune admin 1 inj, < 8 yrs 0.17 0.49 0.49 NA NA 0.01 XXX90466 A Immune admin addl inj, < 8 y 0.15 0.24 0.20 0.07 0.07 0.01 ZZZ90467 R Immune admin o or n, < 8 yrs 0.17 0.49 0.49 NA NA 0.01 XXX90468 R Immune admin o/n, addl < 8 y 0.15 0.19 0.18 0.07 0.07 0.01 ZZZ90470 I Immune admin H1N1 im/nasal 0.20 0.39 0.39 NA NA 0.01 XXX90471 A Immunization admin 0.17 0.49 0.49 NA NA 0.01 XXX90472 A Immunization admin, each add 0.15 0.19 0.18 0.07 0.07 0.01 ZZZ90473 R Immune admin oral/nasal 0.17 0.49 0.49 NA NA 0.01 XXX90474 R Immune admin oral/nasal addl 0.15 0.19 0.18 0.07 0.07 0.01 ZZZ90476 E Adenovirus vaccine, type 4 0.00 0.00 0.00 0.00 0.00 0.00 XXX90477 E Adenovirus vaccine, type 7 0.00 0.00 0.00 0.00 0.00 0.00 XXX90581 E Anthrax vaccine, sc 0.00 0.00 0.00 0.00 0.00 0.00 XXX90585 E Bcg vaccine, percut 0.00 0.00 0.00 0.00 0.00 0.00 XXX90586 E Bcg vaccine, intravesical 0.00 0.00 0.00 0.00 0.00 0.00 XXX90632 E Hep a vaccine, adult im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90633 E Hep a vacc, ped/adol, 2dose 0.00 0.00 0.00 0.00 0.00 0.00 XXX90634 E Hep a vacc, ped/adol, 3dose 0.00 0.00 0.00 0.00 0.00 0.00 XXX90636 E Hep a/hep b vacc, adult im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90644 X HIB/men/tt vaccine, im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90645 E Hib vaccine, hboc, im0.00 0.00 0.00 0.00 0.00 0.00 XXX90646 E Hib vaccine, prp-d, im0.00 0.00 0.00 0.00 0.00 0.00 XXX90647 E Hib vaccine, prp-omp,im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90648 E Hib vaccine, prp-t, im0.00 0.00 0.00 0.00 0.00 0.00 XXXCMS-1503-P1113**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**90649 E Hpv vaccine 4 valent, im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90650 E Hpv vaccine 2 valent, im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90655 X Flu vaccine no preserv 6-35m 0.00 0.00 0.00 0.00 0.00 0.00 XXX90656 X Flu vaccine no preserv 3 & > 0.00 0.00 0.00 0.00 0.00 0.00 XXX90657 X Flu vaccine, 3 yrs, im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90658 X Flu vaccine, 3 yrs & >, im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90660 X Flu vaccine, nasal 0.00 0.00 0.00 0.00 0.00 0.00 XXX90661 X Flu vacc cell cult prsv free 0.00 0.00 0.00 0.00 0.00 0.00 XXX90662 X Flu vacc prsv free inc antig 0.00 0.00 0.00 0.00 0.00 0.00 XXX90663 X Flu vacc pandemic H1N1 0.00 0.00 0.00 0.00 0.00 0.00 XXX90665 E Lyme disease vaccine, im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90669 X Pneumococcal vacc, 7 val im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90670 X Pneumococcal vacc, 13 val im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90675 E Rabies vaccine, im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90676 E Rabies vaccine, id 0.00 0.00 0.00 0.00 0.00 0.00 XXX90680 E Rotovirus vacc 3 dose, oral 0.00 0.00 0.00 0.00 0.00 0.00 XXX90681 E Rotavirus vacc 2 dose oral 0.00 0.00 0.00 0.00 0.00 0.00 XXX90690 E Typhoid vaccine, oral 0.00 0.00 0.00 0.00 0.00 0.00 XXX90691 E Typhoid vaccine, im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90692 E Typhoid vaccine, h-p, sc/id 0.00 0.00 0.00 0.00 0.00 0.00 XXX90693 E Typhoid vaccine, akd, sc 0.00 0.00 0.00 0.00 0.00 0.00 XXX90696 E Dtap-ipv vacc 4-6 yr im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90698 E Dtap-hib-ip vaccine, im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90700 E Dtap vaccine, < 7 yrs, im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90701 E Dtp vaccine, im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90702 E Dt vaccine < 7, im 0.00 0.00 0.00 0.00 0.00 0.00 XXXCMS-1503-P1114**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**90703 E Tetanus vaccine, im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90704 E Mumps vaccine, sc 0.00 0.00 0.00 0.00 0.00 0.00 XXX90705 E Measles vaccine, sc 0.00 0.00 0.00 0.00 0.00 0.00 XXX90706 E Rubella vaccine, sc 0.00 0.00 0.00 0.00 0.00 0.00 XXX90707 E Mmr vaccine, sc 0.00 0.00 0.00 0.00 0.00 0.00 XXX90708 E Measles-rubella vaccine, sc 0.00 0.00 0.00 0.00 0.00 0.00 XXX90710 E Mmrv vaccine, sc 0.00 0.00 0.00 0.00 0.00 0.00 XXX90712 E Oral poliovirus vaccine 0.00 0.00 0.00 0.00 0.00 0.00 XXX90713 E Poliovirus, ipv, sc/im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90714 E Td vaccine no prsrv >/= 7 im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90715 E Tdap vaccine >7 im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90716 E Chicken pox vaccine, sc 0.00 0.00 0.00 0.00 0.00 0.00 XXX90717 E Yellow fever vaccine, sc 0.00 0.00 0.00 0.00 0.00 0.00 XXX90718 E Td vaccine > 7, im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90719 E Diphtheria vaccine, im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90720 E Dtp/hib vaccine, im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90721 E Dtap/hib vaccine, im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90723 I Dtap-hep b-ipv vaccine, im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90725 E Cholera vaccine, injectable 0.00 0.00 0.00 0.00 0.00 0.00 XXX90727 E Plague vaccine, im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90732 X Pneumococcal vaccine 0.00 0.00 0.00 0.00 0.00 0.00 XXX90733 E Meningococcal vaccine, sc 0.00 0.00 0.00 0.00 0.00 0.00 XXX90734 E Meningococcal vaccine, im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90735 E Encephalitis vaccine, sc 0.00 0.00 0.00 0.00 0.00 0.00 XXX90736 E Zoster vacc, sc 0.00 0.00 0.00 0.00 0.00 0.00 XXX90738 I Inactivated je vacc im 0.00 0.00 0.00 0.00 0.00 0.00 XXXCMS-1503-P1115**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**90740 X Hepb vacc, ill pat 3 dose im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90743 X Hep b vacc, adol, 2 dose, im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90744 X Hepb vacc ped/adol 3 doseim 0.00 0.00 0.00 0.00 0.00 0.00 XXX90746 X Hep b vaccine, adult, im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90747 X Hepb vacc, ill pat 4 dose im 0.00 0.00 0.00 0.00 0.00 0.00 XXX90748 I Hep b/hib vaccine, im0.00 0.00 0.00 0.00 0.00 0.00 XXX90749 E Vaccine toxoid 0.00 0.00 0.00 0.00 0.00 0.00 XXX90801 A Psy dx interview 2.80 1.51 1.59 0.59 0.71 0.11 XXX90802 A Intac psy dx interview 3.01 1.78 1.76 0.76 0.83 0.13 XXX90804 A Psytx, office, 20-30 min 1.21 0.55 0.59 0.17 0.24 0.04 XXX90805 A Psytx, off, 20-30 min w/e&m 1.37 0.68 0.68 0.28 0.31 0.06 XXX90806 A Psytx, off, 45-50 min 1.86 0.45 0.57 0.24 0.36 0.07 XXX90807 A Psytx, off, 45-50 min w/e&m 2.02 0.81 0.83 0.41 0.46 0.08 XXX90808 A Psytx, office, 75-80 min 2.79 0.62 0.78 0.42 0.58 0.10 XXX90809 A Psytx, off, 75-80, w/e&m 2.95 1.00 1.04 0.63 0.70 0.13 XXX90810 A Intac psytx, off, 20-30 min 1.32 0.47 0.55 0.20 0.27 0.06 XXX90811 A Intac psytx, 20-30, w/e&m 1.48 0.84 0.82 0.31 0.35 0.07 XXX90812 A Intac psytx, off, 45-50 min 1.97 0.56 0.69 0.26 0.39 0.07 XXX90813 A Intac psytx, 45-50 min w/e&m 2.13 0.95 0.96 0.42 0.49 0.08 XXX90814 A Intac psytx, off, 75-80 min 2.90 0.73 0.93 0.36 0.60 0.11 XXX90815 A Intac psytx, 75-80 w/e&m 3.06 1.32 1.27 0.79 0.79 0.14 XXX90816 A Psytx, hosp, 20-30 min 1.25 0.26 0.34 0.26 0.34 0.04 XXX90817 A Psytx, hosp, 20-30 min w/e&m 1.41 0.40 0.43 0.40 0.43 0.06 XXX90818 A Psytx, hosp, 45-50 min 1.89 0.33 0.47 0.33 0.47 0.07 XXX90819 A Psytx, hosp, 45-50 min w/e&m 2.05 0.54 0.58 0.54 0.58 0.08 XXX90821 A Psytx, hosp, 75-80 min 2.83 0.47 0.66 0.47 0.66 0.10 XXXCMS-1503-P1116**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**90822 A Psytx, hosp, 75-80 min w/e&m 2.99 0.72 0.79 0.72 0.79 0.13 XXX90823 A Intac psytx, hosp, 20-30 min 1.36 0.28 0.37 0.28 0.37 0.04 XXX90824 A Intac psytx, hsp 20-30 w/e&m 1.52 0.42 0.46 0.42 0.46 0.07 XXX90826 A Intac psytx, hosp, 45-50 min 2.01 0.37 0.50 0.37 0.50 0.07 XXX90827 A Intac psytx, hsp 45-50 w/e&m 2.16 0.55 0.60 0.55 0.60 0.08 XXX90828 A Intac psytx, hosp, 75-80 min 2.94 0.50 0.69 0.50 0.69 0.10 XXX90829 A Intac psytx, hsp 75-80 w/e&m 3.10 0.73 0.81 0.73 0.81 0.13 XXX90845 A Psychoanalysis 1.79 0.42 0.47 0.34 0.41 0.07 XXX90846 R Family psytx w/o patient 1.83 0.48 0.57 0.39 0.49 0.07 XXX90847 R Family psytx w/patient2.21 0.68 0.79 0.43 0.55 0.08 XXX90849 R Multiple family group psytx 0.59 0.38 0.37 0.22 0.24 0.03 XXX90853 A Group psychotherapy 0.59 0.32 0.32 0.24 0.25 0.03 XXX90857 A Intac group psytx 0.63 0.43 0.42 0.29 0.28 0.03 XXX90862 A Medication management 0.95 0.71 0.69 0.31 0.33 0.04 XXX90865 A Narcosynthesis 2.84 1.72 1.66 0.68 0.78 0.11 XXX90870 A Electroconvulsive therapy 1.88 2.20 2.22 0.44 0.48 0.0800090875 N Psychophysiological therapy 1.20 0.82 0.85 0.52 0.51 0.08 XXX90876 N Psychophysiological therapy 1.90 1.11 1.13 0.82 0.81 0.13 XXX90880 A Hypnotherapy 2.19 0.51 0.68 0.36 0.47 0.08 XXX90882 N Environmental manipulation 0.00 0.00 0.00 0.00 0.00 0.00 XXX90885 B Psy evaluation of records 0.97 0.42 0.41 0.42 0.41 0.07 XXX90887 B Consultation with family 1.48 0.97 0.97 0.64 0.63 0.10 XXX90889 B Preparation of report 0.00 0.00 0.00 0.00 0.00 0.00 XXX90899 C Psychiatric service/therapy 0.00 0.00 0.00 0.00 0.00 0.00 XXX90901 A Biofeedback train, any meth 0.41 0.68 0.64 0.19 0.17 0.01 00090911 A Biofeedback peri/uro/rectal 0.89 1.45 1.58 0.37 0.38 0.07 000CMS-1503-P1117**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**90935 A Hemodialysis, one evaluation 1.22 NA NA 0.69 0.70 0.07 00090937 A Hemodialysis, repeated eval 2.11 NA NA 1.02 1.02 0.11 00090940 X Hemodialysis access study 0.00 0.00 0.00 0.00 0.00 0.00 XXX90945 A Dialysis, one evaluation 1.28 NA NA 0.71 0.71 0.07 00090947 A Dialysis, repeated eval 2.16 NA NA 1.03 1.03 0.13 00090951 A Esrd serv, 4 visits p mo, <2 18.46 7.75 8.45 7.75 8.45 1.06 XXX90952 C Esrd serv, 2-3 vsts p mo, <2 0.00 0.00 0.00 0.00 0.00 0.00 XXX90953 C Esrd serv, 1 visit p mo, <2 0.00 0.00 0.00 0.00 0.00 0.00 XXX90954 A Esrd serv, 4 vsts p mo, 2-11 15.98 6.63 6.52 6.63 6.52 0.93 XXX90955 A Esrd srv 2-3 vsts p mo, 2-11 8.79 3.90 3.93 3.90 3.93 0.51 XXX90956 A Esrd srv, 1 visit p mo, 2-11 5.95 2.85 2.78 2.85 2.78 0.35 XXX90957 A Esrd srv, 4 vsts p mo, 12-19 12.52 5.34 5.45 5.34 5.45 0.75 XXX90958 A Esrd srv 2-3 vsts p mo 12-19 8.34 3.79 3.84 3.79 3.84 0.49 XXX90959 A Esrd serv, 1 vst p mo, 12-19 5.50 2.71 2.62 2.71 2.62 0.32 XXX90960 A Esrd srv, 4 visits p mo, 20+ 5.18 2.65 2.81 2.65 2.81 0.32 XXX90961 A Esrd srv, 2-3 vsts p mo, 20+ 4.26 2.32 2.30 2.32 2.30 0.27 XXX90962 A Esrd serv, 1 visit p mo, 20+ 3.15 1.92 1.74 1.92 1.74 0.21 XXX90963 A Esrd home pt, serv p mo, <2 10.56 4.55 4.77 4.55 4.77 0.62 XXX90964 A Esrd home pt serv p mo, 2-11 9.14 4.03 3.87 4.03 3.87 0.54 XXX90965 A Esrd home pt serv p mo 12-19 8.69 3.87 3.71 3.87 3.71 0.51 XXX90966 A Esrd home pt, serv p mo, 20+ 4.26 2.31 2.26 2.31 2.26 0.27 XXX90967 A Esrd home pt serv p day, <2 0.35 0.15 0.18 0.15 0.18 0.01 XXX90968 A Esrd home pt srv p day, 2-11 0.30 0.13 0.13 0.13 0.13 0.01 XXX90969 A Esrd home pt srv p day 12-19 0.29 0.13 0.13 0.13 0.13 0.01 XXX90970 A Esrd home pt serv p day, 20+ 0.14 0.08 0.08 0.08 0.08 0.01 XXX90989 X Dialysis training, complete 0.00 0.00 0.00 0.00 0.00 0.00 XXXCMS-1503-P1118**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**90993 X Dialysis training, incompl 0.00 0.00 0.00 0.00 0.00 0.00 XXX90997 A Hemoperfusion 1.84 NA NA 0.64 0.66 0.10 00090999 C Dialysis procedure 0.00 0.00 0.00 0.00 0.00 0.00 XXX91000 A Esophageal intubation 0.73 2.25 2.12 NA NA 0.04 00091000 TC A Esophageal intubation 0.00 1.96 1.83 NA NA 0.01 00091000 26 A Esophageal intubation 0.73 0.29 0.29 0.29 0.29 0.03 00091010 A Esophagus motility study 1.25 3.80 4.16 NA NA 0.08 00091010 TC A Esophagusmotility study 0.00 3.14 3.50 NA NA 0.01 00091010 26 A Esophagus motility study 1.25 0.66 0.66 0.66 0.66 0.07 00091011 A Esophagus motility study 1.50 5.35 5.82 NA NA 0.07 00091011 TC A Esophagusmotility study 0.00 4.53 4.99 NA NA 0.01 00091011 26 A Esophagus motility study 1.50 0.82 0.83 0.82 0.83 0.06 00091012 A Esophagus motility study 1.46 5.42 5.94 NA NA 0.07 00091012 TC A Esophagusmotility study 0.00 4.63 5.15 NA NA 0.01 00091012 26 A Esophagus motility study 1.46 0.79 0.79 0.79 0.79 0.06 00091020 A Gastric motility studies 1.44 5.11 5.36 NA NA 0.08 00091020 TC A Gastric motility studies 0.00 4.34 4.61 NA NA 0.01 00091020 26 A Gastric motility studies 1.44 0.77 0.75 0.77 0.75 0.07 00091022 A Duodenal motility study 1.44 3.38 3.83 NA NA 0.07 00091022 TC A Duodenal motility study 0.00 2.59 3.03 NA NA 0.01 00091022 26 A Duodenal motility study 1.44 0.79 0.80 0.79 0.80 0.06 00091030 A Acid perfusion of esophagus 0.91 2.94 3.13 NA NA 0.05 00091030 TC A Acid perfusion of esophagus 0.00 2.44 2.63 NA NA 0.01 00091030 26 A Acid perfusion of esophagus 0.91 0.50 0.50 0.50 0.50 0.04 00091034 A Gastroesophageal reflux test 0.97 4.27 4.71 NA NA 0.05 00091034 TC A Gastroesophageal reflux test 0.00 3.76 4.21 NA NA 0.01 000CMS-1503-P1119**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**91034 26 A Gastroesophageal reflux test 0.97 0.51 0.50 0.51 0.50 0.04 00091035 A G-esoph reflx tst w/electrod 1.59 11.71 12.43 NA NA 0.08 00091035 TC A G-esoph reflx tst w/electrod 0.00 10.87 11.59 NA NA 0.01 00091035 26 A G-esoph reflx tst w/electrod 1.59 0.84 0.84 0.84 0.84 0.07 00091037 A Esoph imped function test 0.97 3.50 3.70 NA NA 0.08 00091037 TC A Esoph imped function test 0.00 2.99 3.18 NA NA 0.01 00091037 26 A Esoph imped function test 0.97 0.51 0.52 0.51 0.52 0.07 00091038 A Esoph imped funct test > 1h 1.10 11.69 7.45 NA NA 0.07 00091038 TC A Esoph imped funct test > 1h 0.00 11.10 6.86 NA NA 0.01 00091038 26 A Esoph imped funct test > 1h 1.10 0.59 0.59 0.59 0.59 0.06 00091040 A Esoph balloon distension tst 0.97 6.99 8.98 NA NA 0.04 00091040 TC A Esoph balloon distension tst 0.00 6.61 8.51 NA NA 0.01 00091040 26 A Esoph balloon distension tst 0.97 0.38 0.47 0.38 0.47 0.03 00091052 A Gastric analysis test 0.79 2.96 2.98 NA NA 0.02 00091052 TC A Gastric analysis test 0.00 2.53 2.58 NA NA 0.01 00091052 26 A Gastric analysis test 0.79 0.43 0.40 0.43 0.40 0.01 00091055 A Gastric intubation for smear 0.94 2.80 2.96 NA NA 0.04 00091055 TC A Gastric intubation for smear 0.00 2.38 2.57 NA NA 0.01 00091055 26 A Gastric intubation for smear 0.94 0.42 0.39 0.42 0.39 0.03 00091065 A Breath hydrogen test 0.20 2.30 2.08 NA NA 0.02 00091065 TC A Breath hydrogen test 0.00 2.19 1.98 NA NA 0.01 00091065 26 A Breath hydrogen test 0.20 0.11 0.10 0.11 0.10 0.01 00091105 A Gastric intubation treatment 0.37 2.25 2.17 0.10 0.09 0.03 00091110 A Gi tract capsule endoscopy 3.64 21.05 22.86 NA NA 0.18 XXX91110 TC A Gi tract capsule endoscopy 0.00 19.08 20.89 NA NA 0.01 XXX91110 26 A Gi tract capsule endoscopy 3.64 1.97 1.97 1.97 1.97 0.17 XXXCMS-1503-P1120**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**91111 A Esophageal capsule endoscopy 1.00 18.94 20.25 NA NA 0.05 XXX91111 TC A Esophageal capsule endoscopy 0.00 18.40 19.70 NA NA 0.01 XXX91111 26 A Esophageal capsule endoscopy 1.00 0.54 0.55 0.54 0.55 0.04 XXX91120 A Rectal sensation test 0.97 8.85 10.08 NA NA 0.09 XXX91120 TC A Rectal sensation test 0.00 8.42 9.67 NA NA 0.01 XXX91120 26 A Rectal sensation test0.97 0.43 0.41 0.43 0.41 0.08 XXX91122 A Anal pressure record 1.77 4.35 4.77 NA NA 0.11 00091122 TC A Anal pressure record 0.00 3.58 4.01 NA NA 0.01 00091122 26 A Anal pressure record 1.77 0.77 0.76 0.77 0.76 0.10 00091123 B Irrigate fecal impaction 0.00 0.00 0.00 0.00 0.00 0.00 XXX91132 C Electrogastrography 0.00 0.00 0.00 NA NA 0.00 XXX91132 TC C Electrogastrography 0.00 0.00 0.00 NA NA 0.00 XXX91132 26 A Electrogastrography0.52 0.28 0.28 0.28 0.28 0.03 XXX91133 C Electrogastrography w/test 0.00 0.00 0.00 NA NA 0.00 XXX91133 TC C Electrogastrography w/test 0.00 0.00 0.00 NA NA 0.00 XXX91133 26 A Electrogastrography w/test 0.66 0.36 0.37 0.36 0.37 0.04 XXX91299 C Gastroenterology procedure 0.00 0.00 0.00 NA NA 0.00 XXX91299 TC C Gastroenterology procedure 0.00 0.00 0.00 NA NA 0.00 XXX91299 26 C Gastroenterology procedure 0.00 0.00 0.00 0.00 0.00 0.00 XXX92002 A Eye exam, new patient 0.88 1.36 1.26 0.49 0.43 0.07 XXX92004 A Eye exam, new patient 1.82 2.36 2.17 1.06 0.91 0.13 XXX92012 A Eye exam established pat 0.92 1.47 1.35 0.61 0.50 0.07 XXX92014 A Eye exam & treatment 1.42 2.06 1.88 0.90 0.75 0.10 XXX92015 N Refraction 0.38 0.18 0.38 0.16 0.16 0.03 XXX92018 A New eye exam & treatment 2.50 NA NA 1.66 1.42 0.17 XXX92019 A Eye exam & treatment 1.31 NA NA 0.67 0.59 0.07 XXXCMS-1503-P1121**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**92020 A Special eye evaluation 0.37 0.40 0.37 0.24 0.21 0.03 XXX92025 A Corneal topography 0.35 0.70 0.64 NA NA 0.02 XXX92025 TC A Corneal topography 0.00 0.47 0.45 NA NA 0.01 XXX92025 26 A Corneal topography0.35 0.23 0.19 0.23 0.19 0.01 XXX92060 A Special eye evaluation 0.69 1.13 1.03 NA NA 0.04 XXX92060 TC A Special eye evaluation 0.00 0.70 0.66 NA NA 0.01 XXX92060 26 A Special eye evaluation 0.69 0.43 0.37 0.43 0.37 0.03 XXX92065 A Orthoptic/pleoptic training 0.37 1.13 1.03 NA NA 0.02 XXX92065 TC A Orthoptic/pleoptic training 0.00 0.97 0.89 NA NA 0.01 XXX92065 26 A Orthoptic/pleoptic training 0.37 0.16 0.14 0.16 0.14 0.01 XXX92070 A Fitting of contact lens 0.70 1.29 1.22 0.43 0.37 0.04 XXX92081 A Visual field examination(s) 0.36 1.29 1.22 NA NA 0.04 XXX92081 TC A Visual field examination(s) 0.00 1.08 1.04 NA NA 0.01 XXX92081 26 A Visual field examination(s) 0.36 0.21 0.18 0.21 0.18 0.03 XXX92082 A Visual field examination(s) 0.44 1.75 1.66 NA NA 0.05 XXX92082 TC A Visual field examination(s) 0.00 1.50 1.44 NA NA 0.01 XXX92082 26 A Visual field examination(s) 0.44 0.25 0.22 0.25 0.22 0.04 XXX92083 A Visual field examination(s) 0.50 2.04 1.93 NA NA 0.04 XXX92083 TC A Visual field examination(s) 0.00 1.72 1.65 NA NA 0.01 XXX92083 26 A Visual field examination(s) 0.50 0.32 0.28 0.32 0.28 0.03 XXX92100 A Serial tonometry exam(s) 0.92 1.81 1.68 0.55 0.47 0.06 XXX92120 A Tonography & eye evaluation 0.81 1.40 1.31 0.47 0.41 0.06 XXX92130 A Water provocation tonography 0.81 1.65 1.55 0.51 0.44 0.04 XXX92135 A Ophth dx imaging post seg 0.35 1.09 1.03 NA NA 0.02 XXX92135 TC A Ophth dx imaging post seg 0.00 0.86 0.83 NA NA 0.01 XXX92135 26 A Ophth dx imaging post seg 0.35 0.23 0.20 0.23 0.20 0.01 XXXCMS-1503-P1122**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**92136 A Ophthalmic biometry 0.54 1.94 1.86 NA NA 0.02 XXX92136 TC A Ophthalmic biometry 0.00 1.56 1.54 NA NA 0.01 XXX92136 26 A Ophthalmic biometry0.54 0.38 0.32 0.38 0.32 0.01 XXX92140 A Glaucoma provocative tests 0.50 1.24 1.18 0.28 0.24 0.03 XXX92225 A Special eye exam, initial 0.38 0.39 0.34 0.24 0.21 0.03 XXX92226 A Special eye exam, subsequent 0.33 0.38 0.33 0.23 0.19 0.01 XXX92230 A Eye exam with photos 0.60 1.00 1.04 0.36 0.31 0.04 XXX92235 A Eye exam with photos 0.81 3.07 2.96 NA NA 0.04 XXX92235 TC A Eye exam with photos 0.00 2.50 2.47 NA NA 0.01 XXX92235 26 A Eye exam with photos 0.81 0.57 0.49 0.57 0.49 0.03 XXX92240 A Icg angiography 1.10 5.83 5.81 NA NA 0.04 XXX92240 TC A Icg angiography 0.00 5.05 5.15 NA NA 0.01 XXX92240 26 A Icg angiography 1.10 0.78 0.66 0.78 0.66 0.03 XXX92250 A Eye exam with photos 0.44 1.73 1.68 NA NA 0.02 XXX92250 TC A Eye exam with photos 0.00 1.47 1.45 NA NA 0.01 XXX92250 26 A Eye exam with photos 0.44 0.26 0.23 0.26 0.23 0.01 XXX92260 A Ophthalmoscopy/dynamometry 0.20 0.33 0.31 0.13 0.11 0.01 XXX92265 A Eye muscle evaluation 0.81 1.59 1.46 NA NA 0.02 XXX92265 TC A Eye muscle evaluation 0.00 1.02 1.02 NA NA 0.01 XXX92265 26 A Eye muscle evaluation 0.81 0.57 0.44 0.57 0.44 0.01 XXX92270 A Electro-oculography 0.81 1.68 1.68 NA NA 0.04 XXX92270 TC A Electro-oculography 0.00 1.30 1.33 NA NA 0.01 XXX92270 26 A Electro-oculography0.81 0.38 0.35 0.38 0.35 0.03 XXX92275 A Electroretinography 1.01 3.37 3.08 NA NA 0.05 XXX92275 TC A Electroretinography 0.00 2.67 2.49 NA NA 0.01 XXX92275 26 A Electroretinography1.01 0.70 0.59 0.70 0.59 0.04 XXXCMS-1503-P1123**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**92283 A Color vision examination 0.17 1.31 1.23 NA NA 0.02 XXX92283 TC A Color vision examination 0.00 1.22 1.15 NA NA 0.01 XXX92283 26 A Color vision examination 0.17 0.09 0.08 0.09 0.08 0.01 XXX92284 A Dark adaptation eye exam 0.24 1.39 1.47 NA NA 0.02 XXX92284 TC A Dark adaptation eye exam 0.00 1.28 1.37 NA NA 0.01 XXX92284 26 A Dark adaptation eye exam 0.24 0.11 0.10 0.11 0.10 0.01 XXX92285 A Eye photography 0.20 1.04 1.03 NA NA 0.04 XXX92285 TC A Eye photography 0.00 0.92 0.92 NA NA 0.01 XXX92285 26 A Eye photography 0.20 0.12 0.11 0.12 0.11 0.03 XXX92286 A Internal eye photography 0.66 2.78 2.79 NA NA 0.02 XXX92286 TC A Internal eye photography 0.00 2.36 2.43 NA NA 0.01 XXX92286 26 A Internal eye photography 0.66 0.42 0.36 0.42 0.36 0.01 XXX92287 A Internal eye photography 0.81 2.65 2.55 0.57 0.47 0.04 XXX92310 N Contact lens fitting 1.17 1.47 1.47 0.51 0.50 0.08 XXX92311 A Contact lens fitting 1.08 1.81 1.66 0.56 0.49 0.08 XXX92312 A Contact lens fitting 1.26 2.10 1.89 0.65 0.57 0.06 XXX92313 A Contact lens fitting 0.92 1.98 1.79 0.58 0.48 0.06 XXX92314 N Prescription of contact lens 0.69 1.49 1.47 0.30 0.29 0.04 XXX92315 A Prescription of contact lens 0.45 1.69 1.56 0.22 0.19 0.04 XXX92316 A Prescription of contact lens 0.68 2.30 2.02 0.48 0.39 0.04 XXX92317 A Prescription of contact lens 0.45 1.66 1.57 0.18 0.17 0.01 XXX92325 A Modification of contact lens 0.00 1.06 0.97 NA NA 0.01 XXX92326 A Replacement of contactlens 0.00 0.92 1.03 NA NA 0.01 XXX92340 N Fitting of spectacles 0.37 0.59 0.63 0.16 0.16 0.03 XXX92341 N Fitting of spectacles 0.47 0.64 0.68 0.20 0.20 0.03 XXX92342 N Fitting of spectacles 0.53 0.66 0.70 0.23 0.23 0.04 XXXCMS-1503-P1124**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**92352 B Special spectacles fitting 0.37 0.74 0.77 0.16 0.16 0.03 XXX92353 B Special spectacles fitting 0.50 0.80 0.82 0.22 0.21 0.03 XXX92354 B Special spectacles fitting 0.00 0.35 1.64 NA NA 0.01 XXX92355 B Special spectacles fitting 0.00 0.54 1.14 NA NA 0.01 XXX92358 B Eye prosthesis service 0.00 0.29 0.41 NA NA 0.01 XXX92370 N Repair & adjust spectacles 0.32 0.52 0.55 0.14 0.14 0.03 XXX92371 B Repair & adjust spectacles 0.00 0.30 0.36 NA NA 0.01 XXX92499 C Eye service or procedure 0.00 0.00 0.00 NA NA 0.00 XXX92499 TC C Eye service or procedure 0.00 0.00 0.00 NA NA 0.00 XXX92499 26 C Eye service or procedure 0.00 0.00 0.00 0.00 0.00 0.00 XXX92502 A Ear and throat examination 1.51 NA NA 1.33 1.25 0.07 00092504 A Ear microscopy examination 0.18 0.72 0.71 0.10 0.09 0.01 XXX92506 A Speech/hearing evaluation 0.86 3.96 3.90 NA NA 0.06 XXX92507 A Speech/hearing therapy 0.52 1.37 1.38 NA NA 0.03 XXX92508 A Speech/hearing therapy 0.26 0.67 0.66 NA NA 0.01 XXX92511 A Nasopharyngoscopy 0.84 3.74 3.76 0.92 0.88 0.0400092512 A Nasal function studies 0.55 1.19 1.21 0.30 0.26 0.03 XXX92516 A Facial nerve function test 0.43 1.57 1.51 0.24 0.22 0.03 XXX92520 A Laryngeal function studies 0.75 1.35 1.18 0.48 0.41 0.04 XXX92526 A Oral function therapy 1.34 0.72 1.32 NA NA 0.07 XXX92531 B Spontaneous nystagmus study 0.00 0.00 0.00 0.00 0.00 0.00 XXX92532 B Positional nystagmus test 0.00 0.00 0.00 0.00 0.00 0.00 XXX92533 B Caloric vestibular test 0.00 0.00 0.00 0.00 0.00 0.00 XXX92534 B Optokinetic nystagmus test 0.00 0.00 0.00 0.00 0.00 0.00 XXX92540 A Basic vestibular evaluation 1.50 1.28 1.28 NA NA 0.05 XXX92540 TC A Basic vestibular evaluation 0.00 0.53 0.53 NA NA 0.01 XXXCMS-1503-P1125**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**92540 26 A Basic vestibular evaluation 1.50 0.75 0.75 0.75 0.75 0.04 XXX92541 A Spontaneous nystagmus test 0.40 0.45 0.90 NA NA 0.02 XXX92541 TC A Spontaneous nystagmus test 0.00 0.25 0.72 NA NA 0.01 XXX92541 26 A Spontaneous nystagmus test 0.40 0.20 0.18 0.20 0.18 0.01 XXX92542 A Positional nystagmus test 0.33 0.41 0.97 NA NA 0.02 XXX92542 TC A Positional nystagmus test 0.00 0.24 0.81 NA NA 0.01 XXX92542 26 A Positional nystagmus test 0.33 0.17 0.16 0.17 0.16 0.01 XXX92543 A Caloric vestibular test 0.10 0.30 0.53 NA NA 0.02 XXX92543 TC A Caloric vestibular test 0.00 0.25 0.48 NA NA 0.01 XXX92543 26 A Caloric vestibular test 0.10 0.05 0.05 0.05 0.05 0.01 XXX92544 A Optokinetic nystagmus test 0.26 0.36 0.80 NA NA 0.02 XXX92544 TC A Optokinetic nystagmus test 0.00 0.23 0.68 NA NA 0.01 XXX92544 26 A Optokinetic nystagmus test 0.26 0.13 0.12 0.13 0.12 0.01 XXX92545 A Oscillating tracking test 0.23 0.34 0.76 NA NA 0.02 XXX92545 TC A Oscillating tracking test 0.00 0.23 0.65 NA NA 0.01 XXX92545 26 A Oscillating tracking test 0.23 0.11 0.11 0.11 0.11 0.01 XXX92546 A Sinusoidal rotational test 0.29 2.53 2.41 NA NA 0.02 XXX92546 TC A Sinusoidal rotational test 0.00 2.39 2.28 NA NA 0.01 XXX92546 26 A Sinusoidal rotational test 0.29 0.14 0.13 0.14 0.13 0.01 XXX92547 A Supplemental electrical test 0.00 0.15 0.13 0.15 0.13 0.01 ZZZ92548 A Posturography 0.50 2.58 2.43 NA NA 0.02 XXX92548 TC A Posturography 0.00 2.33 2.20 NA NA 0.01 XXX92548 26 A Posturography 0.50 0.25 0.23 0.25 0.23 0.01 XXX92550 A Tympanometry & reflex thresh 0.35 0.24 0.24 NA NA 0.01 XXX92551 N Pure tone hearing test, air 0.00 0.31 0.32 NA NA 0.01 XXX92552 A Pure tone audiometry, air 0.00 0.79 0.73 NA NA 0.01 XXXCMS-1503-P1126**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**92553 A Audiometry, air & bone 0.00 0.96 0.92 NA NA 0.01 XXX92555 A Speech threshold audiometry 0.00 0.57 0.53 NA NA 0.01 XXX92556 A Speech audiometry, complete 0.00 0.90 0.82 NA NA 0.01 XXX92557 A Comprehensive hearing test 0.60 0.46 0.55 0.32 0.44 0.03 XXX92559 N Group audiometric testing 0.00 0.00 0.00 0.00 0.00 0.00 XXX92560 N Bekesy audiometry, screen 0.00 0.00 0.00 0.00 0.00 0.00 XXX92561 A Bekesy audiometry, diagnosis 0.00 1.01 0.93 NA NA 0.01 XXX92562 A Loudness balance test 0.00 1.10 0.90 NA NA 0.01 XXX92563 A Tone decay hearing test 0.00 0.78 0.71 NA NA 0.01 XXX92564 A Sisi hearing test 0.00 0.68 0.63 NA NA 0.01 XXX92565 A Stenger test, pure tone 0.00 0.36 0.37 NA NA 0.01 XXX92567 A Tympanometry 0.20 0.20 0.24 0.11 0.16 0.01 XXX92568 A Acoustic refl threshold tst 0.29 0.16 0.18 0.16 0.18 0.01 XXX92570 A Acoustic immittance testing 0.55 0.35 0.35 0.29 0.29 0.03 XXX92571 A Filtered speech hearing test 0.00 0.63 0.56 NA NA 0.01 XXX92572 A Staggered spondaic word test 0.00 1.24 0.90 NA NA 0.01 XXX92575 A Sensorineural acuity test 0.00 1.69 1.41 NA NA 0.01 XXX92576 A Synthetic sentence test 0.00 0.91 0.77 NA NA 0.01 XXX92577 A Stenger test, speech 0.00 0.42 0.46 NA NA 0.01 XXX92579 A Visual audiometry (vra) 0.70 0.54 0.54 0.40 0.42 0.03 XXX92582 A Conditioning play audiometry 0.00 1.65 1.46 NA NA 0.01 XXX92583 A Select picture audiometry 0.00 1.03 1.02 NA NA 0.01 XXX92584 A Electrocochleography 0.00 1.84 1.91 NA NA 0.01 XXX92585 A Auditor evoke potent, compre 0.50 2.98 2.75 NA NA 0.02 XXX92585 TC A Auditor evoke potent, compre 0.00 2.72 2.51 NA NA 0.01 XXX92585 26 A Auditor evoke potent, compre 0.50 0.26 0.24 0.26 0.24 0.01 XXXCMS-1503-P1127**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**92586 A Auditor evoke potent, limit 0.00 2.14 2.02 NA NA 0.01 XXX92587 A Evoked auditory test 0.13 0.85 0.91 NA NA 0.02 XXX92587 TC A Evoked auditory test 0.00 0.78 0.85 NA NA 0.01 XXX92587 26 A Evoked auditory test 0.13 0.07 0.06 0.07 0.06 0.01 XXX92588 A Evoked auditory test 0.36 1.57 1.53 NA NA 0.02 XXX92588 TC A Evoked auditory test 0.00 1.38 1.36 NA NA 0.01 XXX92588 26 A Evoked auditory test 0.36 0.19 0.17 0.19 0.17 0.01 XXX92590 N Hearing aid exam, oneear 0.00 0.00 0.00 0.00 0.00 0.00 XXX92591 N Hearing aid exam, bothears 0.00 0.00 0.00 0.00 0.00 0.00 XXX92592 N Hearing aid check, one ear 0.00 0.00 0.00 0.00 0.00 0.00 XXX92593 N Hearing aid check, bothears 0.00 0.00 0.00 0.00 0.00 0.00 XXX92594 N Electro hearng aid test,one 0.00 0.00 0.00 0.00 0.00 0.00 XXX92595 N Electro hearng aid tst,both 0.00 0.00 0.00 0.00 0.00 0.00 XXX92596 A Ear protector evaluation 0.00 1.20 1.14 NA NA 0.01 XXX92597 A Oral speech device eval 1.26 0.78 1.52 NA NA 0.07 XXX92601 A Cochlear implt f/up exam < 7 2.30 1.49 1.85 0.99 1.38 0.11 XXX92602 A Reprogram cochlear implt < 7 1.30 1.00 1.26 0.56 0.84 0.07 XXX92603 A Cochlear implt f/up exam 7 > 2.25 1.83 1.80 1.19 1.28 0.11 XXX92604 A Reprogram cochlear implt 7 > 1.25 1.19 1.16 0.66 0.73 0.06 XXX92605 B Eval for nonspeech device rx 0.00 0.00 0.00 0.00 0.00 0.00 XXX92606 B Non-speech device service 0.00 0.00 0.00 0.00 0.00 0.00 XXX92607 A Ex for speech device rx, 1hr 0.00 5.22 5.09 NA NA 0.07 XXX92608 A Ex for speech device rx addl 0.00 1.36 1.14 NA NA 0.01 XXX92609 A Use of speech device service 0.00 2.13 2.38 NA NA 0.04 XXX92610 A Evaluate swallowing function 1.30 0.89 1.69 0.64 0.64 0.07 XXX92611 A Motion fluoroscopy/swallow 1.34 1.05 1.88 NA NA 0.08 XXXCMS-1503-P1128**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**92612 A Endoscopy swallow tst (fees) 1.27 3.52 3.50 0.70 0.65 0.07 XXX92613 A Endoscopy swallow tst (fees) 0.71 0.39 0.37 0.39 0.37 0.04 XXX92614 A Laryngoscopic sensory test 1.27 3.02 2.97 0.72 0.66 0.07 XXX92615 A Eval laryngoscopy sense tst 0.63 0.36 0.34 0.36 0.34 0.03 XXX92616 A Fees w/laryngeal sense test 1.88 3.86 3.86 1.02 0.95 0.10 XXX92617 A Interprt fees/laryngealtest 0.79 0.43 0.40 0.43 0.40 0.04 XXX92620 A Auditory function, 60 min 1.50 1.15 0.84 0.87 0.70 0.07 XXX92621 A Auditory function, + 15 min 0.35 0.27 0.20 0.18 0.15 0.01 ZZZ92625 A Tinnitus assessment 1.15 0.81 0.64 0.61 0.54 0.06 XXX92626 A Eval aud rehab status 1.40 1.09 0.99 0.73 0.80 0.07 XXX92627 A Eval aud status rehab add-on 0.33 0.29 0.26 0.17 0.20 0.01 ZZZ92630 I Aud rehab pre-ling hear loss 0.00 0.00 0.00 0.00 0.00 0.00 XXX92633 I Aud rehab postling hear loss 0.00 0.00 0.00 0.00 0.00 0.00 XXX92640 A Aud brainstem implt programg 1.76 1.20 0.76 0.89 0.60 0.38 XXX92700 C Ent procedure/service 0.00 0.00 0.00 0.00 0.00 0.00 XXX92950 A Heart/lung resuscitation cpr 3.79 4.07 4.10 1.04 1.03 0.31 00092953 A Temporary external pacing 0.23 NA NA 0.07 0.08 0.01 00092960 A Cardioversion electric, ext 2.25 3.60 4.65 1.13 1.39 0.14 00092961 A Cardioversion, electric, int 4.59 NA NA 2.03 2.45 0.45 00092970 A Cardioassist, internal 3.51 NA NA 1.37 1.51 0.25 00092971 A Cardioassist, external 1.77 NA NA 0.82 1.04 0.11 00092973 A Percut coronary thrombectomy 3.28 NA NA 1.29 1.63 0.73 ZZZ92974 A Cath place, cardio brachytx 3.00 NA NA 1.17 1.50 0.68 ZZZ92975 A Dissolve clot, heart vessel 7.24 NA NA 2.88 3.60 1.64 00092977 A Dissolve clot, heart vessel 0.00 1.42 2.66 NA NA 0.03 XXX92978 C Intravasc us, heart add-on 0.00 0.00 0.00 NA NA 0.00 ZZZCMS-1503-P1129**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**92978 TC C Intravasc us, heart add-on 0.00 0.00 0.00 NA NA 0.00 ZZZ92978 26 A Intravasc us, heart add-on 1.80 0.71 0.89 0.71 0.89 0.13 ZZZ92979 C Intravasc us, heart add-on 0.00 0.00 0.00 NA NA 0.00 ZZZ92979 TC C Intravasc us, heart add-on 0.00 0.00 0.00 NA NA 0.00 ZZZ92979 26 A Intravasc us, heart add-on 1.44 0.56 0.72 0.56 0.72 0.10 ZZZ92980 A Insert intracoronary stent 14.82 NA NA 5.99 7.59 3.36 00092981 A Insert intracoronary stent 4.16 NA NA 1.63 2.07 0.93 ZZZ92982 A Coronary artery dilation 10.96 NA NA 4.48 5.67 2.47 00092984 A Coronary artery dilation 2.97 NA NA 1.16 1.48 0.66 ZZZ92986 A Revision of aortic valve 22.85 NA NA 11.68 14.46 5.17 09092987 A Revision of mitral valve 23.63 NA NA 11.91 14.88 5.34 09092990 A Revision of pulmonary valve 18.27 NA NA 9.74 11.72 4.14 09092992 C Revision of heart chamber 0.00 0.00 0.00 0.00 0.00 0.00 09092993 C Revision of heart chamber 0.00 0.00 0.00 0.00 0.00 0.00 09092995 A Coronary atherectomy 12.07 NA NA 4.91 6.24 2.73 00092996 A Coronary atherectomy add-on 3.26 NA NA 1.28 1.63 0.73 ZZZ92997 A Pul art balloon repr, percut 11.98 NA NA 4.84 5.58 2.71 00092998 A Pul art balloon repr, percut 5.99 NA NA 2.33 2.84 1.36 ZZZ93000 A Electrocardiogram, complete 0.17 0.32 0.39 NA NA 0.02 XXX93005 A Electrocardiogram, tracing 0.00 0.25 0.31 NA NA 0.01 XXX93010 A Electrocardiogram report 0.17 0.07 0.08 0.07 0.08 0.01 XXX93012 A Transmission of ecg 0.00 3.87 4.86 NA NA 0.01 XXX93014 A Report on transmitted ecg0.52 0.21 0.24 0.21 0.24 0.03 XXX93015 A Cardiovascular stress test 0.75 1.56 1.92 NA NA 0.03 XXX93016 A Cardiovascular stress test 0.45 0.18 0.22 0.18 0.22 0.01 XXX93017 A Cardiovascular stress test 0.00 1.26 1.56 NA NA 0.01 XXXCMS-1503-P1130**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**93018 A Cardiovascular stress test 0.30 0.12 0.14 0.12 0.14 0.01 XXX93024 A Cardiac drug stress test 1.17 1.88 2.19 NA NA 0.05 XXX93024 TC A Cardiac drug stress test 0.00 1.42 1.64 NA NA 0.01 XXX93024 26 A Cardiac drug stress test 1.17 0.46 0.55 0.46 0.55 0.04 XXX93025 A Microvolt t-wave assess 0.75 3.63 4.83 NA NA 0.04 XXX93025 TC A Microvolt t-wave assess 0.00 3.33 4.46 NA NA 0.01 XXX93025 26 A Microvolt t-wave assess 0.75 0.30 0.37 0.30 0.37 0.03 XXX93040 A Rhythm ECG with report 0.16 0.19 0.21 NA NA 0.02 XXX93041 A Rhythm ECG, tracing 0.00 0.14 0.15 NA NA 0.01 XXX93042 A Rhythm ECG, report 0.16 0.05 0.06 0.05 0.06 0.01 XXX93224 A ECG monitor/report, 24 hrs 0.52 1.95 2.50 NA NA 0.03 XXX93225 A ECG monitor/record, 24 hrs 0.00 0.89 0.99 NA NA 0.01 XXX93226 A ECG monitor/report, 24 hrs 0.00 0.82 1.24 NA NA 0.01 XXX93227 A ECG monitor/review, 24 hrs 0.52 0.24 0.27 0.24 0.27 0.01 XXX93228 A Remote 30 day ecg rev/report 0.52 0.21 0.21 0.21 0.21 0.03 XXX93229 C Remote 30 day ecg tech supp 0.00 0.00 0.00 0.00 0.00 0.00 XXX93230 A ECG monitor/report, 24 hrs 0.52 1.95 2.55 NA NA 0.03 XXX93231 A Ecg monitor/record, 24 hrs 0.00 0.78 0.93 NA NA 0.01 XXX93232 A ECG monitor/report, 24 hrs 0.00 0.96 1.38 NA NA 0.01 XXX93233 A ECG monitor/review, 24 hrs 0.52 0.21 0.24 0.21 0.24 0.01 XXX93235 C ECG monitor/report, 24 hrs 0.00 0.00 0.00 0.00 0.00 0.00 XXX93236 C ECG monitor/report, 24 hrs 0.00 0.00 0.00 0.00 0.00 0.00 XXX93237 A ECG monitor/review, 24 hrs 0.45 0.18 0.22 0.18 0.22 0.03 XXX93268 A ECG record/review 0.52 5.52 6.70 NA NA 0.03 XXX93270 A ECG recording 0.00 0.23 0.43 NA NA 0.01 XXX93271 A Ecg/monitoring and analysis 0.00 5.09 6.04 NA NA 0.01 XXXCMS-1503-P1131**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**93272 A Ecg/review, interpret only 0.52 0.20 0.23 0.20 0.23 0.01 XXX93278 A ECG/signal-averaged 0.25 0.60 0.75 NA NA 0.02 XXX93278 TC A ECG/signal-averaged 0.00 0.49 0.64 NA NA 0.01 XXX93278 26 A ECG/signal-averaged 0.25 0.11 0.11 0.11 0.11 0.01 XXX93279 A Pm device progr eval, sngl 0.65 0.70 0.86 NA NA 0.04 XXX93279 TC A Pm device progr eval, sngl 0.00 0.44 0.53 NA NA 0.01 XXX93279 26 A Pm device progr eval, sngl 0.65 0.26 0.33 0.26 0.33 0.03 XXX93280 A Pm device progr eval, dual 0.77 0.80 1.01 NA NA 0.04 XXX93280 TC A Pm device progr eval, dual 0.00 0.50 0.61 NA NA 0.01 XXX93280 26 A Pm device progr eval,dual 0.77 0.30 0.40 0.30 0.40 0.03 XXX93281 A Pm device progr eval, multi 0.90 0.93 1.17 NA NA 0.04 XXX93281 TC A Pm device progr eval, multi 0.00 0.58 0.71 NA NA 0.01 XXX93281 26 A Pm device progr eval,multi 0.90 0.35 0.460.35 0.46 0.03 XXX93282 A Icd device prog eval, 1 sngl 0.85 0.84 1.06 NA NA 0.04 XXX93282 TC A Icd device prog eval, 1 sngl 0.00 0.51 0.63 NA NA 0.01 XXX93282 26 A Icd device prog eval, 1sngl 0.85 0.33 0.43 0.33 0.43 0.03 XXX93283 A Icd device progr eval, dual 1.15 1.05 1.29 NA NA 0.05 XXX93283 TC A Icd device progr eval, dual 0.00 0.60 0.73 NA NA 0.01 XXX93283 26 A Icd device progr eval, dual 1.15 0.45 0.56 0.45 0.56 0.04 XXX93284 A Icd device progr eval, mult 1.25 1.17 1.48 NA NA 0.05 XXX93284 TC A Icd device progr eval, mult 0.00 0.68 0.83 NA NA 0.01 XXX93284 26 A Icd device progr eval, mult 1.25 0.49 0.65 0.49 0.65 0.04 XXX93285 A Ilr device eval progr 0.52 0.61 0.76 NA NA 0.02 XXX93285 TC A Ilr device eval progr 0.00 0.40 0.49 NA NA 0.01 XXX93285 26 A Ilr device eval progr 0.52 0.21 0.27 0.21 0.27 0.01 XXX93286 A Pre-op pm device eval 0.30 0.41 0.46 NA NA 0.02 XXXCMS-1503-P1132**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**93286 TC A Pre-op pm device eval 0.00 0.29 0.34 NA NA 0.01 XXX93286 26 A Pre-op pm device eval 0.30 0.12 0.12 0.12 0.12 0.01 XXX93287 A Pre-op icd device eval 0.45 0.50 0.55 NA NA 0.02 XXX93287 TC A Pre-op icd device eval 0.00 0.32 0.37 NA NA 0.01 XXX93287 26 A Pre-op icd device eval 0.45 0.18 0.18 0.18 0.18 0.01 XXX93288 A Pm device eval in person 0.43 0.57 0.72 NA NA 0.02 XXX93288 TC A Pm device eval in person 0.00 0.40 0.50 NA NA 0.01 XXX93288 26 A Pm device eval in person 0.43 0.17 0.22 0.17 0.22 0.01 XXX93289 A Icd device interrogate 0.92 0.86 1.04 NA NA 0.04 XXX93289 TC A Icd device interrogate 0.00 0.50 0.61 NA NA 0.01 XXX93289 26 A Icd device interrogate 0.92 0.36 0.43 0.36 0.43 0.03 XXX93290 A Icm device eval 0.43 0.40 0.44 NA NA 0.02 XXX93290 TC A Icm device eval 0.00 0.23 0.27 NA NA 0.01 XXX93290 26 A Icm device eval 0.43 0.17 0.17 0.17 0.17 0.01 XXX93291 A Ilr device interrogate 0.43 0.54 0.67 NA NA 0.02 XXX93291 TC A Ilr device interrogate 0.00 0.37 0.45 NA NA 0.01 XXX93291 26 A Ilr device interrogate0.43 0.17 0.22 0.17 0.22 0.01 XXX93292 A Wcd device interrogate 0.43 0.45 0.56 NA NA 0.02 XXX93292 TC A Wcd device interrogate 0.00 0.28 0.34 NA NA 0.01 XXX93292 26 A Wcd device interrogate 0.43 0.17 0.22 0.17 0.22 0.01 XXX93293 A Pm phone r-strip device eval 0.32 1.13 1.30 NA NA 0.02 XXX93293 TC A Pm phone r-strip device eval 0.00 1.01 1.16 NA NA 0.01 XXX93293 26 A Pm phone r-strip deviceeval 0.32 0.12 0.14 0.12 0.14 0.01 XXX93294 A Pm device interrogate remote 0.65 0.26 0.33 0.26 0.33 0.04 XXX93295 A Icd device interrogat remote 1.29 0.51 0.63 0.51 0.63 0.08 XXX93296 A Pm/icd remote tech serv 0.00 0.69 0.94 NA NA 0.01 XXXCMS-1503-P1133**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**93297 A Icm device interrogat remote 0.52 0.20 0.20 0.20 0.20 0.03 XXX93298 A Ilr device interrogat remote 0.52 0.20 0.27 0.20 0.27 0.03 XXX93299 C Icm/ilr remote tech serv 0.00 0.00 0.00 0.00 0.00 0.00 XXX93303 A Echo transthoracic 1.30 4.16 4.77 NA NA 0.05 XXX93303 TC A Echo transthoracic 0.00 3.64 4.17 NA NA 0.01 XXX93303 26 A Echo transthoracic 1.30 0.52 0.60 0.52 0.60 0.04 XXX93304 A Echo transthoracic 0.75 2.82 3.11 NA NA 0.04 XXX93304 TC A Echo transthoracic 0.00 2.52 2.78 NA NA 0.01 XXX93304 26 A Echo transthoracic 0.75 0.30 0.33 0.30 0.33 0.03 XXX93306 A Tte w/doppler, complete 1.30 3.97 5.43 NA NA 0.05 XXX93306 TC A Tte w/doppler, complete 0.00 3.45 4.78 NA NA 0.01 XXX93306 26 A Tte w/doppler, complete 1.30 0.52 0.65 0.52 0.65 0.04 XXX93307 A Tte w/o doppler, complete 0.92 2.25 3.36 NA NA 0.04 XXX93307 TC A Tte w/o doppler, complete 0.00 1.87 2.91 NA NA 0.01 XXX93307 26 A Tte w/o doppler, complete 0.92 0.38 0.45 0.38 0.45 0.03 XXX93308 A Tte, f-up or lmtd 0.53 2.14 2.52 NA NA 0.02 XXX93308 TC A Tte, f-up or lmtd 0.00 1.93 2.26 NA NA 0.01 XXX93308 26 A Tte, f-up or lmtd 0.53 0.21 0.26 0.21 0.26 0.01 XXX93312 A Echo transesophageal 2.20 6.49 7.13 NA NA 0.10 XXX93312 TC A Echo transesophageal 0.00 5.70 6.17 NA NA 0.03 XXX93312 26 A Echo transesophageal 2.20 0.79 0.96 0.79 0.96 0.07 XXX93313 A Echo transesophageal 0.95 NA NA 0.22 0.19 0.07 XXX93314 A Echo transesophageal 1.25 6.49 6.97 NA NA 0.07 XXX93314 TC A Echo transesophageal 0.00 6.03 6.42 NA NA 0.03 XXX93314 26 A Echo transesophageal 1.25 0.46 0.55 0.46 0.55 0.04 XXX93315 C Echo transesophageal 0.00 0.00 0.00 NA NA 0.00 XXXCMS-1503-P1134**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**93315 TC C Echo transesophageal 0.00 0.00 0.00 NA NA 0.00 XXX93315 26 A Echo transesophageal 2.78 1.04 1.27 1.04 1.27 0.24 XXX93316 A Echo transesophageal 0.95 NA NA 0.27 0.29 0.07 XXX93317 C Echo transesophageal 0.00 0.00 0.00 NA NA 0.00 XXX93317 TC C Echo transesophageal 0.00 0.00 0.00 NA NA 0.00 XXX93317 26 A Echo transesophageal 1.83 0.66 0.72 0.66 0.72 0.24 XXX93318 C Echo transesophageal intraop 0.00 0.00 0.00 NA NA 0.00 XXX93318 TC C Echo transesophageal intraop 0.00 0.00 0.00 NA NA 0.00 XXX93318 26 A Echo transesophageal intraop 2.20 0.76 0.86 0.76 0.86 0.32 XXX93320 A Doppler echo exam, heart 0.38 0.87 1.43 NA NA 0.02 ZZZ93320 TC A Doppler echo exam, heart 0.00 0.72 1.25 NA NA 0.01 ZZZ93320 26 A Doppler echo exam, heart 0.38 0.15 0.18 0.15 0.18 0.01 ZZZ93321 A Doppler echo exam, heart 0.15 0.50 0.69 NA NA 0.02 ZZZ93321 TC A Doppler echo exam, heart 0.00 0.44 0.62 NA NA 0.01 ZZZ93321 26 A Doppler echo exam, heart 0.15 0.06 0.07 0.06 0.07 0.01 ZZZ93325 A Doppler color flow add-on 0.07 0.47 0.95 NA NA 0.02 ZZZ93325 TC A Doppler color flow add-on 0.00 0.44 0.92 NA NA 0.01 ZZZ93325 26 A Doppler color flow add-on 0.07 0.03 0.03 0.03 0.03 0.01 ZZZ93350 A Stress tte only 1.46 4.14 4.61 NA NA 0.07 XXX93350 TC A Stress tte only 0.00 3.56 3.89 NA NA 0.01 XXX93350 26 A Stress tte only 1.46 0.58 0.72 0.58 0.72 0.06 XXX93351 A Stress tte complete 1.75 4.70 5.40 NA NA 0.09 XXX93351 TC A Stress tte complete 0.00 4.01 4.50 NA NA 0.03 XXX93351 26 A Stress tte complete 1.75 0.69 0.90 0.69 0.90 0.06 XXX93352 A Admin ecg contrast agent 0.19 0.71 0.86 NA NA 0.01 ZZZ93501 A Right heart catheterization 3.02 15.50 18.56 NA NA 0.59 000CMS-1503-P1135**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**93501 TC A Right heart catheterization 0.00 14.32 17.08 NA NA 0.01 00093501 26 A Right heart catheterization 3.02 1.18 1.48 1.18 1.48 0.58 00093503 A Insert/place heart catheter 2.91 NA NA 0.77 0.77 0.28 00093505 A Biopsy of heart lining 4.37 17.19 18.14 NA NA 0.89 00093505 TC A Biopsy of heart lining 0.00 15.47 16.00 NA NA 0.03 00093505 26 A Biopsy of heart lining 4.37 1.72 2.14 1.72 2.14 0.86 00093508 A Cath placement, angiography 4.09 23.65 26.49 NA NA 0.81 00093508 TC A Cath placement, angiography 0.00 22.05 24.39 NA NA 0.03 00093508 26 A Cath placement, angiography 4.09 1.60 2.10 1.60 2.10 0.78 00093510 A Left heart catheterization 4.32 23.12 29.59 NA NA 0.86 00093510 TC A Left heart catheterization 0.00 21.43 27.38 NA NA 0.03 00093510 26 A Left heart catheterization 4.32 1.69 2.21 1.69 2.21 0.83 00093511 C Left heart catheterization 0.00 NA NA NA NA 0.00 00093511 TC C Left heart catheterization 0.00 NA NA NA NA 0.00 00093511 26 A Left heart catheterization 5.02 1.96 2.56 1.96 2.56 1.14 00093514 C Left heart catheterization 0.00 NA NA NA NA 0.00 00093514 TC C Left heart catheterization 0.00 NA NA NA NA 0.00 00093514 26 A Left heart catheterization 7.04 2.75 3.46 2.75 3.46 1.60 00093524 C Left heart catheterization 0.00 NA NA NA NA 0.00 00093524 TC C Left heart catheterization 0.00 NA NA NA NA 0.00 00093524 26 A Left heart catheterization 6.94 2.72 3.53 2.72 3.53 1.57 00093526 A Rt & Lt heart catheters 5.98 28.80 37.22 NA NA 1.20 00093526 TC A Rt & Lt heart catheters 0.00 26.46 34.18 NA NA 0.03 00093526 26 A Rt & Lt heart catheters 5.98 2.34 3.04 2.34 3.04 1.17 00093527 C Rt & Lt heart catheters 0.00 NA NA NA NA 0.00 00093527 TC C Rt & Lt heart catheters 0.00 NA NA NA NA 0.00 000CMS-1503-P1136**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**93527 26 A Rt & Lt heart catheters 7.27 2.84 3.66 2.84 3.66 1.64 00093528 C Rt & Lt heart catheters 0.00 NA NA NA NA 0.00 00093528 TC C Rt & Lt heart catheters 0.00 NA NA NA NA 0.00 00093528 26 A Rt & Lt heart catheters 8.99 3.51 4.20 3.51 4.20 2.02 00093529 C Rt, lt heart catheterization 0.00 NA NA NA NA 0.00 00093529 TC C Rt, lt heart catheterization 0.00 NA NA NA NA 0.00 00093529 26 A Rt, lt heart catheterization 4.79 1.87 2.44 1.87 2.44 1.09 00093530 C Rt heart cath, congenital 0.00 NA NA NA NA 0.00 00093530 TC C Rt heart cath, congenital 0.00 NA NA NA NA 0.00 00093530 26 A Rt heart cath, congenital 4.22 1.67 2.03 1.67 2.03 0.95 00093531 C R & l heart cath, congenital 0.00 NA NA NA NA 0.00 00093531 TC C R & l heart cath, congenital 0.00 NA NA NA NA 0.00 00093531 26 A R & l heart cath, congenital 8.34 3.26 3.92 3.26 3.92 1.89 00093532 C R & l heart cath, congenital 0.00 NA NA NA NA 0.00 00093532 TC C R & l heart cath, congenital 0.00 NA NA NA NA 0.00 00093532 26 A R & l heart cath, congenital 9.99 3.90 4.60 3.90 4.60 2.26 00093533 C R & l heart cath, congenital 0.00 NA NA NA NA 0.00 00093533 TC C R & l heart cath, congenital 0.00 NA NA NA NA 0.00 00093533 26 A R & l heart cath, congenital 6.69 2.60 3.10 2.60 3.10 1.53 00093539 A Injection, cardiac cath 0.40 2.03 2.10 0.16 0.20 0.03 00093540 A Injection, cardiac cath 0.43 3.86 5.64 0.17 0.22 0.03 00093541 A Injection for lung angiogram 0.29 0.11 0.14 0.11 0.14 0.01 00093542 A Injection for heart x-rays 0.29 2.37 3.41 0.11 0.14 0.01 00093543 A Injection for heart x-rays 0.29 2.16 2.23 0.11 0.14 0.01 00093544 A Injection for aortography 0.25 1.52 1.57 0.10 0.13 0.01 00093545 A Inject for coronary x-rays 0.40 4.86 4.97 0.16 0.20 0.03 000CMS-1503-P1137**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**93555 A Imaging, cardiac cath 0.81 0.45 1.47 NA NA 0.04 XXX93555 TC A Imaging, cardiac cath 0.00 0.13 1.07 NA NA 0.01 XXX93555 26 A Imaging, cardiac cath 0.81 0.32 0.40 0.32 0.40 0.03 XXX93556 A Imaging, cardiac cath 0.83 0.65 2.24 NA NA 0.04 XXX93556 TC A Imaging, cardiac cath 0.00 0.33 1.83 NA NA 0.01 XXX93556 26 A Imaging, cardiac cath 0.83 0.32 0.41 0.32 0.41 0.03 XXX93561 C Cardiac output measurement 0.00 NA NA NA NA 0.00 00093561 TC C Cardiac output measurement 0.00 NA NA NA NA 0.00 00093561 26 A Cardiac output measurement 0.50 0.20 0.18 0.20 0.18 0.04 00093562 C Cardiac output measurement 0.00 NA NA NA NA 0.00 00093562 TC C Cardiac output measurement 0.00 NA NA NA NA 0.00 00093562 26 A Cardiac output measurement 0.16 0.06 0.05 0.06 0.05 0.01 00093571 C Heart flow reserve measure 0.00 NA NA NA NA 0.00 ZZZ93571 TC C Heart flow reserve measure 0.00 NA NA NA NA 0.00 ZZZ93571 26 A Heart flow reserve measure 1.80 0.71 0.89 0.71 0.89 0.11 ZZZ93572 C Heart flow reserve measure 0.00 NA NA NA NA 0.00 ZZZ93572 TC C Heart flow reserve measure 0.00 NA NA NA NA 0.00 ZZZ93572 26 A Heart flow reserve measure 1.44 0.56 0.69 0.56 0.69 0.11 ZZZ93580 A Transcath closure of asd 17.97 NA NA 7.39 9.12 4.07 00093581 A Transcath closure of vsd 24.39 NA NA 9.85 11.47 5.52 00093600 C Bundle of His recording 0.00 0.00 0.00 NA NA 0.00 00093600 TC C Bundle of His recording 0.00 0.00 0.00 NA NA 0.00 00093600 26 A Bundle of His recording 2.12 0.84 1.04 0.84 1.04 0.47 00093602 C Intra-atrial recording 0.00 0.00 0.00 NA NA 0.00 00093602 TC C Intra-atrial recording 0.00 0.00 0.00 NA NA 0.00 00093602 26 A Intra-atrial recording 2.12 0.83 1.02 0.83 1.02 0.47 000CMS-1503-P1138**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**93603 C Right ventricular recording 0.00 0.00 0.00 NA NA 0.00 00093603 TC C Right ventricular recording 0.00 0.00 0.00 NA NA 0.00 00093603 26 A Right ventricular recording 2.12 0.82 1.02 0.82 1.02 0.47 00093609 C Map tachycardia, add-on 0.00 0.00 0.00 NA NA 0.00 ZZZ93609 TC C Map tachycardia, add-on 0.00 0.00 0.00 NA NA 0.00 ZZZ93609 26 A Map tachycardia, add-on4.99 1.96 2.46 1.96 2.46 1.13 ZZZ93610 C Intra-atrial pacing 0.00 0.00 0.00 NA NA 0.00 00093610 TC C Intra-atrial pacing 0.00 0.00 0.00 NA NA 0.00 00093610 26 A Intra-atrial pacing 3.02 1.17 1.44 1.17 1.44 0.68 00093612 C Intraventricular pacing 0.00 0.00 0.00 NA NA 0.00 00093612 TC C Intraventricular pacing 0.00 0.00 0.00 NA NA 0.00 00093612 26 A Intraventricular pacing 3.02 1.16 1.42 1.16 1.42 0.68 00093613 A Electrophys map 3d, add-on 6.99 NA NA 2.74 3.46 1.58 ZZZ93615 C Esophageal recording 0.00 0.00 0.00 NA NA 0.00 00093615 TC C Esophageal recording 0.00 0.00 0.00 NA NA 0.00 00093615 26 A Esophageal recording 0.99 0.39 0.48 0.39 0.48 0.06 00093616 C Esophageal recording 0.00 0.00 0.00 NA NA 0.00 00093616 TC C Esophageal recording 0.00 0.00 0.00 NA NA 0.00 00093616 26 A Esophageal recording 1.49 0.33 0.38 0.33 0.38 0.11 00093618 C Heart rhythm pacing 0.00 0.00 0.00 NA NA 0.00 00093618 TC C Heart rhythm pacing 0.00 0.00 0.00 NA NA 0.00 00093618 26 A Heart rhythm pacing 4.25 1.66 2.12 1.66 2.12 0.95 00093619 C Electrophysiology evaluation 0.00 0.00 0.00 NA NA 0.00 00093619 TC C Electrophysiology evaluation 0.00 0.00 0.00 NA NA 0.00 00093619 26 A Electrophysiology evaluation 7.31 2.86 3.68 2.86 3.68 1.65 00093620 C Electrophysiology evaluation 0.00 0.00 0.00 NA NA 0.00 000CMS-1503-P1139**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**93620 TC C Electrophysiology evaluation 0.00 0.00 0.00 NA NA 0.00 00093620 26 A Electrophysiology evaluation 11.57 4.54 5.76 4.54 5.76 2.61 00093621 C Electrophysiology evaluation 0.00 0.00 0.00 NA NA 0.00 ZZZ93621 TC C Electrophysiology evaluation 0.00 0.00 0.00 NA NA 0.00 ZZZ93621 26 A Electrophysiology evaluation 2.10 0.82 1.04 0.82 1.04 0.47 ZZZ93622 C Electrophysiology evaluation 0.00 0.00 0.00 NA NA 0.00 ZZZ93622 TC C Electrophysiology evaluation 0.00 0.00 0.00 NA NA 0.00 ZZZ93622 26 A Electrophysiology evaluation 3.10 1.22 1.50 1.22 1.50 0.69 ZZZ93623 C Stimulation, pacing heart 0.00 0.00 0.00 NA NA 0.00 ZZZ93623 TC C Stimulation, pacing heart 0.00 0.00 0.00 NA NA 0.00 ZZZ93623 26 A Stimulation, pacing heart 2.85 1.12 1.40 1.12 1.40 0.65 ZZZ93624 C Electrophysiologic study 0.00 0.00 0.00 NA NA 0.00 00093624 TC C Electrophysiologic study 0.00 0.00 0.00 NA NA 0.00 00093624 26 A Electrophysiologic study 4.80 1.87 2.42 NA NA 1.09 00093631 C Heart pacing, mapping 0.00 0.00 0.00 NA NA 0.00 00093631 TC C Heart pacing, mapping 0.00 0.00 0.00 NA NA 0.00 00093631 26 A Heart pacing, mapping 7.59 2.74 3.03 2.74 3.03 1.88 00093640 C Evaluation heart device 0.00 0.00 0.00 NA NA 0.00 00093640 TC C Evaluation heart device 0.00 0.00 0.00 NA NA 0.00 00093640 26 A Evaluation heart device 3.51 1.38 1.72 1.38 1.72 0.79 00093641 C Electrophysiology evaluation 0.00 0.00 0.00 NA NA 0.00 00093641 TC C Electrophysiology evaluation 0.00 0.00 0.00 NA NA 0.00 00093641 26 A Electrophysiology evaluation 5.92 2.32 2.92 2.32 2.92 1.34 00093642 A Electrophysiology evaluation 4.88 5.66 7.43 NA NA 0.21 00093642 TC A Electrophysiology evaluation 0.00 3.74 4.96 NA NA 0.03 00093642 26 A Electrophysiology evaluation 4.88 1.92 2.47 1.92 2.47 0.18 000CMS-1503-P1140**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**93650 A Ablate heart dysrhythm focus 10.49 NA NA 4.39 5.48 2.36 00093651 A Ablate heart dysrhythm focus 16.23 NA NA 6.37 8.00 3.67 00093652 A Ablate heart dysrhythm focus 17.65 NA NA 6.95 8.73 4.00 00093660 A Tilt table evaluation 1.89 2.34 2.84 NA NA 0.08 00093660 TC A Tilt table evaluation 0.00 1.59 1.91 NA NA 0.01 00093660 26 A Tilt table evaluation1.89 0.75 0.93 0.75 0.93 0.07 00093662 C Intracardiac ecg (ice) 0.00 0.00 0.00 NA NA 0.00 ZZZ93662 TC C Intracardiac ecg (ice) 0.00 0.00 0.00 NA NA 0.00 ZZZ93662 26 A Intracardiac ecg (ice) 2.80 1.09 1.38 1.09 1.38 0.21 ZZZ93668 N Peripheral vascular rehab 0.00 0.50 0.53 NA NA 0.01 XXX93701 A Bioimpedance, cv analysis 0.00 0.64 0.77 NA NA 0.01 XXX93720 A Total body plethysmography 0.17 1.19 1.22 NA NA 0.02 XXX93721 A Plethysmography tracing 0.00 1.13 1.16 NA NA 0.01 XXX93722 A Plethysmography report 0.17 0.06 0.06 0.06 0.06 0.01 XXX93724 A Analyze pacemaker system 4.88 2.66 3.73 NA NA 0.19 00093724 TC A Analyze pacemaker system 0.00 0.71 1.33 NA NA 0.01 00093724 26 A Analyze pacemaker system 4.88 1.95 2.40 1.95 2.40 0.18 00093740 B Temperature gradient studies 0.16 0.07 0.08 NA NA 0.02 XXX93740 TC B Temperature gradient studies 0.00 0.00 0.02 NA NA 0.01 XXX93740 26 B Temperature gradient studies 0.16 0.07 0.06 0.07 0.06 0.01 XXX93745 C Set-up cardiovert-defibrill 0.00 0.00 0.00 NA NA 0.00 XXX93745 TC C Set-up cardiovert-defibrill 0.00 0.00 0.00 NA NA 0.00 XXX93745 26 C Set-up cardiovert-defibrill 0.00 0.00 0.00 0.00 0.00 0.00 XXX93750 A Interrogation vad, in person 0.92 0.54 0.54 0.34 0.34 0.06 XXX93770 B Measure venous pressure 0.16 0.07 0.07 NA NA 0.02 XXX93770 TC B Measure venous pressure 0.00 0.00 0.01 NA NA 0.01 XXXCMS-1503-P1141**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**93770 26 B Measure venous pressure 0.16 0.07 0.06 0.07 0.06 0.01 XXX93784 A Ambulatory BP monitoring 0.38 1.10 1.39 NA NA 0.03 XXX93786 A Ambulatory BP recording 0.00 0.81 0.89 NA NA 0.01 XXX93788 A Ambulatory BP analysis 0.00 0.13 0.34 NA NA 0.01 XXX93790 A Review/report BP recording 0.38 0.16 0.16 0.16 0.16 0.01 XXX93797 A Cardiac rehab 0.18 0.30 0.34 0.08 0.09 0.01 00093798 A Cardiac rehab/monitor 0.28 0.40 0.46 0.11 0.14 0.01 00093799 C Cardiovascular procedure 0.00 0.00 0.00 NA NA 0.00 XXX93799 TC C Cardiovascular procedure 0.00 0.00 0.00 NA NA 0.00 XXX93799 26 C Cardiovascular procedure 0.00 0.00 0.00 0.00 0.00 0.00 XXX93875 A Extracranial study 0.22 2.68 2.82 NA NA 0.02 XXX93875 TC A Extracranial study 0.00 2.59 2.73 NA NA 0.01 XXX93875 26 A Extracranial study 0.22 0.09 0.09 0.09 0.09 0.01 XXX93880 A Extracranial study 0.60 6.10 6.60 NA NA 0.05 XXX93880 TC A Extracranial study 0.00 5.87 6.35 NA NA 0.01 XXX93880 26 A Extracranial study 0.60 0.23 0.25 0.23 0.25 0.04 XXX93882 A Extracranial study 0.40 4.49 4.58 NA NA 0.07 XXX93882 TC A Extracranial study 0.00 4.34 4.43 NA NA 0.01 XXX93882 26 A Extracranial study 0.40 0.15 0.15 0.15 0.15 0.06 XXX93886 A Intracranial study 0.94 8.84 8.56 NA NA 0.05 XXX93886 TC A Intracranial study 0.00 8.44 8.17 NA NA 0.01 XXX93886 26 A Intracranial study 0.94 0.40 0.39 0.40 0.39 0.04 XXX93888 A Intracranial study 0.62 5.24 5.45 NA NA 0.05 XXX93888 TC A Intracranial study 0.00 4.99 5.19 NA NA 0.01 XXX93888 26 A Intracranial study 0.62 0.25 0.26 0.25 0.26 0.04 XXX93890 A Tcd, vasoreactivity study 1.00 6.54 6.77 NA NA 0.05 XXXCMS-1503-P1142**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**93890 TC A Tcd, vasoreactivity study 0.00 6.13 6.37 NA NA 0.01 XXX93890 26 A Tcd, vasoreactivity study 1.00 0.41 0.40 0.41 0.40 0.04 XXX93892 A Tcd, emboli detect w/o inj 1.15 8.37 8.01 NA NA 0.07 XXX93892 TC A Tcd, emboli detect w/o inj 0.00 7.87 7.54 NA NA 0.01 XXX93892 26 A Tcd, emboli detect w/o inj 1.15 0.50 0.47 0.50 0.47 0.06 XXX93893 A Tcd, emboli detect w/inj 1.15 9.18 8.41 NA NA 0.07 XXX93893 TC A Tcd, emboli detect w/inj 0.00 8.67 7.93 NA NA 0.01 XXX93893 26 A Tcd, emboli detect w/inj 1.15 0.51 0.48 0.51 0.48 0.06 XXX93922 A Extremity study 0.25 3.26 3.41 NA NA 0.02 XXX93922 TC A Extremity study 0.00 3.17 3.31 NA NA 0.01 XXX93922 26 A Extremity study 0.25 0.09 0.10 0.09 0.10 0.01 XXX93923 A Extremity study 0.45 4.84 5.09 NA NA 0.05 XXX93923 TC A Extremity study 0.00 4.67 4.92 NA NA 0.01 XXX93923 26 A Extremity study 0.45 0.17 0.17 0.17 0.17 0.04 XXX93924 A Extremity study 0.50 5.96 6.32 NA NA 0.05 XXX93924 TC A Extremity study 0.00 5.77 6.12 NA NA 0.01 XXX93924 26 A Extremity study 0.50 0.19 0.20 0.19 0.20 0.04 XXX93925 A Lower extremity study 0.58 7.95 8.53 NA NA 0.07 XXX93925 TC A Lower extremity study 0.00 7.73 8.30 NA NA 0.03 XXX93925 26 A Lower extremity study 0.58 0.22 0.23 0.22 0.23 0.04 XXX93926 A Lower extremity study 0.39 5.26 5.52 NA NA 0.07 XXX93926 TC A Lower extremity study 0.00 5.12 5.37 NA NA 0.01 XXX93926 26 A Lower extremity study 0.39 0.14 0.15 0.14 0.15 0.06 XXX93930 A Upper extremity study 0.46 6.33 6.72 NA NA 0.05 XXX93930 TC A Upper extremity study 0.00 6.16 6.54 NA NA 0.01 XXX93930 26 A Upper extremity study 0.46 0.17 0.18 0.17 0.18 0.04 XXXCMS-1503-P1143**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**93931 A Upper extremity study 0.31 4.21 4.49 NA NA 0.04 XXX93931 TC A Upper extremity study 0.00 4.10 4.37 NA NA 0.01 XXX93931 26 A Upper extremity study 0.31 0.11 0.12 0.11 0.12 0.03 XXX93965 A Extremity study 0.35 3.05 3.28 NA NA 0.04 XXX93965 TC A Extremity study 0.00 2.92 3.14 NA NA 0.01 XXX93965 26 A Extremity study 0.35 0.13 0.14 0.13 0.14 0.03 XXX93970 A Extremity study 0.68 6.29 6.69 NA NA 0.08 XXX93970 TC A Extremity study 0.00 6.05 6.43 NA NA 0.01 XXX93970 26 A Extremity study 0.68 0.24 0.26 0.24 0.26 0.07 XXX93971 A Extremity study 0.45 4.08 4.40 NA NA 0.05 XXX93971 TC A Extremity study 0.00 3.92 4.22 NA NA 0.01 XXX93971 26 A Extremity study 0.45 0.16 0.18 0.16 0.18 0.04 XXX93975 A Vascular study 1.80 8.33 9.05 NA NA 0.17 XXX93975 TC A Vascular study 0.00 7.67 8.33 NA NA 0.03 XXX93975 26 A Vascular study 1.80 0.66 0.72 0.66 0.72 0.14 XXX93976 A Vascular study 1.21 4.54 4.97 NA NA 0.09 XXX93976 TC A Vascular study 0.00 4.11 4.49 NA NA 0.01 XXX93976 26 A Vascular study 1.21 0.43 0.48 0.43 0.48 0.08 XXX93978 A Vascular study 0.65 5.98 6.32 NA NA 0.08 XXX93978 TC A Vascular study 0.00 5.74 6.07 NA NA 0.01 XXX93978 26 A Vascular study 0.65 0.24 0.25 0.24 0.25 0.07 XXX93979 A Vascular study 0.44 4.15 4.40 NA NA 0.05 XXX93979 TC A Vascular study 0.00 3.99 4.23 NA NA 0.01 XXX93979 26 A Vascular study 0.44 0.16 0.17 0.16 0.17 0.04 XXX93980 A Penile vascular study 1.25 3.48 3.82 NA NA 0.08 XXX93980 TC A Penile vascular study 0.00 2.99 3.28 NA NA 0.01 XXXCMS-1503-P1144**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**93980 26 A Penile vascular study 1.25 0.49 0.54 0.49 0.54 0.07 XXX93981 A Penile vascular study 0.44 2.64 3.03 NA NA 0.04 XXX93981 TC A Penile vascular study 0.00 2.48 2.85 NA NA 0.01 XXX93981 26 A Penile vascular study 0.44 0.16 0.18 0.16 0.18 0.03 XXX93982 R Aneurysm pressure sens study 0.30 0.85 0.90 NA NA 0.06 XXX93990 A Doppler flow testing 0.25 5.80 5.82 NA NA 0.05 XXX93990 TC A Doppler flow testing 0.00 5.71 5.73 NA NA 0.01 XXX93990 26 A Doppler flow testing 0.25 0.09 0.09 0.09 0.09 0.04 XXX94002 A Vent mgmt inpat, init day 1.99 NA NA 0.58 0.50 0.17 XXX94003 A Vent mgmt inpat, subq day 1.37 NA NA 0.48 0.44 0.10 XXX94004 A Vent mgmt nf per day 1.00 NA NA 0.34 0.32 0.07 XXX94005 B Home vent mgmt supervision 1.50 1.08 1.07 NA NA 0.10 XXX94010 A Breathing capacity test 0.17 0.81 0.83 NA NA 0.02 XXX94010 TC A Breathing capacity test 0.00 0.74 0.77 NA NA 0.01 XXX94010 26 A Breathing capacity test0.17 0.07 0.06 0.07 0.06 0.01 XXX94011 A Up to 2 yrs old, spirometry 2.00 NA NA 0.74 0.74 0.14 XXX94012 A = 2 yrs, spiromtry w/dilator 3.10 NA NA 1.12 1.12 0.24 XXX94013 A = 2 yrs, lung volumes 0.66 NA NA 0.21 0.21 0.04 XXX94014 A Patient recorded spirometry 0.52 0.81 0.88 NA NA 0.02 XXX94015 A Patient recorded spirometry 0.00 0.63 0.70 NA NA 0.01 XXX94016 A Review patient spirometry 0.52 0.18 0.18 0.18 0.18 0.01 XXX94060 A Evaluation of wheezing 0.31 1.39 1.43 NA NA 0.02 XXX94060 TC A Evaluation of wheezing 0.00 1.27 1.32 NA NA 0.01 XXX94060 26 A Evaluation of wheezing 0.31 0.12 0.11 0.12 0.11 0.01 XXX94070 A Evaluation of wheezing 0.60 1.07 1.10 NA NA 0.04 XXX94070 TC A Evaluation of wheezing 0.00 0.85 0.89 NA NA 0.01 XXXCMS-1503-P1145**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**94070 26 A Evaluation of wheezing 0.60 0.22 0.21 0.22 0.21 0.03 XXX94150 B Vital capacity test 0.07 0.60 0.61 NA NA 0.02 XXX94150 TC B Vital capacity test 0.00 0.57 0.58 NA NA 0.01 XXX94150 26 B Vital capacity test0.07 0.03 0.03 0.03 0.03 0.01 XXX94200 A Lung function test (MBC/MVV) 0.11 0.55 0.57 NA NA 0.02 XXX94200 TC A Lung function test (MBC/MVV) 0.00 0.51 0.53 NA NA 0.01 XXX94200 26 A Lung function test (MBC/MVV) 0.11 0.04 0.04 0.04 0.04 0.01 XXX94240 A Residual lung capacity 0.26 0.83 0.88 NA NA 0.02 XXX94240 TC A Residual lung capacity 0.00 0.74 0.79 NA NA 0.01 XXX94240 26 A Residual lung capacity0.26 0.09 0.09 0.09 0.09 0.01 XXX94250 A Expired gas collection 0.11 0.56 0.61 NA NA 0.02 XXX94250 TC A Expired gas collection 0.00 0.52 0.57 NA NA 0.01 XXX94250 26 A Expired gas collection 0.11 0.04 0.04 0.04 0.04 0.01 XXX94260 A Thoracic gas volume 0.13 0.75 0.79 NA NA 0.02 XXX94260 TC A Thoracic gas volume 0.00 0.71 0.75 NA NA 0.01 XXX94260 26 A Thoracic gas volume 0.13 0.04 0.04 0.04 0.04 0.01 XXX94350 A Lung nitrogen washout curve 0.26 0.66 0.73 NA NA 0.02 XXX94350 TC A Lung nitrogen washout curve 0.00 0.57 0.64 NA NA 0.01 XXX94350 26 A Lung nitrogen washout curve 0.26 0.09 0.09 0.09 0.09 0.01 XXX94360 A Measure airflow resistance 0.26 0.96 1.01 NA NA 0.02 XXX94360 TC A Measure airflow resistance 0.00 0.87 0.92 NA NA 0.01 XXX94360 26 A Measure airflow resistance 0.26 0.09 0.09 0.09 0.09 0.01 XXX94370 A Breath airway closing volume 0.26 0.68 0.71 NA NA 0.02 XXX94370 TC A Breath airway closing volume 0.00 0.58 0.62 NA NA 0.01 XXX94370 26 A Breath airway closing volume 0.26 0.10 0.09 0.10 0.09 0.01 XXX94375 A Respiratory flow volume loop 0.31 0.75 0.78 NA NA 0.02 XXXCMS-1503-P1146**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**94375 TC A Respiratory flow volume loop 0.00 0.64 0.68 NA NA 0.01 XXX94375 26 A Respiratory flow volumeloop 0.31 0.11 0.10 0.11 0.10 0.01 XXX94400 A CO2 breathing response curve 0.40 1.10 1.14 NA NA 0.02 XXX94400 TC A CO2 breathing response curve 0.00 0.96 1.00 NA NA 0.01 XXX94400 26 A CO2 breathing response curve 0.40 0.14 0.14 0.14 0.14 0.01 XXX94450 A Hypoxia response curve 0.40 1.44 1.29 NA NA 0.02 XXX94450 TC A Hypoxia response curve 0.00 1.27 1.15 NA NA 0.01 XXX94450 26 A Hypoxia response curve 0.40 0.17 0.14 0.17 0.14 0.01 XXX94452 A Hast w/report 0.31 1.25 1.33 NA NA 0.02 XXX94452 TC A Hast w/report 0.00 1.14 1.23 NA NA 0.01 XXX94452 26 A Hast w/report 0.31 0.11 0.10 0.11 0.10 0.01 XXX94453 A Hast w/oxygen titrate 0.40 1.71 1.82 NA NA 0.02 XXX94453 TC A Hast w/oxygen titrate 0.00 1.58 1.69 NA NA 0.01 XXX94453 26 A Hast w/oxygen titrate 0.40 0.13 0.13 0.13 0.13 0.01 XXX94610 A Surfactant admin thru tube 1.16 0.55 0.50 0.55 0.50 0.07 XXX94620 A Pulmonary stress test/simple 0.64 0.87 1.16 NA NA 0.04 XXX94620 TC A Pulmonary stress test/simple 0.00 0.64 0.94 NA NA 0.01 XXX94620 26 A Pulmonary stress test/simple 0.64 0.23 0.22 0.23 0.22 0.03 XXX94621 A Pulm stress test/complex 1.42 3.03 3.25 NA NA 0.07 XXX94621 TC A Pulm stress test/complex 0.00 2.51 2.71 NA NA 0.01 XXX94621 26 A Pulm stress test/complex 1.42 0.52 0.54 0.52 0.54 0.06 XXX94640 A Airway inhalation treatment 0.00 0.47 0.45 NA NA 0.01 XXX94642 C Aerosol inhalation treatment 0.00 0.00 0.00 0.00 0.00 0.00 XXX94644 A Cbt, 1st hour 0.00 1.18 1.15 NA NA 0.01 XXX94645 A Cbt, each addl hour 0.00 0.39 0.41 NA NA 0.01 XXX94660 A Pos airway pressure, CPAP 0.76 0.93 0.92 0.29 0.27 0.06 XXXCMS-1503-P1147**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**94662 A Neg press ventilation, cnp 0.76 NA NA 0.25 0.25 0.06 XXX94664 A Evaluate pt use of inhaler 0.00 0.46 0.45 NA NA 0.01 XXX94667 A Chest wall manipulation 0.00 0.65 0.64 NA NA 0.01 XXX94668 A Chest wall manipulation 0.00 0.62 0.62 NA NA 0.01 XXX94680 A Exhaled air analysis, o2 0.26 1.32 1.42 NA NA 0.02 XXX94680 TC A Exhaled air analysis, o2 0.00 1.21 1.32 NA NA 0.01 XXX94680 26 A Exhaled air analysis, o2 0.26 0.11 0.10 0.11 0.10 0.01 XXX94681 A Exhaled air analysis, o2/co2 0.20 1.17 1.43 NA NA 0.02 XXX94681 TC A Exhaled air analysis, o2/co2 0.00 1.09 1.36 NA NA 0.01 XXX94681 26 A Exhaled air analysis, o2/co2 0.20 0.08 0.07 0.08 0.07 0.01 XXX94690 A Exhaled air analysis 0.07 1.28 1.41 NA NA 0.02 XXX94690 TC A Exhaled air analysis 0.00 1.25 1.38 NA NA 0.01 XXX94690 26 A Exhaled air analysis 0.07 0.03 0.03 0.03 0.03 0.01 XXX94720 A Monoxide diffusing capacity 0.26 1.15 1.23 NA NA 0.02 XXX94720 TC A Monoxide diffusing capacity 0.00 1.06 1.14 NA NA 0.01 XXX94720 26 A Monoxide diffusing capacity 0.26 0.09 0.09 0.09 0.09 0.01 XXX94725 A Membrane diffusion capacity 0.26 1.14 1.44 NA NA 0.02 XXX94725 TC A Membrane diffusion capacity 0.00 1.04 1.35 NA NA 0.01 XXX94725 26 A Membrane diffusion capacity 0.26 0.10 0.09 0.10 0.09 0.01 XXX94750 A Pulmonary compliance study 0.23 1.99 2.00 NA NA 0.02 XXX94750 TC A Pulmonary compliance study 0.00 1.90 1.92 NA NA 0.01 XXX94750 26 A Pulmonary compliance study 0.23 0.09 0.08 0.09 0.08 0.01 XXX94760 T Measure blood oxygen level 0.00 0.07 0.07 NA NA 0.01 XXX94761 T Measure blood oxygen level 0.00 0.12 0.12 NA NA 0.01 XXX94762 A Measure blood oxygen level 0.00 0.28 0.57 NA NA 0.01 XXX94770 A Exhaled carbon dioxide test 0.15 0.06 0.50 NA NA 0.02 XXXCMS-1503-P1148**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**94770 TC A Exhaled carbon dioxide test 0.00 0.00 0.44 NA NA 0.01 XXX94770 26 A Exhaled carbon dioxide test 0.15 0.06 0.06 0.06 0.06 0.01 XXX94772 C Breath recording, infant 0.00 0.00 0.00 NA NA 0.00 XXX94772 TC C Breath recording, infant 0.00 0.00 0.00 NA NA 0.00 XXX94772 26 C Breath recording, infant 0.00 0.00 0.00 0.00 0.00 0.00 XXX94774 C Ped home apnea rec, compl 0.00 0.00 0.00 0.00 0.00 0.00 YYY94775 C Ped home apnea rec, hk-up 0.00 0.00 0.00 0.00 0.00 0.00 YYY94776 C Ped home apnea rec, downld 0.00 0.00 0.00 0.00 0.00 0.00 YYY94777 C Ped home apnea rec, report 0.00 0.00 0.00 0.00 0.00 0.00 YYY94799 C Pulmonary service/procedure 0.00 0.00 0.00 NA NA 0.00 XXX94799 TC C Pulmonary service/procedure 0.00 0.00 0.00 NA NA 0.00 XXX94799 26 C Pulmonary service/procedure 0.00 0.00 0.00 0.00 0.00 0.00 XXX95004 A Percut allergy skin tests 0.01 0.16 0.17 NA NA 0.01 XXX95010 A Percut allergy titrate test 0.15 0.37 0.37 NA NA 0.01 XXX95012 A Exhaled nitric oxide meas 0.00 0.54 0.59 NA NA 0.01 XXX95015 A Id allergy titrate-drug/bug 0.15 0.29 0.26 NA NA 0.01 XXX95024 A Id allergy test, drug/bug 0.01 0.19 0.19 NA NA 0.01 XXX95027 A Id allergy titrate-airborne 0.01 0.11 0.12 NA NA 0.01 XXX95028 A Id allergy test-delayed type 0.00 0.37 0.36 NA NA 0.01 XXX95044 A Allergy patch tests 0.00 0.15 0.17 NA NA 0.01 XXX95052 A Photo patch test 0.00 0.17 0.19 NA NA 0.01 XXX95056 A Photosensitivity tests 0.00 1.20 1.17 NA NA 0.01 XXX95060 A Eye allergy tests 0.00 0.90 0.82 0.90 0.82 0.01 XXX95065 A Nose allergy test 0.00 0.70 0.70 0.70 0.70 0.01 XXX95070 A Bronchial allergy tests 0.00 0.78 1.09 NA NA 0.01 XXX95071 A Bronchial allergy tests 0.00 1.20 1.47 NA NA 0.01 XXXCMS-1503-P1149**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**95075 A Ingestion challenge test 0.95 0.89 0.89 0.43 0.41 0.04 XXX95115 A Immunotherapy, one injection 0.00 0.25 0.29 NA NA 0.01 XXX95117 A Immunotherapy injections 0.00 0.30 0.35 NA NA 0.01 XXX95120 I Immunotherapy, one injection 0.00 0.00 0.00 0.00 0.00 0.00 XXX95125 I Immunotherapy, many antigens 0.00 0.00 0.00 0.00 0.00 0.00 XXX95130 I Immunotherapy, insect venom 0.00 0.00 0.00 0.00 0.00 0.00 XXX95131 I Immunotherapy, insect venoms 0.00 0.00 0.00 0.00 0.00 0.00 XXX95132 I Immunotherapy, insect venoms 0.00 0.00 0.00 0.00 0.00 0.00 XXX95133 I Immunotherapy, insect venoms 0.00 0.00 0.00 0.00 0.00 0.00 XXX95134 I Immunotherapy, insect venoms 0.00 0.00 0.00 0.00 0.00 0.00 XXX95144 A Antigen therapy services 0.06 0.29 0.30 0.03 0.03 0.01 XXX95145 A Antigen therapy services 0.06 0.54 0.48 0.03 0.03 0.01 XXX95146 A Antigen therapy services 0.06 1.03 0.89 0.03 0.03 0.01 XXX95147 A Antigen therapy services 0.06 0.93 0.83 0.03 0.03 0.01 XXX95148 A Antigen therapy services 0.06 1.42 1.24 0.03 0.03 0.01 XXX95149 A Antigen therapy services 0.06 1.93 1.67 0.03 0.03 0.01 XXX95165 A Antigen therapy services 0.06 0.29 0.30 0.03 0.03 0.01 XXX95170 A Antigen therapy services 0.06 0.21 0.21 0.03 0.03 0.01 XXX95180 A Rapid desensitization 2.01 1.90 2.03 0.97 1.00 0.07 XXX95199 C Allergy immunology services 0.00 0.00 0.00 0.00 0.00 0.00 XXX95250 A Glucose monitoring, cont 0.00 4.25 4.26 NA NA 0.01 XXX95251 A Gluc monitor, cont, phys i&r 0.85 0.38 0.33 0.38 0.33 0.04 XXX95803 A Actigraphy testing 1.00 3.05 3.05 NA NA 0.05 XXX95803 TC A Actigraphy testing 0.00 2.58 2.58 NA NA 0.01 XXX95803 26 A Actigraphy testing 1.00 0.47 0.47 0.47 0.47 0.04 XXX95805 A Multiple sleep latency test 1.88 7.45 9.36 NA NA 0.11 XXXCMS-1503-P1150**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**95805 TC A Multiple sleep latency test 0.00 6.72 8.66 NA NA 0.04 XXX95805 26 A Multiple sleep latency test 1.88 0.73 0.70 0.73 0.70 0.07 XXX95806 A Sleep study unatt&resp efft 1.66 4.22 4.36 NA NA 0.10 XXX95806 TC A Sleep study unatt&resp efft 0.00 3.58 3.74 NA NA 0.03 XXX95806 26 A Sleep study unatt&resp efft 1.66 0.64 0.62 0.64 0.62 0.07 XXX95807 A Sleep study, attended 1.66 11.94 12.90 NA NA 0.17 XXX95807 TC A Sleep study, attended 0.00 11.35 12.31 NA NA 0.10 XXX95807 26 A Sleep study, attended 1.66 0.59 0.59 0.59 0.59 0.07 XXX95808 A Polysomnography, 1-3 2.65 18.28 18.00 NA NA 0.21 XXX95808 TC A Polysomnography, 1-3 0.00 17.21 16.99 NA NA 0.10 XXX95808 26 A Polysomnography, 1-3 2.65 1.07 1.01 1.07 1.01 0.11 XXX95810 A Polysomnography, 4 or more 3.52 18.17 19.41 NA NA 0.25 XXX95810 TC A Polysomnography, 4 or more 0.00 16.85 18.15 NA NA 0.11 XXX95810 26 A Polysomnography, 4 or more 3.52 1.32 1.26 1.32 1.26 0.14 XXX95811 A Polysomnography w/cpap 3.79 20.09 21.50 NA NA 0.30 XXX95811 TC A Polysomnography w/cpap 0.00 18.68 20.15 NA NA 0.13 XXX95811 26 A Polysomnography w/cpap 3.79 1.41 1.35 1.41 1.35 0.17 XXX95812 A Eeg, 41-60 minutes 1.08 9.44 7.91 NA NA 0.07 XXX95812 TC A Eeg, 41-60 minutes 0.00 8.94 7.45 NA NA 0.03 XXX95812 26 A Eeg, 41-60 minutes 1.08 0.50 0.46 0.50 0.46 0.04 XXX95813 A Eeg, over 1 hour 1.73 9.39 8.36 NA NA 0.11 XXX95813 TC A Eeg, over 1 hour 0.00 8.61 7.64 NA NA 0.04 XXX95813 26 A Eeg, over 1 hour 1.73 0.78 0.72 0.78 0.72 0.07 XXX95816 A Eeg, awake and drowsy 1.08 8.71 7.22 NA NA 0.09 XXX95816 TC A Eeg, awake and drowsy 0.00 8.20 6.76 NA NA 0.03 XXX95816 26 A Eeg, awake and drowsy 1.08 0.51 0.46 0.51 0.46 0.06 XXXCMS-1503-P1151**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**95819 A Eeg, awake and asleep 1.08 10.12 8.20 NA NA 0.07 XXX95819 TC A Eeg, awake and asleep 0.00 9.61 7.74 NA NA 0.03 XXX95819 26 A Eeg, awake and asleep 1.08 0.51 0.46 0.51 0.46 0.04 XXX95822 A Eeg, coma or sleep only 1.08 8.99 7.59 NA NA 0.07 XXX95822 TC A Eeg, coma or sleep only 0.00 8.48 7.13 NA NA 0.03 XXX95822 26 A Eeg, coma or sleep only 1.08 0.51 0.46 0.51 0.46 0.04 XXX95824 C Eeg, cerebral death only 0.00 0.00 0.00 NA NA 0.00 XXX95824 TC C Eeg, cerebral death only 0.00 0.00 0.00 NA NA 0.00 XXX95824 26 A Eeg, cerebral death only 0.74 0.34 0.32 0.34 0.32 0.06 XXX95827 A Eeg, all night recording 1.08 18.67 14.83 NA NA 0.14 XXX95827 TC A Eeg, all night recording 0.00 18.16 14.37 NA NA 0.08 XXX95827 26 A Eeg, all night recording 1.08 0.51 0.46 0.51 0.46 0.06 XXX95829 A Surgery electrocorticogram 6.20 41.25 36.63 NA NA 0.23 XXX95829 TC A Surgery electrocorticogram 0.00 38.33 33.96 NA NA 0.06 XXX95829 26 A Surgery electrocorticogram 6.20 2.92 2.67 2.92 2.67 0.17 XXX95830 A Insert electrodes forEEG 1.70 3.74 3.69 0.72 0.69 0.14 XXX95831 A Limb muscle testing, manual 0.28 0.56 0.53 0.14 0.13 0.03 XXX95832 A Hand muscle testing, manual 0.29 0.55 0.49 0.16 0.14 0.03 XXX95833 A Body muscle testing, manual 0.47 0.60 0.59 0.16 0.18 0.01 XXX95834 A Body muscle testing, manual 0.60 0.80 0.71 0.25 0.24 0.03 XXX95851 A Range of motion measurements 0.16 0.34 0.34 0.06 0.06 0.01 XXX95852 A Range of motion measurements 0.11 0.34 0.31 0.05 0.05 0.01 XXX95857 A Tensilon test 0.53 0.90 0.80 0.30 0.26 0.04 XXX95860 A Muscle test, one limb 0.96 1.79 1.63 NA NA 0.04 XXX95860 TC A Muscle test, one limb 0.00 1.30 1.17 NA NA 0.01 XXX95860 26 A Muscle test, one limb 0.96 0.49 0.46 0.49 0.46 0.03 XXXCMS-1503-P1152**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**95861 A Muscle test, 2 limbs 1.54 2.52 2.21 NA NA 0.07 XXX95861 TC A Muscle test, 2 limbs 0.00 1.74 1.48 NA NA 0.01 XXX95861 26 A Muscle test, 2 limbs 1.54 0.78 0.73 0.78 0.73 0.06 XXX95863 A Muscle test, 3 limbs 1.87 3.07 2.64 NA NA 0.08 XXX95863 TC A Muscle test, 3 limbs 0.00 2.16 1.80 NA NA 0.01 XXX95863 26 A Muscle test, 3 limbs 1.87 0.91 0.84 0.91 0.84 0.07 XXX95864 A Muscle test, 4 limbs 1.99 3.25 2.98 NA NA 0.08 XXX95864 TC A Muscle test, 4 limbs 0.00 2.28 2.07 NA NA 0.01 XXX95864 26 A Muscle test, 4 limbs 1.99 0.97 0.91 0.97 0.91 0.07 XXX95865 A Muscle test, larynx 1.57 2.01 1.86 NA NA 0.05 XXX95865 TC A Muscle test, larynx 0.00 1.19 1.09 NA NA 0.01 XXX95865 26 A Muscle test, larynx 1.57 0.82 0.77 0.82 0.77 0.04 XXX95866 A Muscle test, hemidiaphragm 1.25 1.96 1.70 NA NA 0.07 XXX95866 TC A Muscle test, hemidiaphragm 0.00 1.37 1.13 NA NA 0.01 XXX95866 26 A Muscle test, hemidiaphragm 1.25 0.59 0.57 0.59 0.57 0.06 XXX95867 A Muscle test cran nerv unilat 0.79 1.68 1.50 NA NA 0.04 XXX95867 TC A Muscle test cran nerv unilat 0.00 1.28 1.13 NA NA 0.01 XXX95867 26 A Muscle test cran nerv unilat 0.79 0.40 0.37 0.40 0.37 0.03 XXX95868 A Muscle test cran nerve bilat 1.18 2.19 1.93 NA NA 0.05 XXX95868 TC A Muscle test cran nerve bilat 0.00 1.61 1.39 NA NA 0.01 XXX95868 26 A Muscle test cran nerve bilat 1.18 0.58 0.54 0.58 0.54 0.04 XXX95869 A Muscle test, thor paraspinal 0.37 1.59 1.29 NA NA 0.02 XXX95869 TC A Muscle test, thor paraspinal 0.00 1.40 1.12 NA NA 0.01 XXX95869 26 A Muscle test, thor paraspinal 0.37 0.19 0.17 0.19 0.17 0.01 XXX95870 A Muscle test, nonparaspinal 0.37 1.55 1.26 NA NA 0.02 XXX95870 TC A Muscle test, nonparaspinal 0.00 1.37 1.09 NA NA 0.01 XXXCMS-1503-P1153**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**95870 26 A Muscle test, nonparaspinal 0.37 0.18 0.17 0.18 0.17 0.01 XXX95872 A Muscle test, one fiber 2.88 2.50 2.18 NA NA 0.12 XXX95872 TC A Muscle test, one fiber 0.00 1.16 1.00 NA NA 0.01 XXX95872 26 A Muscle test, one fiber 2.88 1.34 1.18 1.34 1.18 0.11 XXX95873 A Guide nerv destr, elec stim 0.37 1.57 1.30 NA NA 0.02 ZZZ95873 TC A Guide nerv destr, elec stim 0.00 1.36 1.10 NA NA 0.01 ZZZ95873 26 A Guide nerv destr, elec stim 0.37 0.21 0.20 0.21 0.20 0.01 ZZZ95874 A Guide nerv destr, needle emg 0.37 1.49 1.22 NA NA 0.02 ZZZ95874 TC A Guide nerv destr, needle emg 0.00 1.30 1.04 NA NA 0.01 ZZZ95874 26 A Guide nerv destr, needle emg 0.37 0.19 0.18 0.19 0.18 0.01 ZZZ95875 A Limb exercise test 1.10 2.14 1.88 NA NA 0.07 XXX95875 TC A Limb exercise test 0.00 1.62 1.40 NA NA 0.01 XXX95875 26 A Limb exercise test 1.10 0.52 0.48 0.52 0.48 0.06 XXX95900 A Motor nerve conduction test 0.42 1.40 1.30 NA NA 0.02 XXX95900 TC A Motor nerve conduction test 0.00 1.19 1.10 NA NA 0.01 XXX95900 26 A Motor nerve conduction test 0.42 0.21 0.20 0.21 0.20 0.01 XXX95903 A Motor nerve conduction test 0.60 1.50 1.38 NA NA 0.04 XXX95903 TC A Motor nerve conduction test 0.00 1.21 1.12 NA NA 0.01 XXX95903 26 A Motor nerve conduction test 0.60 0.29 0.26 0.29 0.26 0.03 XXX95904 A Sense nerve conduction test 0.34 1.25 1.17 NA NA 0.02 XXX95904 TC A Sense nerve conduction test 0.00 1.08 1.01 NA NA 0.01 XXX95904 26 A Sense nerve conduction test 0.34 0.17 0.16 0.17 0.16 0.01 XXX95905 A Motor/sens nrve conduct test 0.05 2.34 2.34 NA NA 0.02 XXX95905 TC A Motor/sens nrve conduct test 0.00 2.32 2.32 NA NA 0.01 XXX95905 26 A Motor/sens nrve conduct test 0.05 0.02 0.02 0.02 0.02 0.01 XXX95920 A Intraop nerve test add-on 2.11 2.62 2.41 NA NA 0.09 ZZZCMS-1503-P1154**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**95920 TC A Intraop nerve test add-on 0.00 1.62 1.48 NA NA 0.01 ZZZ95920 26 A Intraop nerve test add-on 2.11 1.00 0.93 1.00 0.93 0.08 ZZZ95921 A Autonomic nerv function test 0.90 1.49 1.38 NA NA 0.04 XXX95921 TC A Autonomic nerv function test 0.00 1.09 1.01 NA NA 0.01 XXX95921 26 A Autonomic nerv function test 0.90 0.40 0.37 0.40 0.37 0.03 XXX95922 A Autonomic nerv function test 0.96 2.05 1.86 NA NA 0.04 XXX95922 TC A Autonomic nerv function test 0.00 1.62 1.46 NA NA 0.01 XXX95922 26 A Autonomic nerv function test 0.96 0.43 0.40 0.43 0.40 0.03 XXX95923 A Autonomic nerv function test 0.90 3.80 3.22 NA NA 0.05 XXX95923 TC A Autonomic nerv function test 0.00 3.37 2.83 NA NA 0.01 XXX95923 26 A Autonomic nerv function test 0.90 0.43 0.39 0.43 0.39 0.04 XXX95925 A Somatosensory testing 0.54 4.79 3.96 NA NA 0.02 XXX95925 TC A Somatosensory testing 0.00 4.54 3.72 NA NA 0.01 XXX95925 26 A Somatosensory testing 0.54 0.25 0.24 0.25 0.24 0.01 XXX95926 A Somatosensory testing 0.54 4.50 3.78 NA NA 0.04 XXX95926 TC A Somatosensory testing 0.00 4.25 3.55 NA NA 0.01 XXX95926 26 A Somatosensory testing 0.54 0.25 0.23 0.25 0.23 0.03 XXX95927 A Somatosensory testing 0.54 3.94 3.54 NA NA 0.02 XXX95927 TC A Somatosensory testing 0.00 3.69 3.30 NA NA 0.01 XXX95927 26 A Somatosensory testing 0.54 0.25 0.24 0.25 0.24 0.01 XXX95928 A C motor evoked, uppr limbs 1.50 6.06 5.17 NA NA 0.10 XXX95928 TC A C motor evoked, uppr limbs 0.00 5.35 4.52 NA NA 0.03 XXX95928 26 A C motor evoked, uppr limbs 1.50 0.71 0.65 0.71 0.65 0.07 XXX95929 A C motor evoked, lwr limbs 1.50 6.51 5.57 NA NA 0.10 XXX95929 TC A C motor evoked, lwr limbs 0.00 5.80 4.91 NA NA 0.03 XXX95929 26 A C motor evoked, lwr limbs 1.50 0.71 0.66 0.71 0.66 0.07 XXXCMS-1503-P1155**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**95930 A Visual evoked potential test 0.35 3.98 3.48 NA NA 0.02 XXX95930 TC A Visual evoked potential test 0.00 3.80 3.32 NA NA 0.01 XXX95930 26 A Visual evoked potential test 0.35 0.18 0.16 0.18 0.16 0.01 XXX95933 A Blink reflex test 0.59 1.73 1.51 NA NA 0.04 XXX95933 TC A Blink reflex test 0.00 1.44 1.25 NA NA 0.01 XXX95933 26 A Blink reflex test 0.59 0.29 0.26 0.29 0.26 0.03 XXX95934 A H-reflex test 0.51 1.27 1.09 NA NA 0.02 XXX95934 TC A H-reflex test 0.00 1.02 0.86 NA NA 0.01 XXX95934 26 A H-reflex test 0.51 0.25 0.23 0.25 0.23 0.01 XXX95936 A H-reflex test 0.55 0.87 0.78 NA NA 0.02 XXX95936 TC A H-reflex test 0.00 0.61 0.53 NA NA 0.01 XXX95936 26 A H-reflex test 0.55 0.26 0.25 0.26 0.25 0.01 XXX95937 A Neuromuscular junction test 0.65 1.36 1.18 NA NA 0.05 XXX95937 TC A Neuromuscular junction test 0.00 1.05 0.89 NA NA 0.01 XXX95937 26 A Neuromuscular junction test 0.65 0.31 0.29 0.31 0.29 0.04 XXX95950 A Ambulatory eeg monitoring 1.51 7.96 6.74 NA NA 0.10 XXX95950 TC A Ambulatory eeg monitoring 0.00 7.25 6.09 NA NA 0.03 XXX95950 26 A Ambulatory eeg monitoring 1.51 0.71 0.65 0.71 0.65 0.07 XXX95951 C EEG monitoring/videorecord 0.00 0.00 0.00 NA NA 0.00 XXX95951 TC C EEG monitoring/videorecord 0.00 0.00 0.00 NA NA 0.00 XXX95951 26 A EEG monitoring/videorecord 5.99 2.82 2.59 2.82 2.59 0.49 XXX95953 A EEG monitoring/computer 3.30 12.06 10.36 NA NA 0.20 XXX95953 TC A EEG monitoring/computer 0.00 10.51 8.95 NA NA 0.03 XXX95953 26 A EEG monitoring/computer 3.30 1.55 1.41 1.55 1.41 0.17 XXX95954 A EEG monitoring/giving drugs 2.45 7.85 6.41 NA NA 0.15 XXX95954 TC A EEG monitoring/giving drugs 0.00 6.98 5.64 NA NA 0.04 XXXCMS-1503-P1156**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**95954 26 A EEG monitoring/giving drugs 2.45 0.87 0.77 0.87 0.77 0.11 XXX95955 A EEG during surgery 1.01 4.48 3.78 NA NA 0.05 XXX95955 TC A EEG during surgery 0.00 4.01 3.36 NA NA 0.01 XXX95955 26 A EEG during surgery 1.01 0.47 0.42 0.47 0.42 0.04 XXX95956 A Eeg monitoring, cable/radio 3.08 22.11 20.56 NA NA 0.31 XXX95956 TC A Eeg monitoring, cable/radio 0.00 20.74 19.27 NA NA 0.17 XXX95956 26 A Eeg monitoring, cable/radio 3.08 1.37 1.29 1.37 1.29 0.14 XXX95957 A EEG digital analysis 1.98 9.42 7.67 NA NA 0.11 XXX95957 TC A EEG digital analysis 0.00 8.50 6.82 NA NA 0.01 XXX95957 26 A EEG digital analysis 1.98 0.92 0.85 0.92 0.85 0.10 XXX95958 A EEG monitoring/function test 4.24 10.07 8.61 NA NA 0.27 XXX95958 TC A EEG monitoring/function test 0.00 8.17 6.81 NA NA 0.04 XXX95958 26 A EEG monitoring/function test 4.24 1.90 1.80 1.90 1.80 0.23 XXX95961 A Electrode stimulation,brain 2.97 4.83 4.17 NA NA 0.15 XXX95961 TC A Electrode stimulation,brain 0.00 3.40 2.84 NA NA 0.01 XXX95961 26 A Electrode stimulation,brain 2.97 1.43 1.33 1.43 1.33 0.14 XXX95962 A Electrode stim, brain add-on 3.21 3.65 3.21 NA NA 0.15 ZZZ95962 TC A Electrode stim, brain add-on 0.00 2.12 1.81 NA NA 0.01 ZZZ95962 26 A Electrode stim, brain add-on 3.21 1.53 1.40 1.53 1.40 0.14 ZZZ95965 C Meg, spontaneous 0.00 0.00 0.00 NA NA 0.00 XXX95965 TC C Meg, spontaneous 0.00 0.00 0.00 NA NA 0.00 XXX95965 26 A Meg, spontaneous 7.99 3.76 3.61 3.76 3.61 0.66 XXX95966 C Meg, evoked, single 0.00 0.00 0.00 NA NA 0.00 XXX95966 TC C Meg, evoked, single 0.00 0.00 0.00 NA NA 0.00 XXX95966 26 A Meg, evoked, single 3.99 1.88 1.81 1.88 1.81 0.32 XXX95967 C Meg, evoked, each addl 0.00 0.00 0.00 NA NA 0.00 ZZZCMS-1503-P1157**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**95967 TC C Meg, evoked, each addl 0.00 0.00 0.00 NA NA 0.00 ZZZ95967 26 A Meg, evoked, each addl3.49 1.64 1.52 1.64 1.52 0.30 ZZZ95970 A Analyze neurostim, no prog 0.45 1.36 1.21 0.21 0.18 0.04 XXX95971 A Analyze neurostim, simple 0.78 0.81 0.84 0.34 0.32 0.07 XXX95972 A Analyze neurostim, complex 1.50 1.54 1.47 0.70 0.63 0.14 XXX95973 A Analyze neurostim, complex 0.92 0.85 0.75 0.46 0.39 0.08 ZZZ95974 A Cranial neurostim, complex 3.00 2.42 2.13 1.37 1.25 0.27 XXX95975 A Cranial neurostim, complex 1.70 1.24 1.09 0.80 0.73 0.13 ZZZ95978 A Analyze neurostim brain/1h 3.50 3.01 2.64 1.68 1.52 0.40 XXX95979 A Analyz neurostim brain addon 1.64 1.21 1.07 0.78 0.72 0.14 ZZZ95980 A Io anal gast n-stim init 0.80 NA NA 0.43 0.37 0.17 XXX95981 A Io anal gast n-stim subsq 0.30 0.59 0.56 0.20 0.17 0.03 XXX95982 A Io ga n-stim subsq w/reprog 0.65 0.79 0.69 0.36 0.30 0.06 XXX95990 A Spin/brain pump refil & main 0.00 2.45 2.17 NA NA 0.03 XXX95991 A Spin/brain pump refil & main 0.77 2.60 2.25 0.36 0.29 0.06 XXX95992 A Canalith repositioning proc 0.75 0.45 0.44 0.32 0.31 0.06 XXX95999 C Neurological procedure 0.00 0.00 0.00 0.00 0.00 0.00 XXX96000 A Motion analysis, video/3d 1.80 NA NA 0.91 0.75 0.11 XXX96001 A Motion test w/ft press meas 2.15 NA NA 0.65 0.67 0.13 XXX96002 A Dynamic surface emg 0.41 NA NA 0.20 0.18 0.03 XXX96003 A Dynamic fine wire emg 0.37 NA NA 0.17 0.15 0.03 XXX96004 A Phys review of motiontests 2.14 1.00 0.98 1.00 0.98 0.14 XXX96020 C Functional brain mapping 0.00 0.00 0.00 NA NA 0.00 XXX96020 TC C Functional brain mapping 0.00 0.00 0.00 NA NA 0.00 XXX96020 26 A Functional brain mapping 3.43 1.19 1.39 1.19 1.39 0.32 XXX96040 B Genetic counseling, 30 min 0.00 1.20 1.26 NA NA 0.03 XXXCMS-1503-P1158**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**96101 A Psycho testing by psych/phys 1.86 0.30 0.41 0.28 0.39 0.07 XXX96102 A Psycho testing by technician 0.50 1.13 1.12 0.17 0.16 0.03 XXX96103 A Psycho testing admin by comp 0.51 1.29 1.10 0.19 0.18 0.03 XXX96105 A Assessment of aphasia 0.00 2.42 2.33 NA NA 0.04 XXX96110 A Developmental test, lim 0.00 0.23 0.22 NA NA 0.01 XXX96111 A Developmental test, extend 2.60 0.82 0.91 0.65 0.78 0.17 XXX96116 A Neurobehavioral statusexam 1.86 0.69 0.71 0.54 0.55 0.10 XXX96118 A Neuropsych tst by psych/phys 1.86 0.68 0.91 0.25 0.37 0.07 XXX96119 A Neuropsych testing by tec 0.55 1.36 1.48 0.09 0.12 0.01 XXX96120 A Neuropsych tst admin w/comp 0.51 2.03 1.84 0.18 0.17 0.03 XXX96125 A Cognitive test by hc pro 1.70 1.02 0.97 NA NA 0.07 XXX96150 A Assess hlth/behave, init 0.50 0.07 0.11 0.06 0.10 0.01 XXX96151 A Assess hlth/behave, subseq 0.48 0.07 0.11 0.07 0.10 0.01 XXX96152 A Intervene hlth/behave, indiv 0.46 0.07 0.10 0.06 0.09 0.01 XXX96153 A Intervene hlth/behave, group 0.10 0.02 0.03 0.02 0.02 0.01 XXX96154 A Interv hlth/behav, fam w/pt 0.45 0.06 0.10 0.06 0.09 0.01 XXX96155 N Interv hlth/behav fam no pt 0.44 0.19 0.19 0.19 0.19 0.03 XXX96360 A Hydration iv infusion, init 0.17 1.30 1.45 NA NA 0.03 XXX96361 A Hydrate iv infusion, add-on 0.09 0.30 0.35 NA NA 0.01 ZZZ96365 A Ther/proph/diag iv inf, init 0.21 1.66 1.81 NA NA 0.03 XXX96366 A Ther/proph/diag iv inf addon 0.18 0.41 0.44 NA NA 0.01 ZZZ96367 A Tx/proph/dg addl seq iv inf 0.19 0.64 0.76 NA NA 0.01 ZZZ96368 A Ther/diag concurrent inf 0.17 0.34 0.39 NA NA 0.01 ZZZ96369 A Sc ther infusion, up to 1 hr 0.21 4.71 4.69 NA NA 0.03 XXX96370 A Sc ther infusion, addl hr 0.18 0.25 0.26 NA NA 0.01 ZZZ96371 A Sc ther infusion, reset pump 0.00 2.18 2.30 NA NA 0.01 ZZZCMS-1503-P1159**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**96372 A Ther/proph/diag inj, sc/im 0.17 0.49 0.49 NA NA 0.01 XXX96373 A Ther/proph/diag inj, ia 0.17 0.37 0.37 NA NA 0.01 XXX96374 A Ther/proph/diag inj, iv push 0.18 1.26 1.40 NA NA 0.03 XXX96375 A Tx/pro/dx inj new drug addon 0.10 0.47 0.55 NA NA 0.01 ZZZ96376 X Tx/pro/dx inj new drug adon 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ96379 C Ther/prop/diag inj/inf proc 0.00 0.00 0.00 0.00 0.00 0.00 XXX96401 A Chemo, anti-neopl, sq/im 0.21 1.71 1.85 NA NA 0.04 XXX96402 A Chemo hormon antineopl sq/im 0.19 0.66 0.82 NA NA 0.01 XXX96405 A Chemo intralesional, up to 7 0.52 1.74 1.95 0.36 0.33 0.03 00096406 A Chemo intralesional over 7 0.80 2.30 2.59 0.49 0.44 0.04 00096409 A Chemo, iv push, sngl drug 0.24 2.57 2.97 NA NA 0.06 XXX96411 A Chemo, iv push, addl drug 0.20 1.38 1.60 NA NA 0.03 ZZZ96413 A Chemo, iv infusion, 1 hr 0.28 3.33 3.91 NA NA 0.06 XXX96415 A Chemo, iv infusion, addl hr 0.19 0.60 0.70 NA NA 0.01 ZZZ96416 A Chemo prolong infuse w/pump 0.21 3.75 4.38 NA NA 0.07 XXX96417 A Chemo iv infus each addl seq 0.21 1.59 1.85 NA NA 0.03 ZZZ96420 A Chemo, ia, push tecnique 0.17 2.52 2.90 NA NA 0.08 XXX96422 A Chemo ia infusion up to 1 hr 0.17 4.14 4.82 NA NA 0.08 XXX96423 A Chemo ia infuse each addl hr 0.17 1.84 2.10 NA NA 0.04 ZZZ96425 A Chemotherapy,infusion method 0.17 4.43 4.92 NA NA 0.10 XXX96440 A Chemotherapy, intracavitary 2.37 19.36 18.15 1.47 1.42 0.57 00096445 A Chemotherapy, intracavitary 2.20 5.10 5.90 1.11 1.10 0.21 00096450 A Chemotherapy, into CNS 1.53 3.26 4.12 0.72 0.85 0.11 00096521 A Refill/maint, portable pump 0.21 3.26 3.59 NA NA 0.06 XXX96522 A Refill/maint pump/resvr syst 0.21 2.63 2.95 NA NA 0.06 XXX96523 T Irrig drug delivery device 0.04 0.59 0.69 NA NA 0.01 XXXCMS-1503-P1160**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**96542 A Chemotherapy injection 0.75 2.31 2.90 0.44 0.49 0.04 XXX96549 C Chemotherapy, unspecified 0.00 0.00 0.00 0.00 0.00 0.00 XXX96567 A Photodynamic tx, skin 0.00 3.67 3.76 NA NA 0.01 XXX96570 A Photodynmc tx, 30 min add-on 1.10 0.43 0.46 0.43 0.46 0.18 ZZZ96571 A Photodynamic tx, addl 15 min 0.55 0.18 0.20 0.18 0.20 0.04 ZZZ96900 A Ultraviolet light therapy 0.00 0.55 0.59 NA NA 0.01 XXX96902 B Trichogram 0.41 0.20 0.20 0.18 0.17 0.03 XXX96904 R Whole body photography0.00 1.75 1.94 NA NA 0.01 XXX96910 A Photochemotherapy with UV-B 0.00 1.93 1.99 NA NA 0.01 XXX96912 A Photochemotherapy with UV-A 0.00 2.49 2.56 NA NA 0.01 XXX96913 A Photochemotherapy, UV-A or B 0.00 3.50 3.56 NA NA 0.01 XXX96920 A Laser tx, skin < 250 sq cm 1.15 3.72 3.83 0.83 0.77 0.04 00096921 A Laser tx, skin 250-500 sq cm 1.17 3.84 3.82 0.83 0.75 0.04 00096922 A Laser tx, skin > 500 sq cm 2.10 4.95 5.07 1.52 1.35 0.08 00096999 C Dermatological procedure 0.00 0.00 0.00 0.00 0.00 0.00 XXX97001 A Pt evaluation 1.20 0.91 0.87 NA NA 0.06 XXX97002 A Pt re-evaluation 0.60 0.57 0.54 NA NA 0.03 XXX97003 A Ot evaluation 1.20 1.20 1.08 NA NA 0.06 XXX97004 A Ot re-evaluation 0.60 0.87 0.78 NA NA 0.03 XXX97005 I Athletic train eval 0.00 0.00 0.00 0.00 0.00 0.00 XXX97006 I Athletic train reeval 0.00 0.00 0.00 0.00 0.00 0.00 XXX97010 B Hot or cold packs therapy 0.06 0.10 0.09 NA NA 0.01 XXX97012 A Mechanical traction therapy 0.25 0.20 0.18 NA NA 0.01 XXX97014 I Electric stimulation therapy 0.18 0.26 0.24 NA NA 0.01 XXX97016 A Vasopneumatic device therapy 0.18 0.35 0.31 NA NA 0.01 XXX97018 A Paraffin bath therapy 0.06 0.23 0.20 NA NA 0.01 XXXCMS-1503-P1161**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**97022 A Whirlpool therapy 0.17 0.47 0.41 NA NA 0.01 XXX97024 A Diathermy eg, microwave 0.06 0.11 0.11 NA NA 0.01 XXX97026 A Infrared therapy 0.06 0.10 0.09 NA NA 0.01 XXX97028 A Ultraviolet therapy 0.08 0.12 0.11 NA NA 0.01 XXX97032 A Electrical stimulation 0.25 0.28 0.25 NA NA 0.01 XXX97033 A Electric current therapy 0.26 0.63 0.56 NA NA 0.01 XXX97034 A Contrast bath therapy 0.21 0.29 0.26 NA NA 0.01 XXX97035 A Ultrasound therapy 0.21 0.14 0.13 NA NA 0.01 XXX97036 A Hydrotherapy 0.28 0.62 0.56 NA NA 0.01 XXX97039 C Physical therapy treatment 0.00 0.00 0.00 0.00 0.00 0.00 XXX97110 A Therapeutic exercises 0.45 0.45 0.41 NA NA 0.01 XXX97112 A Neuromuscular reeducation 0.45 0.48 0.45 NA NA 0.01 XXX97113 A Aquatic therapy/exercises 0.44 0.75 0.68 NA NA 0.01 XXX97116 A Gait training therapy 0.40 0.39 0.36 NA NA 0.01 XXX97124 A Massage therapy 0.35 0.38 0.35 NA NA 0.01 XXX97139 C Physical medicine procedure 0.00 0.00 0.00 0.00 0.00 0.00 XXX97140 A Manual therapy 0.43 0.41 0.37 NA NA 0.01 XXX97150 A Group therapeutic procedures 0.27 0.30 0.28 NA NA 0.01 XXX97530 A Therapeutic activities 0.44 0.53 0.49 NA NA 0.01 XXX97532 A Cognitive skills development 0.44 0.31 0.29 NA NA 0.01 XXX97533 A Sensory integration 0.44 0.38 0.35 NA NA 0.01 XXX97535 A Self care mngment training 0.45 0.53 0.48 NA NA 0.01 XXX97537 A Community/work reintegration 0.45 0.39 0.37 NA NA 0.01 XXX97542 A Wheelchair mngment training 0.45 0.41 0.38 NA NA 0.01 XXX97545 R Work hardening 0.00 0.00 0.00 0.00 0.00 0.00 XXX97546 R Work hardening add-on 0.00 0.00 0.00 0.00 0.00 0.00 ZZZCMS-1503-P1162**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**97597 A Active wound care/20 cm or < 0.58 1.56 1.38 0.17 0.24 0.06 XXX97598 A Active wound care > 20 cm 0.80 1.80 1.60 0.23 0.31 0.07 XXX97602 B Wound(s) care non-selective 0.00 0.00 0.00 0.00 0.00 0.00 XXX97605 A Neg press wound tx, < 50 cm 0.55 0.57 0.52 0.16 0.17 0.08 XXX97606 A Neg press wound tx, > 50 cm 0.60 0.58 0.53 0.17 0.18 0.10 XXX97750 A Physical performance test 0.45 0.47 0.43 NA NA 0.03 XXX97755 A Assistive technology assess 0.62 0.38 0.36 NA NA 0.03 XXX97760 A Orthotic mgmt and training 0.45 0.60 0.55 NA NA 0.03 XXX97761 A Prosthetic training 0.45 0.46 0.42 NA NA 0.03 XXX97762 A C/o for orthotic/prosth use 0.25 1.04 0.91 NA NA 0.01 XXX97799 C Physical medicine procedure 0.00 0.00 0.00 0.00 0.00 0.00 XXX97802 A Medical nutrition, indiv,in 0.53 0.40 0.36 0.35 0.31 0.03 XXX97803 A Med nutrition, indiv, subseq 0.45 0.35 0.33 0.30 0.27 0.03 XXX97804 A Medical nutrition, group 0.25 0.17 0.15 0.16 0.14 0.01 XXX97810 N Acupunct w/o stimul 15min 0.60 0.41 0.41 0.26 0.26 0.04 XXX97811 N Acupunct w/o stimul addl 15m 0.50 0.26 0.26 0.22 0.21 0.03 ZZZ97813 N Acupunct w/stimul 15min 0.65 0.43 0.43 0.28 0.28 0.04 XXX97814 N Acupunct w/stimul addl 15m 0.55 0.31 0.31 0.24 0.23 0.04 ZZZ98925 A Osteopathic manipulation 0.45 0.43 0.40 0.20 0.18 0.03 00098926 A Osteopathic manipulation 0.65 0.55 0.50 0.27 0.26 0.03 00098927 A Osteopathic manipulation 0.87 0.69 0.63 0.34 0.32 0.04 00098928 A Osteopathic manipulation 1.03 0.77 0.71 0.40 0.38 0.06 00098929 A Osteopathic manipulation 1.19 0.90 0.82 0.47 0.44 0.07 00098940 A Chiropractic manipulation 0.45 0.29 0.28 0.16 0.15 0.01 00098941 A Chiropractic manipulation 0.65 0.38 0.36 0.23 0.22 0.03 00098942 A Chiropractic manipulation 0.87 0.46 0.43 0.30 0.30 0.03 000CMS-1503-P1163**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**98943 N Chiropractic manipulation 0.40 0.27 0.27 0.17 0.17 0.03 XXX98960 B Self-mgmt educ & train, 1 pt 0.00 0.71 0.75 NA NA 0.01 XXX98961 B Self-mgmt educ/train, 2-4 pt 0.00 0.34 0.36 NA NA 0.01 XXX98962 B Self-mgmt educ/train, 5-8 pt 0.00 0.25 0.26 NA NA 0.01 XXX98966 N Hc pro phone call 5-10 min 0.25 0.14 0.14 0.11 0.10 0.01 XXX98967 N Hc pro phone call 11-20 min 0.50 0.25 0.25 0.22 0.21 0.03 XXX98968 N Hc pro phone call 21-30 min 0.75 0.36 0.35 0.32 0.31 0.06 XXX98969 N Online service by hc pro 0.00 0.00 0.00 0.00 0.00 0.00 XXX99000 B Specimen handling 0.00 0.00 0.00 0.00 0.00 0.00 XXX99001 B Specimen handling 0.00 0.00 0.00 0.00 0.00 0.00 XXX99002 B Device handling 0.00 0.00 0.00 0.00 0.00 0.00 XXX99024 B Postop follow-up visit 0.00 0.00 0.00 0.00 0.00 0.00 XXX99026 N In-hospital on call service 0.00 0.00 0.00 0.00 0.00 0.00 XXX99027 N Out-of-hosp on call service 0.00 0.00 0.00 0.00 0.00 0.00 XXX99050 B Medical services afterhrs 0.00 0.00 0.00 0.00 0.00 0.00 XXX99051 B Med serv, eve/wkend/holiday 0.00 0.00 0.00 0.00 0.00 0.00 XXX99053 B Med serv 10pm-8am, 24 hr fac 0.00 0.00 0.00 0.00 0.00 0.00 XXX99056 B Med service out of office 0.00 0.00 0.00 0.00 0.00 0.00 XXX99058 B Office emergency care 0.00 0.00 0.00 0.00 0.00 0.00 XXX99060 B Out of office emerg med serv 0.00 0.00 0.00 0.00 0.00 0.00 XXX99070 B Special supplies 0.00 0.00 0.00 0.00 0.00 0.00 XXX99071 B Patient education materials 0.00 0.00 0.00 0.00 0.00 0.00 XXX99075 N Medical testimony0.00 0.00 0.00 0.00 0.00 0.00 XXX99078 B Group health education 0.00 0.00 0.00 0.00 0.00 0.00 XXX99080 B Special reports or forms 0.00 0.00 0.00 0.00 0.00 0.00 XXX99082 C Unusual physician travel 0.00 0.00 0.00 0.00 0.00 0.00 XXXCMS-1503-P1164**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**99090 B Computer data analysis 0.00 0.00 0.00 0.00 0.00 0.00 XXX99091 B Collect/review data from pt 1.10 0.48 0.46 NA NA 0.07 XXX99100 B Special anesthesia service 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ99116 B Anesthesia with hypothermia 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ99135 B Special anesthesia procedure 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ99140 B Emergency anesthesia 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ99143 C Mod cs by same phys, < 5 yrs 0.00 0.00 0.00 0.00 0.00 0.00 XXX99144 C Mod cs by same phys, 5 yrs + 0.00 0.00 0.00 0.00 0.00 0.00 XXX99145 C Mod cs by same phys add-on 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ99148 C Mod cs diff phys < 5 yrs 0.00 0.00 0.00 0.00 0.00 0.00 XXX99149 C Mod cs diff phys 5 yrs + 0.00 0.00 0.00 0.00 0.00 0.00 XXX99150 C Mod cs diff phys add-on 0.00 0.00 0.00 0.00 0.00 0.00 ZZZ99170 A Anogenital exam, child 1.75 2.13 2.33 0.84 0.89 0.13 00099172 N Ocular function screen 0.00 0.00 0.00 0.00 0.00 0.00 XXX99173 N Visual acuity screen 0.00 0.07 0.07 NA NA 0.01 XXX99174 N Ocular photoscreening 0.00 0.76 0.80 NA NA 0.01 XXX99175 A Induction of vomiting 0.00 0.64 0.69 NA NA 0.01 XXX99183 A Hyperbaric oxygen therapy 2.34 3.60 3.46 0.97 0.87 0.27 XXX99190 X Special pump services0.00 0.00 0.00 0.00 0.00 0.00 XXX99191 X Special pump services0.00 0.00 0.00 0.00 0.00 0.00 XXX99192 X Special pump services0.00 0.00 0.00 0.00 0.00 0.00 XXX99195 A Phlebotomy 0.00 2.54 2.43 NA NA 0.06 XXX99199 C Special service/proc/report 0.00 0.00 0.00 0.00 0.00 0.00 XXX99201 A Office/outpatient visit, new 0.48 0.71 0.68 0.26 0.23 0.04 XXX99202 A Office/outpatient visit, new 0.93 1.13 1.07 0.48 0.43 0.07 XXX99203 A Office/outpatient visit, new 1.42 1.54 1.44 0.71 0.63 0.14 XXXCMS-1503-P1165**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**99204 A Office/outpatient visit, new 2.43 2.11 1.97 1.19 1.04 0.24 XXX99205 A Office/outpatient visit, new 3.17 2.46 2.32 1.47 1.32 0.28 XXX99211 A Office/outpatient visit, est 0.18 0.36 0.38 0.08 0.08 0.01 XXX99212 A Office/outpatient visit, est 0.48 0.71 0.69 0.24 0.22 0.04 XXX99213 A Office/outpatient visit, est 0.97 1.03 0.97 0.46 0.41 0.07 XXX99214 A Office/outpatient visit, est 1.50 1.45 1.38 0.70 0.62 0.10 XXX99215 A Office/outpatient visit, est 2.11 1.86 1.76 0.98 0.88 0.14 XXX99217 A Observation care discharge 1.28 NA NA 0.72 0.67 0.08 XXX99218 A Observation care 1.28 NA NA 0.56 0.52 0.08 XXX99219 A Observation care 2.14 NA NA 0.96 0.87 0.14 XXX99220 A Observation care 2.99 NA NA 1.31 1.21 0.21 XXX99221 A Initial hospital care 1.92 NA NA 0.84 0.75 0.18 XXX99222 A Initial hospital care 2.61 NA NA 1.18 1.04 0.23 XXX99223 A Initial hospital care 3.86 NA NA 1.73 1.52 0.30 XXX99231 A Subsequent hospital care 0.76 NA NA 0.34 0.31 0.06 XXX99232 A Subsequent hospital care 1.39 NA NA 0.62 0.56 0.08 XXX99233 A Subsequent hospital care 2.00 NA NA 0.88 0.80 0.13 XXX99234 A Observ/hosp same date 2.56 NA NA 1.14 1.07 0.23 XXX99235 A Observ/hosp same date 3.41 NA NA 1.52 1.40 0.24 XXX99236 A Observ/hosp same date 4.26 NA NA 1.86 1.71 0.30 XXX99238 A Hospital discharge day 1.28 NA NA 0.72 0.67 0.07 XXX99239 A Hospital discharge day 1.90 NA NA 1.06 0.95 0.11 XXX99241 I Office consultation 0.64 0.66 0.66 0.24 0.24 0.07 XXX99242 I Office consultation 1.34 1.10 1.10 0.51 0.51 0.14 XXX99243 I Office consultation 1.88 1.46 1.46 0.71 0.71 0.18 XXX99244 I Office consultation 3.02 1.96 1.96 1.14 1.14 0.23 XXXCMS-1503-P1166**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**99245 I Office consultation 3.77 2.30 2.30 1.38 1.38 0.30 XXX99251 I Inpatient consultation 1.00 NA NA 0.32 0.32 0.07 XXX99252 I Inpatient consultation 1.50 NA NA 0.52 0.52 0.13 XXX99253 I Inpatient consultation 2.27 NA NA 0.84 0.84 0.16 XXX99254 I Inpatient consultation 3.29 NA NA 1.23 1.23 0.18 XXX99255 I Inpatient consultation 4.00 NA NA 1.44 1.44 0.25 XXX99281 A Emergency dept visit 0.45 NA NA 0.14 0.13 0.03 XXX99282 A Emergency dept visit 0.88 NA NA 0.26 0.23 0.07 XXX99283 A Emergency dept visit 1.34 NA NA 0.38 0.35 0.10 XXX99284 A Emergency dept visit 2.56 NA NA 0.65 0.61 0.23 XXX99285 A Emergency dept visit 3.80 NA NA 0.88 0.86 0.31 XXX99288 B Direct advanced life support 0.00 0.00 0.00 0.00 0.00 0.00 XXX99291 A Critical care, first hour 4.50 2.94 2.88 1.62 1.52 0.35 XXX99292 A Critical care, addl 30 min 2.25 1.10 1.04 0.82 0.76 0.18 ZZZ99304 A Nursing facility care, init 1.64 0.92 0.80 0.92 0.80 0.14 XXX99305 A Nursing facility care, init 2.35 1.25 1.07 1.25 1.07 0.21 XXX99306 A Nursing facility care, init 3.06 1.55 1.31 1.55 1.31 0.24 XXX99307 A Nursing fac care, subseq 0.76 0.48 0.43 0.48 0.43 0.04 XXX99308 A Nursing fac care, subseq 1.16 0.75 0.66 0.75 0.66 0.07 XXX99309 A Nursing fac care, subseq 1.55 0.97 0.86 0.97 0.86 0.08 XXX99310 A Nursing fac care, subseq 2.35 1.38 1.21 1.38 1.21 0.14 XXX99315 A Nursing fac discharge day 1.13 0.68 0.60 0.68 0.60 0.07 XXX99316 A Nursing fac discharge day 1.50 0.85 0.75 0.85 0.75 0.08 XXX99318 A Annual nursing fac assessmnt 1.71 0.96 0.82 0.96 0.82 0.10 XXX99324 A Domicil/r-home visit new pat 1.01 0.54 0.53 NA NA 0.07 XXX99325 A Domicil/r-home visit new pat 1.52 0.72 0.71 NA NA 0.10 XXXCMS-1503-P1167**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**99326 A Domicil/r-home visit new pat 2.63 1.28 1.16 NA NA 0.17 XXX99327 A Domicil/r-home visit new pat 3.46 1.70 1.51 NA NA 0.23 XXX99328 A Domicil/r-home visit new pat 4.09 1.95 1.73 NA NA 0.25 XXX99334 A Domicil/r-home visit est pat 1.07 0.61 0.57 NA NA 0.07 XXX99335 A Domicil/r-home visit est pat 1.72 0.92 0.82 NA NA 0.10 XXX99336 A Domicil/r-home visit est pat 2.46 1.28 1.12 NA NA 0.14 XXX99337 A Domicil/r-home visit est pat 3.58 1.79 1.56 NA NA 0.24 XXX99339 B Domicil/r-home care supervis 1.25 0.90 0.89 NA NA 0.08 XXX99340 B Domicil/r-home care supervis 1.80 1.21 1.20 NA NA 0.13 XXX99341 A Home visit, new patient 1.01 0.52 0.52 NA NA 0.07 XXX99342 A Home visit, new patient 1.52 0.69 0.70 NA NA 0.11 XXX99343 A Home visit, new patient 2.53 1.13 1.09 NA NA 0.18 XXX99344 A Home visit, new patient 3.38 1.71 1.51 NA NA 0.23 XXX99345 A Home visit, new patient 4.09 2.00 1.77 NA NA 0.27 XXX99347 A Home visit, est patient 1.00 0.54 0.52 NA NA 0.07 XXX99348 A Home visit, est patient 1.56 0.79 0.74 NA NA 0.10 XXX99349 A Home visit, est patient 2.33 1.23 1.09 NA NA 0.14 XXX99350 A Home visit, est patient 3.28 1.66 1.46 NA NA 0.23 XXX99354 A Prolonged service, office 1.77 0.98 0.91 0.80 0.74 0.11 ZZZ99355 A Prolonged service, office 1.77 0.94 0.88 0.76 0.71 0.11 ZZZ99356 A Prolonged service, inpatient 1.71 NA NA 0.83 0.74 0.11 ZZZ99357 A Prolonged service, inpatient 1.71 NA NA 0.83 0.75 0.11 ZZZ99358 B Prolong service w/o contact 2.10 0.94 0.92 0.94 0.92 0.14 XXX99359 B Prolong serv w/o contact add 1.00 0.47 0.46 0.47 0.46 0.07 ZZZ99360 X Physician standby services 1.20 NA NA 0.52 0.50 0.08 XXX99363 B Anticoag mgmt, init 1.65 1.83 1.86 0.71 0.69 0.11 XXXCMS-1503-P1168**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**99364 B Anticoag mgmt, subseq 0.63 0.56 0.56 0.27 0.26 0.04 XXX99366 B Team conf w/pat by hc pro 0.82 0.37 0.36 0.35 0.34 0.06 XXX99367 B Team conf w/o pat by phys 1.10 NA NA 0.48 0.46 0.07 XXX99368 B Team conf w/o pat by hc pro 0.72 NA NA 0.31 0.30 0.04 XXX99374 B Home health care supervision 1.10 0.83 0.83 0.48 0.47 0.07 XXX99375 I Home health care supervision 1.73 1.18 1.26 0.75 0.87 0.11 XXX99377 B Hospice care supervision 1.10 0.83 0.83 0.48 0.47 0.07 XXX99378 I Hospice care supervision 1.73 1.18 1.32 0.75 0.93 0.11 XXX99379 B Nursing fac care supervision 1.10 0.83 0.83 0.48 0.47 0.07 XXX99380 B Nursing fac care supervision 1.73 1.18 1.17 0.75 0.74 0.11 XXX99381 N Init pm e/m, new pat, inf 1.19 1.40 1.46 0.51 0.50 0.08 XXX99382 N Init pm e/m, new pat 1-4 yrs 1.36 1.47 1.53 0.59 0.58 0.08 XXX99383 N Prev visit, new, age 5-11 1.36 1.46 1.51 0.59 0.58 0.08 XXX99384 N Prev visit, new, age 12-17 1.53 1.53 1.58 0.66 0.65 0.10 XXX99385 N Prev visit, new, age 18-39 1.53 1.53 1.58 0.66 0.65 0.10 XXX99386 N Prev visit, new, age 40-64 1.88 1.68 1.74 0.81 0.80 0.13 XXX99387 N Init pm e/m, new pat 65+ yrs 2.06 1.87 1.93 0.89 0.88 0.14 XXX99391 N Per pm reeval, est pat, inf 1.02 1.20 1.22 0.44 0.43 0.07 XXX99392 N Prev visit, est, age 1-4 1.19 1.28 1.29 0.51 0.50 0.08 XXX99393 N Prev visit, est, age 5-11 1.19 1.27 1.28 0.51 0.50 0.08 XXX99394 N Prev visit, est, age 12-17 1.36 1.34 1.36 0.59 0.58 0.08 XXX99395 N Prev visit, est, age 18-39 1.36 1.35 1.37 0.59 0.58 0.08 XXX99396 N Prev visit, est, age 40-64 1.53 1.42 1.44 0.66 0.65 0.10 XXX99397 N Per pm reeval est pat 65+ yr 1.71 1.62 1.63 0.74 0.73 0.11 XXX99401 N Preventive counseling, indiv 0.48 0.51 0.54 0.21 0.21 0.03 XXX99402 N Preventive counseling, indiv 0.98 0.73 0.77 0.42 0.42 0.07 XXXCMS-1503-P1169**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**99403 N Preventive counseling, indiv 1.46 0.94 0.98 0.63 0.62 0.10 XXX99404 N Preventive counseling, indiv 1.95 1.15 1.19 0.84 0.83 0.13 XXX99406 A Behav chng smoking 3-10 min 0.24 0.15 0.14 0.10 0.09 0.01 XXX99407 A Behav chng smoking > 10 min 0.50 0.27 0.24 0.22 0.20 0.03 XXX99408 N Audit/dast, 15-30 min0.65 0.33 0.32 0.28 0.27 0.04 XXX99409 N Audit/dast, over 30 min 1.30 0.61 0.60 0.56 0.55 0.08 XXX99411 N Preventive counseling, group 0.15 0.29 0.29 0.06 0.06 0.01 XXX99412 N Preventive counseling, group 0.25 0.33 0.34 0.11 0.11 0.01 XXX99420 N Health risk assessment test 0.00 0.27 0.29 NA NA 0.01 XXX99429 N Unlisted preventive service 0.00 0.00 0.00 0.00 0.00 0.00 XXX99441 N Phone e/m by phys 5-10 min 0.25 0.14 0.14 0.11 0.10 0.01 XXX99442 N Phone e/m by phys 11-20 min 0.50 0.25 0.25 0.22 0.21 0.03 XXX99443 N Phone e/m by phys 21-30 min 0.75 0.36 0.35 0.32 0.31 0.06 XXX99444 N Online e/m by phys 0.00 0.00 0.00 0.00 0.00 0.00 XXX99450 N Basic life disability exam 0.00 0.00 0.00 0.00 0.00 0.00 XXX99455 R Work related disabilityexam 0.00 0.00 0.00 0.00 0.00 0.00 XXX99456 R Disability examination 0.00 0.00 0.00 0.00 0.00 0.00 XXX99460 A Init nb em per day, hosp 1.17 NA NA 0.53 0.47 0.06 XXX99461 A Init nb em per day, non-fac 1.26 1.42 1.32 0.54 0.53 0.08 XXX99462 A Sbsq nb em per day, hosp 0.62 NA NA 0.28 0.26 0.04 XXX99463 A Same day nb discharge 1.50 NA NA 0.84 0.74 0.08 XXX99464 A Attendance at delivery 1.50 NA NA 0.58 0.53 0.07 XXX99465 A Nb resuscitation 2.93 NA NA 0.65 0.91 0.23 XXX99466 A Ped crit care transport 4.79 NA NA 2.19 1.94 1.06 XXX99467 A Ped crit care transport addl 2.40 NA NA 1.04 0.94 0.14 ZZZ99468 A Neonate crit care, initial 18.46 NA NA 7.15 6.31 1.58 XXXCMS-1503-P1170**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**99469 A Neonate crit care, subsq 7.99 NA NA 3.46 3.06 0.44 XXX99471 A Ped critical care, initial 15.98 NA NA 6.19 5.79 0.90 XXX99472 A Ped critical care, subsq 7.99 NA NA 3.16 2.92 0.49 XXX99475 A Ped crit care age 2-5, init 11.25 4.37 3.90 4.37 3.90 0.89 XXX99476 A Ped crit care age 2-5, subsq 6.75 2.81 2.43 2.81 2.43 0.54 XXX99477 A Init day hosp neonate care 7.00 NA NA 3.03 2.75 0.40 XXX99478 A Ic, lbw inf < 1500 gm subsq 2.75 NA NA 1.07 1.08 0.18 XXX99479 A Ic lbw inf 1500-2500 g subsq 2.50 NA NA 1.19 1.02 0.17 XXX99480 A Ic inf pbw 2501-5000 g subsq 2.40 NA NA 0.93 0.88 0.17 XXX99499 C Unlisted e&m service 0.00 0.00 0.00 0.00 0.00 0.00 XXX99500 I Home visit, prenatal 0.00 0.00 0.00 0.00 0.00 0.00 XXX99501 I Home visit, postnatal 0.00 0.00 0.00 0.00 0.00 0.00 XXX99502 I Home visit, nb care 0.00 0.00 0.00 0.00 0.00 0.00 XXX99503 I Home visit, resp therapy 0.00 0.00 0.00 0.00 0.00 0.00 XXX99504 I Home visit mech ventilator 0.00 0.00 0.00 0.00 0.00 0.00 XXX99505 I Home visit, stoma care 0.00 0.00 0.00 0.00 0.00 0.00 XXX99506 I Home visit, im injection 0.00 0.00 0.00 0.00 0.00 0.00 XXX99507 I Home visit, cath maintain 0.00 0.00 0.00 0.00 0.00 0.00 XXX99509 I Home visit day life activity 0.00 0.00 0.00 0.00 0.00 0.00 XXX99510 I Home visit, sing/m/fam couns 0.00 0.00 0.00 0.00 0.00 0.00 XXX99511 I Home visit, fecal/enema mgmt 0.00 0.00 0.00 0.00 0.00 0.00 XXX99512 I Home visit for hemodialysis 0.00 0.00 0.00 0.00 0.00 0.00 XXX99600 I Home visit nos 0.00 0.00 0.00 0.00 0.00 0.00 XXX99601 I Home infusion/visit, 2 hrs 0.00 0.00 0.00 0.00 0.00 0.00 XXX99602 I Home infusion, each addtl hr 0.00 0.00 0.00 0.00 0.00 0.00 XXX99605 X Mtms by pharm, np, 15 min 0.00 0.00 0.00 0.00 0.00 0.00 XXXCMS-1503-P1171**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**99606 X Mtms by pharm, est, 15 min 0.00 0.00 0.00 0.00 0.00 0.00 XXX99607 X Mtms by pharm, addl 15 min 0.00 0.00 0.00 0.00 0.00 0.00 XXXA4641 C Radiopharm dx agent noc 0.00 0.00 0.00 0.00 0.00 0.00 XXXA4642 C In111 satumomab 0.00 0.00 0.00 0.00 0.00 0.00 XXXA4890 R Repair/maint cont hemo equip 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9500 C Tc99m sestamibi 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9501 C Technetium TC-99m teboroxime 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9502 C Tc99m tetrofosmin 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9503 C Tc99m medronate 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9504 C Tc99m apcitide 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9505 C TL201 thallium 0.000.00 0.00 0.00 0.00 0.00 XXXA9507 C In111 capromab 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9508 C I131 iodobenguate, dx 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9509 C Iodine I-123 sod iodidemil 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9510 C Tc99m disofenin 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9512 C Tc99m pertechnetate0.00 0.00 0.00 0.00 0.00 0.00 XXXA9516 C Iodine I-123 sod iodidemic 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9517 C I131 iodide cap, rx0.00 0.00 0.00 0.00 0.00 0.00 XXXA9521 C Tc99m exametazime 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9524 C I131 serum albumin, dx 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9526 C Nitrogen N-13 ammonia 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9527 C Iodine I-125 sodium iodide 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9528 C Iodine I-131 iodide cap,dx 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9529 C I131 iodide sol, dx0.00 0.00 0.00 0.00 0.00 0.00 XXXA9530 C I131 iodide sol, rx0.00 0.00 0.00 0.00 0.00 0.00 XXXA9531 C I131 max 100uCi 0.00 0.00 0.00 0.00 0.00 0.00 XXXCMS-1503-P1172**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**A9532 C I125 serum albumin, dx 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9536 C Tc99m depreotide 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9537 C Tc99m mebrofenin 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9538 C Tc99m pyrophosphate 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9539 C Tc99m pentetate 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9540 C Tc99m MAA 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9541 C Tc99m sulfur colloid 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9542 C In111 ibritumomab, dx 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9543 C Y90 ibritumomab, rx 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9544 C I131 tositumomab, dx 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9545 C I131 tositumomab, rx 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9546 C Co57/58 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9547 C In111 oxyquinoline 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9548 C In111 pentetate 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9550 C Tc99m gluceptate 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9551 C Tc99m succimer 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9552 C F18 fdg 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9553 C Cr51 chromate 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9554 C I125 iothalamate, dx0.00 0.00 0.00 0.00 0.00 0.00 XXXA9555 C Rb82 rubidium 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9556 C Ga67 gallium 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9557 C Tc99m bicisate 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9558 C Xe133 xenon 10mci 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9559 C Co57 cyano 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9560 C Tc99m labeled rbc 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9561 C Tc99m oxidronate 0.00 0.00 0.00 0.00 0.00 0.00 XXXCMS-1503-P1173**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**A9562 C Tc99m mertiatide 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9563 C P32 Na phosphate 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9564 C P32 chromic phosphate 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9566 C Tc99m fanolesomab 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9567 C Technetium TC-99m aerosol 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9568 C Technetium tc99m arcitumomab 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9569 C Technetium TC-99m auto WBC 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9570 C Indium In-111 auto WBC 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9571 C Indium IN-111 auto platelet 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9572 C Indium In-111 pentetreotide 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9580 C Sodium fluoride F-18 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9600 C Sr89 strontium 0.00 0.00 0.00 0.00 0.00 0.00 XXXA9699 C Radiopharm rx agent noc 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0008 X Admin influenza virus vac 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0009 X Admin pneumococcal vaccine 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0010 X Admin hepatitis b vaccine 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0027 X Semen analysis 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0101 A CA screen;pelvic/breastexam 0.45 0.59 0.59 0.31 0.45 0.03 XXXG0102 A Prostate ca screening; dre 0.17 0.36 0.38 0.08 0.08 0.01 XXXG0103 X PSA screening 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0104 A CA screen;flexi sigmoidscope 0.96 2.86 2.89 0.78 0.75 0.14 000G0105 A Colorectal scrn; hi risk ind 3.69 6.98 7.24 2.23 2.19 0.61 000G0105 53 A Colorectal scrn; hi risk ind 0.96 2.86 2.89 0.78 0.75 0.14 000G0106 A Colon CA screen;barium enema 0.99 4.92 5.07 NA NA 0.04 XXXG0106 TC A Colon CA screen;barium enema 0.00 4.58 4.68 NA NA 0.01 XXXG0106 26 A Colon CA screen;barium enema 0.99 0.34 0.39 0.34 0.39 0.03 XXXCMS-1503-P1174**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**G0108 A Diab manage trn per indiv 0.90 0.56 0.66 NA NA 0.06 XXXG0109 A Diab manage trn ind/group 0.25 0.15 0.28 NA NA 0.01 XXXG0117 T Glaucoma scrn hgh risk direc 0.45 1.02 0.96 NA NA 0.03 XXXG0118 T Glaucoma scrn hgh risk direc 0.17 0.86 0.82 NA NA 0.01 XXXG0120 A Colon ca scrn; barium enema 0.99 4.92 5.07 NA NA 0.04 XXXG0120 TC A Colon ca scrn; barium enema 0.00 4.58 4.68 NA NA 0.01 XXXG0120 26 A Colon ca scrn; barium enema 0.99 0.34 0.39 0.34 0.39 0.03 XXXG0121 A Colon ca scrn not hi rsk ind 3.69 6.98 7.24 2.23 2.19 0.61 000G0121 53 A Colon ca scrn not hi rsk ind 0.96 2.86 2.89 0.78 0.75 0.14 000G0122 N Colon ca scrn; barium enema 0.99 7.02 6.75 NA NA 0.05 XXXG0122 TC N Colon ca scrn; barium enema 0.00 6.59 6.33 NA NA 0.01 XXXG0122 26 N Colon ca scrn; barium enema 0.99 0.43 0.42 0.43 0.42 0.04 XXXG0123 X Screen cerv/vag thin layer 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0124 A Screen c/v thin layer by MD 0.42 0.40 0.39 0.40 0.39 0.03 XXXG0127 R Trim nail(s) 0.17 0.47 0.44 0.05 0.06 0.01 000G0128 R CORF skilled nursing service 0.08 0.20 0.18 NA NA 0.01 XXXG0130 A Single energy x-ray study 0.22 0.70 0.73 NA NA 0.02 XXXG0130 TC A Single energy x-ray study 0.00 0.60 0.64 NA NA 0.01 XXXG0130 26 A Single energy x-ray study 0.22 0.10 0.09 0.10 0.09 0.01 XXXG0141 A Scr c/v cyto,autosys and md 0.42 0.40 0.39 0.40 0.39 0.03 XXXG0143 X Scr c/v cyto,thinlayer,rescr 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0144 X Scr c/v cyto,thinlayer,rescr 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0145 X Scr c/v cyto,thinlayer,rescr 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0147 X Scr c/v cyto, automated sys 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0148 X Scr c/v cyto, autosys, rescr 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0166 A Extrnl counterpulse, per tx 0.07 3.80 4.35 NA NA 0.03 XXXCMS-1503-P1175**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**G0168 A Wound closure by adhesive 0.45 2.07 2.01 0.30 0.27 0.03 000G0173 X Linear acc stereo radsur com 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0175 X OPPS Service,sched teamconf 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0176 X OPPS/PHP;activity therapy 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0177 X OPPS/PHP; train & educ serv 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0179 A MD recertification HHA PT 0.45 0.66 0.70 0.43 0.58 0.03 XXXG0180 A MD certification HHA patient 0.67 0.78 0.83 0.55 0.71 0.04 XXXG0181 A Home health care supervision 1.73 1.25 1.21 NA NA 0.10 XXXG0182 A Hospice care supervision 1.73 1.25 1.25 NA NA 0.10 XXXG0186 C Dstry eye lesn,fdr vssl tech 0.00 0.00 0.00 0.00 0.00 0.00 YYYG0202 A Screeningmammographydigital 0.70 3.31 3.34 NA NA 0.05 XXXG0202 TC A Screeningmammographydigital 0.00 3.03 3.05 NA NA 0.01 XXXG0202 26 A Screeningmammographydigital 0.70 0.28 0.29 0.28 0.29 0.04 XXXG0204 A Diagnosticmammographydigital 0.87 4.01 3.96 NA NA 0.07 XXXG0204 TC A Diagnosticmammographydigital 0.00 3.66 3.61 NA NA 0.01 XXXG0204 26 A Diagnosticmammographydigital 0.87 0.35 0.35 0.35 0.35 0.06 XXXG0206 A Diagnosticmammographydigital 0.70 3.14 3.12 NA NA 0.05 XXXG0206 TC A Diagnosticmammographydigital 0.00 2.86 2.83 NA NA 0.01 XXXG0206 26 A Diagnosticmammographydigital 0.70 0.28 0.29 0.28 0.29 0.04 XXXG0219 N PET img wholbod melano nonco 0.00 0.00 0.00 NA NA 0.00 XXXG0219 TC N PET img wholbod melano nonco 0.00 0.00 0.00 NA NA 0.00 XXXG0219 26 N PET img wholbod melano nonco 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0235 N PET not otherwise specified 0.00 0.00 0.00 NA NA 0.00 XXXG0235 TC N PET not otherwise specified 0.00 0.00 0.00 NA NA 0.00 XXXG0235 26 N PET not otherwise specified 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0237 A Therapeutic procd strg endur 0.00 0.24 0.28 NA NA 0.01 XXXCMS-1503-P1176**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**G0238 A Oth resp proc, indiv 0.00 0.25 0.30 NA NA 0.01 XXXG0239 A Oth resp proc, group 0.00 0.30 0.33 NA NA 0.01 XXXG0245 R Initial foot exam pt lops 0.88 1.13 1.07 0.48 0.43 0.06 XXXG0246 R Followup eval of foot ptlop 0.45 0.71 0.69 0.24 0.22 0.03 XXXG0247 R Routine footcare pt w lops 0.50 0.84 0.79 0.20 0.20 0.04 ZZZG0248 R Demonstrate use home inr mon 0.00 3.17 4.05 NA NA 0.01 XXXG0249 R Provide INR test mater/equip 0.00 2.96 3.58 NA NA 0.01 XXXG0250 R MD INR test revie inter mgmt 0.18 0.07 0.08 NA NA 0.01 XXXG0251 E Linear acc based stero radio 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0252 N PET imaging initial dx 0.00 0.00 0.00 NA NA 0.00 XXXG0252 TC N PET imaging initial dx 0.00 0.00 0.00 NA NA 0.00 XXXG0252 26 N PET imaging initial dx 1.50 0.65 0.69 0.65 0.69 0.10 XXXG0255 N Current percep threshold tst 0.00 0.00 0.00 NA NA 0.00 XXXG0255 TC N Current percep threshold tst 0.00 0.00 0.00 NA NA 0.00 XXXG0255 26 N Current percep threshold tst 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0257 E Unsched dialysis ESRD pthos 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0259 E Inject for sacroiliac joint 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0260 E Inj for sacroiliac jt anesth 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0268 A Removal of impacted wax md 0.61 0.89 0.84 0.35 0.31 0.03 000G0269 B Occlusive device in veinart 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0270 A MNT subs tx for change dx 0.45 0.35 0.33 0.30 0.27 0.03 XXXG0271 A Group MNT 2 or more 30mins 0.25 0.17 0.15 0.16 0.14 0.01 XXXG0275 A Renal angio, cardiac cath 0.25 NA NA 0.10 0.13 0.01 ZZZG0278 A Iliac art angio,cardiac cath 0.25 NA NA 0.10 0.13 0.01 ZZZG0281 A Elec stim unattend for press 0.18 0.20 0.18 NA NA 0.01 XXXG0282 N Elect stim wound care not pd 0.00 0.00 0.00 0.00 0.00 0.00 XXXCMS-1503-P1177**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**G0283 A Elec stim other than wound 0.18 0.20 0.18 NA NA 0.01 XXXG0288 A Recon, CTA for surg plan 0.00 0.98 2.52 NA NA 0.01 XXXG0289 A Arthro, loose body + chondro 1.48 NA NA 0.86 0.83 0.30 ZZZG0290 E Drug-eluting stents, single 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0291 E Drug-eluting stents,each add 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0293 E Non-cov surg proc,clin trial 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0294 E Non-cov proc, clinicaltrial 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0295 N Electromagnetic therapyonc 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0302 X Pre-op service LVRS complete 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0303 X Pre-op service LVRS 10-15dos 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0304 X Pre-op service LVRS 1-9 dos 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0305 X Post op service LVRS min 6 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0306 X CBC/diffwbc w/o platelet 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0307 X CBC without platelet0.00 0.00 0.00 0.00 0.00 0.00 XXXG0328 X Fecal blood scrn immunoassay 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0329 A Electromagntic tx for ulcers 0.06 0.21 0.19 NA NA 0.01 XXXG0333 X Dispense fee initial 30 day 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0337 X Hospice evaluation preelecti 1.42 0.61 0.61 0.61 0.61 0.10 XXXG0339 C Robot lin-radsurg com, first 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0340 C Robt lin-radsurg fractx 2-5 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0341 A Percutaneous islet celltrans 6.98 51.68 28.38 NA NA 0.51 000G0342 A Laparoscopy islet cell trans 11.92 NA NA 7.73 7.04 0.88 090G0343 A Laparotomy islet cell transp 19.85 NA NA 13.12 11.91 1.46 090G0364 A Bone marrow aspirate &biopsy 0.16 0.18 0.19 0.09 0.09 0.01 ZZZG0365 A Vessel mapping hemo access 0.25 5.80 5.82 NA NA 0.04 XXXG0365 TC A Vessel mapping hemo access 0.00 5.71 5.73 NA NA 0.01 XXXCMS-1503-P1178**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**G0365 26 A Vessel mapping hemo access 0.25 0.09 0.09 0.09 0.09 0.03 XXXG0372 A MD service required for PMD 0.17 0.08 0.12 0.08 0.07 0.01 XXXG0378 X Hospital observation per hr 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0379 X Direct refer hospital observ 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0389 A Ultrasound exam AAA screen 0.58 2.36 2.61 NA NA 0.04 XXXG0389 TC A Ultrasound exam AAA screen 0.00 2.15 2.37 NA NA 0.01 XXXG0389 26 A Ultrasound exam AAA screen 0.58 0.21 0.24 0.21 0.24 0.03 XXXG0396 A Alcohol/subs interv 15-30mn 0.65 0.32 0.28 0.26 0.23 0.04 XXXG0397 A Alcohol/subs interv >30 min 1.30 0.80 0.61 0.75 0.56 0.08 XXXG0398 C Home sleep test/type 2 Porta 0.00 0.00 0.00 NA NA 0.00 XXXG0398 TC C Home sleep test/type 2 Porta 0.00 0.00 0.00 NA NA 0.00 XXXG0398 26 C Home sleep test/type 2Porta 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0399 C Home sleep test/type 3 Porta 0.00 0.00 0.00 NA NA 0.00 XXXG0399 TC C Home sleep test/type 3 Porta 0.00 0.00 0.00 NA NA 0.00 XXXG0399 26 C Home sleep test/type 3Porta 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0400 C Home sleep test/type 4 Porta 0.00 0.00 0.00 NA NA 0.00 XXXG0400 TC C Home sleep test/type 4 Porta 0.00 0.00 0.00 NA NA 0.00 XXXG0400 26 C Home sleep test/type 4Porta 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0402 A Initial preventive exam 2.43 2.14 1.76 NA NA 0.13 XXXG0403 A EKG for initial prevent exam 0.17 0.32 0.39 0.32 0.40 0.02 XXXG0404 A EKG tracing for initial prev 0.00 0.25 0.31 0.25 0.34 0.01 XXXG0405 A EKG interpret & report preve 0.17 0.07 0.08 0.07 0.06 0.01 XXXG0406 A Telhealth inpt consult 15min 0.76 NA NA 0.34 0.31 0.06 XXXG0407 A Telheath inpt consult 25min 1.39 NA NA 0.62 0.56 0.08 XXXG0408 A Telhealth inpt consult 35min 2.00 NA NA 0.88 0.80 0.13 XXXG0409 A CORF related serv 15 mins ea 0.00 0.29 0.28 NA NA 0.01 XXXCMS-1503-P1179**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**G0410 X Grp psych partial hosp 45-50 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0411 X Inter active grp psych parti 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0412 A Open tx iliac spine uni/bil 10.45 NA NA 9.03 8.56 2.12 090G0413 A Pelvic ring fracture uni/bil 15.73 NA NA 12.41 11.95 3.18 090G0414 A Pelvic ring fx treat int fix 14.65 NA NA 12.31 11.77 2.97 090G0415 A Open tx post pelvic fxcture 20.93 NA NA 16.01 15.05 4.37 090G0416 A Sat biopsy prostate 1-20 spc 3.09 13.96 13.96 NA NA 0.12 XXXG0416 TC A Sat biopsy prostate 1-20 spc 0.00 12.14 12.14 NA NA 0.01 XXXG0416 26 A Sat biopsy prostate 1-20spc 3.09 1.82 1.82 1.82 1.82 0.11 XXXG0417 A Sat biopsy prostate 21-40 5.86 27.26 27.26 NA NA 0.26 XXXG0417 TC A Sat biopsy prostate 21-40 0.00 23.71 23.71 NA NA 0.01 XXXG0417 26 A Sat biopsy prostate 21-40 5.86 3.55 3.55 3.55 3.55 0.25 XXXG0418 A Sat biopsy prostate 41-60 10.30 46.56 46.56 NA NA 0.43 XXXG0418 TC A Sat biopsy prostate 41-60 0.00 40.50 40.50 NA NA 0.01 XXXG0418 26 A Sat biopsy prostate 41-60 10.30 6.06 6.06 6.06 6.06 0.42 XXXG0419 A Sat biopsy prostate: >60 11.61 55.86 55.86 NA NA 0.48 XXXG0419 TC A Sat biopsy prostate: >60 0.00 48.60 48.60 NA NA 0.01 XXXG0419 26 A Sat biopsy prostate: >60 11.61 7.26 7.26 7.26 7.26 0.47 XXXG0420 A Ed svc CKD ind per session 2.12 1.01 1.01 NA NA 0.11 XXXG0421 A Ed svc CKD grp per session 0.50 0.23 0.23 NA NA 0.03 XXXG0422 A Intens cardiac rehab w/exerc 0.60 0.87 0.88 0.87 0.88 0.04 XXXG0423 A Intens cardiac rehab noexer 0.60 0.87 0.88 0.87 0.88 0.04 XXXG0424 A Pulmonary rehab w exer 0.28 0.58 0.58 0.12 0.12 0.03 XXXG0425 A Inpt telehealth consult 30m 1.92 NA NA 0.84 0.84 0.18 XXXG0426 A Inpt telehealth consult 50m 2.61 NA NA 1.18 1.18 0.23 XXXG0427 A Inpt telehealth con 70/>m 3.86 NA NA 1.73 1.73 0.30 XXXCMS-1503-P1180**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**G0430 X Drug screen multi class 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0431 X Drug screen single class 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0432 X EIA HIV-1/HIV-2 screen 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0433 X ELISA HIV-1/HIV-2 screen 0.00 0.00 0.00 0.00 0.00 0.00 XXXG0435 X Oral HIV-1/HIV-2 screen 0.00 0.00 0.00 0.00 0.00 0.00 XXXG3001 X Admin + supply, tositumomab 0.00 0.00 0.00 0.00 0.00 0.00 XXXG9001 X MCCD, initial rate 0.00 0.00 0.00 0.00 0.00 0.00 XXXG9002 X MCCD,maintenance rate 0.00 0.00 0.00 0.00 0.00 0.00 XXXG9003 X MCCD, risk adj hi, initial 0.00 0.00 0.00 0.00 0.00 0.00 XXXG9004 X MCCD, risk adj lo, initial 0.00 0.00 0.00 0.00 0.00 0.00 XXXG9005 X MCCD, risk adj, maintenance 0.00 0.00 0.00 0.00 0.00 0.00 XXXG9006 X MCCD, Home monitoring 0.00 0.00 0.00 0.00 0.00 0.00 XXXG9007 X MCCD, sch team conf 0.00 0.00 0.00 0.00 0.00 0.00 XXXG9008 X Mccd,phys coor-care ovrsght 0.00 0.00 0.00 0.00 0.00 0.00 XXXG9009 X MCCD, risk adj, level 3 0.00 0.00 0.00 0.00 0.00 0.00 XXXG9010 X MCCD, risk adj, level 4 0.00 0.00 0.00 0.00 0.00 0.00 XXXG9011 X MCCD, risk adj, level 5 0.00 0.00 0.00 0.00 0.00 0.00 XXXG9012 X Other Specified Case Mgmt 0.00 0.00 0.00 0.00 0.00 0.00 XXXG9013 N ESRD demo bundle level I 0.00 0.00 0.00 0.00 0.00 0.00 XXXG9014 N ESRD demo bundle-level II 0.00 0.00 0.00 0.00 0.00 0.00 XXXG9016 N Demo-smoking cessation coun 0.00 0.00 0.00 0.00 0.00 0.00 XXXG9017 X Amantadine HCL 100mg oral 0.00 0.00 0.00 0.00 0.00 0.00 XXXG9018 X Zanamivir,inhalation pwd 10m 0.00 0.00 0.00 0.00 0.00 0.00 XXXG9019 X Oseltamivir phosphate 75mg 0.00 0.00 0.00 0.00 0.00 0.00 XXXG9020 X Rimantadine HCL 100mg oral 0.00 0.00 0.00 0.00 0.00 0.00 XXXG9033 X Amantadine HCL oral brand 0.00 0.00 0.00 0.00 0.00 0.00 XXXCMS-1503-P1181**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**G9034 X Zanamivir, inh pwdr, brand 0.00 0.00 0.00 0.00 0.00 0.00 XXXG9035 X Oseltamivir phosp, brand 0.00 0.00 0.00 0.00 0.00 0.00 XXXG9036 X Rimantadine HCL, brand 0.00 0.00 0.00 0.00 0.00 0.00 XXXG9041 A Low vision rehab occupationa 0.69 0.28 0.28 0.28 0.28 0.04 XXXG9042 A Low vision rehab orient/mobi 0.25 0.25 0.25 0.25 0.25 0.01 XXXG9043 A Low vision lowvision therapi 0.25 0.25 0.25 0.25 0.25 0.01 XXXG9044 A Low vision rehabilate teache 0.24 0.19 0.19 0.19 0.19 0.01 XXXG9140 X Frontier extended stay demo 0.00 0.00 0.00 0.00 0.00 0.00 XXXG9141 X Influenza A H1N1,admin w cou 0.00 0.00 0.00 0.00 0.00 0.00 XXXG9142 X Influenza A H1N1, vaccine 0.00 0.00 0.00 0.00 0.00 0.00 XXXG9143 X Warfarin respon genetic test 0.00 0.00 0.00 0.00 0.00 0.00 XXXG9147 N Outpt IV insulin tx any mea 0.00 0.00 0.00 0.00 0.00 0.00 XXXGXXX1 A Skin/dermal subs init 25or< 2.22 3.10 3.10 1.43 1.43 0.28 000GXXX2 A Skin/dermal subs each addition 0.50 0.81 0.81 0.19 0.19 0.07 ZZZGXXXA A PPPS, initial visit 2.43 2.14 2.14 NA NA 0.13 XXXGXXXB A PPPS, subseq visit 1.50 1.59 1.59 NA NA 0.03 XXXM0064 A Visit for drug monitoring 0.37 1.04 0.97 0.07 0.09 0.01 XXXP3001 A Screening pap smear by phys 0.42 0.40 0.39 0.40 0.39 0.03 XXXQ0035 A Cardiokymography 0.17 0.30 0.35 NA NA 0.02 XXXQ0035 TC A Cardiokymography 0.00 0.24 0.29 NA NA 0.01 XXXQ0035 26 A Cardiokymography0.17 0.06 0.06 0.06 0.06 0.01 XXXQ0091 A Obtaining screen pap smear 0.37 0.85 0.86 0.17 0.15 0.03 XXXQ0092 A Set up port xray equipment 0.00 0.69 0.61 0.69 0.61 0.01 XXXQ3001 C Brachytherapy Radioelements 0.00 0.00 0.00 0.00 0.00 0.00 XXXQ3014 X Telehealth facility fee 0.00 0.00 0.00 0.00 0.00 0.00 XXXR0070 C Transport portable x-ray 0.00 0.00 0.00 0.00 0.00 0.00 XXXCMS-1503-P1182**CPT 1** **/ HCPCS** **Code Mod Status Short Descriptor Physi** **cian Work** **RVUs 2,3** **Fully Imple** **mented Non** **facility PE** **RVUs 2,3** **CY 2011 Transi** **tional Non** **facility PE** **RVUs 2,3** **Fully Imple** **mented Facility** **PE RVUs** **2,3 CY 2011** **Transi tional** **Facility PE** **RVUs 2,3** **Mal practice** **RVUs 2,3** **Global**R0075 C Transport port x-ray multipl 0.00 0.00 0.00 0.00 0.00 0.00 XXXR0076 B Transport portable EKG 0.00 0.00 0.00 0.00 0.00 0.00 XXXV5299 R Hearing service 0.00 0.00 0.00 0.00 0.00 0.00 XXX1 CPT codes and descriptors only are copyright 2010 American Medical Association. All Rights Reserved. Applicable FARS/DFARSapply.2 If values are reflected for codes not payable by Medicare, please note that these values have been established as a courtesyto the general public and are not used forMedicare payment.3 The budget neutrality reduction from the chiropractic demonstration is not reflected in the RVUs for CPT codes 98940, 98941,and 98942. The required reduction willonly be reflected in the files used for Medicare payment.

### CMS-1503-P 1183

ADDENDUM C: [Reserved]

### CMS-1503-P 1184

ADDENDUM D: Proposed CY 2011 Geograp hic Adjustment Factors (GAFs)

Contractor Locality Locality Name 2010 GAF 1 

### 2011 GAF 2 

### Percent Change (2010 to 2011) 00831 01 Alaska ** 1.288 1.267 -1.63% 01102 06 San Mateo, CA 1.203 1.187 -1.33% 01102 05 San Francisco, CA 1.201 1.186 -1.25% 13202 02 NYC Suburbs/Long I., NY 1.162 1.153 -0.77% 13202 01 Manhattan, NY 1.164 1.148 -1.37% 01102 09 Santa Clara, CA 1.148 1.147 -0.09% 13292 04 Queens, NY 1.130 1.135 0.44% 01102 07 Oakland/Berkley, CA 1.130 1.126 -0.35% 01192 26 Anaheim/Santa Ana, CA 1.128 1.118 -0.89% 12202 01 DC + MD/VA Suburbs 1.121 1.117 -0.36% 12402 01 Northern NJ 1.134 1.116 -1.59% 09102 04 Miami, FL 1.114 1.111 -0.27% 01102 03 Marin/Napa/Solano, CA 1.112 1.110 -0.18% 01192 17 Ventura, CA 1.121 1.103 -1.61% 14202 01 Metropolitan Boston 1.133 1.101 -2.82% 01192 18 Los Angeles, CA 1.112 1.097 -1.35% 13102 00 Connecticut 1.100 1.091 -0.82% 00952 16 Chicago, IL 1.084 1.084 0.00% 12502 01 Metropolitan Philadelphia, PA 1.075 1.070 -0.47% 12402 99 Rest of New Jersey 1.082 1.070 -1.11% 00953 01 Detroit, MI 1.071 1.065 -0.56% 01202 01 Hawaii/Guam 1.057 1.063 0.57% 00952 15 Suburban Chicago, IL 1.063 1.063 0.00% 09102 03 Fort Lauderdale, FL 1.056 1.057 0.09% 12302 01 Baltimore/Surr. Cntys, MD 1.035 1.050 1.45% 00836 02 Seattle (King Cnty), WA 1.033 1.044 1.06% 14402 01 Rhode Island 1.045 1.043 -0.19% 14202 99 Rest of Massachusetts 1.041 1.038 -0.29% 13202 03 Poughkpsie/N NYC Suburbs, NY 1.034 1.034 0.00% 01302 00 Nevada*** 1.016 1.023 0.69% 01102 99 Rest of California* 1.012 1.020 0.79% 01192 99 Rest of California* 1.012 1.020 0.79% 00952 12 East St. Louis, IL 1.013 1.016 0.30% 12102 01 Delaware 1.013 1.010 -0.30% 04402 18 Houston, TX 1.019 1.009 -0.98% 09102 99 Rest of Florida 1.015 1.006 -0.89% 04402 11 Dallas, TX 1.009 1.004 -0.50% 12302 99 Rest of Maryland 0.991 1.002 1.11% 10202 01 Atlanta, GA 1.004 1.002 -0.20% 04402 15 Galveston, TX 1.000 0.999 -0.10% 00528 01 New Orleans, LA 1.018 0.998 -1.96% 14302 40 New Hampshire 0.996 0.997 0.10% 09202 50 Virgin Islands 0.996 0.997 0.10% 04402 09 Brazoria, TX 1.002 0.997 -0.50%

### CMS-1503-P 1185

Contractor Locality Locality Name 2010 GAF 1 

### 2011 GAF 2 

### Percent Change (2010 to 2011) 00883 00 Ohio 0.993 0.993 0.00% 00835 01 Portland, OR 0.987 0.992 0.51% 05302 02 Metropolitan Kansas City, MO 0.995 0.992 -0.30% 04402 28 Fort Worth, TX 0.994 0.990 -0.40% 05302 01 Metropolitan St Louis, MO 0.988 0.986 -0.20% 04402 31 Austin, TX 0.995 0.986 -0.90% 03602 21 Wyoming*** 0.961 0.985 2.50% 04102 01 Colorado 0.984 0.985 0.10% 00953 99 Rest of Michigan 0.987 0.985 -0.20% 14102 03 Southern Maine 0.991 0.985 -0.61% 00836 99 Rest of Washington 0.983 0.983 0.00% 12502 99 Rest of Pennsylvania 0.987 0.982 -0.51% 03102 00 Arizona 0.984 0.981 -0.30% 00952 99 Rest of Illinois 0.982 0.976 -0.61% 04202 05 New Mexico 0.980 0.972 -0.82% 00904 00 Virginia 0.975 0.971 -0.41% 03502 09 Utah 0.981 0.971 -1.02% 03202 01 Montana*** 0.954 0.970 1.68% 04402 20 Beaumont, TX 0.986 0.968 -1.83% 14502 50 Vermont 0.977 0.966 -1.13% 00954 00 Minnesota 0.967 0.965 -0.21% 04402 99 Rest of Texas 0.976 0.961 -1.54% 13282 99 Rest of New York 0.961 0.960 -0.10% 10202 99 Rest of Georgia 0.968 0.960 -0.83% 00884 16 West Virginia 0.976 0.960 -1.64% 00951 00 Wisconsin 0.960 0.958 -0.21% 03302 01 North Dakota*** 0.942 0.956 1.49% 05535 00 North Carolina 0.970 0.956 -1.44% 00835 99 Rest of Oregon 0.964 0.955 -0.93% 00630 00 Indiana 0.967 0.955 -1.24% 00528 99 Rest of Louisiana 0.969 0.950 -1.96% 03402 02 South Dakota*** 0.948 0.949 0.11% 05202 00 Kansas 0.957 0.948 -0.94% 00880 01 South Carolina 0.959 0.947 -1.25% 10302 35 Tennessee 0.961 0.947 -1.46% 05130 00 Idaho 0.957 0.946 -1.15% 00660 00 Kentucky 0.956 0.945 -1.15% 14102 99 Rest of Maine 0.957 0.943 -1.46% 00512 00 Mississippi 0.961 0.942 -1.98% 05302 99 Rest of Missouri 0.961 0.941 -2.08% 10102 00 Alabama 0.949 0.938 -1.16% 04302 00 Oklahoma 0.953 0.936 -1.78% 05102 00 Iowa 0.950 0.931 -2.00% 05402 00 Nebraska 0.947 0.928 -2.01% 00520 13 Arkansas 0.945 0.926 -2.01% 09202 20 Puerto Rico 0.904 0.856 -5.31% * Indicates multiple contractors.

### CMS-1503-P 1186

** GAF reflects a 1.5 work GPCI floor in Alaska established by the MIPPA. *** 2011 GAF reflects a 1.0 PE GPCI floor for frontier states as required by the Affordable Care Act. 1 2010 GAF equation: (0.52466*work GPCI)+(0.43669*PE GPCI)+(0.03865*MP GPCI). 2010 GAF contains a 1.0 work GPCI floor and reflects a limited recognition of cost differences for the rent and employee compensation components of the PE GPCI as required by the Affordable Care Act. 2 2011 GAF equation: (0.48266*work GPCI) + (0.47439*PE GPCI) + (0.04295*MP GPCI). 2011 GAF does not contain a 1.0 work GPCI floor which expires December 31, 2010 as required by the Affordable Care Act. 2011 GAF reflects a limited recognition of cost differences for the rent and employee compensation components of the PE GPCI as required by the Affordable Care Act.CMS-1503-P1187ADDENDUM E: Proposed CY 2011 Geographic Practice CostIndices (GPCIs) by State and Medicare Locality****Contractor Locality Locality Name2010WorkGPCI12010PEGPCI22010MPGPCI2011WorkGPCI32011PEGPCI2011MPGPCI2012WorkGPCI32012PEGPCI42012MPGPCI10102 00 Alabama 1.000 0.927 0.496 0.979 0.937 0.484 0.976 0.892 0.47200831 01 Alaska** 1.500 1.090 0.646 1.500 1.086 0.647 1.500 1.081 0.64803102 00 Arizona 1.000 0.979 0.822 0.983 0.985 0.913 0.977 0.982 1.00300520 13 Arkansas 1.000 0.923 0.446 0.964 0.932 0.444 0.967 0.880 0.44101192 26 Anaheim/Santa Ana, CA 1.034 1.269 0.811 1.039 1.232 0.742 1.043 1.195 0.67201192 18 Los Angeles, CA 1.041 1.225 0.804 1.039 1.190 0.721 1.036 1.154 0.63801102 03 Marin/Napa/Solano, CA 1.034 1.265 0.432 1.042 1.239 0.443 1.050 1.213 0.45401102 07 Oakland/Berkley, CA 1.053 1.286 0.425 1.055 1.258 0.469 1.057 1.229 0.51301102 05 San Francisco, CA 1.059 1.441 0.414 1.065 1.375 0.464 1.071 1.309 0.51301102 06 San Mateo, CA 1.072 1.433 0.394 1.072 1.371 0.454 1.071 1.309 0.51301102 09 Santa Clara, CA 1.083 1.294 0.377 1.080 1.279 0.445 1.077 1.264 0.51301192 17 Ventura, CA 1.027 1.265 0.766 1.030 1.216 0.683 1.033 1.166 0.60001102 99 Rest of California* 1.007 1.058 0.549 1.016 1.067 0.546 1.024 1.076 0.54301192 99 Rest of California* 1.007 1.058 0.549 1.016 1.067 0.546 1.024 1.076 0.54304102 01 Colorado 1.000 0.996 0.641 0.991 0.999 0.754 0.996 1.002 0.86713102 00 Connecticut 1.038 1.185 0.980 1.031 1.151 1.102 1.023 1.117 1.22412202 01 DC + MD/VA Suburbs 1.047 1.218 1.032 1.048 1.191 1.081 1.048 1.163 1.12912102 01 Delaware 1.011 1.046 0.678 1.012 1.039 0.678 1.012 1.031 0.67809102 03 Fort Lauderdale, FL 1.000 1.018 2.250 0.992 1.028 2.112 0.994 1.038 1.97309102 04 Miami, FL 1.000 1.069 3.167 0.998 1.057 2.984 0.996 1.045 2.80009102 99 Rest of Florida 1.000 0.970 1.724 0.978 0.977 1.634 0.983 0.966 1.54410202 01 Atlanta, GA 1.009 1.014 0.836 1.006 1.007 0.891 1.002 0.999 0.94510202 99 Rest of Georgia 1.000 0.942 0.829 0.978 0.950 0.876 0.977 0.915 0.92301202 01 Hawaii/Guam 1.000 1.161 0.665 0.999 1.162 0.685 1.000 1.162 0.70405130 00 Idaho 1.000 0.942 0.546 0.974 0.951 0.572 0.981 0.917 0.59700952 16 Chicago, IL 1.025 1.080 1.940 1.028 1.058 2.005 1.030 1.036 2.06900952 12 East St. Louis, IL 1.000 0.960 1.793 0.988 0.968 1.851 0.987 0.950 1.908CMS-1503-P1188Contractor Locality Locality Name2010WorkGPCI12010PEGPCI22010MPGPCI2011WorkGPCI32011PEGPCI2011MPGPCI2012WorkGPCI32012PEGPCI42012MPGPCI00952 15 Suburban Chicago, IL 1.017 1.068 1.629 1.021 1.052 1.664 1.024 1.036 1.69900952 99 Rest of Illinois 1.000 0.940 1.219 0.976 0.949 1.275 0.976 0.915 1.33000630 00 Indiana 1.000 0.960 0.599 0.978 0.963 0.603 0.969 0.932 0.60605102 00 Iowa 1.000 0.935 0.434 0.962 0.943 0.443 0.958 0.899 0.45105202 00 Kansas 1.000 0.941 0.557 0.966 0.948 0.746 0.962 0.907 0.93500660 00 Kentucky 1.000 0.930 0.652 0.971 0.941 0.701 0.972 0.901 0.74900528 01 New Orleans, LA 1.000 1.044 0.956 0.985 1.017 0.933 0.983 0.978 0.91000528 99 Rest of Louisiana 1.000 0.939 0.892 0.969 0.943 0.816 0.967 0.894 0.73914102 03 Southern Maine 1.000 1.025 0.492 0.982 1.024 0.583 0.984 1.023 0.67414102 99 Rest of Maine 1.000 0.947 0.492 0.964 0.954 0.583 0.965 0.921 0.67412302 01 Baltimore/Surr. Cntys, MD 1.012 1.057 1.086 1.019 1.073 1.146 1.026 1.089 1.20612302 99 Rest of Maryland 1.000 0.991 0.874 1.002 1.008 0.930 1.010 1.034 0.98614202 01 Metropolitan Boston 1.029 1.291 0.764 1.021 1.212 0.776 1.013 1.132 0.78814202 99 Rest of Massachusetts 1.007 1.106 0.764 1.010 1.090 0.776 1.013 1.073 0.78800953 01 Detroit, MI 1.036 1.040 1.906 1.029 1.030 1.855 1.021 1.019 1.80300953 99 Rest of Michigan 1.000 0.962 1.083 0.995 0.967 1.075 0.991 0.944 1.06600954 00 Minnesota 1.000 0.992 0.245 0.995 0.998 0.262 0.997 1.005 0.27900512 00 Mississippi 1.000 0.927 0.808 0.961 0.937 0.782 0.962 0.891 0.75605302 02 Metropolitan Kansas City, MO 1.000 0.973 1.188 0.986 0.978 1.204 0.982 0.964 1.21905302 01 Metropolitan St Louis, MO 1.000 0.966 1.075 0.992 0.973 1.063 0.990 0.958 1.05105302 99 Rest of Missouri 1.000 0.911 0.997 0.953 0.924 1.004 0.956 0.871 1.01003202 01 Montana *** 1.000 0.924 0.673 0.948 1.000 0.887 0.946 1.000 1.10005402 00 Nebraska 1.000 0.946 0.245 0.964 0.951 0.280 0.968 0.910 0.31401302 00 Nevada *** 1.002 1.026 1.083 0.999 1.036 1.149 0.996 1.045 1.21514302 40 New Hampshire 1.000 1.039 0.462 0.987 1.038 0.658 0.991 1.037 0.85312402 01 Northern NJ 1.057 1.228 1.116 1.051 1.185 1.077 1.044 1.142 1.03712402 99 Rest of New Jersey 1.042 1.126 1.116 1.031 1.110 1.077 1.020 1.093 1.03704202 05 New Mexico 1.000 0.946 1.096 0.981 0.955 1.053 0.989 0.925 1.01013202 01 Manhattan, NY 1.064 1.298 1.010 1.063 1.235 1.137 1.062 1.172 1.264CMS-1503-P1189Contractor Locality Locality Name2010WorkGPCI12010PEGPCI22010MPGPCI2011WorkGPCI32011PEGPCI2011MPGPCI2012WorkGPCI32012PEGPCI42012MPGPCI13202 02 NYC Suburbs/Long I., NY 1.051 1.289 1.235 1.050 1.242 1.334 1.048 1.195 1.43313202 03 Poughkpsie/N NYC Suburbs, NY 1.014 1.077 0.822 1.013 1.064 0.945 1.011 1.050 1.06713292 04 Queens, NY 1.032 1.239 1.220 1.047 1.206 1.351 1.062 1.172 1.48213282 99 Rest of New York 1.000 0.961 0.425 0.993 0.969 0.493 0.988 0.952 0.56005535 00 North Carolina 1.000 0.963 0.634 0.972 0.966 0.664 0.971 0.937 0.69303302 01 North Dakota *** 1.000 0.922 0.387 0.957 1.000 0.453 0.966 1.000 0.51900883 00 Ohio 1.000 0.964 1.232 0.996 0.968 1.229 0.998 0.940 1.22604302 00 Oklahoma 1.000 0.925 0.627 0.960 0.936 0.671 0.955 0.890 0.71500835 01 Portland, OR 1.002 1.015 0.472 1.003 1.021 0.542 1.004 1.027 0.61200835 99 Rest of Oregon 1.000 0.964 0.472 0.974 0.974 0.542 0.980 0.965 0.61212502 01 Metropolitan Philadelphia, PA 1.016 1.097 1.617 1.015 1.077 1.619 1.014 1.056 1.62112502 99 Rest of Pennsylvania 1.000 0.963 1.081 0.990 0.964 1.100 0.987 0.930 1.11909202 20 Puerto Rico 1.000 0.847 0.250 0.907 0.860 0.249 0.909 0.744 0.24814402 01 Rhode Island 1.013 1.088 0.996 1.015 1.067 1.089 1.016 1.045 1.18100880 01 South Carolina 1.000 0.954 0.446 0.976 0.959 0.483 0.976 0.926 0.51903402 02 South Dakota*** 1.000 0.932 0.420 0.946 1.000 0.424 0.950 1.000 0.42810302 35 Tennessee 1.000 0.945 0.608 0.976 0.952 0.566 0.973 0.916 0.52304402 31 Austin, TX 1.000 0.992 0.969 0.988 0.995 0.859 0.984 0.993 0.74804402 20 Beaumont, TX 1.000 0.938 1.346 0.978 0.944 1.131 0.971 0.899 0.91604402 09 Brazoria, TX 1.019 0.961 1.223 1.014 0.973 1.070 1.008 0.968 0.91604402 11 Dallas, TX 1.009 1.001 1.110 1.009 1.003 0.970 1.008 1.005 0.82904402 28 Fort Worth, TX 1.000 0.977 1.110 0.999 0.984 0.966 0.999 0.981 0.82104402 15 Galveston, TX 1.000 0.980 1.223 1.000 0.988 1.100 1.008 0.989 0.97704402 18 Houston, TX 1.016 0.994 1.345 1.012 0.995 1.131 1.008 0.989 0.91604402 99 Rest of Texas 1.000 0.940 1.065 0.974 0.949 0.936 0.979 0.916 0.80703502 09 Utah 1.000 0.954 1.026 0.975 0.959 1.058 0.972 0.925 1.09014502 50 Vermont 1.000 0.992 0.489 0.973 1.000 0.523 0.977 1.013 0.55700904 00 Virginia 1.000 0.972 0.657 0.988 0.980 0.692 0.993 0.974 0.72609202 50 Virgin Islands 1.000 0.990 1.009 0.998 0.995 1.006 0.998 0.997 1.003CMS-1503-P1190Contractor Locality Locality Name2010WorkGPCI12010PEGPCI22010MPGPCI2011WorkGPCI32011PEGPCI2011MPGPCI2012WorkGPCI32012PEGPCI42012MPGPCI00836 02 Seattle (King Cnty), WA 1.014 1.085 0.706 1.020 1.091 0.786 1.025 1.096 0.86500836 99 Rest of Washington 1.000 0.988 0.693 0.991 0.994 0.770 0.994 0.999 0.84600884 16 West Virginia 1.000 0.914 1.353 0.968 0.923 1.279 0.963 0.861 1.20500951 00 Wisconsin 1.000 0.961 0.409 0.988 0.971 0.477 0.987 0.962 0.54403602 21 Wyoming *** 1.000 0.921 0.889 0.964 1.000 1.052 0.972 1.000 1.21412010 work GPCI reflects a 1.0 floor required by the Affordable Care Act.22010 PE GPCI reflects a limited recognition of cost differences for the rent and employee compensation components and application of the hold harmless provision as required by Affordable Care Act.32011 and 2012 work GPCI does not reflect a 1.0 floor which expires December 31, 2010 as required by the Affordable Care Act.42012 PE GPCI does not reflect a limited recognition of cost differences for the rent and employee compensation components whichexpires December 31, 2011 as required by the Affordable Care Act.* Indicates multiple contractors.** Work GPCI reflects a 1.5 floor in Alaska established by the MIPPA.*** 2011 and 2012 PE GPCIs reflect a 1.0 floor for frontier states as required by the Affordable Care Act.****2011 GPCIs are the first year of the update transition; 2012 GPCIs are the fully implemented updated GPCIs.2011 work GPCI transition: 1⁄2 the difference between 2010 (without 1.0 work GPCI floor) and 2012 work GPCI.2011 PE GPCI transition (and hold harmless as required by the ACA): Greater of1⁄2 the difference between 2010 PE GPCI and 2012 PE GPCI withlimited recognition of cost differences for the rentand employee compensation components (as required by the Affordable Care Act) or 1⁄2 the difference between 2010 PE GPCI and 2012 PE GPCI withoutthe limited recognition of cost differences forthe rent and employee compensation components. 2011 MP GPCI transition: 1⁄2 the difference between 2010 MP GPCI and 2012 MP GPCI.

### CMS-1503-P 1191

ADDENDUM F--Proposed CY 2011 Diagnostic Imaging Services Subject to the Multiple Procedure Payment Reduction CPT/HCPCS Code Short Descriptor 70336 Magnetic image, jaw joint 70450 Ct head/brain w/o dye 70460 Ct head/brain w/dye 70470 Ct head/brain w/o & w/dye 70480 Ct orbit/ear/fossa w/o dye 70481 Ct orbit/ear/fossa w/dye 70482 Ct orbit/ear/fossa w/o&w/dye 70486 Ct maxillofacial w/o dye 70487 Ct maxillofacial w/dye 70488 Ct maxillofacial w/o & w/dye 70490 Ct soft tissue neck w/o dye 70491 Ct soft tissue neck w/dye 70492 Ct sft tsue nck w/o & w/dye 70496 Ct angiography, head 70498 Ct angiography, neck 70540 Mri orbit/face/neck w/o dye 70542 Mri orbit/face/neck w/dye 70543 Mri orbt/fac/nck w/o & w/dye 70544 Mr angiography head w/o dye 70545 Mr angiography head w/dye 70546 Mr angiograph head w/o&w/dye 70547 Mr angiography neck w/o dye 70548 Mr angiography neck w/dye 70549 Mr angiograph neck w/o&w/dye 70551 Mri brain w/o dye 70552 Mri brain w/dye 70553 Mri brain w/o & w/dye 70554 Fmri brain by tech 71250 Ct thorax w/o dye 71260 Ct thorax w/dye 71270 Ct thorax w/o & w/dye 71275 Ct angiography, chest 71550 Mri chest w/o dye 71551 Mri chest w/dye 71552 Mri chest w/o & w/dye 71555 Mri angio chest w or w/o dye 72125 Ct neck spine w/o dye 72126 Ct neck spine w/dye 72127 Ct neck spine w/o & w/dye 72128 Ct chest spine w/o dye 72129 Ct chest spine w/dye 72130 Ct chest spine w/o & w/dye

### CMS-1503-P 1192

CPT/HCPCS Code Short Descriptor 72131 Ct lumbar spine w/o dye 72132 Ct lumbar spine w/dye 72133 Ct lumbar spine w/o & w/dye 72141 Mri neck spine w/o dye 72142 Mri neck spine w/dye 72146 Mri chest spine w/o dye 72147 Mri chest spine w/dye 72148 Mri lumbar spine w/o dye 72149 Mri lumbar spine w/dye 72156 Mri neck spine w/o & w/dye 72157 Mri chest spine w/o & w/dye 72158 Mri lumbar spine w/o & w/dye 72191 Ct angiograph pelv w/o&w/dye 72192 Ct pelvis w/o dye 72193 Ct pelvis w/dye 72194 Ct pelvis w/o & w/dye 72195 Mri pelvis w/o dye 72196 Mri pelvis w/dye 72197 Mri pelvis w/o & w/dye 72198 Mr angio pelvis w/o & w/dye 73200 Ct upper extremity w/o dye 73201 Ct upper extremity w/dye 73202 Ct uppr extremity w/o&w/dye 73206 Ct angio upr extrm w/o&w/dye 73218 Mri upper extremity w/o dye 73219 Mri upper extremity w/dye 73220 Mri uppr extremity w/o&w/dye 73221 Mri joint upr extrem w/o dye 73222 Mri joint upr extrem w/dye 73223 Mri joint upr extr w/o&w/dye 73700 Ct lower extremity w/o dye 73701 Ct lower extremity w/dye 73702 Ct lwr extremity w/o&w/dye 73706 Ct angio lwr extr w/o&w/dye 73718 Mri lower extremity w/o dye 73719 Mri lower extremity w/dye 73720 Mri lwr extremity w/o&w/dye 73721 Mri jnt of lwr extre w/o dye 73722 Mri joint of lwr extr w/dye 73723 Mri joint lwr extr w/o&w/dye 73725 Mr ang lwr ext w or w/o dye 74150 Ct abdomen w/o dye 74160 Ct abdomen w/dye 74170 Ct abdomen w/o & w/dye 74175 Ct angio abdom w/o & w/dye

### CMS-1503-P 1193

CPT/HCPCS Code Short Descriptor 74181 Mri abdomen w/o dye 74182 Mri abdomen w/dye 74183 Mri abdomen w/o & w/dye 74185 Mri angio, abdom w orw/o dye 74261 Ct colonography, w/o dye 74262 Ct colonography, w/dye 75557 Cardiac mri for morph 75559 Cardiac mri w/stress img 75561 Cardiac mri for morph w/dye 75563 Card mri w/stress img & dye 75571 Ct hrt w/o dye w/ca test 75572 Ct hrt w/3d image 75573 Ct hrt w/3d image, congen 75574 Ct angio hrt w/3d image 75574 Ct angio hrt w/3d image 75635 Ct angio abdominal arteries 76604 Us exam, chest 76700 Us exam, abdom, complete 76705 Echo exam of abdomen 76770 Us exam abdo back wall, comp 76775 Us exam abdo back wall, lim 76776 Us exam k transpl w/doppler 76831 Echo exam, uterus 76856 Us exam, pelvic, complete 76857 Us exam, pelvic, limited 76870 Us exam, scrotum 77058 Mri, one breast 77059 Mri, both breasts

### CMS-1503-P 1194

ADDENDUM G: CPT/HCPCS Imaging Codes Defined By Section 5102(b) of the DRA

CPT/HCPCS Code Short Descriptor 31620 Endobronchial us add-on 37250 Iv us first vessel add-on 37251 Iv us each add vessel add-on 51798 Us urine capacity measure 70010 Contrast x-ray of brain 70015 Contrast x-ray of brain 70030 X-ray eye for foreign body 70100 X-ray exam of jaw 70110 X-ray exam of jaw 70120 X-ray exam of mastoids 70130 X-ray exam of mastoids 70134 X-ray exam of middle ear 70140 X-ray exam of facial bones 70150 X-ray exam of facial bones 70160 X-ray exam of nasal bones 70170 X-ray exam of tear duct 70190 X-ray exam of eye sockets 70200 X-ray exam of eye sockets 70210 X-ray exam of sinuses 70220 X-ray exam of sinuses 70240 X-ray exam, pituitary saddle 70250 X-ray exam of skull 70260 X-ray exam of skull 70300 X-ray exam of teeth 70310 X-ray exam of teeth 70320 Full mouth x-ray of teeth 70328 X-ray exam of jaw joint 70330 X-ray exam of jaw joints 70332 X-ray exam of jaw joint 70336 Magnetic image, jaw joint 70350 X-ray head for orthodontia 70355 Panoramic x-ray of jaws 70360 X-ray exam of neck 70370 Throat x-ray & fluoroscopy 70371 Speech evaluation, complex 70373 Contrast x-ray of larynx 70380 X-ray exam of salivary gland 70390 X-ray exam of salivary duct 70450 Ct head/brain w/o dye 70460 Ct head/brain w/dye 70470 Ct head/brain w/o & w/dye 70480 Ct orbit/ear/fossa w/o dye

### CMS-1503-P 1195

CPT/HCPCS Code Short Descriptor 70481 Ct orbit/ear/fossa w/dye 70482 Ct orbit/ear/fossa w/o&w/dye 70486 Ct maxillofacial w/o dye 70487 Ct maxillofacial w/dye 70488 Ct maxillofacial w/o & w/dye 70490 Ct soft tissue neck w/o dye 70491 Ct soft tissue neck w/dye 70492 Ct sft tsue nck w/o & w/dye 70496 Ct angiography, head 70498 Ct angiography, neck 70540 Mri orbit/face/neck w/o dye 70542 Mri orbit/face/neck w/dye 70543 Mri orbt/fac/nck w/o & w/dye 70544 Mr angiography head w/o dye 70545 Mr angiography head w/dye 70546 Mr angiograph head w/o&w/dye 70547 Mr angiography neck w/o dye 70548 Mr angiography neck w/dye 70549 Mr angiograph neck w/o&w/dye 70551 Mri brain w/o dye 70552 Mri brain w/dye 70553 Mri brain w/o & w/dye 70557 Mri brain w/o dye 70558 Mri brain w/dye 70559 Mri brain w/o & w/dye 71010 Chest x-ray 71015 Chest x-ray 71020 Chest x-ray 71021 Chest x-ray 71022 Chest x-ray 71023 Chest x-ray and fluoroscopy 71030 Chest x-ray 71034 Chest x-ray and fluoroscopy 71035 Chest x-ray 71040 Contrast x-ray of bronchi 71060 Contrast x-ray of bronchi 71090 X-ray & pacemaker insertion 71100 X-ray exam of ribs 71101 X-ray exam of ribs/chest 71110 X-ray exam of ribs 71111 X-ray exam of ribs/chest 71120 X-ray exam of breastbone 71130 X-ray exam of breastbone 71250 Ct thorax w/o dye

### CMS-1503-P 1196

CPT/HCPCS Code Short Descriptor 71260 Ct thorax w/dye 71270 Ct thorax w/o & w/dye 71275 Ct angiography, chest 71550 Mri chest w/o dye 71551 Mri chest w/dye 71552 Mri chest w/o & w/dye 71555 Mri angio chest w or w/o dye 72010 X-ray exam of spine 72020 X-ray exam of spine 72040 X-ray exam of neck spine 72050 X-ray exam of neck spine 72052 X-ray exam of neck spine 72069 X-ray exam of trunk spine 72070 X-ray exam of thoracic spine 72072 X-ray exam of thoracic spine 72074 X-ray exam of thoracic spine 72080 X-ray exam of trunk spine 72090 X-ray exam of trunk spine 72100 X-ray exam of lower spine 72110 X-ray exam of lower spine 72114 X-ray exam of lower spine 72120 X-ray exam of lower spine 72125 Ct neck spine w/o dye 72126 Ct neck spine w/dye 72127 Ct neck spine w/o & w/dye 72128 Ct chest spine w/o dye 72129 Ct chest spine w/dye 72130 Ct chest spine w/o & w/dye 72131 Ct lumbar spine w/o dye 72132 Ct lumbar spine w/dye 72133 Ct lumbar spine w/o & w/dye 72141 Mri neck spine w/o dye 72142 Mri neck spine w/dye 72146 Mri chest spine w/o dye 72147 Mri chest spine w/dye 72148 Mri lumbar spine w/o dye 72149 Mri lumbar spine w/dye 72156 Mri neck spine w/o & w/dye 72157 Mri chest spine w/o & w/dye 72158 Mri lumbar spine w/o & w/dye 72159 Mr angio spine w/o&w/dye 72170 X-ray exam of pelvis 72190 X-ray exam of pelvis 72191 Ct angiograph pelv w/o&w/dye

### CMS-1503-P 1197

CPT/HCPCS Code Short Descriptor 72192 Ct pelvis w/o dye 72193 Ct pelvis w/dye 72194 Ct pelvis w/o & w/dye 72195 Mri pelvis w/o dye 72196 Mri pelvis w/dye 72197 Mri pelvis w/o & w/dye 72198 Mr angio pelvis w/o & w/dye 72200 X-ray exam sacroiliac joints 72202 X-ray exam sacroiliac joints 72220 X-ray exam of tailbone 72240 Contrast x-ray of neck spine 72255 Contrast x-ray, thorax spine 72265 Contrast x-ray, lower spine 72270 Contrast x-ray, spine 72275 Epidurography 72285 X-ray c/t spine disk 72291 Percut vertebroplasty fluor 72293 Percut vertebroplasty, ct 72295 X-ray of lower spine disk 73000 X-ray exam of collar bone 73010 X-ray exam of shoulder blade 73020 X-ray exam of shoulder 73030 X-ray exam of shoulder 73040 Contrast x-ray of shoulder 73050 X-ray exam of shoulders 73060 X-ray exam of humerus 73070 X-ray exam of elbow 73080 X-ray exam of elbow 73085 Contrast x-ray of elbow 73090 X-ray exam of forearm 73092 X-ray exam of arm, infant 73100 X-ray exam of wrist 73110 X-ray exam of wrist 73115 Contrast x-ray of wrist 73120 X-ray exam of hand 73130 X-ray exam of hand 73140 X-ray exam of finger(s) 73200 Ct upper extremity w/o dye 73201 Ct upper extremity w/dye 73202 Ct uppr extremity w/o&w/dye 73206 Ct angio upr extrm w/o&w/dye 73218 Mri upper extremity w/o dye 73219 Mri upper extremity w/dye 73220 Mri uppr extremity w/o&w/dye

### CMS-1503-P 1198

CPT/HCPCS Code Short Descriptor 73221 Mri joint upr extrem w/o dye 73222 Mri joint upr extrem w/dye 73223 Mri joint upr extr w/o&w/dye 73225 Mr angio upr extr w/o&w/dye 73500 X-ray exam of hip 73510 X-ray exam of hip 73520 X-ray exam of hips 73525 Contrast x-ray of hip 73530 X-ray exam of hip 73540 X-ray exam of pelvis & hips 73542 X-ray exam, sacroiliac joint 73550 X-ray exam of thigh 73560 X-ray exam of knee, 1 or 2 73562 X-ray exam of knee, 3 73564 X-ray exam, knee, 4 or more 73565 X-ray exam of knees 73580 Contrast x-ray of knee joint 73590 X-ray exam of lower leg 73592 X-ray exam of leg, infant 73600 X-ray exam of ankle 73610 X-ray exam of ankle 73615 Contrast x-ray of ankle 73620 X-ray exam of foot 73630 X-ray exam of foot 73650 X-ray exam of heel 73660 X-ray exam of toe(s) 73700 Ct lower extremity w/o dye 73701 Ct lower extremity w/dye 73702 Ct lwr extremity w/o&w/dye 73706 Ct angio lwr extr w/o&w/dye 73718 Mri lower extremity w/o dye 73719 Mri lower extremity w/dye 73720 Mri lwr extremity w/o&w/dye 73721 Mri jnt of lwr extre w/o dye 73722 Mri joint of lwr extr w/dye 73723 Mri joint lwr extr w/o&w/dye 73725 Mr ang lwr ext w or w/o dye 74000 X-ray exam of abdomen 74010 X-ray exam of abdomen 74020 X-ray exam of abdomen 74022 X-ray exam series, abdomen 74150 Ct abdomen w/o dye 74160 Ct abdomen w/dye 74170 Ct abdomen w/o & w/dye

### CMS-1503-P 1199

CPT/HCPCS Code Short Descriptor 74175 Ct angio abdom w/o & w/dye 74181 Mri abdomen w/o dye 74182 Mri abdomen w/dye 74183 Mri abdomen w/o & w/dye 74185 Mri angio, abdom w orw/o dye 74190 X-ray exam of peritoneum 74210 Contrst x-ray exam of throat 74220 Contrast x-ray, esophagus 74230 Cine/vid x-ray, throat/esoph 74235 Remove esophagus obstruction 74240 X-ray exam, upper gi tract 74241 X-ray exam, upper gi tract 74245 X-ray exam, upper gi tract 74246 Contrst x-ray uppr gi tract 74247 Contrst x-ray uppr gi tract 74249 Contrst x-ray uppr gi tract 74250 X-ray exam of small bowel 74251 X-ray exam of small bowel 74260 X-ray exam of small bowel 74261 Ct colonography, w/o dye 74262 Ct colonography, w/dye 74263 Ct colonography, screen 74270 Contrast x-ray exam of colon 74280 Contrast x-ray exam of colon 74283 Contrast x-ray exam of colon 74290 Contrast x-ray, gallbladder 74291 Contrast x-rays, gallbladder 74300 X-ray bile ducts/pancreas 74301 X-rays at surgery add-on 74305 X-ray bile ducts/pancreas 74320 Contrast x-ray of bile ducts 74327 X-ray bile stone removal 74328 X-ray bile duct endoscopy 74329 X-ray for pancreas endoscopy 74330 X-ray bile/panc endoscopy 74340 X-ray guide for GI tube 74355 X-ray guide, intestinal tube 74360 X-ray guide, GI dilation 74363 X-ray, bile duct dilation 74400 Contrst x-ray, urinary tract 74410 Contrst x-ray, urinary tract 74415 Contrst x-ray, urinary tract 74420 Contrst x-ray, urinary tract 74425 Contrst x-ray, urinary tract

### CMS-1503-P 1200

CPT/HCPCS Code Short Descriptor 74430 Contrast x-ray, bladder 74440 X-ray, male genital tract 74445 X-ray exam of penis 74450 X-ray, urethra/bladder 74455 X-ray, urethra/bladder 74470 X-ray exam of kidney lesion 74475 X-ray control, cath insert 74480 X-ray control, cath insert 74485 X-ray guide, GU dilation 74710 X-ray measurement of pelvis 74740 X-ray, female genital tract 74742 X-ray, fallopian tube 74775 X-ray exam of perineum 75557 Cardiac MRI w/o contrast 75559 Cardiac MRI w/ stress imaging 75561 Cardiac MRI w/ & w/o contrast 75563 Cardiac MRI w/ stress imaging 75565 Card mri vel flw map add-on 75571 Ct hrt w/o dye w/ca test 75572 Ct hrt w/3d image 75573 Ct hrt w/3d image, congen 75574 Ct angio hrt w/3d image 75600 Contrast x-ray exam of aorta 75605 Contrast x-ray exam of aorta 75625 Contrast x-ray exam of aorta 75630 X-ray aorta, leg arteries 75635 Ct angio abdominal arteries 75650 Artery x-rays, head & neck 75658 Artery x-rays, arm 75660 Artery x-rays, head & neck 75662 Artery x-rays, head & neck 75665 Artery x-rays, head & neck 75671 Artery x-rays, head & neck 75676 Artery x-rays, neck 75680 Artery x-rays, neck 75685 Artery x-rays, spine 75705 Artery x-rays, spine 75710 Artery x-rays, arm/leg 75716 Artery x-rays, arms/legs 75722 Artery x-rays, kidney 75724 Artery x-rays, kidneys 75726 Artery x-rays, abdomen 75731 Artery x-rays, adrenal gland 75733 Artery x-rays, adrenals

### CMS-1503-P 1201

CPT/HCPCS Code Short Descriptor 75736 Artery x-rays, pelvis 75741 Artery x-rays, lung 75743 Artery x-rays, lungs 75746 Artery x-rays, lung 75756 Artery x-rays, chest 75774 Artery x-ray, each vessel 75790 Visualize A-V shunt 75791 Av dialysis shunt imaging 75801 Lymph vessel x-ray, arm/leg 75803 Lymph vessel x-ray,arms/legs 75805 Lymph vessel x-ray, trunk 75807 Lymph vessel x-ray, trunk 75809 Nonvascular shunt, x-ray 75810 Vein x-ray, spleen/liver 75820 Vein x-ray, arm/leg 75822 Vein x-ray, arms/legs 75825 Vein x-ray, trunk 75827 Vein x-ray, chest 75831 Vein x-ray, kidney 75833 Vein x-ray, kidneys 75840 Vein x-ray, adrenal gland 75842 Vein x-ray, adrenal glands 75860 Vein x-ray, neck 75870 Vein x-ray, skull 75872 Vein x-ray, skull 75880 Vein x-ray, eye socket 75885 Vein x-ray, liver 75887 Vein x-ray, liver 75889 Vein x-ray, liver 75891 Vein x-ray, liver 75893 Venous sampling by catheter 75894 X-rays, transcath therapy 75896 X-rays, transcath therapy 75898 Follow-up angiography 75900 Intravascular cath exchange 75901 Remove cva device obstruct 75902 Remove cva lumen obstruct 75940 X-ray placement, vein filter 75945 Intravascular us 75946 Intravascular us add-on 75953 Abdom aneurysm endovas rpr 75956 Xray, endovasc thor ao repr 75957 Xray, endovasc thor ao repr 75958 Xray, place prox ext thor ao

### CMS-1503-P 1202

CPT/HCPCS Code Short Descriptor 75959 Xray, place dist ext thor ao 75960 Transcath iv stent rs&i 75961 Retrieval, broken catheter 75962 Repair arterial blockage 75964 Repair artery blockage, each 75966 Repair arterial blockage 75968 Repair artery blockage, each 75970 Vascular biopsy 75978 Repair venous blockage 75980 Contrast xray exam bile duct 75982 Contrast xray exam bile duct 75984 Xray control catheter change 75989 Abscess drainage under x-ray 75992 Atherectomy, x-ray exam 76000 Fluoroscope examination 76001 Fluoroscope exam, extensive 76010 X-ray, nose to rectum 76080 X-ray exam of fistula 76098 X-ray exam, breast specimen 76100 X-ray exam of body section 76101 Complex body section x-ray 76102 Complex body section x-rays 76120 Cine/video x-rays 76125 Cine/video x-rays add-on 76140 X-ray consultation 76150 X-ray exam, dry process 76350 Special x-ray contrast study 76376 3d render w/o postprocess 76377 3d rendering w/postprocess 76380 CAT scan follow-up study 76390 Mr spectroscopy 76496 Fluoroscopic procedure 76497 Ct procedure 76498 Mri procedure 76506 Echo exam of head 76510 Ophth us, b & quant a 76511 Ophth us, quant a only 76512 Ophth us, b w/non-quant a 76513 Echo exam of eye, water bath 76514 Echo exam of eye, thickness 76516 Echo exam of eye 76519 Echo exam of eye 76529 Echo exam of eye 76536 Us exam of head and neck

### CMS-1503-P 1203

CPT/HCPCS Code Short Descriptor 76604 Us exam, chest, b-scan 76645 Us exam, breast(s) 76700 Us exam, abdom, complete 76705 Echo exam of abdomen 76770 Us exam abdo back wall, comp 76775 Us exam abdo back wall, lim 76778 Us exam kidney transplant 76800 Us exam, spinal canal 76801 Ob us < 14 wks, single fetus 76802 Ob us < 14 wks, add’l fetus 76805 Ob us >/= 14 wks, sngl fetus 76810 Ob us >/= 14 wks, addl fetus 76811 Ob us, detailed, sngl fetus 76812 Ob us, detailed, addl fetus 76815 Ob us, limited, fetus(s) 76816 Ob us, follow-up, per fetus 76817 Transvaginal us, obstetric 76818 Fetal biophys profile w/nst 76819 Fetal biophys profil w/o nst 76820 Umbilical artery echo 76821 Middle cerebral artery echo 76825 Echo exam of fetal heart 76826 Echo exam of fetal heart 76827 Echo exam of fetal heart 76828 Echo exam of fetal heart 76830 Transvaginal us, non-ob 76831 Echo exam, uterus 76856 Us exam, pelvic, complete 76857 Us exam, pelvic, limited 76870 Us exam, scrotum 76872 Us, transrectal 76873 Echograp trans r, pros study 76880 Us exam, extremity 76885 Us exam infant hips, dynamic 76886 Us exam infant hips, static 76930 Echo guide, cardiocentesis 76932 Echo guide for heart biopsy 76936 Echo guide for artery repair 76937 Us guide, vascular access 76940 Us guide, tissue ablation 76941 Echo guide for transfusion 76942 Echo guide for biopsy 76945 Echo guide, villus sampling 76946 Echo guide for amniocentesis

### CMS-1503-P 1204

CPT/HCPCS Code Short Descriptor 76948 Echo guide, ova aspiration 76950 Echo guidance radiotherapy 76965 Echo guidance radiotherapy 76970 Ultrasound exam follow-up 76975 GI endoscopic ultrasound 76977 Us bone density measure 76998 Ultrasound guide intraoper 77001 Fluoroguide for vein device 77002 Needle localization by x-ray 77003 Fluoroguide for spine inject 77011 Ct scan for localization 77012 Ct scan for needle biopsy 77013 Ct guide for tissue ablation 77014 Ct scan for therapy guide 77021 Mr guidance for needle place 77022 Mri for tissue ablation 77031 Stereotactic breast biopsy 77032 X-ray of needle wire, breast 77053 X-ray of mammary duct 77054 X-ray of mammary ducts 77058 Magnetic image, breast 77059 Magnetic image, both breasts 77071 X-ray stress view 77072 X-rays for bone age 77073 X-rays, bone evaluation 77074 X-rays, bone survey 77075 X-rays, bone survey 77076 X-rays, bone evaluation 77077 Joint survey, single view 77078 Ct bone density, axial 77079 Ct bone density, peripheral 77081 Dxa bone density/peripheral 77083 Radiographic absorptiometry 77084 Magnetic image, bone marrow 77417 Radiology port film(s) 77421 Stereoscopic x-ray guidance 78006 Thyroid imaging with uptake 78007 Thyroid image, mult uptakes 78010 Thyroid imaging 78011 Thyroid imaging with flow 78015 Thyroid met imaging 78016 Thyroid met imaging/studies 78018 Thyroid met imaging, body 78020 Thyroid met uptake

### CMS-1503-P 1205

CPT/HCPCS Code Short Descriptor 78070 Parathyroid nuclear imaging 78075 Adrenal nuclear imaging 78102 Bone marrow imaging, ltd 78103 Bone marrow imaging, mult 78104 Bone marrow imaging, body 78135 Red cell survival kinetics 78140 Red cell sequestration 78185 Spleen imaging 78190 Platelet survival, kinetics 78195 Lymph system imaging 78201 Liver imaging 78202 Liver imaging with flow 78205 Liver imaging (3D) 78206 Liver image (3d) with flow 78215 Liver and spleen imaging 78216 Liver & spleen image/flow 78220 Liver function study 78223 Hepatobiliary imaging 78230 Salivary gland imaging 78231 Serial salivary imaging 78232 Salivary gland function exam 78258 Esophageal motility study 78261 Gastric mucosa imaging 78262 Gastroesophageal reflux exam 78264 Gastric emptying study 78278 Acute GI blood loss imaging 78282 GI protein loss exam 78290 Meckel’s divert exam 78291 Leveen/shunt patency exam 78300 Bone imaging, limited area 78305 Bone imaging, multiple areas 78306 Bone imaging, whole body 78315 Bone imaging, 3 phase 78320 Bone imaging (3D) 78350 Bone mineral, single photon 78351 Bone mineral, dual photon 78428 Cardiac shunt imaging 78445 Vascular flow imaging 78451 Ht muscle image spect, sing 78452 Ht muscle image spect, mult 78453 Ht muscle image,planar,sing 78454 Ht musc image, planar, mult 78456 Acute venous thrombus image 78457 Venous thrombosis imaging

### CMS-1503-P 1206

CPT/HCPCS Code Short Descriptor 78458 Ven thrombosis images, bilat 78459 Heart muscle imaging (PET) 78466 Heart infarct image 78468 Heart infarct image (ef) 78469 Heart infarct image (3D) 78472 Gated heart, planar, single 78473 Gated heart, multiple 78481 Heart first pass, single 78483 Heart first pass, multiple 78491 Heart image (pet), single 78492 Heart image (pet), multiple 78494 Heart image, spect 78496 Heart first pass add-on 78580 Lung perfusion imaging 78584 Lung V/Q image single breath 78585 Lung V/Q imaging 78586 Aerosol lung image, single 78587 Aerosol lung image, multiple 78588 Perfusion lung image 78591 Vent image, 1 breath, 1 proj 78593 Vent image, 1 proj, gas 78594 Vent image, mult proj, gas 78596 Lung differential function 78600 Brain imaging, ltd static 78601 Brain imaging, ltd w/flow 78605 Brain imaging, complete 78606 Brain imaging, compl w/flow 78607 Brain imaging (3D) 78608 Brain imaging (PET) 78609 Brain imaging (PET) 78610 Brain flow imaging only 78630 Cerebrospinal fluid scan 78635 CSF ventriculography 78645 CSF shunt evaluation 78647 Cerebrospinal fluid scan 78650 CSF leakage imaging 78660 Nuclear exam of tear flow 78700 Kidney imaging, static 78701 Kidney imaging with flow 78704 Imaging renogram 78707 Kidney flow/function image 78708 Kidney flow/function image 78709 Kidney flow/function image 78710 Kidney imaging (3D)

### CMS-1503-P 1207

CPT/HCPCS Code Short Descriptor 78715 Renal vascular flow exam 78730 Urinary bladder retention 78740 Ureteral reflux study 78760 Testicular imaging 78761 Testicular imaging/flow 78800 Tumor imaging, limited area 78801 Tumor imaging, mult areas 78802 Tumor imaging, whole body 78803 Tumor imaging (3D) 78804 Tumor imaging, whole body 78805 Abscess imaging, ltd area 78806 Abscess imaging, whole body 78807 Nuclear localization/abscess 78808 Iv inj ra drug dx study 78811 Tumor imaging (pet), limited 78812 Tumor image (pet)/skul-thigh 78813 Tumor image (pet) full body 78814 Tumor image pet/ct, limited 78815 Tumorimage pet/ct skul-thigh 78816 Tumor image pet/ct full body 92135 Scanning computer ophthalmic 92235 Fluorscein angioscopy 92240 IDC green angiography 92250 Fundus photography 92285 External ocular photography 92286 Anterior segment photography 93303 Echo transthoracic 93304 Echo transthoracic 93306 Tte w/doppler, complete 93307 Echo exam of heart 93308 Echo exam of heart 93312 Echo transesophageal 93313 Echo transesophageal 93314 Echo transesophageal 93315 Echo transesophageal 93316 Echo transesophageal 93317 Echo transesophageal 93318 Echo transesophageal intraop 93320 Doppler echo exam, heart 93321 Doppler echo exam, heart 93325 Doppler color flow add-on 93350 Echo transthoracic 93351 Stress tte complete 93352 Admin ecg contrast agent

### CMS-1503-P 1208

CPT/HCPCS Code Short Descriptor 93555 Imaging, cardiac cath 93556 Imaging, cardiac cath 93571 Heart flow reserve measure 93572 Heart flow reserve measure 93880 Extracranial study 93882 Extracranial study 93886 Intracranial study 93888 Intracranial study 93890 Tcd, vasoreactivity study 93892 Tcd, emboli detect w/o inj 93893 Tcd, emboli detect w/inj 93925 Lower extremity study 93926 Lower extremity study 93930 Upper extremity study 93931 Upper extremity study 93970 Extremity study 93971 Extremity study 93975 Vascular study 93976 Vascular study 93978 Vascular study 93979 Vascular study 93980 Penile vascular study 93981 Penile vascular study 93990 Doppler flow testing 0028T Dexa body composition study 0042T Ct perfusion w/contrast, cbf 0066T Ct colonography;screen 0080T Endovasc aort repr rad s&i 0081T Endovasc visc extnsn s&i 0144T CT heart wo dye; qual calc 0145T CT heart w/wo dye funct 0146T CCTA w/wo dye 0147T CCTA w/wo, quan calcium 0148T CCTA w/wo, strxr 0149T CCTA w/wo, strxr quan calc 0150T CCTA w/wo, disease strxr 0151T CT heart funct add-on 0152T Computer chest add-on G0120 Colon ca scrn; barium enema G0122 Colon ca scrn; barium enema G0130 Single energy x-ray study G0219 PET img wholbod melano nonco G0235 PET not otherwise specified G0275 Renal angio, cardiac cath

### CMS-1503-P 1209

CPT/HCPCS Code Short Descriptor G0278 Iliac art angio,cardiac cath G0288 Recon, CTA for surg plan G0365 Vessel mapping hemo access

### CMS-1503-P 1210

Addendum H--Proposed CY 2011 “Always Therapy” Services* Subject to the Multiple Procedure Payment Reduction HCPCS/CPT Code Short Descriptor 92506 Speech/hearing evaluation 92507 Speech/hearing therapy 92508 Speech/hearing therapy 92526 Oral function therapy 92597 Oral speech device eval 92607 Ex for speech device rx, 1hr 92608 Ex for speech device rx addl 92609 Use of speech device service 96125 Cognitive test by hc pro 97001 Pt evaluation 97002 Pt re-evaluation 97003 Ot evaluation 97004 Ot re-evaluation 97012 Mechanical traction therapy 97016 Vasopneumatic device therapy 97018 Paraffin bath therapy 97022 Whirlpool therapy 97024 Diathermy eg, microwave 97026 Infrared therapy 97028 Ultraviolet therapy 97032 Electrical stimulation 97033 Electric current therapy 97034 Contrast bath therapy 97035 Ultrasound therapy 97036 Hydrotherapy 97110 Therapeutic exercises 97112 Neuromuscular reeducation 97113 Aquatic therapy/exercises 97116 Gait training therapy 97124 Massage therapy 97140 Manual therapy 97150 Group therapeutic procedures 97530 Therapeutic activities 97533 Sensory integration 97535 Self care mngment training 97537 Community/work reintegration 97542 Wheelchair mngment training

### CMS-1503-P 1211

HCPCS/CPT Code Short Descriptor 97750 Physical performance test 97755 Assistive technology assess 97760 Orthotic mgmt and training 97761 Prosthetic training 97762 C/o for orthotic/prosth use G0281 Elec stim unattend for press G0283 Elec stim other than wound G0329 Electromagntic tx for ulcers *Excludes contractor-priced codes and bundled codes.

### CMS-1503-P 1212

ADDENDUM I: [Reserved]

### CMS-1503-P 1213

ADDENDUM J: [Reserved]

### CMS-1503-P 1214

ADDENDUM K: Proposed CY 2011 ESRD PPS and Composite Rate Wage Indices for Urban Areas Based on CBSA Labor Market Areas

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 10180 Abilene, TX Callahan County, TX Jones County, TX Taylor County, TX 0.8473 0.8016

10380 Aguadilla-Isabela-San Sebastián, PR Aguada Municipio, PR Aguadilla Municipio, PR Añasco Municipio, PR Isabela Municipio, PR Lares Municipio, PR Moca Municipio, PR Rincón Municipio, PR San Sebastián Municipio, PR 0.6342 0.6000

10420 Akron, OH Portage County, OH Summit County, OH 0.9362 0.8857

10500 Albany, GA Baker County, GA Dougherty County, GA Lee County, GA Terrell County, GA Worth County, GA 0.9566 0.9050

10580 Albany-Schenectady-Troy, NY Albany County, NY Rensselaer County, NY Saratoga County, NY Schenectady County, NY Schoharie County, NY 0.9162 0.8667

10740 Albuquerque, NM Bernalillo County, NM Sandoval County, NM Torrance County, NM Valencia County, NM 0.9993 0.9454

10780 Alexandria, LA Grant Parish, LA Rapides Parish, LA 0.8465 0.8008

10900 Allentown-Bethlehem-Easton, PA-NJ Warren County, NJ Carbon County, PA Lehigh County, PA Northampton County, PA 0.9702 0.9178

11020 Altoona, PA Blair County, PA 0.9127 0.8634

### CMS-1503-P 1215

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 11100 Amarillo, TX Armstrong County, TX Carson County, TX Potter County, TX Randall County, TX 0.9152 0.8658

11180 Ames, IA Story County, IA 1.0556 0.9986 11260 Anchorage, AK Anchorage Municipality, AK Matanuska-Susitna Borough, AK 1.2668 1.1984

11300 Anderson, IN Madison County, IN 0.9732 0.9207 11340 Anderson, SC Anderson County, SC 0.9460 0.8949 11460 Ann Arbor, MI Washtenaw County, MI 1.0719 1.0140 11500 Anniston-Oxford, AL Calhoun County, AL 0.8384 0.7931 11540 Appleton, WI Calumet County, WI Outagamie County, WI 0.9911 0.9376

11700 Asheville, NC Buncombe County, NC Haywood County, NC Henderson County, NC Madison County, NC 0.9530 0.9016

12020 Athens-Clarke County, GA Clarke County, GA Madison County, GA Oconee County, GA Oglethorpe County, GA 1.0091 0.9546

### CMS-1503-P 1216

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 12060 Atlanta-Sandy Springs-Marietta, GA Barrow County, GA Bartow County, GA Butts County, GA Carroll County, GA Cherokee County, GA Clayton County, GA Cobb County, GA Coweta County, GA Dawson County, GA DeKalb County, GA Douglas County, GA Fayette County, GA Forsyth County, GA Fulton County, GA Gwinnett County, GA Haralson County, GA Heard County, GA Henry County, GA Jasper County, GA Lamar County, GA Meriwether County, GA Newton County, GA Paulding County, GA Pickens County, GA Pike County, GA Rockdale County, GA Spalding County, GA Walton County, GA 1.0112 0.9566

12100 Atlantic City-Hammonton, NJ Atlantic County, NJ 1.1783 1.1147 12220 Auburn-Opelika, AL Lee County, AL 0.7669 0.7255 12260 Augusta-Richmond County, GA-SC Burke County, GA Columbia County, GA McDuffie County, GA Richmond County, GA Aiken County, SC Edgefield County, SC 1.0065 0.9522

12420 Austin-Round Rock-San Marcos, TX Bastrop County, TX Caldwell County, TX Hays County, TX Travis County, TX Williamson County, TX 1.0073 0.9529

12540 Bakersfield-Delano, CA Kern County, CA 1.2320 1.1655

### CMS-1503-P 1217

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 12580 Baltimore-Towson, MD Anne Arundel County, MD Baltimore County, MD Carroll County, MD Harford County, MD Howard County, MD Queen Anne's County, MD Baltimore City, MD 1.0853 1.0267

12620 Bangor, ME Penobscot County, ME 1.0352 0.9793 12700 Barnstable Town, MA Barnstable County, MA 1.3577 1.2844 12940 Baton Rouge, LA Ascension Parish, LA East Baton Rouge Parish, LA East Feliciana Parish, LA Iberville Parish, LA Livingston Parish, LA Pointe Coupee Parish, LA St. Helena Parish, LA West Baton Rouge Parish, LA West Feliciana Parish, LA 0.9088 0.8597

12980 Battle Creek, MI Calhoun County, MI 1.0223 0.9671 13020 Bay City, MI Bay County, MI 0.9762 0.9235 13140 Beaumont-Port Arthur, TX Hardin County, TX Jefferson County, TX Orange County, TX 0.8987 0.8502

13380 Bellingham, WA Whatcom County, WA 1.2059 1.1408 13460 Bend, OR Deschutes County, OR 1.2038 1.1388 13644 Bethesda-Rockville-Frederick, MD Frederick County, MD Montgomery County, MD 1.1143 1.0542

13740 Billings, MT Carbon County, MT Yellowstone County, MT 0.9184 0.8688

13780 Binghamton, NY Broome County, NY Tioga County, NY 0.9231 0.8733

### CMS-1503-P 1218

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 13820 Birmingham-Hoover, AL Bibb County, AL Blount County, AL Chilton County, AL Jefferson County, AL St. Clair County, AL Shelby County, AL Walker County, AL 0.9108 0.8616

13900 Bismarck, ND Burleigh County, ND Morton County, ND 0.7780 0.7360

13980 Blacksburg-Christiansburg-Radford, VA Giles County, VA Montgomery County, VA Pulaski County, VA Radford City, VA 0.8803 0.8328

14020 Bloomington, IN Greene County, IN Monroe County, IN Owen County, IN 0.9518 0.9004

14060 Bloomington-Normal, IL McLean County, IL 0.9994 0.9455 14260 Boise City-Nampa, ID Ada County, ID Boise County, ID Canyon County, ID Gem County, ID Owyhee County, ID 0.9818 0.9288

14484 Boston-Quincy, MA Norfolk County, MA Plymouth County, MA Suffolk County, MA 1.2912 1.2215

14500 Boulder, CO Boulder County, CO 1.0656 1.0081 14540 Bowling Green, KY Edmonson County, KY Warren County, KY 0.9175 0.8680

14740 Bremerton-Silverdale, WA Kitsap County, WA 1.1294 1.0684 14860 Bridgeport-Stamford-Norwalk, CT Fairfield County, CT 1.3284 1.2567 15180 Brownsville-Harlingen, TX Cameron County, TX 0.9712 0.9188 15260 Brunswick, GA Brantley County, GA Glynn County, GA McIntosh County, GA 0.9750 0.9224

### CMS-1503-P 1219

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 15380 Buffalo-Niagara Falls, NY Erie County, NY Niagara County, NY 1.0090 0.9545

15500 Burlington, NC Alamance County, NC 0.9385 0.8878 15540 Burlington-South Burlington, VT Chittenden County, VT Franklin County, VT Grand Isle County, VT 1.0531 0.9963

15764 Cambridge-Newton-Framingham, MA Middlesex County, MA 1.1911 1.1268 15804 Camden, NJ Burlington County, NJ Camden County, NJ Gloucester County, NJ 1.0997 1.0403

15940 Canton-Massillon, OH Carroll County, OH Stark County, OH 0.9261 0.8761

15980 Cape Coral-Fort Myers, FL Lee County, FL 0.9715 0.9191 16020 Cape Girardeau-Jackson, MO-IL Alexander County, IL Bollinger County, MO Cape Girardeau County, MO 0.9413 0.8905

16180 Carson City, NV Carson City, NV 1.1080 1.0482 16220 Casper, WY Natrona County, WY 1.0222 0.9670 16300 Cedar Rapids, IA Benton County, IA Jones County, IA Linn County, IA 0.9363 0.8858

16580 Champaign-Urbana, IL Champaign County, IL Ford County, IL Piatt County, IL 1.0836 1.0251

16620 Charleston, WV Boone County, WV Clay County, WV Kanawha County, WV Lincoln County, WV Putnam County, WV 0.8359 0.7908

16700 Charleston-North Charleston-Summerville, SC Berkeley County, SC Charleston County, SC Dorchester County, SC 0.9878 0.9345

### CMS-1503-P 1220

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 16740 Charlotte-Gastonia-Rock Hill, NC-SC Anson County, NC Cabarrus County, NC Gaston County, NC Mecklenburg County, NC Union County, NC York County, SC 0.9973 0.9435

16820 Charlottesville, VA Albemarle County, VA Fluvanna County, VA Greene County, VA Nelson County, VA Charlottesville City, VA 0.9892 0.9358

16860 Chattanooga, TN-GA Catoosa County, GA Dade County, GA Walker County, GA Hamilton County, TN Marion County, TN Sequatchie County, TN 0.9255 0.8755

16940 Cheyenne, WY Laramie County, WY 0.9945 0.9408 16974 Chicago-Joliet-Naperville, IL Cook County, IL DeKalb County, IL DuPage County, IL Grundy County, IL Kane County, IL Kendall County, IL McHenry County, IL Will County, IL 1.1176 1.0573

17020 Chico, CA Butte County, CA 1.2232 1.1572 17140 Cincinnati-Middletown, OH-KY-IN Dearborn County, IN Franklin County, IN Ohio County, IN Boone County, KY Bracken County, KY Campbell County, KY Gallatin County, KY Grant County, KY Kenton County, KY Pendleton County, KY Brown County, OH Butler County, OH Clermont County, OH Hamilton County, OH Warren County, OH 1.0268 0.9714

### CMS-1503-P 1221

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 17300 Clarksville, TN-KY Christian County, KY Trigg County, KY Montgomery County, TN Stewart County, TN 0.8349 0.7898

17420 Cleveland, TN Bradley County, TN Polk County, TN 0.8186 0.7744

17460 Cleveland-Elyria-Mentor, OH Cuyahoga County, OH Geauga County, OH Lake County, OH Lorain County, OH Medina County, OH 0.9568 0.9052

17660 Coeur d'Alene, ID Kootenai County, ID 0.9914 0.9379 17780 College Station-Bryan, TX Brazos County, TX Burleson County, TX Robertson County, TX 1.0152 0.9604

17820 Colorado Springs, CO El Paso County, CO Teller County, CO 1.0039 0.9497

17860 Columbia, MO Boone County, MO Howard County, MO 0.8768 0.8295

17900 Columbia, SC Calhoun County, SC Fairfield County, SC Kershaw County, SC Lexington County, SC Richland County, SC Saluda County, SC 0.9219 0.8721

17980 Columbus, GA-AL Russell County, AL Chattahoochee County, GA Harris County, GA Marion County, GA Muscogee County, GA 0.9558 0.9042

18020 Columbus, IN Bartholomew County, IN 0.9988 0.9449

### CMS-1503-P 1222

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 18140 Columbus, OH Delaware County, OH Fairfield County, OH Franklin County, OH Licking County, OH Madison County, OH Morrow County, OH Pickaway County, OH Union County, OH 1.0737 1.0157

18580 Corpus Christi, TX Aransas County, TX Nueces County, TX San Patricio County, TX 0.9090 0.8599

18700 Corvallis, OR Benton County, OR 1.1070 1.0472 18880 Crestview-Fort Walton Beach-Destin, FL Okaloosa, FL 0.9361 0.8856 19060 Cumberland, MD-WV Allegany County, MD Mineral County, WV 0.8667 0.8199

19124 Dallas-Plano-Irving, TX Collin County, TX Dallas County, TX Delta County, TX Denton County, TX Ellis County, TX Hunt County, TX Kaufman County, TX Rockwall County, TX 1.0410 0.9848

19140 Dalton, GA Murray County, GA Whitfield County, GA 0.9101 0.8610

19180 Danville, IL Vermilion County, IL 1.0262 0.9708 19260 Danville, VA Pittsylvania County, VA Danville City, VA 0.8649 0.8182

19340 Davenport-Moline-Rock Island, IA-IL Henry County, IL Mercer County, IL Rock Island County, IL Scott County, IA 0.8894 0.8414

19380 Dayton, OH Greene County, OH Miami County, OH Montgomery County, OH Preble County, OH 0.9677 0.9155

### CMS-1503-P 1223

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 19460 Decatur, AL Lawrence County, AL Morgan County, AL 0.8053 0.7618

19500 Decatur, IL Macon County, IL 0.8381 0.7929 19660 Deltona-Daytona Beach-Ormond Beach, FL Volusia County, FL 0.9249 0.8750

19740 Denver-Aurora- Broomfield, CO Adams County, CO Arapahoe County, CO Broomfield County, CO Clear Creek County, CO Denver County, CO Douglas County, CO Elbert County, CO Gilpin County, CO Jefferson County, CO Park County, CO 1.1348 1.0735

19780 Des Moines-West Des Moines, IA Dallas County, IA Guthrie County, IA Madison County, IA Polk County, IA Warren County, IA 1.0187 0.9637

19804 Detroit-Livonia-Dearborn, MI Wayne County, MI 1.0256 0.9702 20020 Dothan, AL Geneva County, AL Henry County, AL Houston County, AL 0.8071 0.7635

20100 Dover, DE Kent County, DE 1.0504 0.9937 20220 Dubuque, IA Dubuque County, IA 0.9289 0.8788 20260 Duluth, MN-WI Carlton County, MN St. Louis County, MN Douglas County, WI 1.1066 1.0469

20500 Durham-Chapel Hill, NC Chatham County, NC Durham County, NC Orange County, NC Person County, NC 1.0232 0.9680

20740 Eau Claire, WI Chippewa County, WI Eau Claire County, WI 1.0206 0.9655

### CMS-1503-P 1224

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 20764 Edison-New Brunswick, NJ Middlesex County, NJ Monmouth County, NJ Ocean County, NJ Somerset County, NJ 1.1651 1.1022

20940 El Centro, CA Imperial County, CA 0.9802 0.9273 21060 Elizabethtown, KY Hardin County, KY Larue County, KY 0.8946 0.8463

21140 Elkhart-Goshen, IN Elkhart County, IN 1.0021 0.9480 21300 Elmira, NY Chemung County, NY 0.8942 0.8459 21340 El Paso, TX El Paso County, TX 0.8973 0.8489 21500 Erie, PA Erie County, PA 0.8849 0.8371 21660 Eugene-Springfield, OR Lane County, OR 1.2053 1.1402 21780 Evansville, IN-KY Gibson County, IN Posey County, IN Vanderburgh County, IN Warrick County, IN Henderson County, KY Webster County, KY 0.8928 0.8446

21820 Fairbanks, AK Fairbanks North Star Borough, AK 1.1731 1.1098 21940 Fajardo, PR Ceiba Municipio, PR Fajardo Municipio, PR Luquillo Municipio, PR 0.6342 0.6000

22020 Fargo, ND-MN Cass County, ND Clay County, MN 0.8508 0.8049

22140 Farmington, NM San Juan County, NM 0.8456 0.8000 22180 Fayetteville, NC Cumberland County, NC Hoke County, NC 0.9872 0.9339

22220 Fayetteville-Springdale-Rogers, AR-MO Benton County, AR Madison County, AR Washington County, AR McDonald County, MO 0.9122 0.8630

22380 Flagstaff, AZ Coconino County, AZ 1.3174 1.2463

### CMS-1503-P 1225

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 22420 Flint, MI Genesee County, MI 1.2172 1.1515 22500 Florence, SC Darlington County, SC Florence County, SC 0.8736 0.8264

22520 Florence-Muscle Shoals, AL Colbert County, AL Lauderdale County, AL 0.8518 0.8058

22540 Fond du Lac, WI Fond du Lac County, WI 0.9765 0.9238 22660 Fort Collins-Loveland, CO Larimer County, CO 1.0473 0.9908 22744 Fort Lauderdale-Pompano Beach-Deerfield Beach, FL Broward County, FL 1.0750 1.0170 22900 Fort Smith, AR-OK Crawford County, AR Franklin County, AR Sebastian County, AR Le Flore County, OK Sequoyah County, OK 0.8035 0.7601

23060 Fort Wayne, IN Allen County, IN Wells County, IN Whitley County, IN 0.9854 0.9322

23104 Fort Worth-Arlington, TX Johnson County, TX Parker County, TX Tarrant County, TX Wise County, TX 1.0031 0.9490

23420 Fresno, CA Fresno County, CA 1.2092 1.1439 23460 Gadsden, AL Etowah County, AL 0.7429 0.7028 23540 Gainesville, FL Alachua County, FL Gilchrist County, FL 0.9698 0.9175

23580 Gainesville, GA Hall County, GA 0.9922 0.9386 23844 Gary, IN Jasper County, IN Lake County, IN Newton County, IN Porter County, IN 0.9618 0.9099

24020 Glens Falls, NY Warren County, NY Washington County, NY 0.9007 0.8521

### CMS-1503-P 1226

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 24140 Goldsboro, NC Wayne County, NC 0.9599 0.9081 24220 Grand Forks, ND-MN Polk County, MN Grand Forks County, ND 0.8170 0.7729

24300 Grand Junction, CO Mesa County, CO 1.0429 0.9866 24340 Grand Rapids-Wyoming, MI Barry County, MI Ionia County, MI Kent County, MI Newaygo County, MI 0.9707 0.9183

24500 Great Falls, MT Cascade County, MT 0.8777 0.8303 24540 Greeley, CO Weld County, CO 1.0054 0.9511 24580 Green Bay, WI Brown County, WI Kewaunee County, WI Oconto County, WI 1.0149 0.9601

24660 Greensboro-High Point, NC Guilford County, NC Randolph County, NC Rockingham County, NC 0.9405 0.8897

24780 Greenville, NC Greene County, NC Pitt County, NC 0.9920 0.9385

24860 Greenville-Mauldin-Easley, SC Greenville County, SC Laurens County, SC Pickens County, SC 1.0109 0.9563

25020 Guayama, PR Arroyo Municipio, PR Guayama Municipio, PR Patillas Municipio, PR 0.6342 0.6000

25060 Gulfport-Biloxi, MS Hancock County, MS Harrison County, MS Stone County, MS 0.9503 0.8990

25180 Hagerstown-Martinsburg, MD-WV Washington County, MD Berkeley County, WV Morgan County, WV 0.9798 0.9269

25260 Hanford-Corcoran, CA Kings County, CA 1.1863 1.1223

### CMS-1503-P 1227

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 25420 Harrisburg-Carlisle, PA Cumberland County, PA Dauphin County, PA Perry County, PA 0.9842 0.9311

25500 Harrisonburg, VA Rockingham County, VA Harrisonburg City, VA 0.9696 0.9173

25540 Hartford-West Hartford-East Hartford, CT Hartford County, CT Middlesex County, CT Tolland County, CT 1.1560 1.0936

25620 Hattiesburg, MS Forrest County, MS Lamar County, MS Perry County, MS 0.8168 0.7727

25860 Hickory-Lenoir-Morganton, NC Alexander County, NC Burke County, NC Caldwell County, NC Catawba County, NC 0.9204 0.8707

25980 Hinesville-Fort Stewart, GA Liberty County, GA Long County, GA 0.9466 0.8955

26100 Holland-Grand Haven, MI Ottawa County, MI 0.9139 0.8646 26180 Honolulu, HI Honolulu County, HI 1.2474 1.1801 26300 Hot Springs, AR Garland County, AR 0.9689 0.9166 26380 Houma-Bayou Cane-Thibodaux, LA Lafourche Parish, LA Terrebonne Parish, LA 0.8314 0.7865

726420 Houston-Sugar Land-Baytown, TX Austin County, TX Brazoria County, TX Chambers County, TX Fort Bend County, TX Galveston County, TX Harris County, TX Liberty County, TX Montgomery County, TX San Jacinto County, TX Waller County, TX 1.0399 0.9838

### CMS-1503-P 1228

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 26580 Huntington-Ashland, WV-KY-OH Boyd County, KY Greenup County, KY Lawrence County, OH Cabell County, WV Wayne County, WV 0.9479 0.8967

26620 Huntsville, AL Limestone County, AL Madison County, AL 0.9651 0.9130

26820 Idaho Falls, ID Bonneville County, ID Jefferson County, ID 1.0230 0.9678

26900 Indianapolis-Carmel, IN Boone County, IN Brown County, IN Hamilton County, IN Hancock County, IN Hendricks County, IN Johnson County, IN Marion County, IN Morgan County, IN Putnam County, IN Shelby County, IN 1.0240 0.9687

26980 Iowa City, IA Johnson County, IA Washington County, IA 1.0224 0.9672

27060 Ithaca, NY Tompkins County, NY 1.0420 0.9858 27100 Jackson, MI Jackson County, MI 0.9693 0.9170 27140 Jackson, MS Copiah County, MS Hinds County, MS Madison County, MS Rankin County, MS Simpson County, MS 0.8567 0.8105

27180 Jackson, TN Chester County, TN Madison County, TN 0.8898 0.8418

27260 Jacksonville, FL Baker County, FL Clay County, FL Duval County, FL Nassau County, FL St. Johns County, FL 0.9407 0.8899

27340 Jacksonville, NC Onslow County, NC 0.8265 0.7819

### CMS-1503-P 1229

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 27500 Janesville, WI Rock County, WI 0.9968 0.9430 27620 Jefferson City, MO Callaway County, MO Cole County, MO Moniteau County, MO Osage County, MO 0.8930 0.8448

27740 Johnson City, TN Carter County, TN Unicoi County, TN Washington County, TN 0.7684 0.7269

27780 Johnstown, PA Cambria County, PA 0.8565 0.8103 27860 Jonesboro, AR Craighead County, AR Poinsett County, AR 0.8213 0.7770

27900 Joplin, MO Jasper County, MO Newton County, MO 0.8696 0.8227

28020 Kalamazoo-Portage, MI Kalamazoo County, MI Van Buren County, MI 1.0897 1.0309

28100 Kankakee-Bradley, IL Kankakee County, IL 1.1243 1.0636 28140 Kansas City, MO-KS Franklin County, KS Johnson County, KS Leavenworth County, KS Linn County, KS Miami County, KS Wyandotte County, KS Bates County, MO Caldwell County, MO Cass County, MO Clay County, MO Clinton County, MO Jackson County, MO Lafayette County, MO Platte County, MO Ray County, MO 1.0219 0.9667

28420 Kennewick-Pasco-Richland, WA Benton County, WA Franklin County, WA 1.0562 0.9992

28660 Killeen-Temple-Fort Hood, TX Bell County, TX Coryell County, TX Lampasas County, TX 0.9208 0.8711

### CMS-1503-P 1230

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 28700 Kingsport-Bristol-Bristol, TN-VA Hawkins County, TN Sullivan County, TN Bristol City, VA Scott County, VA Washington County, VA 0.8029 0.7596

28740 Kingston, NY Ulster County, NY 0.9608 0.9089 28940 Knoxville, TN Anderson County, TN Blount County, TN Knox County, TN Loudon County, TN Union County, TN 0.8304 0.7856

29020 Kokomo, IN Howard County, IN Tipton County, IN 0.9655 0.9134

29100 La Crosse, WI-MN Houston County, MN La Crosse County, WI 1.0379 0.9819

29140 Lafayette, IN Benton County, IN Carroll County, IN Tippecanoe County, IN 0.9835 0.9304

29180 Lafayette, LA Lafayette Parish, LA St. Martin Parish, LA 0.8984 0.8499

29340 Lake Charles, LA Calcasieu Parish, LA Cameron Parish, LA 0.8677 0.8209

29404 Lake County-Kenosha County, IL-WI Lake County, IL Kenosha County, WI 1.1415 1.0799

29420 Lake Havasu City-Kingman, AZ Mohave County, AZ 1.0837 1.0252 29460 Lakeland-Winter Haven, FL Polk County, FL 0.8944 0.8461 29540 Lancaster, PA Lancaster County, PA 0.9893 0.9359 29620 Lansing-East Lansing, MI Clinton County, MI Eaton County, MI Ingham County, MI 1.0904 1.0315

29700 Laredo, TX Webb County, TX 0.8379 0.7927 29740 Las Cruces, NM Dona Ana County, NM 0.9842 0.9311

### CMS-1503-P 1231

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 29820 Las Vegas-Paradise, NV Clark County, NV 1.2810 1.2119 29940 Lawrence, KS Douglas County, KS 0.9035 0.8547 30020 Lawton, OK Comanche County, OK 0.8771 0.8298 30140 Lebanon, PA Lebanon County, PA 0.8266 0.7820 30300 Lewiston, ID-WA Nez Perce County, ID Asotin County, WA 0.9908 0.9373

30340 Lewiston-Auburn, ME Androscoggin County, ME 0.9426 0.8917 30460 Lexington-Fayette, KY Bourbon County, KY Clark County, KY Fayette County, KY Jessamine County, KY Scott County, KY Woodford County, KY 0.9336 0.8832

30620 Lima, OH Allen County, OH 0.9815 0.9285 30700 Lincoln, NE Lancaster County, NE Seward County, NE 1.0183 0.9633

30780 Little Rock-North Little Rock-Conway, AR Faulkner County, AR Grant County, AR Lonoke County, AR Perry County, AR Pulaski County, AR Saline County, AR 0.9029 0.8542

30860 Logan, UT-ID Franklin County, ID Cache County, UT 0.9311 0.8808

30980 Longview, TX Gregg County, TX Rusk County, TX Upshur County, TX 0.9072 0.8582

31020 Longview, WA Cowlitz County, WA 1.0901 1.0313 31084 Los Angeles-Long Beach-Santa Ana, CA Los Angeles County, CA 1.2742 1.2054

### CMS-1503-P 1232

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 31140 Louisville-Jefferson County, KY-IN Clark County, IN Floyd County, IN Harrison County, IN Washington County, IN Bullitt County, KY Henry County, KY Meade County, KY Nelson County, KY Oldham County, KY Shelby County, KY Spencer County, KY Trimble County, KY 0.9406 0.8898

31180 Lubbock, TX Crosby County, TX Lubbock County, TX 0.9368 0.8862

31340 Lynchburg, VA Amherst County, VA Appomattox County, VA Bedford County, VA Campbell County, VA Bedford City, VA Lynchburg City, VA 0.9174 0.8679

31420 Macon, GA Bibb County, GA Crawford County, GA Jones County, GA Monroe County, GA Twiggs County, GA 0.9560 0.9044

31460 Madera-Chowchilla, CA Madera County, CA 0.8455 0.7999 31540 Madison, WI Columbia County, WI Dane County, WI Iowa County, WI 1.1952 1.1307

31700 Manchester-Nashua, NH Hillsborough County, NH 1.0449 0.9885 31740 Manhattan, KS Geary County, KS Pottawatomie County, KS Riley County, KS 0.8308 0.7860

31860 Mankato-North Mankato, MN Blue Earth County, MN Nicollet County, MN 0.9617 0.9098

31900 Mansfield, OH Richland County, OH 0.9442 0.8932

### CMS-1503-P 1233

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 32420 Mayagüez, PR Hormigueros Municipio, PR Mayagüez Municipio, PR 0.6342 0.6000

32580 McAllen-Edinburg-Mission, TX Hidalgo County, TX 0.9357 0.8852 32780 Medford, OR Jackson County, OR 1.0652 1.0077 32820 Memphis, TN-MS-AR Crittenden County, AR DeSoto County, MS Marshall County, MS Tate County, MS Tunica County, MS Fayette County, TN Shelby County, TN Tipton County, TN 0.9730 0.9205

32900 Merced, CA Merced County, CA 1.2939 1.2241 33124 Miami-Miami Beach-Kendall, FL Miami-Dade County, FL 1.0723 1.0144 33140 Michigan City-La Porte, IN LaPorte County, IN 1.0026 0.9485 33260 Midland, TX Midland County, TX 1.0282 0.9727 33340 Milwaukee-Waukesha-West Allis, WI Milwaukee County, WI Ozaukee County, WI Washington County, WI Waukesha County, WI 1.0782 1.0200

33460 Minneapolis-St. Paul-Bloomington, MN-WI Anoka County, MN Carver County, MN Chisago County, MN Dakota County, MN Hennepin County, MN Isanti County, MN Ramsey County, MN Scott County, MN Sherburne County, MN Washington County, MN Wright County, MN Pierce County, WI St. Croix County, WI 1.1798 1.1161

33540 Missoula, MT Missoula County, MT 0.9445 0.8935 33660 Mobile, AL Mobile County, AL 0.8403 0.7949

### CMS-1503-P 1234

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 33700 Modesto, CA Stanislaus County, CA 1.2815 1.2123 33740 Monroe, LA Ouachita Parish, LA Union Parish, LA 0.8465 0.8008

33780 Monroe, MI Monroe County, MI 0.9194 0.8698 33860 Montgomery, AL Autauga County, AL Elmore County, AL Lowndes County, AL Montgomery County, AL 0.8822 0.8346

34060 Morgantown, WV Monongalia County, WV Preston County, WV 0.8615 0.8150

34100 Morristown, TN Grainger County, TN Hamblen County, TN Jefferson County, TN 0.7448 0.7046

34580 Mount Vernon-Anacortes, WA Skagit County, WA 1.0971 1.0379 34620 Muncie, IN Delaware County, IN 0.8688 0.8219 34740 Muskegon-Norton Shores, MI Muskegon County, MI 1.0364 0.9805 34820 Myrtle Beach-North My rtle Beach-Conway, SC Horry County, SC 0.9224 0.8726 34900 Napa, CA Napa County, CA 1.5463 1.4628 34940 Naples-Marco Island, FL Collier County, FL 1.0268 0.9714 34980 Nashville-Davidson-—Murfreesboro--Franklin, TN Cannon County, TN Cheatham County, TN Davidson County, TN Dickson County, TN Hickman County, TN Macon County, TN Robertson County, TN Rutherford County, TN Smith County, TN Sumner County, TN Trousdale County, TN Williamson County, TN Wilson County, TN 0.9926 0.9390

35004 Nassau-Suffolk, NY Nassau County, NY Suffolk County, NY 1.3037 1.2333

### CMS-1503-P 1235

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 35084 Newark-Union, NJ-PA Essex County, NJ Hunterdon County, NJ Morris County, NJ Sussex County, NJ Union County, NJ Pike County, PA 1.2115 1.1461

35300 New Haven-Milford, CT New Haven County, CT 1.2192 1.1534 35380 New Orleans-Metairie-Kenner, LA Jefferson Parish, LA Orleans Parish, LA Plaquemines Parish, LA St. Bernard Parish, LA St. Charles Parish, LA St. John the Baptist Parish, LA St. Tammany Parish, LA 0.9603 0.9085

35644 New York-White Plains-Wayne, NY-NJ Bergen County, NJ Hudson County, NJ Passaic County, NJ Bronx County, NY Kings County, NY New York County, NY Putnam County, NY Queens County, NY Richmond County, NY Rockland County, NY Westchester County, NY 1.3688 1.2949

35660 Niles-Benton Harbor, MI Berrien County, MI 0.9394 0.8887 35840 North Port-Bradenton-Sarasota, FL New London County, CT 1.0037 0.9495 35980 Norwich-New London, CT New London County, CT 1.1875 1.1234 36084 Oakland-Fremont-Hayward, CA Alameda County, CA Contra Costa County, CA 1.7308 1.6374

36100 Ocala, FL Marion County, FL 0.8966 0.8482 36140 Ocean City, NJ Cape May County, NJ 1.1518 1.0896 36220 Odessa, TX Ector County, TX 0.9990 0.9451 36260 Ogden-Clearfield, UT Davis County, UT Morgan County, UT Weber County, UT 0.9812 0.9282

### CMS-1503-P 1236

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 36420 Oklahoma City, OK Canadian County, OK Cleveland County, OK Grady County, OK Lincoln County, OK Logan County, OK McClain County, OK Oklahoma County, OK 0.9399 0.8892

36500 Olympia, WA Thurston County, WA 1.1931 1.1287 36540 Omaha-Council Bluffs, NE-IA Harrison County, IA Mills County, IA Pottawattamie County, IA Cass County, NE Douglas County, NE Sarpy County, NE Saunders County, NE Washington County, NE 1.0147 0.9599

36740 Orlando-Kissimmee-Sanford, FL Lake County, FL Orange County, FL Osceola County, FL Seminole County, FL 0.9682 0.9159

36780 Oshkosh-Neenah, WI Winnebago County, WI 1.0129 0.9582 36980 Owensboro, KY Daviess County, KY Hancock County, KY McLean County, KY 0.8862 0.8384

37100 Oxnard-Thousand Oaks-Ventura, CA Ventura County, CA 1.3104 1.2397 37340 Palm Bay-Melbourne-Titusville, FL Brevard County, FL 0.9752 0.9226 37380 Palm Coast, FL Flagler County, FL 0.8899 0.8419 37460 Panama City-Lynn Haven-Panama City Beach, FL Bay County, FL 0.8422 0.7967 37620 Parkersburg-Marietta-Vienna, WV-OH Washington County, OH Pleasants County, WV Wirt County, WV Wood County, WV 0.7893 0.7467

37700 Pascagoula, MS George County, MS Jackson County, MS 0.8786 0.8312

37764 Peabody, MA Essex County, MA 1.1623 1.0996

### CMS-1503-P 1237

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 37860 Pensacola-Ferry Pass-Brent, FL Escambia County, FL Santa Rosa County, FL 0.8739 0.8267

37900 Peoria, IL Marshall County, IL Peoria County, IL Stark County, IL Tazewell County, IL Woodford County, IL 0.9686 0.9163

37964 Philadelphia, PA Bucks County, PA Chester County, PA Delaware County, PA Montgomery County, PA Philadelphia County, PA 1.1435 1.0818

38060 Phoenix-Mesa-Glendale, AZ Maricopa County, AZ Pinal County, AZ 1.1270 1.0662

38220 Pine Bluff, AR Cleveland County, AR Jefferson County, AR Lincoln County, AR 0.8483 0.8025

38300 Pittsburgh, PA Allegheny County, PA Armstrong County, PA Beaver County, PA Butler County, PA Fayette County, PA Washington County, PA Westmoreland County, PA 0.9111 0.8619

38340 Pittsfield, MA Berkshire County, MA 1.0981 1.0388 38540 Pocatello, ID Bannock County, ID Power County, ID 1.0066 0.9523

38660 Ponce, PR Juana Díaz Municipio, PR Ponce Municipio, PR Villalba Municipio, PR 0.6342 0.6000

38860 Portland-South Portland-Biddeford, ME Cumberland County, ME Sagadahoc County, ME York County, ME 1.0470 0.9905

### CMS-1503-P 1238

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 38900 Portland-Vancouver-Hillsboro, OR-WA Clackamas County, OR Columbia County, OR Multnomah County, OR Washington County, OR Yamhill County, OR Clark County, WA Skamania County, WA 1.2151 1.1495

38940 Port St. Lucie, FL Martin County, FL St. Lucie County, FL 1.1353 1.0740

39100 Poughkeepsie-Newburgh-Middletown, NY Dutchess County, NY Orange County, NY 1.1998 1.1350

39140 Prescott, AZ Yavapai County, AZ 1.2952 1.2253 39300 Providence-New Bedford-Fall River, RI-MA Bristol County, MA Bristol County, RI Kent County, RI Newport County, RI Providence County, RI Washington County, RI 1.1343 1.0731

39340 Provo-Orem, UT Juab County, UT Utah County, UT 0.9869 0.9336

39380 Pueblo, CO Pueblo County, CO 0.9233 0.8735 39460 Punta Gorda, FL Charlotte County, FL 0.9274 0.8773 39540 Racine, WI Racine County, WI 1.1202 1.0597 39580 Raleigh-Cary, NC Franklin County, NC Johnston County, NC Wake County, NC 1.0388 0.9827

39660 Rapid City, SD Meade County, SD Pennington County, SD 1.1056 1.0459

39740 Reading, PA Berks County, PA 0.9427 0.8918 39820 Redding, CA Shasta County, CA 1.4953 1.4146 39900 Reno-Sparks, NV Storey County, NV Washoe County, NV 1.1031 1.0436

### CMS-1503-P 1239

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 40060 Richmond, VA Amelia County, VA Caroline County, VA Charles City County, VA Chesterfield County, VA Cumberland County, VA Dinwiddie County, VA Goochland County, VA Hanover County, VA Henrico County, VA King and Queen County, VA King William County, VA Louisa County, VA New Kent County, VA Powhatan County, VA Prince George County, VA Sussex County, VA Colonial Heights City, VA Hopewell City, VA Petersburg City, VA Richmond City, VA 1.0229 0.9677

40140 Riverside-San Bernardino-Ontario, CA Riverside County, CA San Bernardino County, CA 1.2212 1.1553

40220 Roanoke, VA Botetourt County, VA Craig County, VA Franklin County, VA Roanoke County, VA Roanoke City, VA Salem City, VA 0.9345 0.8841

40340 Rochester, MN Dodge County, MN Olmsted County, MN Wabasha County, MN 1.1585 1.0960

40380 Rochester, NY Livingston County, NY Monroe County, NY Ontario County, NY Orleans County, NY Wayne County, NY 0.9100 0.8609

40420 Rockford, IL Boone County, IL Winnebago County, IL 1.0622 1.0049

40484 Rockingham, NH Rockingham County, NH Strafford County, NH 1.0615 1.0042

### CMS-1503-P 1240

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 40580 Rocky Mount, NC Edgecombe County, NC Nash County, NC 0.9565 0.9049

40660 Rome, GA Floyd County, GA 0.9320 0.8817 40900 Sacramento--Arden-Arcade--Roseville, CA El Dorado County, CA Placer County, CA Sacramento County, CA Yolo County, CA 1.4745 1.3949

40980 Saginaw-Saginaw Township North, MI Saginaw County, MI 0.9241 0.8742 41060 St. Cloud, MN Benton County, MN Stearns County, MN 1.1691 1.1060

41100 St. George, UT Washington County, UT 0.9670 0.9148 41140 St. Joseph, MO-KS Doniphan County, KS Andrew County, MO Buchanan County, MO DeKalb County, MO 1.0907 1.0318

41180 St. Louis, MO-IL Bond County, IL Calhoun County, IL Clinton County, IL Jersey County, IL Macoupin County, IL Madison County, IL Monroe County, IL St. Clair County, IL Crawford County, MO Franklin County, MO Jefferson County, MO Lincoln County, MO St. Charles County, MO St. Louis County, MO Warren County, MO Washington County, MO St. Louis City, MO 0.9625 0.9105

41420 Salem, OR Marion County, OR Polk County, OR 1.1787 1.1151

41500 Salinas, CA Monterey County, CA 1.6607 1.5711 41540 Salisbury, MD Somerset County, MD Wicomico County, MD 0.9535 0.9020

### CMS-1503-P 1241

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 41620 Salt Lake City, UT Salt Lake County, UT Summit County, UT Tooele County, UT 0.9811 0.9281

41660 San Angelo, TX Irion County, TX Tom Green County, TX 0.8792 0.8317

41700 San Antonio- New Braunfels, TX Atascosa County, TX Bandera County, TX Bexar County, TX Comal County, TX Guadalupe County, TX Kendall County, TX Medina County, TX Wilson County, TX 0.9527 0.9013

41740 San Diego-Carlsbad-San Marcos, CA San Diego County, CA 1.2535 1.1858 41780 Sandusky, OH Erie County, OH 0.9196 0.8700 41884 San Francisco-San Mateo-Redwood City, CA Marin County, CA San Francisco County, CA San Mateo County, CA 1.6638 1.5740

41900 San Germán-Cabo Rojo, PR Cabo Rojo Municipio, PR Lajas Municipio, PR Sabana Grande Municipio, PR San Germán Municipio, PR 0.6342 0.6000

41940 San Jose-Sunnyvale-Santa Clara, CA San Benito County, CA Santa Clara County, CA 1.7685 1.6730

### CMS-1503-P 1242

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 41980 San Juan-Caguas-Guaynabo, PR Aguas Buenas Municipio, PR Aibonito Municipio, PR Arecibo Municipio, PR Barceloneta Municipio, PR Barranquitas Municipio, PR Bayamón Municipio, PR Caguas Municipio, PR Camuy Municipio, PR Canóvanas Municipio, PR Carolina Municipio, PR Cataño Municipio, PR Cayey Municipio, PR Ciales Municipio, PR Cidra Municipio, PR Comerío Municipio, PR Corozal Municipio, PR Dorado Municipio, PR Florida Municipio, PR Guaynabo Municipio, PR Gurabo Municipio, PR Hatillo Municipio, PR Humacao Municipio, PR Juncos Municipio, PR Las Piedras Municipio, PR Loíza Municipio, PR Manatí Municipio, PR Maunabo Municipio, PR Morovis Municipio, PR Naguabo Municipio, PR Naranjito Municipio, PR Orocovis Municipio, PR Quebradillas Municipio, PR Río Grande Municipio, PR San Juan Municipio, PR San Lorenzo Municipio, PR Toa Alta Municipio, PR Toa Baja Municipio, PR Trujillo Alto Municipio, PR Vega Alta Municipio, PR Vega Baja Municipio, PR Yabucoa Municipio, PR 0.6342 0.6000

42020 San Luis Obispo-Paso Robles, CA San Luis Obispo County, CA 1.3665 1.2927 42044 Santa Ana-Anaheim-Irvine, CA Orange County, CA 1.2876 1.2181 42060 Santa Barbara-Santa Maria-Goleta, CA Santa Barbara County, CA 1.2670 1.1986

### CMS-1503-P 1243

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 42100 Santa Cruz-Watsonville, CA Santa Cruz County, CA 1.7725 1.6768 42140 Santa Fe, NM Santa Fe County, NM 1.1484 1.0864 42220 Santa Rosa-Petaluma, CA Sonoma County, CA 1.7089 1.6167 42340 Savannah, GA Bryan County, GA Chatham County, GA Effingham County, GA 0.9427 0.8918

42540 Scranton--Wilkes-Barre, PA Lackawanna County, PA Luzerne County, PA Wyoming County, PA 0.8723 0.8252

42644 Seattle-Bellevue-Everett, WA King County, WA Snohomish County, WA 1.2234 1.1574

42680 Sebastian-Vero Beach, FL Indian River County, FL 0.9631 0.9111 43100 Sheboygan, WI Sheboygan County, WI 0.9776 0.9248 43300 Sherman-Denison, TX Grayson County, TX 0.8765 0.8292 43340 Shreveport-Bossier City, LA Bossier Parish, LA Caddo Parish, LA De Soto Parish, LA 0.9038 0.8550

43580 Sioux City, IA-NE-SD Woodbury County, IA Dakota County, NE Dixon County, NE Union County, SD 0.9626 0.9106

43620 Sioux Falls, SD Lincoln County, SD McCook County, SD Minnehaha County, SD Turner County, SD 0.9845 0.9314

43780 South Bend-Mishawaka, IN-MI St. Joseph County, IN Cass County, MI 1.0533 0.9964

43900 Spartanburg, SC Spartanburg County, SC 0.9797 0.9268 44060 Spokane, WA Spokane County, WA 1.1192 1.0588 44100 Springfield, IL Menard County, IL Sangamon County, IL 0.9667 0.9145

### CMS-1503-P 1244

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 44140 Springfield, MA Franklin County, MA Hampden County, MA Hampshire County, MA 1.0820 1.0236

44180 Springfield, MO Christian County, MO Dallas County, MO Greene County, MO Polk County, MO Webster County, MO 0.8743 0.8271

44220 Springfield, OH Clark County, OH 0.9777 0.9249 44300 State College, PA Centre County, PA 0.9295 0.8793 44600 Steubenville-Weirton, OH-WV Centre County, PA 0.7744 0.7326 44700 Stockton, CA San Joaquin County, CA 1.3294 1.2576 44940 Sumter, SC Sumter County, SC 0.8322 0.7873 45060 Syracuse, NY Madison County, NY Onondaga County, NY Oswego County, NY 1.0181 0.9631

45104 Tacoma, WA Pierce County, WA 1.2010 1.1362 45220 Tallahassee, FL Gadsden County, FL Jefferson County, FL Leon County, FL Wakulla County, FL 0.9323 0.8820

45300 Tampa-St. Petersburg-Clearwater, FL Hernando County, FL Hillsborough County, FL Pasco County, FL Pinellas County, FL 0.9585 0.9068

45460 Terre Haute, IN Clay County, IN Sullivan County, IN Vermillion County, IN Vigo County, IN 0.9746 0.9220

45500 Texarkana, TX-Texarkana, AR Miller County, AR Bowie County, TX 0.8091 0.7654

### CMS-1503-P 1245

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 45780 Toledo, OH Fulton County, OH Lucas County, OH Ottawa County, OH Wood County, OH 0.9986 0.9447

45820 Topeka, KS Jackson County, KS Jefferson County, KS Osage County, KS Shawnee County, KS Wabaunsee County, KS 0.9479 0.8967

45940 Trenton-Ewing, NJ Mercer County, NJ 1.0747 1.0167 46060 Tucson, AZ Pima County, AZ 1.0037 0.9495 46140 Tulsa, OK Creek County, OK Okmulgee County, OK Osage County, OK Pawnee County, OK Rogers County, OK Tulsa County, OK Wagoner County, OK 0.9304 0.8802

46220 Tuscaloosa, AL Greene County, AL Hale County, AL Tuscaloosa County, AL 0.8460 0.8003

46340 Tyler, TX Smith County, TX 0.8539 0.8078 46540 Utica-Rome, NY Herkimer County, NY Oneida County, NY 0.8969 0.8485

46660 Valdosta, GA Brooks County, GA Echols County, GA Lanier County, GA Lowndes County, GA 0.8390 0.7937

46700 Vallejo-Fairfield, CA Solano County, CA 1.5791 1.4939 47020 Victoria, TX Calhoun County, TX Goliad County, TX Victoria County, TX 0.8702 0.8232

47220 Vineland-Millville-Bridgeton, NJ Cumberland County, NJ 1.1027 1.0432

### CMS-1503-P 1246

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 47260 Virginia Beach-Norfolk-Newport News, VA-NC Currituck County, NC Gloucester County, VA Isle of Wight County, VA James City County, VA Mathews County, VA Surry County, VA York County, VA Chesapeake City, VA Hampton City, VA Newport News City, VA Norfolk City, VA Poquoson City, VA Portsmouth City, VA Suffolk City, VA Virginia Beach City, VA Williamsburg City, VA 0.9487 0.8975

47300 Visalia-Porterville, CA Tulare County, CA 1.1370 1.0756 47380 Waco, TX McLennan County, TX 0.8897 0.8417 47580 Warner Robins, GA Houston County, GA 0.8405 0.7951 47644 Warren-Troy-Farmington Hills, MI Lapeer County, MI Livingston County, MI Macomb County, MI Oakland County, MI St. Clair County, MI 1.0213 0.9662

### CMS-1503-P 1247

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 47894 Washington-Arlington-Alexandria, DC-VA-MD-WV District of Columbia, DC Calvert County, MD Charles County, MD Prince George's County, MD Arlington County, VA Clarke County, VA Fairfax County, VA Fauquier County, VA Loudoun County, VA Prince William County, VA Spotsylvania County, VA Stafford County, VA Warren County, VA Alexandria City, VA Fairfax City, VA Falls Church City, VA Fredericksburg City, VA Manassas City, VA Manassas Park City, VA Jefferson County, WV 1.1334 1.0722

47940 Waterloo-Cedar Falls, IA Black Hawk County, IA Bremer County, IA Grundy County, IA 0.8960 0.8476

48140 Wausau, WI Marathon County, WI 0.9892 0.9358 48300 Wenatchee-East Wenatchee, WA Chelan County, WA Douglas County, WA 1.0181 0.9631

48424 West Palm Beach-Boca Raton-Boynton Beach, FL Palm Beach County, FL 1.0517 0.9949 48540 Wheeling, WV-OH Belmont County, OH Marshall County, WV Ohio County, WV 0.7067 0.6686

48620 Wichita, KS Butler County, KS Harvey County, KS Sedgwick County, KS Sumner County, KS 0.9422 0.8913

48660 Wichita Falls, TX Archer County, TX Clay County, TX Wichita County, TX 1.0128 0.9581

48700 Williamsport, PA Lycoming County, PA 0.7682 0.7267

### CMS-1503-P 1248

CBSA Code Urban Area (Constituent Counties) Composite Rate Wage Index ESRD PPS Wage Index 48864 Wilmington, DE-MD-NJ New Castle County, DE Cecil County, MD Salem County, NJ 1.1202 1.0597

48900 Wilmington, NC Brunswick County, NC New Hanover County, NC Pender County, NC 0.9672 0.9150

49020 Winchester, VA-WV Frederick County, VA Winchester City, VA Hampshire County, WV 1.0590 1.0018

49180 Winston-Salem, NC Davie County, NC Forsyth County, NC Stokes County, NC Yadkin County, NC 0.9464 0.8953

49340 Worcester, MA Worcester County, MA 1.1659 1.1030 49420 Yakima, WA Yakima County, WA 1.0658 1.0083 49500 Yauco, PR Guánica Municipio, PR Guayanilla Municipio, PR Peñuelas Municipio, PR Yauco Municipio, PR 0.6342 0.6000

49620 York-Hanover, PA York County, PA 1.0086 0.9542 49660 Youngstown-Warren-Boardman, OH-PA Mahoning County, OH Trumbull County, OH Mercer County, PA 0.9132 0.8639

49700 Yuba City, CA Sutter County, CA Yuba County, CA 1.1692 1.1061

49740 Yuma, AZ Yuma County, AZ 0.9829 0.9298

### CMS-1503-P 1249

ADDENDUM L: Proposed CY 2011 ESRD Comp osite Rate and PPS Wage Indices for Rural Areas Based on CBSA Labor Market Areas

State Code Nonurban Area Composite Rate Wage Index ESRD PPS Wage Index 1 Alabama 0.7797 0.7376 2 Alaska 1.3368 1.2646 3 Arizona 0.9613 0.9094 4 Arkansas 0.7647 0.7234 5 California 1.3167 1.2456 6 Colorado 1.0517 0.9949 7 Connecticut 1.1775 1.1139 8 Delaware 1.0329 0.9771 10 Florida 0.8903 0.8422 11 Georgia 0.7999 0.7567 12 Hawaii 1.1733 1.1100 13 Idaho 0.8000 0.7568 14 Illinois 0.8834 0.8357 15 Indiana 0.8884 0.8404 16 Iowa 0.9074 0.8584 17 Kansas 0.8450 0.7994 18 Kentucky 0.8274 0.7827 19 Louisiana 0.8165 0.7724 20 Maine 0.9093 0.8602 21 Maryland 0.9713 0.9189 22 Massachusetts 1 

### 1.2460 1.1788 23 Michigan 0.9058 0.8569 24 Minnesota 0.9570 0.9053 25 Mississippi 0.8083 0.7647 26 Missouri 0.8084 0.7648 27 Montana 0.9018 0.8531 28 Nebraska 0.9429 0.8920 29 Nevada 0.9899 0.9365 30 New Hampshire 1.0459 0.9894 31 New Jersey 1 

### ----- ------ 32 New Mexico 0.9459 0.8948 33 New York 0.8666 0.8198 34 North Carolina 0.8857 0.8379 35 North Dakota 0.7232 0.6842 36 Ohio 0.9029 0.8542 37 Oklahoma 0.8316 0.7867 38 Oregon 1.0618 1.0045 39 Pennsylvania 0.8966 0.8482 40 Puerto Rico 0.6342 0.6000

### CMS-1503-P 1250

State Code Nonurban Area Composite Rate Wage Index ESRD PPS Wage Index 41 Rhode Island 1 

### ----- ----- 42 South Carolina 0.8912 0.8431 43 South Dakota 0.9037 0.8549 44 Tennessee 0.8329 0.7879 45 Texas 0.8264 0.7818 46 Utah 0.9157 0.8663 47 Vermont 1.0154 0.9606 48 Virgin Islands 0.8463 0.8006 49 Virginia 0.8301 0.7853 50 Washington 1.0782 1.0200 51 West Virginia 0.7911 0.7484 52 Wisconsin 0.9488 0.8976 53 Wyoming 1.0089 0.9544

1 All counties within the State are classified as urban.



### [FR Doc. 2010-15900 Filed 06/25/2010 at 4:15 pm; Publication Date: 07/13/2010]