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 policies to ensure that our payment systems 

are updated to reflect changes in medical practice and the relative value of services. It 

also addresses, implements or discusses certain provisions of both the Affordable Care 

Act and the Medicare Improvements 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 discussion 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 consideration, comments must be received at one of the 

addresses provided below, no later than 5 p.m. on [OFR—insert date 60 days after the

date of filing for public inspection at OFR.]
CMS-1503-P 2

ADDRESSES: In commenting, please refer to file code CMS-1503-P. Because of staff 

and resource limitations, we cannot accept comments by facsimile (FAX) transmission. 

 You may submit comments in one of four ways (please choose only one of the 

ways listed): 

1. Electronically. You may submit electronic comments on this regulation to 

http://www.regulations.gov. Follow the 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. 
CMS-1503-P 3

4. By hand or courier. If you prefer, you may deliver (by hand or courier) your 

written comments before the close of the comment period to either of the following 

addresses: 

a. For delivery in Washington, DC-- 

 Centers for Medicare & Medicaid Services, 

Department of Health and Human Services, 

Room 445-G, Hubert H. Humphrey Building, 

 200 Independence Avenue, SW., 

 Washington, DC 20201 

(Because access to the interior of the Hubert H. Humphrey Building is not readily 

available to persons without Federal government identification, commenters are 

encouraged to leave their comments in the CMS drop slots located in the main lobby of 

the building. A stamp-in clock is available for persons wishing to retain a proof of filing 

by stamping in and retaining an extra copy of the comments being filed.) 

b. For delivery in Baltimore, MD-- 

 Centers for Medicare & Medicaid Services, 

Department of Health and Human Services, 

7500 Security Boulevard, 

Baltimore, MD 21244-1850. 

If you intend to deliver your comments to the Baltimore address, please call 

telephone number (410) 786-9994 in advance to schedule your arrival with one of our 

staff members. 

 Comments mailed to the addresses indicated as appropriate for hand or courier 

delivery may be delayed and received after the comment period. 

FOR FURTHER INFORMATION CONTACT: 
CMS-1503-P 4

Rebecca Cole, (410) 786-4497, for issues related 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 issues related to ambulance services. 

Glenn McGuirk, (410) 786-5723, for clinical laboratory issues. 

Randall Ricktor, (410) 786-4632, for Federally Qualified Health Center Issues. 

Pauline Lapin, (410)786-6883, for issues related to the chiropractic services 

demonstration BN issue. 

Troy Barsky, (410)786-8873, or Kristin Bohl, (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 Feedback 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 period 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 available for public inspection as they are 

received, generally beginning approximately 3 weeks after publication of a document, at 

the headquarters of the Centers for Medicare & Medicaid Services, 7500 Security 

Boulevard, Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 

a.m. to 4 p.m. To schedule an appointment to view public comments, phone 1-800-743-

3951. 

Table of Contents 

To assist readers in referencing sections 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 exclusively in section V. of this proposed rule. 

I. Background 

 A. Development of the Relative Value System 

 1. Work RVUs 

 2. Practice Expense Relative 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 Components (TCs) and Professional Components 

(PCs) 

 f. Alternative Data Sources and 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 Revised Services Effective Before the Next 5 

Year Review 

 3. Revised Malpractice RVUs for Selected 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 
CMS-1503-P 8

 a. Background 

 b. Progress in Identifying and Reviewing 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 Site-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 Combinations 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 Shares 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 Disease Related Services for Home Dialysis (CPT code 90963, 
CMS-1503-P 11

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 Set-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 Immunization 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 the List of Medicare Telehealth Services 

 C. Submitted Requests for Addition to the 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 Patient Protection and Affordable Care Act of 2010 

 A. Section 3002: Improvements to the Physician Quality Reporting System 

 B. Section 3003: Improvements to the Physician Feedback Program and Section 

3007: Value-based payment modifier under the physician fee schedule 

 1. Background 

 2. Effect of the Patient Protection and Affordable Care Act on the Program 

 3. Implementation of Sections 3003 and 3007 of the Affordable Care Act 

 4. Comments Sought on Specific Policy Topics Related to Both PPACA 

Sections 3003 and 3007 

 a. Risk Adjustment 

 b. Attribution 

 c. Benchmarking and Peer Groups 

 d. Cost and Quality Measures and Composite Measurement 

 C. Section 3102: Extension of the Work Geographic Index Floor and Revisions to 

the Practice Expense Geographic Adjustment under the Medicare Physician 

Fee Schedule, and Protections for Frontier States as amended by Section 

10324 of the Affordable Care Act 

 D. Section 3103: Extension of Exceptions Process for Medicare Therapy Caps 

 E. Section 3104: Extension of Payment 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 Physician Fee Schedule Mental Health Add-On 

 H. Section 3108: Permitting 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 Medicare Reasonable Costs Payments for Certain 

Clinical Diagnostic Laboratory Tests Furnished to Hospital Patients in Certain 

Rural Areas 

 L. Section 3134: Misvalued Codes Under the Physician Fee Schedule 

 M. Section 3135: Modification of Equipment 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 Payment 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 Market Basket Updates and Incorporation of 

Productivity Improvements into Market Basket Updates That Do Not Already 

Incorporate Such Improvements 

 1. ESRD Market Basket Discussion 
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 2. Productivity Adjustment regarding Ambulance and Clinical 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 Preventive Physical Examinations and Routine 

Checkups 

 b. Requirements for Coverage of an Annual Wellness Visit 

 2. Proposed Revisions 

 a. Proposed Revisions to §411.15, Particular 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 Primary 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 Professional Shortage Areas 

 a. Background 

 b. Proposed HPSA Surgical Incentive Payment Program (HSIP) 

 3. Sections 5501(a) and (b) of the Affordable Care Act and Payment for Critical 

Access Hospital Professional Services Under the Optional Method 

 T. Section 6003: Disclosure Requirements for In-Office Ancillary Services 

Exception to the Prohibition on Physician Self-Referral for Certain Imaging 

Services 

 1. Background 

 2. Proposed Disclosure Requirement 

 U. Section 6404: Maximum period for submission of Medicare claims reduced to 

not more than 12 months 

 1. Background 

 2. Provisions of Affordable Care Act 

 V. Section 6410 and MIPPA: Adjustments 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 Collection 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 Coverage of Ambulance Services 

 (2) Medicare Regulations 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 Schedule: Signature on Requisition 

 D. Discussion of Chiropractic Services Demonstration 

 E. Provisions Related to Payment for Renal 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 Add-on Adjustment to the Composite Rate 

 a. Estimating Growth in Expenditures for Drugs and Biologicals for CY 2010 

 b. Estimating Growth in Expenditures for Drugs and Biologicals in CY 2011 

 c. Estimating Per Patient Growth 

 d. Applying the Proposed Growth Update to the Drug Add-On Adjustment 

 e. Proposed Update to the Drug Add-on Adjustment 

 f. Proposed Update to the Geographic Adjustments to the Composite Rate 

 g. Proposed Updates to Core-Based 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 Improvements 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 

 b. Incentive Payments for the 2011 PQRI 

 c. Proposed 2011 Reporting Periods for Individual Eligible Professionals 

 d. Proposed 2011 PQRI Reporting Mechanisms for Individual Eligible 

Professionals 

 (1) Proposed Requirements for Individual Eligible Professionals Who Choose 

the Claims-based Reporting Mechanism 

 (2) Proposed Requirements for Individual Eligible Professionals Who Choose 

the Registry-based Reporting Mechanism 

 (3) Proposed Requirements for Individual Eligible Professionals Who Choose 

the EHR-based Reporting Mechanism 

 (4) Proposed Qualification Requirements for Registries 

 (5) Proposed Qualification Requirements for EHR Vendors and Their 

Products 

 e. Proposed Criteria for Satisfactory Reporting of Individual Quality 

Measures for Individual Eligible Professionals 

 f. Proposed Criteria for Satisfactory 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 Practices 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 Considerations 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 for Registry based Reporting Only 

 (3) New Individual Quality Measures Selected for Proposed for 2011 

 (4) Proposed 2011 Measures Available for EHR-based Reporting 

 (5) Measures Proposed for Inclusion in 2011 Measures Groups 

 j. Proposed 2011 PQRI Quality Measures 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 Integration of PQRI EHR measures and HITECH 

measures in years after 2011 

 2. Section 132: Incentives for Electronic 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 Determination 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 Satisfactory Reporting of the Electronic 

Prescribing Measure by Group Practices 

 (1) Definition of “Group Practice” 

 (2) Process for Group Practices to Participate as Group Practices and Criteria 

for Successful Reporting of the Electronic Prescribing Measure by 

Group Practices 
CMS-1503-P 21

 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, Orthotics, 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 Diabetic 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 
CMS-1503-P 22

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 Final Determination 

 (11) Effective Date of the Contract Termination 

 (12) Effect of Contract Termination 

 H. Provider and Supplier Enrollment Issue: Air Ambulance Provision 

 I. Technical Corrections 

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

 2. Scope of Benefits 

VII. Collection of Information 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 Payment for Technical Component of Certain 

Physician Pathology Services 

3. Sections 3105 and 10311: Extension of Ambulance Add-Ons 

4. Section 3107: Extension of Physician 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 Equipment Utilization Factor for Advanced 

Imaging Services 

8. Section 3136: Revisions in Payments for Power Wheelchairs 

9. Section 3401: Revisions of Certain Market 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 Services and General 

Surgery Services 
CMS-1503-P 24

 13. Section 6003: Disclosure Requirements for In-office Ancillary Services 

Exception to the Prohibition of Physician Self-referral for Certain Imaging Services 

14. Section 6404: Maximum Period for 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 Services Demonstration 

 4. Renal Dialysis Services Furnished by ESRD Facilities 

 5. Section 131(b) of the MIPPA: Physician 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 
CMS-1503-P 25

Addendum C--[Reserved] 

Addendum D--Proposed CY 2011 Geographic Adjustment Factors (GAFs) 

Addendum E--Proposed CY 2011 Geographic Practice Cost Indices (GPCIs) by State and 

Medicare Locality 

Addendum F--Proposed CY 2011 Diagnostic Imaging Services Subject to the Multiple 

Procedure Payment Reduction 

Addendum G--CPT/HCPCS Imaging Codes Defined By Section 5102(b) of the DRA 

Addendum H--Proposed CY 2011 “Always Therapy” 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" 
CMS-1503-P 26

ACC American College of Cardiology 

ACGME Accreditation Council on Graduate 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 Association 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) 
CMS-1503-P 27

BBRA [Medicare, Medicaid and State Child Health Insurance Program] Balanced 

Budget Refinement Act of 1999 (Pub. L. 106-113) 

BIPA Medicare, Medicaid, and SCHIP Benefits 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 
CMS-1503-P 28

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 Procedural 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, prosthetics, orthotics, and supplies 

DOQ Doctor’s Office Quality 

DOS Date of service 

DRA Deficit Reduction Act of 2005 (Pub. L. 109-171) 

DSMT Diabetes self-management training 

E/M Evaluation and management 
CMS-1503-P 29

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 Procedure Coding System 

HCRIS Healthcare Cost Report Information System 
CMS-1503-P 30

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 Information Technology Standards Panel 

HIV Human immunodeficiency virus 

HOPD Hospital outpatient department 

HPSA Health Professional Shortage Area 

HRSA Health Resources Services 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 
CMS-1503-P 31

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 Education 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 Coverage 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 Patients and Providers Act of 2008 

(Pub. L. 110-275) 

MMA Medicare Prescription Drug, Improvement, and Modernization Act of 

2003 (Pub. L. 108-173) 
CMS-1503-P 32

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 Standards 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 Coverage 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 
CMS-1503-P 33

OMB Office of Management and Budget 

ONC [HHS’] Office of the National Coordinator for Health IT 

OPPS Outpatient prospective payment system 

OSCAR Online Survey and Certification 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 
CMS-1503-P 34

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 net 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 
CMS-1503-P 35

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 Department of Education 

USP-DI United States Pharmacopoeia-Drug Information 

VBP Value-based purchasing 

WAMP Widely available market price 
CMS-1503-P 36

I. Background 

 Since January 1, 1992, Medicare has paid for physicians' services under section 

1848 of the Social Security Act (the Act), "Payment 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 the relative resources used in furnishing a 

service. Section 1848(c) of the Act requires that national RVUs be established for 

physician work, practice expense (PE), and malpractice expense. 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 nonphysician 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 (OBRA) 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 for the implementation of the fee schedule 

in January 1992 were developed with extensive input from the physician community. A 

research team at the Harvard School of Public Health developed the original physician 
CMS-1503-P 37

work RVUs for most codes in a cooperative agreement with the Department of Health 

and Human Services (DHHS). In constructing the code-specific vignettes for the original 

physician work RVUs, Harvard worked with panels 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 assure that fee schedule amounts for anesthesia 

services are consistent with those 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 malpractice expenses) comprising PEs. 

 Section 4505(a) of the Balanced Budget 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 period from charge-based PE RVUs to 

resource-based RVUs. 
CMS-1503-P 38

We established the resource-based PE RVUs for each physicians’ service in a 

final rule, published November 2, 1998 (63 FR 58814), effective for services furnished in 

1999. Based on the requirement to transition to a resource-based system 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 nonphysicians (for example, registered nurses 

(RNs)) nominated by physician specialty societies and other groups. The CPEP panels 

identified the direct inputs required 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 established 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 difference 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 under 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 Secretary of Health and Human Services (the Secretary) to 

establish a process under which we accept and 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 interim final rule (65 FR 25664) that set 
CMS-1503-P 39

forth the criteria for the submission of these supplemental PE survey data. The criteria 

were modified in response to comments received, and published in the Federal Register

(65 FR 65376) as part of a November 1, 2000 final 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 supplemental 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 new 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 comment 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 Physician Practice Information Survey (PPIS) 

conducted by the AMA. The PPIS is a multispecialty, nationally representative, PE 

survey of both physicians and nonphysician 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 determine PE/HR values (74 FR 61752). 

3. Resource-Based Malpractice (MP) RVUs 

Section 4505(f) of the BBA amended section 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 implemented 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 third Five-Year Review of physician work 

RVUs was published in the CY 2007 PFS final 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 the CY 2008 PFS final 

rule with comment period (72 FR 66360).) The 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 the 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 the 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 this transition was completed in CY 2010. 

In CY 2010, we also incorporated the new PPIS data to update the specialty-specific 
CMS-1503-P 41

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

RVUs will be addressed 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 addressed in the CY 2006 PFS final rule with 

comment period (70 FR 70153). The second Five-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 differ 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 final rule with comment period (73FR 69730), 

as required by section 133(b) of the Medicare Improvements for Patients and Providers 

Act of 2008 (MIPPA) (Pub. L. 110-275), the separate 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 consistent coding and appropriate payment for 
CMS-1503-P 42

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 comments on the perspectives of physicians and 

nonphysician practitioners caring for Medicare 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 physicians’ 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 relative 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 through the application of a CF, which is 

calculated by CMS’ Office of the Actuary (OACT). 

The formula for calculating the Medicare 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 comment period (74 FR 61738) implemented 

changes to the PFS and other Medicare Part B payment 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 services. The CY 2010 PFS final rule with 
CMS-1503-P 43

comment period also addressed other policies, 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 announced the following for CY 2010: the 

PFS update of -21.2 percent; the initial estimate for the sustainable 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 errors that occurred in the CY 2010 PFS final 

rule with comment period. This correction 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 Extension 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. Section 4 of Pub. L. 111-157 extended through 

May 31, 2010 the zero percent update to the PFS that was in effect for claims with dates 

of services from January 1, 2010 through March 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 
CMS-1503-P 44

CY 2010 PFS final rule with comment 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 Reconciliation 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) throughout this proposed rule. 

II. Provisions of the Proposed Rule 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 Act. 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 resources involved in furnishing each 

service. Direct expense categories include clinical labor, medical supplies and 

medical equipment. Indirect expenses include administrative labor, office 

expense, and all other expenses. The sections that follow provide more detailed 

information about the methodology for translating the resources involved in 

furnishing each service into service-specific PE RVUs. In addition, we note that 

section 1848(c)(2)(B)(ii)(II) of the Act provides that adjustments in RVUs for a 
CMS-1503-P 45

year may not cause total PFS payments to differ by more than $20 million from 

what they would have been if the adjustments were not made. Therefore, 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. 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, equipment, and supplies) typically required to 

provide each service. The costs of the resources are calculated using the refined direct 

PE inputs assigned to each CPT code in our PE database, which are based on our review 

of recommendations received from the American Medical Association’s (AMA's) 

Relative Value Update Committee (RUC). For a detailed explanation of the bottom-up 

direct PE methodology, including examples, we refer readers to the Five-Year Review of 

Work Relative Value Units Under the PFS and Proposed Changes to the Practice 

Expense Methodology proposed notice (71 FR 37242) and the CY 2007 PFS final rule 

with comment period (71 FR 69629). 

b. Indirect Practice Expense per Hour Data 

 We use survey data on indirect practice expenses incurred per hour worked 

(PE/HR) in developing the indirect portion of the PE RVUs. Prior to CY 2010, we 

primarily used the practice expense per hour (PE/HR) by specialty that was obtained 

from the AMA's Socioeconomic Monitoring Surveys (SMS). These surveys were 

conducted from 1995 through 1999. For several specialties that collected additional 
CMS-1503-P 46

PE/HR data through supplemental surveys, we incorporated these data in developing the 

PE/HR values used annually. 

 While the SMS was not specifically designed 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 representativeness. 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 process 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 which we established criteria for acceptance of supplemental 

data. The criteria were modified in the CY 2001 and CY 2003 PFS final rules with 

comment period (65 FR 65380 and 67 FR 79971, respectively). In addition to the SMS, 

we previously used supplemental survey data for the following specialties: cardiology; 

dermatology; gastroenterology; radiology; cardiothoracic surgery; vascular surgery; 

physical and occupational therapy; independent 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 
CMS-1503-P 47

Practice Expense Information Survey (PPIS), which was expanded (relative to the SMS) 

to include nonphysician practitioners (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/PFSFRN/itemdetail.asp?filterType=none&filter

ByDID=-

99&sortByDID=4&sortOrder=descending&itemID=CMS1223902&intNumPerPage=10. 

(See downloads labeled AMA PPIS Worksheets 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 consistent survey instrument and methods highly consistent 

with those used for the SMS and the supplemental surveys. The PPIS gathered 

information from 3,656 respondents across 51 physician specialty and healthcare 

professional groups. 

 We believe the PPIS is the most comprehensive source of PE survey 

information available to date. Therefore, we used the PPIS data to update the PE/HR 

data for almost all of the Medicare-recognized specialties that participated in the survey 

for the CY 2010 PFS. When we changed over to the PPIS data beginning in CY 2010, 

we did not change the PE RVU methodology itself or the manner in which the PE/HR 

data are used in that methodology. We only updated the PE/HR data based on the new 

survey. Furthermore, as we explained in the CY 2010 PFS final rule with comment 

period (74 FR 61751), because of the magnitude of payment reductions for some 

specialties resulting from the use of the PPIS data, we finalized a 4-year transition (75/25 
CMS-1503-P 48

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 Prescription Drug, Improvement, and 

Modernization Act of 2003 (MMA) (Pub. L. 108-173) added section 1848(c)(2)(H)(i) of 

the Act, which requires us to use the medical oncology supplemental survey data 

submitted in 2003 for oncology drug administration services. Therefore, the PE/HR for 

medical oncology, hematology, and hematology/oncology reflects the continued use of 

these supplemental survey data. 

 We do not use the PPIS data for reproductive endocrinology, sleep medicine, 

and spine surgery since these specialties are not separately recognized by Medicare, 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 payments in CY 2005. Supplemental survey data 

from the National Coalition of Quality Diagnostic Imaging Services (NCQDIS), 

representing IDTFs, were blended with supplementary survey data from the American 

College of Radiology (ACR) and implemented for payments in CY 2007. Neither IDTFs 

nor independent labs participated in the PPIS. Therefore, we continue to use the PE/HR 

that was developed from their supplemental survey data. 

 Finally, consistent with our past practice, the previous indirect PE/HR values 

from the supplemental surveys for medical oncology, independent laboratories, and 

IDTFs were updated to CY 2006 using the MEI to put them on a comparable basis with 

the PPIS data. In the CY 2010 PFS final rule with comment period (74 FR 61753), we 

miscalculated the indirect PE/HR for IDTFs as part 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 continuing 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 established PE/HR values for various specialties without 

SMS or supplemental survey data by crosswalking 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 comment 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 these dieticians are paid 85 percent of what a 

physician would be paid for providing 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 registered 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 
CMS-1503-P 50

PPIS PE/HR in calculating the PE RVUs for services furnished by registered dieticians 

but we did not actually crosswalk the specialty 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 proposed resource-based PE RVUs have been 

calculated in accordance with the final policy 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 transition to the PE RVUs calculated using the 

PPIS data. Therefore, in general, the CY 2011 PE RVUs are a 50/50 blend of the 

previous PE RVUs based on the SMS and supplemental survey data and the new PE 

RVUS developed using the PPIS data as described above. Note that the reductions in the 

PE RVUs for expensive diagnostic imaging equipment attributable to the change 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 between the direct cost portions 

of the PE RVUs for any two services is determined by the relative relationship 

between the sum of the direct cost resources (that is, the clinical staff, equipment, 

and supplies) typically required to provide the services. The costs of these 

resources are calculated from the refined direct PE inputs in our PE database. For 

example, if one service has a direct cost sum of $400 from our PE database and 

another service has a direct cost sum of $200, the direct portion of the PE RVUs 
CMS-1503-P 51

of the first service would be twice as much 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-specific indirect costs used in our PE 

calculations. We allocate the indirect costs to the code level on the basis of the 

direct costs specifically associated with a code and the greater of either the 

clinical labor costs or the physician work RVUs. We also incorporate the survey 

data described earlier in the PE/HR discussion. The general approach to 

developing the indirect portion of the PE RVUs is described below. 

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

calculated as described above and the average percentage that direct costs 

represent of total costs (based on survey data) across the specialties that perform 

the service to determine an initial indirect allocator. For example, if the direct 

portion of the PE RVUs for a given service were 2.00 and direct costs, on 

average, represented 25 percent of total costs for the specialties that performed the 

service, the initial indirect allocator would be 6.00 since 2.00 is 25 percent of 

8.00. 

• We then add the greater of the work RVUs or clinical labor portion of 

the direct portion of the PE RVUs to this initial indirect allocator. In our 

example, if this service had work RVUs of 4.00 and the clinical labor portion of 

the direct PE RVUs was 1.50, we would add 6.00 plus 4.00 (since the 4.00 work 

RVUs are greater than the 1.50 clinical labor portion) to get an indirect allocator 

of 10.00. In the absence of any further use of the survey data, the relative 

relationship between the indirect cost portions of the PE RVUs for any two 

services would be determined by the relative relationship between these indirect 
CMS-1503-P 52

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

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

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

the PE RVUs for the second service. 

• We next incorporate the specialty-specific indirect PE/HR data into the 

calculation. As a relatively extreme example for the sake of simplicity, assume in 

our example above that, based on the survey data, the average indirect cost of the 

specialties performing the first service with an allocator of 10.00 was half of the 

average indirect cost of the specialties performing the second service with an 

indirect allocator of 5.00. In this case, the indirect portion of the PE RVUs of the 

first service would be equal to that of the second service. 

d. Facility and Nonfacility Costs 

For procedures that can be furnished in a physician’s office, as well as in a 

hospital or 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 applied independently to yield two separate PE RVUs. 

Because Medicare makes a separate payment to the facility for its costs of 

furnishing a service, the facility PE RVUs are generally lower than the nonfacility 

PE RVUs. 

e. Services with Technical Components (TCs) and Professional 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 different 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 apply the same weighted average indirect 

percentage factor to allocate indirect expenses to the global components, PCs, and 

TCs for a service. (The direct PE RVUs for the TC and PC sum to the global 

under the bottom-up methodology.) 

f. Alternative Data Sources and Public 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 Payment Advisory Commission’s (MedPAC’s) 

comment that in the future, "CMS should 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 stakeholders on the issues raised by MedPAC 

for the future. In particular, we requested public comments regarding MedPAC's 

suggestion that we consider alternatives for 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 sponsor future data collection 

efforts, if participation should be voluntary (such 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 collection efforts. Although no commenters 

detailed a comprehensive overall alternative methodology, several commenters did 

provide suggestions regarding future data collection efforts and specific aspects of the 

current methodology. 

 The commenters that addressed the issue of surveys supported the use of surveys 

if they yielded accurate PE information. The 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 collection efforts should be led by organized 

medicine, individual specialty societies, or CMS. Several commenters that addressed the 

issue of voluntary versus mandatory data collection efforts supported voluntary data 

collection efforts and opposed mandatory data collection efforts. 

 Some commenters recommended no changes to the methodology or PE data in the 

near future. Other commenters indicated that the methodology and data changes needed 

to be made for CY 2011. Although most commenters did not directly address the use of 

the indirect PE/HR data, those that did predominately 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 RVUs 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 scaling factor, while others indicated that the issue should be 

examined more closely. 
CMS-1503-P 55

 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 physician time, but not physician work, should be 

used in the allocation. Other commenters suggested 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-based PE methodology and in subsequent 

revisions to the methodology, including the adoption of the bottom-up 

methodology. While we are not proposing a broad methodological change or 

broad data collection effort 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 period, as presented above. The complete 

public comments on that final rule are 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 rule 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. 
CMS-1503-P 56

(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 (aggregate direct and indirect) RVUs, the CF, 

and the average direct PE percentage from the survey data. 

Step 3: Calculate the aggregate pool of direct costs. This is the sum of the 

product of the direct costs for each service from Step 1 and the utilization data for 

that service. 

Step 4: Using the results of Step 2 and Step 3 calculate a direct PE scaling 

adjustment so that the aggregate direct cost pool does not exceed the current 

aggregate direct cost pool and apply it to the direct costs from Step 1 for each 

service. 

Step 5: Convert the results of Step 4 to an RVU scale for each service. To 

do this, divide the results of Step 4 by the CF. Note that the actual value of the 

CF used in this calculation does not influence the final direct cost PE RVUs, as 

long as the same CF is used in 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. 
CMS-1503-P 57

Step 7: Calculate direct and indirect PE percentages at the service level by 

taking a weighted average of the results of Step 6 for the specialties that furnish 

the service. Note that for services with TCs and PCs, the direct and indirect 

percentages for a given service do not vary by the PC, TC, and global 

components. 

Step 8: Calculate the service level allocators for the indirect 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 technical components), then the indirect allocator is: 

indirect percentage * (direct PE RVUs/direct percentage) + clinical PE 

RVUs + work RVUs. 

• If the clinical labor PE RVUs exceed the work RVUs (and the service is 

not a global service), then the indirect allocator is: indirect percentage * (direct 

PE RVUs/direct percentage) + clinical PE RVUs. 

(Note: For global services, the indirect allocator is based on both the work 

RVUs and the clinical labor PE RVUs. We do this to recognize that, for the PC 

service, indirect PEs will be allocated using the work RVUs, and for the TC 

service, indirect PEs will be allocated using the direct PE RVUs and the clinical 

labor PE RVUs. This also allows the global component RVUs to equal the sum 

of the PC and TC RVUs.) 
CMS-1503-P 58

For presentation purposes in the examples in the Table 2, the formulas 

were divided into two parts for each service. 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 aggregate pool of indirect PE RVUs by 

multiplying the current aggregate pool of PE RVUs by the average indirect PE 

percentage from the survey data. 

Step 10: Calculate an aggregate pool of indirect PE RVUs for all PFS 

services by adding the product of the indirect PE allocators for a service from 

Step 8 and the utilization data for that service. 

Step 11: Using the results of Step 9 and Step 10, calculate an indirect PE 

adjustment so that the aggregate indirect allocation does not exceed the available 

aggregate indirect PE RVUs and apply it to indirect allocators calculated in 

Step 8. 

Calculate the indirect practice cost index. 

Step 12: Using the results of Step 11, calculate aggregate pools of 

specialty-specific adjusted indirect PE allocators for all PFS services for a 

specialty by adding the product of the adjusted indirect PE allocator for each 

service and the utilization data for that service. 

Step 13: Using the specialty-specific indirect PE/HR data, calculate 

specialty-specific aggregate pools of indirect PE for all PFS services for that 

specialty by adding the product of the indirect PE/HR for the specialty, the 
CMS-1503-P 59

physician time for the service, and the specialty’s utilization for the service across 

all services performed by the specialty. 

Step 14: Using the results of Step 12 and Step 13, calculate the 

specialty-specific indirect PE scaling factors. 

Step 15: Using the results of Step 14, calculate an indirect practice cost 

index at the specialty level by dividing each specialty-specific indirect scaling 

factor by the average indirect scaling factor for the entire PFS. 

Step 16: Calculate the indirect practice cost index at the service level to 

ensure the capture of all indirect costs. Calculate a weighted average of the 

practice cost index values for the specialties that furnish the service. (Note: For 

services with TCs and PCs, we calculate the indirect practice cost index across the 

global components, PCs, and TCs. Under this method, the indirect practice cost 

index for a given service (for example, echocardiogram) does not vary by the PC, 

TC, and global component.) 

Step 17: Apply the service level indirect practice cost index calculated in 

Step 16 to the service level adjusted indirect allocators calculated in Step 11 to get 

the indirect PE RVUs. 

(iv) Calculate the Final PE RVUs 

Step 18: Add the direct PE RVUs from Step 6 to the indirect PE RVUs 

from Step 17 and apply the final PE budget neutrality (BN) adjustment, 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 MPPR adjustments) to the current pool of 

PE RVUs. This final BN adjustment is required primarily because certain 
CMS-1503-P 60

specialties are excluded from the PE RVU calculation for ratesetting purposes, but 

all specialties are included for purposes of calculating the final BN adjustment. 

(See "Specialties excluded from ratesetting calculation" below in this section.) 

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

rebase and revise the Medicare Economic Index (MEI) for CY 2011. As 

discussed in section II.C.4. of this proposed rule, 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. 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 the efficiencies in multiple service sessions may be 

appropriate. Consistent with this provision of the ACA, we are proposing a 

limited expansion of the current MPPR policy 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 percentage of the PFS and low volume 

specialties, from the calculation. These specialties are included for the purposes 

of calculating the BN adjustment. They are displayed in Table 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 
CMS-1503-P 61

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 physician specialties: Crosswalk the 

utilization of certain specialties with relatively low PFS utilization to the 

associated specialties. 

• Physical therapy utilization: Crosswalk the utilization associated with 

all physical therapy services to the specialty of physical therapy. 

• Identify professional and technical services not identified under the 

usual TC and 26 modifiers: Flag the services that are PC and TC services, but do 

not use TC and 26 modifiers (for example, electrocardiograms). This flag 

associates the PC and TC with the associated global code for use in creating the 

indirect PE RVUs. For example, the professional service, CPT code 93010 

(Electrocardiogram, routine ECG with at least 12 leads; interpretation and report 
CMS-1503-P 62

only), is associated with the global service, CPT code 93000 (Electrocardiogram, 

routine ECG with at least 12 leads; with interpretation and report). 

• Payment modifiers: Payment modifiers are accounted for in the 

creation of the file. For example, services billed with the assistant at surgery 

modifier are paid 16 percent of the PFS amount for that service; therefore, the 

utilization file is modified to only account for 16 percent of any service that 

contains the assistant at surgery modifier. 

● Work RVUs: The setup file contains the work RVUs from this proposed 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 assumption; 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 the particular piece of equipment. 

maintenance = factor for maintenance; 0.05. 

Note: The use of any particular conversion factor (CF) in Table 2 to illustrate the PE 

calculation has no effect on the resulting RVUs. 
CMS-1503-P 63

TABLE 2: Calculation of PE RVUs under Methodology for Selected Codes 

Step Source Formula 

99213 

Office visit, est 

Nonfacility 

33533 

CABG, 

arterial, single 

Facility 

71020 

Chest x-ray 

Nonfacility 

71020-TC 

Chest x-ray 

Nonfacility 

71020-26 

Chest x-ray 

Nonfacility 

93000 

ECG, com

Nonfacil

(1) 

Labor cost (Lab) 

Step 1 AMA 13.32 77.52 5.74 5.74 0.00 

(2) 

Suppy cost (Sup) 

Step 1 AMA 2.98 7.34 3.39 3.39 0.00 

(3) 

Equipment cost (Eqp) 

Step 1 AMA 0.19 0.65 8.17 8.17 0.00 

(4) 

Direct cost (Dir) 

Step 1 =(1)+(2)+(3) 16.50 85.51 17.31 17.31 0.00 

(5) 

Direct adjustment (Dir Adj) 

Steps 2-4 

See footnote* 0.484 0.484 0.484 0.484 0.484 0

(6) 

Adjusted labor 

Steps 2-4 

=Lab*Dir Adj =(1)*(5) 6.45 37.52 2.78 2.78 0.00 

(7) 

Adjusted supplies 

Steps 2-4 

=Sup*Dir Adj =(2)*(5) 1.44 3.55 1.64 1.64 0.00 

(8) 

Adjusted equipment 

Steps 2-4 

=Eqp*Dir Adj =(3)*(5) 0.09 0.32 3.96 3.96 0.00 

(9) 

Adjusted direct 

Steps 2-4 =(6)+(7)+(8) 7.99 41.39 8.38 8.38 0.00 

(10) 

Conversion Factor (CF) 

Step 5 PFS 36.0791 36.0791 36.0791 36.0791 36.0791 36.

(11) 

Adj. labor cost converted 

Step 5 

=(Lab*Dir Adj)/CF =(6)/(10) 0.18 1.04 0.08 0.08 0.00 

(12) 

Adj. supply cost converted 

Step 5 

=(Sup*Dir Adj)/CF =(7)/(10) 0.04 0.10 0.05 0.05 0.00 

(13) 

Adj. equip cost converted 

Step 5 

=(Eqp*Dir Adj)/CF =(8)/(10) 0.00 0.01 0.11 0.11 0.00 

(14) 

Adj. direct cost converted 

Step 5 =(11)+(12)+(13) 0.22 1.15 0.23 0.23 0.00 

(15) Wrk RVU 

Setup File PFS 0.97 33.75 0.22 0.00 0.22 

(16) Dir_pct 

Steps 6, 7 Surveys 25.5% 18.0% 28.9% 28.9% 28.9% 2
CMS-1503-P 64

Step Source Formula 

99213 

Office visit, est 

Nonfacility 

33533 

CABG, 

arterial, single 

Facility 

71020 

Chest x-ray 

Nonfacility 

71020-TC 

Chest x-ray 

Nonfacility 

71020-26 

Chest x-ray 

Nonfacility 

93000 

ECG, com

Nonfacil

(17) Ind_pct 

Steps 6, 7 Surveys 74.5% 82.0% 71.2% 71.2% 71.2% 7

(18) 

Ind. Alloc. formula (1st part) 

Step 8 See Step 8 ((14)/(16))*(17) ((14)/(16))*(17) ((14)/(16))*(17) ((14)/(16))*(17) ((14)/(16))*(17) ((14)/(16))

(19) 

Ind. Alloc. (1st part) 

Step 8 See (18) 0.65 5.23 0.57 0.57 0.00 

(20) 

Ind. Alloc. formulas (2nd part) 

Step 8 See Step 8 (15) (15) (15)+(11) (11) (15) (15)+

(21) 

Ind. Alloc. (2nd part) 

Step 8 See (20) 0.97 33.75 0.30 0.08 0.22 

(22) 

Indirect Allocator (1st+2nd) 

Step 8 =(19)+(21) 1.62 38.98 0.87 0.65 0.22 

(23) 

Indirect Adjustment (Ind Adj) 

Steps 9-11 

See footnote** 0.369 0.369 0.369 0.369 0.369 0

(24) 

Adjusted Indirect Allocator 

Steps 9-11 

=Ind Alloc * Ind Adj 0.60 14.37 0.32 0.24 0.08 

(25) 

Ind.Practice Cost Index (PCI) 

Steps 12-16 

See Steps 12-16 1.104 0.831 0.852 0.852 0.852 0

(26) 

Adjusted Indirect 

Step 17 

= Adj. Ind Alloc*PCI =(24)*(25) 0.66 11.95 0.27 0.20 0.07 

(27) 

MEI Rebasing Adjustment 

Step 18 PFS 1.168 1.168 1.168 1.168 1.168 

(28) 

MPPR Adjustment 

Step 18 PFS 1.011 1.011 1.011 1.011 1.011 

(29) PE RVU 

Step 18 

=(Adj Dir+Adj Ind) * budn * MEI Adj * MPPR Adj 

=((14)+(26)) *budn *(27) * (28) 1.03 15.36 0.59 0.51 0.08 

Note: 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] 
CMS-1503-P 65

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 example, computed 

tomography (CT) and magnetic resonance imaging (MRI) scanners), for which we 

adopted a 90 percent utilization rate assumption and provided 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 for the diagnostic services listed in Table 3 

(those that include expensive diagnostic imaging 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 added 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 reduced expenditures attributable to this change 

in the utilization rate for CY 2011 and subsequent years shall not be taken into account 

when applying the budget neutrality limitation on annual adjustments described 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 
CMS-1503-P 66

apply the 75 percent utilization rate assumption in CY 2011 to all of the services to which 

we currently apply the transitional 90 percent utilization rate assumption in CY 2010. 

These services are listed in a file on the CMS 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 Utilization Rate Assumption and that Will Be 

Subject to the 75 Percent Equipment Utilization Rate Assumption in CY 2011 

CPT Code Short Descriptor 

70336 Mri, temporomandibular 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 
CMS-1503-P 67

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 
CMS-1503-P 68

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 proposing 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 the 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 
CMS-1503-P 69

catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; 

percutaneous). In contrast, CTA and MRA procedures include a CT room or MRI room, 

respectively, in the direct PE inputs, and the PPIS data confirm that a higher assumed 

utilization rate than 50 percent would be appropriate. 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 appropriate to include 

CTA and MRA procedures in the list of procedures for which we assume a 75 percent 

equipment utilization rate, and we are proposing 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 attributable to this change in the utilization 

rate assumption applicable to CY 2011 shall not be taken into account when applying the 

budget neutrality limitation on annual adjustments described 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 transition 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 specific 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, which 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 the 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 bag from the CY 2011 direct PE database and 

the changes in direct PE inputs for the associated services are reflected in the proposed 

CY 2011 direct PE database. 
CMS-1503-P 71

(2) PE Inputs for Professional Component (PC) Only and Technical Component (TC) 

Only Codes Summing to Global Only Codes 

In the case of selected diagnostic tests, different but related CPT codes are used to 

describe global, professional, 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 differentiate professional and technical components. 

When different but related CPT codes are used to report the components of these 

services, the different CPT codes are referred 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 codes 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 calculations 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 correct the direct PE inputs for the global only 

codes so that the inputs reflect the appropriate 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 derived 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 derived monitoring for 24 hours by continuous 

original waveform recording and storage, with visual superimposition scanning; scanning 

analysis with report 

93230 

Wearable electrocardiographic rhythm derived monitoring for 24 hours by continuous 

original waveform recording and storage without superimposition scanning utilizing a 

device capable of producing a full miniaturized printout; including recording, 

microprocessor-based analysis with report, physician review and interpretation 

93231 

Wearable electrocardiographic rhythm derived 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 derived 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 electrocardiographic 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 electrocardiographic 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 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 

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 equipment 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 that includes the connection, recording, 

and disconnection of the holter monitor (CMS Equipment Code EQ127) used in 24 hour 

continuous electrocardiographic rhythm derived monitoring. The current equipment time 

input for the holter monitor is 42 minutes, which parallels the intra-service 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 the intra-service clinical 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 Equipment 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 include 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 monitoring. The equipment time input for the blood 

pressure monitor should parallel 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 ambulatory 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 pressure 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 physician interpretation and report for ambulatory 

blood pressure monitoring. Under our proposal, its direct PE inputs have been 

appropriately summed to include the 1450 total minutes of time for the ambulatory blood 

pressure monitor that are included in CPT codes 93786 and 93788. 

We have modified the proposed CY 2011 direct 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 estimate of approximately 271 

days for the source’s half-life. The current useful life input for the Colbalt-57 flood 

source is 5 years. Using publicly available catalogs, we found that the Cobalt-57 flood 

source is marketed with a useful life of 2 years. 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 information for the venoms used for the 

five venom immunology CPT codes, specifically 95145(Professional services for the 

supervision of preparation and provision of antigens for allergen immunotherapy (specify 

number of doses); single stinging insect venom); 95146 (Professional services for the 

supervision of preparation and provision of antigens for allergen immunotherapy (specify 

number of doses); 2 single stinging insect venoms); 95147 (Professional services for the 

supervision of preparation and 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 and provision of antigens for allergen immunotherapy (specify 

number of doses); 4 single stinging insect venoms); 95149 (Professional services for the 

supervision of preparation and provision of antigens for allergen immunotherapy (specify 

number of doses); 5 single stinging insect venoms). 

In the CY 2004 PFS final rule with comment period (68 FR 63206), we adopted a 

pricing methodology that utilizes the average price of a 1 milliliter 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 adjustments in the proposed CY 2011 direct PE 

database. 

(7) Equipment Duplication 

We recently identified a number of CPT codes with duplicate equipment inputs in 

the PE database. We are proposing to remove the duplicate equipment items and have 

modified the proposed CY 2011 direct PE database 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) 

19361 Breast reconstr w/lat flap EF031 table, power 

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 Supply Price Inputs Based on Unit Prices and 

Quantities 

 We have identified minor errors in total 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 associated services. We are proposing to modify the direct 

PE database to appropriately 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 changes are small, and we have adjusted the 

proposed CY 2011 direct PE database accordingly. The CPT and Level II HCPCS codes 

and associated supplies for nonfacility and facility settings that are subject to these 

corrections are displayed in Tables 7 and 8, respectively. 

Table 7: Overall Supply Price Calculation 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 Tongue base vol reduction SD009 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 SB034 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 SB034 mask, surgical, with face shield 

50384 Remove ureter stent, percut SB034 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 SB034 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 disinfectant, 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 

96360 Hydration iv infusion, init SC051 syringe 10-12ml 

SG050 gauze, non-sterile 2in x 2in 

96365 Ther/proph/diag iv inf, init SC018 iv infusion set 

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 

96374 Ther/proph/diag inj, iv push SC051 syringe 10-12ml 

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 Calculation 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 Tongue, mouth, jaw surgery SA048 pack, minimum multi-specialty visit 

41153 Tongue, mouth, neck surgery SA048 pack, minimum multi-specialty visit 

41155 Tongue, jaw, & neck surgery SA048 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 

57284 Repair paravag defect, open SA051 pack, pelvic exam 

SB006 drape, non-sterile, sheet 40in x 60in 

57285 Repair paravag defect, vag SA051 pack, pelvic exam 

SB006 drape, non-sterile, sheet 40in x 60in 

57423 Repair paravag defect, lap SA051 pack, pelvic exam 

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, which 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 and Esophageal Function Test 

We are accepting the AMA RUC recommendations for the CY 2011 PE inputs for 

the following CPT codes: 91132 (Electrogastrography, diagnostic, transcutaneous); 

91133 (Electrogastrography, diagnostic, transcutaneous; with provocative testing); 91038 

(Esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal 

impedance electrode(s) placement, recording, analysis and interpretation; prolonged 

(greater than 1 hour, up to 24 hours)). For 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, workstation and cart," based on its entry in the 
CMS-1503-P 86

AHA’s publication, "Estimated Useful Lives of Depreciable Hospital 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 recommendation 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 (Computed tomography, heart, with contrast 

material, for evaluation of cardiac structure and morphology (including 3D image 

postprocessing, assessment of cardiac function, and evaluation of venous structures, if 

performed)); 75573 (Computed tomography, heart, with contrast material, for evaluation 

of cardiac structure and morphology in the setting of congenital heart disease (including 

3D image postprocessing, assessment 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 function, and evaluation of venous structure, if 

performed)). The proposed CY 2011 direct PE database has been modified accordingly. 

(3) Cystometrogram 

The AMA RUC recently identified a rank order anomaly regarding CPT code 

51726 (Complex cystometrogram (ie, 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 profile studies (ie, urethral closure pressure 

profile), any technique); 51728 (Complex cystometrogram (ie, calibrated electronic 

equipment); with voiding pressure studies (ie, bladder voiding pressure), any technique); 

and 51729 (Complex cystometrogram (ie, calibrated electronic equipment); with voiding 

pressure studies (ie, bladder voiding pressure) and urethral pressure profile studies (ie, 

urethral closure pressure profile), any technique). 

Since usual AMA RUC policy is that CPT 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-service 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 codes. 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 these recommendations and, therefore, have 

changed the direct PE inputs for CPT codes 51725 and 51726 in the nonfacility setting in 

the proposed CY 2011 direct PE database. 

(4) Breath Hydrogen Test 

The AMA RUC provide recommendations regarding 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 Tube, Patient Sample" 

into the "BreathTrackerDigital SC Instrument" 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 useful 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 Depreciable Hospital Assets" 

as a standard reference. Additionally, because 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 that include the radiographic 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 agent; intercostal nerve, single); 

64421 (Injection, anesthetic agent; intercostal nerves, multiple, regional block); and 

64620 (Destruction by neurolytic agent, 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 CPT Codes for AMA RUC Review 

 As part of our review of high cost supplies, we conducted a clinical review of the 

procedures associated with high cost supplies to confirm that those supplies currently are 

used in the typical case described by the CPT codes. While we confirmed that most high 

cost supplies could be used in the procedures 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 tolerance specifications) and 77011 

(Computed tomography guidance for stereotactic localization). The documentation used 

in the current pricing of the supply item describes 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 codes 77301 and 77011 were established in CY 2002 

and CY 2003, respectively, we accepted the AMA RUC recommendations to include 

fiducial screws in the PE for these services. 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 the 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 exclusion of fiducial screws in their PE, we 

are asking the AMA RUC to review these CPT 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 recommend 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 inclusion 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 information 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 periodically received requests to change the PE price inputs 

for supplies and equipment in the 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 them 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 supplies and equipment used in existing codes. 

We are proposing to act on public requests to update equipment and supply price 

inputs annually through rulemaking by following 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 proposed rule. In that next proposed rule, we 

would present our review of submitted requests 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 final rule with comment period: 

● Updating the equipment or supply 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 and preparation of issues for the proposed rule, at a 

minimum, we would expect that requesters would provide the following information: 

● Name and contact information 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/PhysicianFeeSched/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 suppliers/manufacturers. 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 furnishing invoices, requestors should take into 

consideration the following parameters: 

++ May be either print or electronic but should be on supplier and/or 

manufacturer stationery (for example, letterhead, billing statement, etc.) 

++ Should be for the typical, common, and customary version of the supply or 

equipment that is used to furnish the services. 

++ Price should be net of typical rebates and/or any discounts available, 

including information regarding the magnitude 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 facilitate 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, using weighted specialty-specific malpractice 

expense percentages and 1991 average allowed charges. Malpractice RVUs for new 

codes after 1991 were extrapolated from similar existing codes or as a percentage of the 

corresponding work RVU. Section 4505(f) of the BBA required us to implement 
CMS-1503-P 93

resource-based malpractice RVUs for services furnished beginning in 2000. Therefore, 

initial implementation of resource-based malpractice RVUs occurred in 2000. 

The statute also requires that we review, and if necessary adjust, RVUs no less 

often than every 5 years. The first review and update of resource-based malpractice 

RVUs was addressed in the CY 2005 PFS final rule with comment period 

(69 FR 66263). Minor modifications to the methodology were addressed in the 

CY 2006 PFS final rule with comment period (70 FR 70153). In the CY 2010 PFS final 

rule with comment period, we implemented the second review and update of 

malpractice RVUs. For a discussion of the second review and update of malpractice 

RVUs see the CY 2010 PFS proposed rule (74 FR 33537) and final rule with comment 

period (74 FR 61758). 

2. Malpractice RVUs for New and Revised Services Effective Before the Next 5-Year 

Review 

Currently, malpractice RVUs for new and revised 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 the 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 the 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 implemented 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 Selected Disc Arthroplasty Services 

As discussed in the CY 2010 PFS proposed rule (74 FR 33539), we assign 

malpractice RVUs to each service based upon a weighted 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 disc arthroplasty (artificial disc), anterior 

approach, including discectomy with end plate preparation (includes osteophytectomy for 

nerve root or spinal cord decompression and microdissection), single interspace, cervical) 

had zero allowed services for CY 2008. Therefore, our contractor 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 separate 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 average physician risk factor would have 

resulted in a significant decrease in malpractice 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 risk 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 code 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 primary procedure)); CPT 

code 63075 (Discectomy, anterior, with decompression of spinal cord and/ or nerve 

root(s), including osteophytectomy; cervical, single interspace); and CPT code 20931 

(Allograft for spine surgery only; structural (list separately in addition to code for 
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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 commenters also brought to our attention that 

other services are clinically similar to CPT code 22856 and have similar work RVUs, and 

therefore, some stakeholders believe these services should all have similar 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 arthroplasty (artificial disc) 

anterior approach, lumbar); CPT code 22864 (Removal of total disc arthroplasty 

(artificial disc), anterior approach, single interspace; cervical); and CPT code 22865 

(Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; 

lumbar). 

After further review of this issue, we are proposing to apply the same risk factor 

used for CPT code 22856 to certain other services within this family of services (CPT 

codes 22857 through 22865) for which there were no allowed services in CY 2008. CPT 

codes 22861 and 22864 had zero allowed services in CY 2008 and 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 factor 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 services under 100). Our policy for low volume 

services is to apply the risk factor of the dominant specialty as indicated by our claims 
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data. We will continue 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 proposed 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 components: 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 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." As discussed in detail 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 these 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 expenses) comprising practice expenses." 
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Section 1848(c)(2)(C)(ii) of the Act specifies 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 resources 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 Care Act was enacted, further requiring the 

Secretary to periodically review and identify potentially misvalued codes and make 

appropriate adjustments to the relative values of those services identified as being 

potentially misvalued. Section 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 review 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 appropriate adjustments. 

As discussed in section I.A.1. of this proposed rule, we establish physician work 

RVUs for new and revised codes based on our review of recommendations received from 

the AMA RUC. The AMA RUC also provides recommendations to CMS on the values 

for codes that have been identified as potentially 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 Subcommittee reviews direct PE (clinical 

labor, medical supplies, and medical equipment) for individual services and examines the 

many broad and methodological issues relating to the development of PE RVUs. 
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In accordance with section 1848(c) of the Act, we determine appropriate 

adjustments to the RVUs, taking into account the recommendations provided by the 

AMA RUC and MedPAC, and publish the explanation 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 other 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, MedPAC 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 hospital services." In that same report MedPAC 

postulated that physicians' services under the 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 physician 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 undervalued 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 have 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 misvalued codes. As MedPAC noted in its March 2009 Report to 

Congress, in the intervening years since MedPAC made the initial recommendations, 

"CMS and the AMA RUC have taken several steps to improve the review process." Most 

recently, section 1848(c)(2)(K)(ii) of the Act (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 established 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 'Harvard-valued codes'). 

(7) Other codes determined to be appropriate by the Secretary. 

Section 1848(c)(2)(K)(iii) of the Act (as added 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 potentially misvalued services. In addition, the 

Secretary may conduct surveys, other data collection activities, studies, or other analyses 
CMS-1503-P 101

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 potentially misvalued codes, conduct surveys or 

collect data, and make recommendations 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 processes for consideration of coding changes) 

which may include consolidation of individual services into bundled codes for payment 

under the physician fee schedule. 

b. Progress in Identifying and Reviewing 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 examining 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 RVUs and/or direct PE inputs and, in accordance with 

section 1848(c) of the Act, we determine if the recommendations constitute appropriate 

adjustments to the RVUs under the PFS. Since CY 2009, CMS and the AMA RUC have 

identified over 700 potentially misvalued codes. 

For example, in regards to the first category (codes and families of codes for 

which there has been the fastest growth), 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 services 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 immediately begin a review of the codes on 

this list. Meanwhile, in parallel with CMS' efforts, the AMA RUC also initiated 

processes to identify and review potentially misvalued codes 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, focusing particularly on high-volume codes where 

the PE payments are increasing significantly 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 initiative 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 determine 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 necessary 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 Report to Congress entitled "Reforming the 

Health Care System" and in the context of a discussion about primary care, MedPAC 

acknowledges, "...Efficiency can improve more easily for other types of services, such as 

procedures, with advances in technology, technique, and other factors. Ideally, when 

such efficiency gains are achieved, the fee schedule's relative value units (RVUs) for the 

affected services should decline accordingly, 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 imaging 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 Editorial Panel has established 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 comprehensive 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 potentially 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 review 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 not 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 codes, focusing first on the high-volume, low 

intensity codes (73 FR 38589). In response to our request, the AMA RUC initially 

conducted an analysis of Harvard-valued services with utilization above 10,000 services 

per year, which resulted in a list of 296 distinct 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 services and also noted that of the 296 services 

identified, 23 had already been identified by another screen and were in the process of 

being reviewed (73 FR 69883). To date, the 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 potentially misvalued codes mentioned in section 

1848(c)(2)(K)(ii) (as added by section 3134 of the 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 valuation of both the site-of-service anomaly codes 

and the "23-hour stay" codes are developed 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 codes 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 RUC has also established screens to identify 

potentially misvalued codes in additional categories, 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 RUC 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 identified 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 period (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 RUC valuations for these site-of-service 

anomaly codes on an interim basis through CY 2010, we had ongoing concerns about the 

methodology used by the AMA RUC to review these services (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 reexamine 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 continue 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 relative value units under the PFS. The validation 

process may include validation of work elements (such as time, mental effort and 

professional judgment, technical skill and physical effort, and stress due to risk) involved 

with furnishing a service and may include validation of the pre, post, and intra-service 
CMS-1503-P 108

components of work. The Secretary is directed to validate a sampling of the work RVUs 

of codes identified through any of the seven categories of potentially misvalued codes 

specified by section 1848(c)(2)(K)(ii) (as 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 RVUs of services. Currently, while CMS does 

assess the AMA RUC- recommended work RVUs to determine if the recommendations 

constitute appropriate adjustments to the RVUs under the 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) (as added by section 3134 of the ACA). 

Therefore, we are soliciting public comments on this proposed rule on possible 

approaches and methodologies that we should consider 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 comments and other input from stakeholders 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-service 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 and 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 claims 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 misvalued 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 category for identifying potentially misvalued 

codes. An example of a high multiple/low work RVU service is CPT code 95004 
CMS-1503-P 111

(Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type 

reaction, including test interpretation and report by a physician, 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 conjunction with the threshold for work RVUs 

of 0.5 RVUs or less, would produce a reasonable 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 general 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 complex 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 that 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 potentially 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 codes would have been valued to include the 

inpatient physician work provided, 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 revised work RVUs for 29 codes for CY 2009 

and 11 codes for CY 2010 that were identified 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 with 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 hospital discharge day management services 

(that is, the "building blocks" of the code) are warranted in the revaluation of the code, 
CMS-1503-P 114

we asked the AMA RUC to adjust the site-of-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 and post-service times of the code under review, the AMA RUC 

should also make associated work RVU adjustments 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 rules 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 concerns about the methodology used by the 

AMA 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 would continue to examine these codes and 

consider whether it would be appropriate to propose additional changes in future 

rulemaking. 

Accordingly, in preparation for CY 2011 rulemaking, we conducted a 

comprehensive analysis of the codes that the AMA RUC reviewed for CYs 2009 and 

2010 due to site-of-service anomaly concerns. We systematically applied the reverse 
CMS-1503-P 115

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

as follows: 

● First, we obtained the original work RVU 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 associated 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 particular pre-, intra-, or post period. For the intensity of the 

intra-service period, we utilized the original IWPUT associated with the code. The AMA 
CMS-1503-P 116

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

service for the site-of-service anomaly codes. That is, CPT code 99238 (Hospital 

discharge day management; 30 minutes 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 original 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 period 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 visit 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. 
CMS-1503-P 117

TABLE 12: 

PreService 

Time 

Median 

IntraService 

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 hospital visits and reduced the outpatient 

visits from 6 to 4 visits. Table 13 shows the building blocks that were recommended for 

CY 2009 by the AMA RUC after its review of the code for site-of- service anomalies. 

TABLE 13: 

PreService 

Time 

Median 

IntraService 

Time 

Immediate 

PostService 

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 that 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 determined 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 the site-of-service anomaly code. Table 14 

shows the RVU changes to the building blocks that were calculated based on the 

methodology discussed above. 

TABLE 14: 

Pre-Service 

Time 

Median 

IntraService 

Time 

Immediate 

PostService 

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 applied 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 Codes1 

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 
CMS-1503-P 119

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 Codes2

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 block 

methodology produced a value that is somewhat lower than the AMA RUCrecommended value. While our results suggest that the majority of the codes with siteof-service anomalies continue to be overvalued under the AMA RUC's most recent 

recommendations, we also found that the methodology may produce a result that is 

considerably reduced or, in several cases, a negative value. We understand that in 

previous years, stakeholders have expressed confusion as to why the application of a 

building block methodology would produce negative values. We believe in some cases, 

the starting value, that is, the original work RVU, may have been misvalued using 
CMS-1503-P 120

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 reverse building block methodology could produce 

aberrant results. Furthermore, in some cases, we noticed that the original IWPUT of the 

code was negative even before the code was reviewed by the AMA RUC for a site-ofservice anomaly. A negative 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 where 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 building block methodology is an objective 

way to account for changes in the resources 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 example, we recognize that the AMA RUC 

looks at families of codes and may assign RVUs based on a particular code ranking 

within the family. This method of valuing services preserves relativity within the relative 

value scale for that code family. However, we have stated that we believe the relative 
CMS-1503-P 121

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 the extensive expertise provided by the AMA 

RUC to recommend appropriate 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 value 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 requesting 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 the 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 the 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 believe is consistent with the work for the service, we are 

proposing to adopt the CY 2011 reverse building 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 building blocks of the code so that a new valuation can be 

determined based on the building block methodology. For such codes, if the revised 

recommendations that we would hope to receive from the AMA RUC are still not 

consistent with the building block methodology upon revision, because we cannot pay for 

these services based on negative work RVUs, we are proposing to modify the AMA 

RUC-recommended values for these codes as CMS 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 block 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 block methodology would be more likely to meet 
CMS-1503-P 123

the standards of a systematic RVU validation process that could 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 services and expressed concern that the value of evaluation and 

management (E/M) visits for inpatients was inappropriately included in the valuation of 

codes that qualify as "23-hour stay" outpatient services. 

We received a number of comments in response 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 inpatient E/M visits to be appropriate in the 

valuation of this category of codes. 

We believe that the 23-hour stay issue encompasses several scenarios. The 

typical patient is commonly in the hospital for less than 24 hours, which often means the 

patient may indeed stay overnight in the hospital. On occasion, the patient may stay 

longer than a single night in the hospital; however, in both cases, the patient is considered 

for Medicare purposes to be a hospital outpatient, not an inpatient, and our claims data 
CMS-1503-P 124

support that the typical 23-hour stay service 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 typically associated with an inpatient service. For 

example, inpatient E/M visit codes such as CPT codes 99231 (Level 1 subsequent 

hospital care, per day); 99232 (Level 2 subsequent hospital care, per day); and 99233 

(Level 3 subsequent hospital care, per day), should not be included at 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 hours or less. In contrast, for those outpatient 

services where the AMA RUC believes that the 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 associated with an inpatient service. In the 2010 

PFS proposed and final rule with comment 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 
CMS-1503-P 125

post-procedure period when care is furnished for 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 patient would typically be cared for by the 

physician furnishing the procedure during that post-procedure period. While we do not 

believe that post-procedure hospital "visits" would be at the inpatient level since the 

typical case is an outpatient who would be ready to be discharged from the hospital in 23 

hours or less, we agree that the intra-service 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 hospital 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 
CMS-1503-P 126

*

 Value associated with 1/2 hospital discharge day management service. 

 ** Value associated with an inpatient 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 relative 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 codes is best applied within the context of 

relativity. We appreciate that the AMA RUC has the ability to assess the 23-hour stay 

code after application of the 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 appropriate valuation 

of the physician work for these services. 

4. Expanding the Multiple Procedure Payment 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 furnished to the same patient by the same 

physician on the same day, largely based on the presence of efficiencies in the PE and 

pre- and post-surgical physician work. Effective January 1, 1995, the multiple procedure 

payment reduction (MPPR) policy, with the same percentage reduction, was extended to 

nuclear medicine diagnostic procedures (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. 
CMS-1503-P 127

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 and subsequent imaging procedures, there are 

some efficiencies in clinical labor, supplies, and equipment time. In particular, certain 

clinical labor activities 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), and ultrasound services within 11 families of 

codes based on imaging modality and body region. When we adopted the policy in 

CY 2007, we stated that we believed efficiencies 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 second and subsequent procedures, potentially 

yielding resource savings in areas such as clerical time, technical preparation, and 

supplies (70 FR 45850). Therefore, the MPPR policy currently applies only to 

procedures involving contiguous body areas within 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 and to the TC of global services, it does not 

apply to professional component (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 
CMS-1503-P 128

additional procedure when an MPPR scenario applies. We had originally planned to 

phase in the MPPR policy over a 2-year period , 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 the PFS payment amount for most imaging 

procedures at the amount paid under the hospital 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 examine 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 final 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 pairs that have the most impact on Medicare 

spending. 
CMS-1503-P 129

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

services under the PFS. MedPAC indicated that it would explore 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 planned 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 warranted. 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 Imaging 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 expansions 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 addressed 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 same session through a single composite 

ambulatory payment classification (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 provided examples to illustrate that we would not 

expect second and subsequent imaging services of the same modality involving 

noncontiguous body areas to require duplicate facility resources (comparable to the TC 

under the PFS) for clinical labor activities such as greeting the patient, providing 

education and obtaining consent, 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 contiguous 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 
CMS-1503-P 131

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 policy in a way that is consistent with the 

standard PFS MPPR policy for surgical procedures 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, and 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 unlikely 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 policy 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 procedure of the same modality to be furnished 

across families and, like the scenario for hospital outpatient imaging services, we would 

expect efficiencies to occur in these cases. Therefore, we believe that an expansion of the 

current imaging MPPR policy to account for efficiencies in such situations would allow 

us to pay more appropriately for these multiple imaging procedure sessions, consistent 

with our ongoing efforts to address misvalued services. 
CMS-1503-P 132

The proposed expansion of the imaging MPPR policy to include all of the current 

codes in a single family to which the standard 50 percent reduction 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 more 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 budget 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 addresses "single-session imaging 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 (CT) colonography, diagnostic, including 

image postprocessing; with contrast 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 effective date of January 1, 2010. These codes 

replaced CPT code 0067T (Computed tomographic (CT) colonography (ie, virtual 
CMS-1503-P 133

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, the reduced expenditures attributable to the 

MPPR for combinations of multiple imaging procedures that we are proposing for CY 

2011 (the MPPR for multiple imaging procedures not involving consecutive body parts) 

would be subject to budget neutrality adjustment under the PFS. We note that this 

formulation for whether reduced expenditures are exempt from budget neutrality applies 

both to procedures currently subject to the 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 are 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 these 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 
CMS-1503-P 134

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 appropriate 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 labor 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 session. 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 several 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 
CMS-1503-P 135

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 Table 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 modifiers to be reported, specifically -GP 

(Services rendered under outpatient physical therapy plan of care); -GO (Services 

rendered under outpatient occupational 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 therapy" 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 the patient on the same day. In the case of 

contractor-priced codes, there is no nationally established pricing 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
CMS-1503-P 136

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. 
CMS-1503-P 137

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 group of services that may sometimes 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 database based on one-half of the total PE inputs 

required for two services provided in a single session, which would account for some 

duplication, this was not the case for all combinations of therapy services. Of the high 

volume therapy services examined, approximately 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 
CMS-1503-P 138

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/counseling/coordinating home care; greet patient/provide gowning; 

obtain measurements, for example, ROM/strength/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 data for these sample code pairs include 

over 3.4 million pairs of CPT codes 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 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 (Manual therapy techniques (e.g., 

mobilization/manipulation, manual lymphatic drainage, manual traction), 1 or more 

regions, each 15 minutes). 
CMS-1503-P 139

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 Reduction

pack, minimum multispecialty visit$1.14 0.5 0.5 0 

Thera-bands (6in width) $0.06 1.5 1.5 1.5 
CMS-1503-P 140

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 labor tasks that were not duplicated. For 

example, for CPT code pair 97001 and 97140 the following tasks were not duplicated: 

post treatment patient assistance; prep and position patient; and 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 
CMS-1503-P 141

applicable to the combination of services. We estimated no reduction for equipment 

time, even though efficiencies would be expected 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 allocated 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 services 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 clinical labor activities and supplies as shown 

in the code combination examples, we believe it would be appropriate 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 therapy 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 beneficiaries would typically have 

more than one therapy session in a single day, we are proposing to apply the 50 percent 

MPPR policy to the PE component of subsequent 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 MPPR 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 
CMS-1503-P 142

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 would 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 furnished 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 health agencies, comprehensive outpatient 

rehabilitation facilities (CORFs), and other entities that are paid by Medicare for 

outpatient therapy services. Table 20 provides 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 commonly furnished together by taking into 
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account the duplicative clinical labor activities and supplies in the PE that are not 

furnished more than once in the single therapy 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 policy is responsive to Congressional concerns 

about significant growth in therapy spending and to MedPAC and GAO 

recommendations regarding the expansion of MPPR policies under the PFS to account 

for additional efficiencies. We note that paying 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 reduced therapy expenditures, and beneficiaries 

would be able to receive more medically necessary 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 supplies that are direct PE inputs in the PE 

database for services paid under the PFS because of their speculation that prices for these 

items may decrease over time as competition increases and new technologies disseminate 

into medical practice. MedPAC in particular has perennially noted that it is important for 

CMS to update the prices of high-priced supplies 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-cost supplies included in the direct PE 
CMS-1503-P 144

database are from 2004 or earlier. There are currently 62 unique supplies with prices of 

$150 or more 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/. 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, and 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), and specialty societies or other relevant 

organizations would provide acceptable documentation supporting the pricing for the 

supplies during the 60-day public comment period. Furthermore, in that same proposed 

rule (73 FR 38582), we provided guidance on what constitutes valid, reliable 

documentation that reflects the typical price of the high-cost item in the marketplace. We 

outlined examples of acceptable documentation, such as a detailed description (including 

system components), sources, and current pricing information, confirmed by copies of 

catalog pages, invoices, and quotes from manufacturers, vendors, or distributors. We 

indicated that documentation that does not include specific pricing information such as 
CMS-1503-P 145

phone numbers and addresses of manufacturers, vendors, or distributors or Web site links 

without pricing information would not be acceptable. We also noted that if acceptable 

documentation was not received within the proposed rule's 60-day public comment 

period, we would use prices from the Internet, retail vendors, and supply catalogs to 

determine the appropriate cost, and that we would 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 comment period (73 FR 69882), we indicated 

that we received many comments on the proposed process and, while some commenters 

expressed support, others believed the proposed process was 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 manufacturer 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 appropriate, typical supply prices for our PFS 

payment methodology that prices the typical service described by a HCPCS code. Rather 

than finalizing the proposed process for updating 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 independent contractor to assist us in obtaining accurate pricing 

information. Furthermore, we informed the public that we planned to study the 

limitations of available pricing data and determine how to revise our proposed process to 
CMS-1503-P 146

elicit better data. 

In the CY 2010 PFS proposed rule and 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 comments on the process. In the CY 2010 PFS 

final rule with comment period, we acknowledged commenters' general support for an 

initiative to ensure accurate pricing of high-cost supplies. In general, the commenters 

strongly preferred a transparent and public process, and we stated that we would consider 

this perspective as we explore the best way 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 intention 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 Research, research pricing information for the 65 

high-cost supplies listed in the CY 2009 proposed rule (73 FR 38583 through 38585) and 

determine what, if any, pricing information reflecting typical market prices could be 

obtained for these high-cost supplies. 

We first requested that the contractor explore publicly available sources to obtain 

typical market prices for these supplies. The contractor utilized supply vendor catalogs 

and web sites and directly contacted vendors, manufacturers, group purchasing 
CMS-1503-P 147

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 match a description of a high-cost supply and/or more than 

one possible vendor or manufacturer was identified, 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 included one item inadvertently listed twice (CMS Supply Code 

SD207 (suture device for vessel closure(Perclose A-T)) and one item (CMS Supply Code 

SH079 (collagen implant)) that was deleted from the PE database after CY 2007 because 

it was no longer used as an input for any codes. While the contractor was able to obtain 

prices for 37 of the 62 unique supplies, the contractor was unable to obtain pricing 

information for the remaining 25 supplies. Documentation 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 pricing information. For the remainder, while the contractor 

was given price quotes over the phone, the sales agents or customer service 

representatives declined to provide any form 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 maximum 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 majority of the medical supplies that were 

researched, specifically 23 supplies with higher prices, 8 with lower prices, and 3 with 
CMS-1503-P 148

the same price. The high-cost supplies studied 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 
CMS-1503-P 149

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 microwave 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 
CMS-1503-P 150

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 
CMS-1503-P 151

CMS 

Supply 

Code 

Supply Description 

Current 

Database 

Unit 

Price 

Associated 

CPT 

Codes 

SD193 plate, surgical, rigid comminuted fracture $389 21461, 

21462 

SD204 sensor, pH capsule (Bravo) $225 91035 

SD205 sheath, endoscope ultrasound balloon $154 31620 

SD207 suture device for vessel 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 and direct contact with vendors, manufacturers, and GPOs. 

We note that the GSA establishes long-term government-wide contracts with commercial 
CMS-1503-P 152

firms for many products, negotiating contracts 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 cases, are established through competition. The 

GSA schedule is an open solicitation 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 substantial 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 add or delete products from the schedule. 

Depending on the aggregate cost estimate associated 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 authority to the Department of Veterans Affairs 

(VA) to procure medical supplies under the VA Federal Supply Schedules Program. 

Using the GSA general search engine under the category "Laboratory, Scientific, 

& Medical" available at 

https://www.gsaadvantage.gov/advgsa/advantage/main/start_page.do the contractor 

obtained nine prices for items similar to the high-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 prior work did not yield an updated price. 

We believe that additional items that are similar to the high-cost supplies in the PE 

database and that may be used with the same procedures may be on the GSA schedule but 

we are still working through the crosswalk between our supplies and the way the supplies 

are presented on the GSA schedule. Examples of high-cost supplies in the PE database 

that the contractor located on the GSA schedule include: (1) kit, capsule, ESO, 
CMS-1503-P 153

endoscopy w-application supplies (ESO), priced 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 use in a refined process for updating the prices 

of high-cost supplies. For historical context, CMS has previously proposed to use VA 

prices that result from the competitive marketplace as comparison points to limit the 

Medicare prices for oxygen and certain items of durable medical equipment and 

prosthetic devices (62 FR 38100 through 38107, and 64 FR 44227 through 44231) in 

1997 and 1999, respectively. These prior proposals were based on our determination that 

the Medicare payment amounts for these items as durable medical equipment or 

prosthetics (not as physicians' services) were not inherently reasonable. We note, 

however, that our current interest in the GSA schedule for pricing high-cost supplies for 

payment of physicians' services is not based on considerations of inherent 

reasonableness, and we do not actually pay the prices in the PE database for supplies 

under the PFS. 

We further note that public commenters 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 have 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 over 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 
CMS-1503-P 154

previously established. Individual vendors do not always publish their product prices or 

provide typical discounts. Moreover, discounts may vary depending on suppliers and the 

volume of supplies purchased. Our understanding of the GSA medical supply schedule is 

that the publicly listed fair and reasonable prices 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 estimate 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, available on the CMS Web site as noted earlier in 

this section, and the corresponding supplies or alternative 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 the GSA schedule. 

At this time, we would like to describe a refined process for regularly updating 

prices for high-cost supplies under the PFS and solicit comments on how we could 

improve on this process. The process could occur every 2 years beginning as soon as 

CY 2013, although we note that we would propose the refined process through 

rulemaking before revising the prices for any high-cost supply item based on the GSA 

schedule. We could also consider establishing 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 
CMS-1503-P 155

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 supply schedule. Since the medical community 

would have several years to examine the GSA medical supply schedule before the refined 

process would be adopted, and we have found no apparent limitations on vendors placing 

products on the GSA schedule, beyond the schedule'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 may currently be missing from the GSA medical 

supply schedule would be included before CMS 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 access 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 percent reduction). We believe that this refined 

process is desirable because it is consistent with commenters' repeated requests for the 

updating methodology to be transparent and predictable. 

Moreover, the VA (with responsibility delegated by the GSA) determines whether 

prices are fair and reasonable by comparing the prices and discounts that a company 

offers the government with the prices and discounts that the company offers to 

commercial customers. Therefore, using the 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 
CMS-1503-P 156

not on the GSA schedule based on general price 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 have the opportunity to provide 

their price to the public on the GSA schedule 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 discussed above, including all aspects of the 

price update methodology that we have presented. Moreover, we believe a similar 

approach could potentially be appropriate to update the prices for other supplies in the PE 

database that would not fall under our definition of high-cost supplies, and we welcome 

further public comments on that possible extension. We also invite further suggestions 

for alternative approaches to updating high-cost supply prices, specifically those that 

would result in a predictable, public, and transparent 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 office 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 
CMS-1503-P 157

physician work GPCIs reflect only one-quarter of the relative cost differences compared 

to the national average. In addition, section 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 and, 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 adjustment over 2 years, applying only one-half 

of any adjustment in each year. As discussed in the CY 2009 PFS final rule with 

comment period (73 FR 69740), the CY 2009 adjustment to the GPCIs reflected the fully 

implemented fifth comprehensive GPCI update. CY 2010 would have typically included 

no adjustments to the GPCIs. However, section 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, which 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 receive 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 section 10324(c) of ACA) establishes a 1.0 PE GPCI floor for 

services furnished in frontier States effective 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 calculated 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. 
CMS-1503-P 158

For the CY 2011 PFS proposed rule, we have completed the sixth review of the 

GPCIs and are proposing new GPCIs. We note that section 1848(e)(1)(E) of the Act (as 

amended by section 3102(a) of ACA) extends the 1.0 work GPCI floor only through 

December 31, 2010. Under current statute, the 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 Alaska 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 required by the statute, the 1.5 work GPCI floor 

for Alaska and the 1.0 PE GPCI floor for frontier 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 section 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 the 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. Additionally, each of the three GPCIs relies 
CMS-1503-P 159

on its own data source(s) and methodology for calculating 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 used 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 physician 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 the PE GPCIs section. As noted 

above, the 1.0 work GPCI floor is set 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 
CMS-1503-P 160

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 compared to the national average. Additionally, 

under section 1848(e)(1)(H)(iii) of the Act (as added by section 3102(b) of the ACA), 

each PFS locality is held harmless 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 section 3102(b) of ACA), the employee compensation and rent 

components of the proposed CY 2011 PE GPCIs were 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 differences 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 provisions of the Act, we calculated transitional 

PE GPCIs based on two scenarios. Under the 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 recognition of cost differences were calculated 
CMS-1503-P 161

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 differences. The first 

scenario represents the transitional PE GPCI values prior to the limited recognition of 

cost differences. In other words, this scenario does not include the effects of sections 

1848(e)(1)(H)(i) and (ii) of the Act (as 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 transitional PE GPCI values with the limited 

recognition of cost differences were calculated using one-half of the CY 2010 PE GPCIs 

with the limited cost differences and one-half of the updated PE GPCIs with the limited 

cost differences. The hold harmless provision 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 calculated with the limited recognition of cost 

differences or the CY 2011 transitional PE GCPI 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 illustrated 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 
CMS-1503-P 162

Section 1848(e)(1)(H)(iv) of the Act (as added by section 3102(b) of ACA) also 

requires the Secretary to "analyze current methods of establishing practice expense 

adjustments under subparagraph (A)(i) and evaluate data that fairly and reliably 

establishes distinctions in the cost of operating a medical practice in different fee 

schedule areas." This section also requires the Secretary to make appropriate adjustments 

to the PE GPCIs no later than by January 1, 2012. To implement this statutory 

requirement, we are proposing to implement changes in PE data sources and cost share 

weights discussed herein effective 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 current methods and data sources used in the 

establishment of the PE GPCIs. With respect 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 significant 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 public comments we have received on the PE GPCIs for 

previous updates, we note that the commenters 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 latter issue (incentivizing the provision of care) 

is outside the scope of the statutory requirement that the PE GPCIs reflect the relative 

costs of the mix of goods and services comprising practice expenses in the different fee 
CMS-1503-P 163

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 and the cost share weight assigned to this 

component. Most significantly, we are proposing that the weight for the office rent 

component be revised from 12.209 percent to 8.410 percent to reflect 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 for 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 discussed 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 equivalent 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 differences beginning in CY 2011. We are 

proposing to assign other newly defined components 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 discussed later in this section, the medical 

equipment, supplies, and other miscellaneous expenses component of the PE GPCIs is 

assumed to have a national market and, therefore, this component is not adjusted for local 

area cost differences. 
CMS-1503-P 164

The proposed expense categories for the PE GPCIs, along with their respective 

cost share weights, are primarily derived 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 medical organizations and captures the costs of 

operating a medical practice, including office rents and nonphysician staff wages. 

Moreover, we also examined the feasibility of using the American Community 

Survey (ACS) and the Bureau of Labor and Statistics (BLS) Occupational Employment 

Statistics (OES) data for the employee compensation component of the PE GPCI. For 

previous updates, the employee compensation component was based on the 2000 

Decennial Census long form data. Since the Census data are significantly outdated and 

the 2010 Census no longer includes occupational wage data, we believed the ACS or 

BLS OES data might be viable alternatives. While the ACS 3-year public use 

microsample (PUMS) is currently 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 pharmacists 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 ACS 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 (including commercial rental 

data and survey data) for use in calculating the PE GPCIs. We could not identify a 
CMS-1503-P 165

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

We do not believe there is a national data 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 distinctions in the cost of operating a 

medical practice in the different fee schedule areas meet the statutory requirements of 

section 1848(e)(1)(H)(iv) of the Act (as added by section 3102(b) of ACA). A more 

detailed discussion of our analysis of current methods of establishing PE GPCIs and 

evaluation of data sources is included in Acumen’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 Index (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 various 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 
CMS-1503-P 166

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 the professional liability insurance category 

weight of 4.295 percent. Therefore, the proposed cost share weight for the PE GPCIs is 

47.439 percent. For the employee compensation 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 miscellaneous expenses component, we removed 

professional liability (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 for the medical equipment, supplies, and other 

miscellaneous expenses component 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 the professional liability 

insurance weight of 4.295 percent was used for 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 requirements of section 1848(e)(1)(H)(iv) of the 

Act (as added by section 3102(b) of ACA). 

The proposed cost share weights for the 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 subparagraph (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 determined 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 persons 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 excludes Alaska and Hawaii from qualifying as 

a frontier State). 

Consistent with the proposed FY 2011 hospital 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 definitions based upon the most recent annual 

population estimates published by the U.S. Census Bureau. We divide each county’s 
CMS-1503-P 168

population total by each county’s reported land 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 publication of a subsequent 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 section 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 according 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; North Dakota; Nevada; and South Dakota (as 

reflected in Table 23). 

Table 23. Frontier States Under Section 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 components: employee compensation, office rent, 
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and medical equipment, supplies and miscellaneous 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 physician office rents. Office rent accounts for 

17.7 percent of the PE GPCIs. 

(iii) Medical Equipment, Supplies, and other Miscellaneous Expenses: We assumed that 

items such as medical equipment and supplies 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 market differences. Medical equipment, 

supplies, and miscellaneous expenses are factored into the PE GPCIs with a component 

index of 1.000. The medical equipment, supplies, 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 reflects 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, the 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 mentioned above, the proposed CY 2011 updated GPCIs for the first 

year of the 2-year transition and summarized GAFs are displayed in Addenda D and E to 

this proposed rule. 

3. Payment Localities 

The current PFS locality structure was 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 structure is described in detail in the CY 1997 PFS 

proposed rule (61 FR 34615) and the subsequent 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 the locality configuration 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 considered making changes to localities without 

the support of a State medical association in order to demonstrate consensus for the 

change among the professionals whose payments would be affected (with some 

increasing and some decreasing). However, we have recognized that, over time, changes 
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in demographics or local economic conditions may lead 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 recent 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 address 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 final rule with comment period, we 

contracted with Acumen to conduct a preliminary study of several 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/PhysicianFeeSched/10_Interim_Study.asp#TopOfPage. 

We accepted public comments on the interim report through November 3, 2008. 

The alternative locality configurations discussed in the report are described 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 Management 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 Medicare 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 counties 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 result, 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 (separate 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 with comment period (74 FR 61757). 

E. PFS Update for CY 2010

1. Rebasing and Revising of the 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 after 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 economic 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 physicians' services. The MEI is a fixed-weight 

input price index, with an adjustment for the change in economy-wide, private nonfarm 
CMS-1503-P 174

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 was detailed in the November 25, 1992 Federal 

Register (57 FR 55896) and was based in part on the recommendations of a 

Congressionally-mandated meeting of experts held in March 1987. Since that time, the 

structure of the MEI has remained essentially unchanged, with three exceptions. First, 

the MEI was rebased in 1998 (63 FR 58845), which moved the cost structure of the index 

from 1992 data to 1996 data. Second, the methodology 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 economy-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 price index, while revising relates to other types 

of changes such as changing data sources, cost categories, or price proxies used in the 

input price index. As is always the case with 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 weights 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 rebasing and revising of the MEI. 
CMS-1503-P 175

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 base 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 periodically rebase and revise the index so that the expense 

shares and their associated price proxies reflect more current conditions. For this reason, 

we propose to rebase the MEI to reflect appropriate physicians’ expenses in 2006. 

We are proposing several changes to the expenses that are eligible to be included 

in the MEI. For instance, we are proposing to remove all costs related 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 Sustainable Growth Rate (SGR) 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 final rule with comment period (74 FR 33651 

and 74 FR 61961, respectively). Additionally, we are proposing to remove costs 

associated with separately billable 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-factor productivity. 
CMS-1503-P 176

c. Rebasing and Revising Expense 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 update. The proposed expense categories in the 

index, along with their respective weights, are primarily derived from data collected in 

the 2006 AMA Physician Practice Information Survey (PPIS) for self-employed 

physicians and selected self-employed non-Medical 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, physicians’ benefits, employed physician payroll, 

nonphysician compensation, office expenses, professional liability insurance (PLI), 

medical equipment, medical supplies, and all 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 Internal 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 expense 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 available; 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 weights) 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 provided below in this 

section. In addition, we are proposing to exclude 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 composition of expense categories based on the 

criteria used to develop the current MEI and other CMS input price index expenditure 

weights. These criteria are timeliness, reliability, relevance, and public availability. 

Table 24 lists the set of mutually exclusive and exhaustive cost categories that make up 
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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)
CMS-1503-P 179

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 Survey (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 the 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 physicians and for the selected self-employed 

specialties referenced previously in this rule. 

We are proposing to continue to add employed physician compensation to selfemployed physician compensation in order to calculate an aggregate Physician 

Compensation cost weight. By including the compensation of employed physicians in 

the physician compensation expense category, these expenses will be adjusted by the 

appropriate price proxies for a physician’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 compensation component into subcategories: 

Wages & Salaries; and Benefits. For Physician Compensation, the ratio for Wages & 

Salaries and Benefits was calculated using data from the PPIS. Self-employed physician 

wages & salaries accounted for 92.3 percent of physician earnings while physician 

benefits accounted for the remaining 7.8 percent. For employed physician payroll, the 

distribution for wages & salaries and benefits 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 proposed 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 Practice Expenses cost weights, we use 

mean expense data from the 2006 PPIS survey. The detailed explanations for the 

derivation of the individual weights under Practice Expenses are listed below. 

(A) Nonphysician Employee Compensation 

The cost weight for Nonphysician Employee Compensation was developed using 

the 2006 AMA PPIS mean expenses for these costs. We further divided this cost share 

into Wages & Salaries and Benefits using 2006 BLS Employer Costs for Employee 

Compensation (ECEC) data for the Health Care and Social Assistance (private industry). 

Although this survey does not contain data specifically 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 assistance services (which include hospitals, 

nursing homes, offices of physicians, and offices 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 ECEC 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 split of 74.0 percent and 

26.0 percent of compensation. 

As in the 2000-based MEI, we are proposing to use 2006 Current Population 

Survey (CPS) data and 2006 BLS Occupational Employment Statistics (OES) data to 

develop cost weights for wages for nonphysician occupational groups. We determined 

total annual earnings for offices of physicians using employment data from the CPS and 

mean annual earnings from the OES. To arrive at a distribution for these separate 

categories, we determined annual earnings for each of the four categories (which are 

Professional & Technical workers, Managers, Clerical workers, and Service workers), 
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using the Standard Occupational Classification (SOC) system. We then determined the 

overall share of the total for each. The proposed 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 expenditure share is directly related to a 

decrease in the total number of employees in Management occupations 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 that 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 employees 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 the BEA 2002-Benchmark I/O data for Offices of 

physicians, dentists, and other 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 systems (including information management 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 Office Expenses. The methodology we used to 

age the data forward involved applying the 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 resulting 2006 distributions to the aggregate 2006 

AMA Office Expenses weight to yield the 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 intent to derive an increased 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 rule. 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, and 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 paper, paperboard, and sanitary paper products) 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 manufacturing industry (accounting for about 

45 percent of the chemical expenses), as well as other chemical industries including but 

not limited to industrial gas manufacturing and all other chemical product 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 rubber 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 Rubber and Plastics is 0.563 percent. 

● Telephone: The telephone cost weight includes expenses classified in the 

telecommunications (accounting for the majority of the telephone expenses) and cable 

industries. The proposed cost weight for Telephone services is 1.415 percent. 

● Postage: The Postage cost weight includes 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, nonresidential 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 for 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 limited to, computer equipment and software, 

as well as the rental and leasing of automotive and industrial machinery equipment. The 

proposed cost weight for Moveable 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 update to the level of coverage purchased by 

physicians in 2006 compared to 2000. 

(D) Medical Equipment Expenses 

The proposed weight for Medical Equipment was calculated using the 2006 AMA 

PPIS mean expense data. This calculation resulted 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-deductible portion of the purchase price or 

replacement value of medical equipment, if not leased. 

(E) Medical Supplies Expenses 

The proposed weight for Medical Supplies was calculated using the 2006 AMA 

PPIS mean expense data. This calculation resulted 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 medical supplies such as sterile gloves, needles, 

bandages, specimen containers, and catheters. Additionally, we are proposing to exclude 

the expenses related to separately billable supplies as these expenses are not paid for 

under the PFS. The Medical Supply cost category does not include expenses related to 

drugs. 

(F) All Other Professional Expenses 

The proposed weight for All Other Professional 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 category from the PPIS. These expenses would 

include fees related to legal, marketing, accounting, billing, office management services, 

professional association memberships, maintenance of certification or licensure, journals 

and continuing education, professional car upkeep and depreciation, and any other 

professional expenses not reported 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 proxies to evaluate their appropriateness. 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 industries, as well as for the nonfarm business 

economy. They are calculated by dividing gross payrolls for wages & salaries by total 

hours. The series reflects shifts in employment 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 occupations 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 variable 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 the 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 defined (in terms of service, commodity, or 

geographic 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, timeliness, 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 Physician Wages & Salaries component (BLS 

series code: CEU0500000008). 

As discussed extensively in the November 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 quantity 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 sector 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 the 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 groups shown in Table 23. The 2000-based 
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MEI was based on CPS data for the Standard Industrial Classification 801 and 803, 

which included both office of physicians and 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 Collar 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 revised 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 weights used to construct 

the 2006 composite benefit index. 

TABLE 26: CMS Composite Price Index for Nonphysician Employee Benefits 

ECI series 

2006 

Weight 

Benefits, Private, Professional & Related 44% 

Benefits, Private, Management, Business, Financial 11% 

Benefits, Private, Office & Administrative Support 32% 

Benefits, Private, Service 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. 
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(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 separately in the 2000-based MEI. 

(I) All Other Services 
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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 category. 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 form, but instead is requested directly from, 

and provided by (on a voluntary basis), several national commercial carriers. As we 

require for our other price proxies, the professional 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 occurrence 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-specialty data are aggregated by effective premium date to 

compute a national total, using counts of physicians by State and specialty as provided in 

the AMA publication, Physician Characteristics 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 includes 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-based 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 types of supplies contained 

within these proxies, including such items as bandages, dressings, catheters, I.V. 
CMS-1503-P 194

equipment, syringes, and other general disposable medical supplies, via wholesale 

purchase, as well as at the retail level. Consequently, we are proposing to combine the 

two aforementioned indexes to reflect those modes of purchase. 

(O) Other Professional Expenses 

This category includes the residual subcategory of other professional expenses 

such as accounting services, legal services, office management services, continuing 

education, professional association memberships, journals, professional 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 moving 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 productivity 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, Practice 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 MEI 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 bigger differences between the annual percent 

change in the rebased and revised MEI and the 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 cost weight. The remaining differences are 

attributable to the higher cost weight for 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 1st quarter 2010 forecast by HIS Global Insight. With historical data through the 

4th 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 the second quarter of 2010; therefore, the current estimated 

increase of 0.3 percent for 2011 may differ in the final rule. 

TABLE 29: Forecasted Annual Percent Change in the Current and Proposed 

Revised and Rebased MEI for CY 2011 

 Proposed 2006-Based MEI 2000-Based MEI 

CY 2011 0.3 0.3 
CMS-1503-P 197

TABLE 30: Forecasted Annual Percent Change in the Proposed Revised and 

Rebased MEI CY 2011, All Categories1 

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. The 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 
CMS-1503-P 198

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 advisory panel later this year to review all 

aspects of the MEI, including the inputs, input weights, price-measurement proxies, and 

productivity adjustment. We will ask the panel 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 intended statutory purpose. We are requesting comments from 

the physician community and other interested members of the public on any other 

specific issues that should be considered 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 current data and establish new weights for physician work, 

PE, and malpractice under the MEI. As stated 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 adjustments to ensure that our estimates of 

aggregate PFS payments for work, PE, and malpractice 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 when the MEI has been rebased, we are 

proposing to make adjustments to ensure that estimates of aggregate CY 2011 PFS 
CMS-1503-P 199

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 increasing the proportion of aggregate CY 2011 

PFS payments for PE and malpractice and decreasing the proportion for work. This 

could be accomplished by applying adjustments 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 neutrality 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 factor of 1.168 and the malpractice RVUs by an 

adjustment factor of 1.413. The RVUs in Addendum 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 Act 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 
CMS-1503-P 200

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 annual, per beneficiary combined cap on 

expenses incurred for outpatient physical therapy and speech-language pathology 

services under Medicare Part B. A similar separate cap for outpatient occupational 

therapy services under Medicare Part B also applies. 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 for 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 amended 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 therapy caps (independent of the outpatient hospital 
CMS-1503-P 201

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 outpatient 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 services and outpatient occupational therapy 

services under the statute. The Balanced 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 medical review of claims and revised the 

report requirements in section 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 services based on classification of individuals by 

diagnostic category, functional status, prior 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 defined, but services documented as therapy 

were billed and reported when furnished by a variety of individuals in many different 
CMS-1503-P 202

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 projects 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 Financial Limitations on Outpatient Therapy 

Services" that referenced two utilization analyses. We periodically updated the 

utilization analyses and posted other contracted reports in order to further respond to the 

requirements of the BBRA. Subsequent reports highlighted the expected effects of 

limiting services in various ways and presented plans to collect data about patient 

condition using available tools. The general belief was that if patient condition could be 

reliably determined, an objective payment policy 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 amounts 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 therapy caps based on patient 

condition has proven difficult to develop. The influence of prior 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 services in 2005 improved the consistency of 

records and facilitated chart review, it became 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 basis for equitable payment. We concluded that 

in order to develop alternative 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 professional community to assess the outcomes of 

therapy. Some tool sponsors collected sufficient 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 manual instructions, but 

proprietary tools do not serve CMS’ purposes because modification 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 widely to identify patient conditions and, by 

some insurers, to pay for efficient and effective 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, Inc. 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-performance 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 affecting services to beneficiaries 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 alternatives. 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 effectiveness 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 available on the contractor’s Web site at 

http://optherapy.rti.org/. The data collection design and 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 collection. While approval is pending, the contractor is 

recruiting potential participants in the data collection, developing 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 project contracted to Computer Sciences 

Corporation (CSC) titled "Short Term Alternatives for Therapy Services" (STATS). 

STATS will provide recommendations regarding alternative payment approaches to 

therapy caps that could be considered before completion of the DOTPA project. The 

STATS project draws upon the analytical and clinical expertise of contractors and 

stakeholders to consider policies, 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, will include recommended 

actions we could take within 2 or 3 calendar years to replace the current cap limits on 

therapy services with a policy that pays appropriately for necessary therapy services. 

c. Potential Short-Term Approaches to Therapy Caps 
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On June 30, 2009, we received a draft of the CSC report titled "STATS 

Outpatient Therapy Practice Guidelines," a summary of expert workgroup discussions, 

and several short-term payment alternatives for consideration. CSC discussed options 

based on the assumption that short-term policy changes should facilitate the development 

of adequate function and/or outcomes reporting tools. In the long-term, CSC 

recommended that payment be based on function 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 considerations. 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 this 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 therapy services, taking into consideration the 

expected efficiencies when services are furnished together. While we are not proposing 

the adoption of an MPPR policy for therapy services specifically as an alternative to the 

therapy caps, we acknowledge that by paying more appropriately for combinations of 

therapy services that are commonly furnished 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 about patient function and 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 that 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 measure 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 inform a potential proposal to adopt such an 

alternative through future rulemaking. The second option would involve introducing 

additional claims edits regarding medical necessity, in order to reduce overutilization. 

The third option would be to adopt a per-session 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 necessitate major claims processing systems changes. 

Moreover, some of the options may affect beneficiaries by changing the type or amount 

of services covered by Medicare or the beneficiary’s cost sharing obligations. 

Option (1): Revise therapy caps exceptions process by requiring the reporting of 

new patient function-related Level II HCPCS codes and severity modifiers. 

 This option would require that clinicians submit beneficiary function-related 

nonpayable HCPCS codes to replace the -KX modifier (Specific required documentation 

on file). Codes would not be submitted on every claim, but at episode onset and at 

periodic intervals (for example, progress report 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 severity/complexity would be utilized to report 

information on the claim. 

Examples of six new function-related G-codes: 

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

● GXXXV – Impairments to body functions and/or structures – goal. 
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● GXXXW – Activity limitations and/or participation restrictions – current. 

● GXXXX – Activity limitations and/or participation restrictions – goal. 

● GXXXY – Environmental barriers – current. 

● GXXXZ – Environmental barriers – goal. 

Two potential severity/complexity scales have been suggested that would require 

the adoption of 5 or 7 new severity modifiers, respectively. Under one scenario, 

modifiers based on the International Classification of Function 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 proportional 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 before 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 outpatient 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 modifiers could be mapped to reliable and 

validated measurement tools (either currently available tools in the public domain or 

newly developed tools from items on the DOTPA instrument or the Continuity 

Assessment Record and Evaluation (CARE) tool). When statistically robust patient 

condition information has been collected from claims data, it may be possible to develop 

Medicare payment approaches for outpatient 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 uses 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 percentage of beneficiaries would surpass in 

a single year. Once these levels were reached, 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 years to implement as an expansion of 

existing policy, and its effects could be anticipated by analysis of the current utilization 

of therapy services. Additional practitioner 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 "Evaluation/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 this 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. Furthermore, 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 individual 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 the 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 the 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 could 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 furnished 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 furnished by or under the permissible supervision 

of all qualified outpatient therapy professionals. 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 under 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 conduct 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 practitioner administrative 

burden to learn new codes and update billing 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 would be minimized. This bundled approach to reporting and 

payment could result in more appropriate valuation of therapy services that reflects 

efficiencies when individually reported services are furnished in the same session. As a 

result, it could lead to reduced therapy expenditures, 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 continue to be committed to developing 

alternatives to the therapy caps that would provide appropriate payment for medically 

necessary and effective therapy services furnished 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 allow exceptions to these caps for certain time 

periods, and the current exceptions are automatically processed based on a practitioner’s 

attestation that medical necessity is documented in the chart for an individual patient. 

We believe that, ultimately, payment for therapy services should incentivize the most 

effective and efficient care, consistent with Medicare’s focus on value in its purchasing. 

Therefore, we are soliciting public comments 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 broad variety of clinicians, administrators, 

scientists, researchers, and other contractors to develop the 3 alternatives presented this 

discussion. We welcome all public comments on this propose rule from interested 

stakeholders, including individual therapists from both facility and nonfacility settings 

treating Part B (outpatient) beneficiaries. 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 patient needs, while minimizing payment for 

inefficient services or those of limited patient benefit; 

● Assessment of the practitioner burden associated with the recommended 

policies; 

● Likelihood that recommended changes would minimize fraud, abuse, and 

waste; 

● Whether the recommendations could assist 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 collected and how it could be utilized to 

ensure necessary care, while minimizing payment 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 identifying 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 achieving the best possible results at the lowest cost. 

 Our STATS and DOTPA projects, which are 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 short-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 payment policy for outpatient therapy services to 

align with the value-based purchasing principles 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 continue 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 provided coverage for DSMT in outpatient settings 

without limiting this coverage to hospital outpatient departments. DSMT services consist 

of educational and training services furnished to an individual with diabetes by a certified 

provider in an outpatient setting. 

Section 4105(a) of the BBA stipulated that 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-monitoring of blood glucose; education about diet 

and exercise; an insulin treatment plan developed 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 (Diabetes outpatient selfmanagement training services, individual, per 30 minutes) and G0109 (Diabetes 

outpatient self-management training 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 Clinical Endocrinologists (AACE), the American Association 

of Diabetes Educators (AADE), and the Juvenile Diabetes Research Foundation, to 

include physician work in valuing DSMT services that is similar to the physician work 

that has been included in medical nutrition therapy (MNT) services since CY 2007 and 

kidney disease education (KDE) services since CY 2010. The stakeholders argued that 

because physicians coordinate DSMT programs, provide patient instruction, and 

communicate with referring physicians, physician work should be included in the RVUs 

for DSMT services. The stakeholders also requested 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 should 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 proposing that HCPCS G0108 for 30 minutes of 

individual DSMT services would be crosswalked to CPT code 97803 (Medical nutrition 

therapy; re-assessment and intervention, individual, 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 are 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 individuals(s)), each 30 minutes) for purposes of 

assigning work RVUs. The rationale for 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 modify 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 comment 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 kidney 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 compared 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 services, 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 and 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 DSMT services more consistently with 

other similar services that are paid under the 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 are also proposing to modify the direct PE 

inputs for these codes for CY 2011. 

C. End-Stage Renal Disease Related Services 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 HCPCS G-codes for end-stage renal disease (ESRD) monthly 

capitation payment (MCP) services. For center-based patients, payment for the G-codes 

varied based on the age of the beneficiary and 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 provide 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 home dialysis patient” (68 FR 63219). 

 Effective January 1, 2009, the CPT Editorial 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 codes 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 vignettes used for the valuation of CPT codes 

90963, 90964, 90965, and 90966 include scheduled (and 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 the MCP, we believe that it is clinically 

appropriate for the physician (or practitioner) to have at least one in-person, face-to-face 

encounter with the patient per month. Therefore, 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 described by CPT codes 90963 through 90966). This 

requirement would be effective for home dialysis MCP services beginning January 1, 

2011. We believe this requirement reflects appropriate, high quality medical care for 

ESRD patients being dialyzed at home and generally 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 recommendations 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 accepted 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 parents; 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 counseling 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 counseling of parents; with 1 face-to-face 

physician visit per month 

90957 

End-stage renal disease (ESRD) related 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) related 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 2-3 face-to-face 

physician visits per month 

90959 

End-stage renal disease (ESRD) related 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 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 face-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) related 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 growth and development, and counseling 

of parents 

90964 

End-stage renal disease (ESRD) related 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) related 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) related 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 month of service, per day; for patients younger 

than 2 years of age); 90968 (End-stage renal disease (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 full month of service, per day; for patients 20 

years of age and older). 

For the MCP codes displayed in Table 32, the AMA RUC initially recommended 

36 minutes of clinical labor time for the pre-service period. They also recommended an 

additional 6 minutes in the post-period for CPT codes 90960, 90961, 90962, and 90966. 

For the four codes describing daily services (CPT codes 90967 through 90970), the AMA 

RUC recommended including 1.2 minutes of clinical 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 comment 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 review the physician times for CPT codes 90960 

and 90961 that are used in the calculation of the 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 calculate the PE RVUs for the entire series 
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of MCP codes displayed in Table 32 by using 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 codes 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 the 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 direct PE resources required 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 codes 90960 and 90961. Consistent with the 

AMA RUC’s recommendations, we are proposing to continue to contractor-price CPT 
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codes 90952 and 90953. 

D. Portable X-Ray Set-Up (HCPCS code Q0092)

When a portable x-ray is furnished to a single 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 portable 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 components of the x-ray service itself (CPT 70000 series). 

Currently, the direct PE database 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 the various radiology codes in the 70000 series 

of CPT. In addition, portable x-ray equipment is included as a direct PE input for 

HCPCS code Q0092. Thus, x-ray equipment currently is recognized within the direct PE 

values for two of the HCPCS codes that would 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 technical 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 aerobic 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). Using CPT code 93797 (Cardiac rehab without 

telemetry) as a reference code, we proposed 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 (includes 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 finalized our proposal with modifications to 

the code descriptor and PE inputs, as recommended by some commenters. 

Based on commenters’ recommendations from the CY 2010 PFS final rule with 

comment period and further information furnished 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 with monitoring (CPT code 93798) in view 

of the monitoring required for HCPCS code G0424. 

In addition, we are also proposing to increase the clinical labor time for the 

respiratory therapist from 15 minutes to 30 minutes and to crosswalk the PE equipment 

inputs for HCPCS code G0424 to those for respiratory 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 public 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 furnished 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 Substitutes 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, these products are also used by other specialists in the 

treatment of other clinical conditions, such as burns. 

Many Medicare contractors have established local coverage determinations 

specifying the circumstances under which these 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 are currently 2 skin repair CPT codes that 

describe Apligraf application, one primary code, CPT 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 code for primary procedure)) and 4 codes that describe 

Dermagraft application, two initial codes based on body area, CPT codes 15360 (Tissue 

cultured allogeneic dermal substitute, trunk, arms, legs; first 100 sq cm or less, or 1% of 

body area of infants and children) and 15365 (Tissue cultured allogeneic dermal 

substitute, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or 

multiple digits; first 100 sq cm or less, or 1% of body area of infants and children) and 

two add-on codes, CPT codes 15361 (Tissue cultured allogeneic dermal 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 primary procedure)) and 

15366 (Tissue cultured allogeneic dermal substitute, 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 children, or part thereof (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 applied 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 furnished. In addition, some stakeholders believe 

that the current coding and payment provides a financial incentive for the selection of one 

tissue-cultured product over another, rather than facilitating clinical decision-making 

based solely on the most clinically appropriate product for the patient’s case. For 
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example, the Dermagraft and Apligraf application codes have 90-day and 10-day global 

periods, respectively, and their current values include several follow-up office visits. 

When patients are treated periodically with repeated 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 management 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 different stakeholders have indicated that 

debridement and site preparation are variably performed when these products are applied, 

the CPT codes for Dermagraft application allow separate reporting of these preparation 

services when they are performed, while the Apligraf application codes bundle these 

services. Since CY 2006, the PFS has accepted 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, provide a single payment for a series of 

applications over 90 days or 10 days, as applicable to the particular code reported for the 

product’s initial application. 

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 that 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 appropriate 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 tissue 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) and 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 Apligraf or Dermagraft to the lower limb. 

These codes would not allow separate reporting 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 temporary, while stakeholders work through the 

usual channels to establish appropriate 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 payment on the physician work relative values and 

the direct PE inputs for the existing CPT codes for Apligraf application, with adjustments 

for the global period differences because the HCPCS G-codes and the Apligraf 

application CPT codes. These 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 appropriately 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 HCPCS G-code proposed CY 2011 work values 

by extracting the values for any office visits and discharge day management services 

because the HCPCS G-codes have a 0-day global period. In addition, we would adjust 

the direct PE inputs of the Apligraf application codes to develop the proposed CY 2011 

direct PE inputs of the HPCPS G-codes 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 HCPCPS GXXX2. The proposed direct PE 

inputs for HCPCS codes GXXX1 and GXXX2 are included in the direct PE database for 

the CY 2011 proposed rule that is posted on the CMS Web site at 

http://www.cms.gov/PhysicianFeeSched/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 policies 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 allogeneic skin or dermal substitutes. 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. However, 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 review or other approaches. 

G. Canalith Repositioning (CPT code 95992)

For CY 2009, CPT created a new code for canalith repositioning, specifically CPT 

code 95992 (Canalith 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 therapists 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 stakeholders 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 service, 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 recommendations 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 crosswalk the PE values for CPT code 90471 

(Immunization administration (includes percutaneous, 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 the physician counsels the patient/family; first 

administration (single or combination vaccine/toxoid), per day) and 90473 (Immunization 

administration by intranasal or oral route; one vaccine (single or combination 

vaccine/toxoid)) . 

Similarly, we are also proposing to crosswalk the PE values for CPT code 90472 

(Immunization administration (includes percutaneous, intradermal, subcutaneous, or 

intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) 

(List separately in addition to code for primary procedure)) to CPT codes 90468 

(Immunization administration younger than age 8 years (includes intranasal or oral routes 

of administration) when the physician counsels the patient/family; 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 PFS 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 need to balance the interests of those who commented on the 

work RVUs against the budgetary and redistributive 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 codes that public commenters, typically 

specialty societies, request be subject to refinement, we establish refinement panels with 

representatives from 4 groups of physicians: clinicians representing the specialty most 

identified with the procedures in question; physicians with practices in related specialties; 

primary care physicians; and contractor medical directors (CMDs). Typically the 

refinement panels meet in the summer prior to the promulgation of the final rule 

finalizing the RVUs for the codes. Typical panels have included 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 review potentially misvalued codes and make 

appropriate adjustments 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 accepting so many recommendations of the RUC. 

We believe the refinement panel process continues to provide stakeholders with a 

meaningful opportunity for review and discussion 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 refinement process, including the established 

composition that includes representatives from the 4 groups of physicians, but with 

administrative modification and clarification. Specifically, for refinement panels 

beginning in CY 2011 (that is, for those codes 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 measure 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 concerns 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 comment period (74 FR 61755), we indicated 

that we continued to have concerns about the issue of developing 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 changes will be communicated through future 

rulemaking. 

 Since publication of the CY 2010 PFS final rule with comment period, we have 

focused our additional analysis on four of the CPT codes that commenters have brought 

to our attention because they involve concurrent, remote, 24/7 attended monitoring of 

multiple patients from a central location: CPT code 93012 (Telephonic transmission of 

post-symptom electrocardiogram rhythm strip(s); 24-hour attended monitoring, per 30 

day period of time; tracing only); CPT code 93229 (Wearable mobile cardiovascular 

telemetry with electrocardiographic recording, concurrent computerized real time data 

analysis and greater than 24 hours of accessible 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; technical support for connection and patient 

instructions for use, attended surveillance, analysis and physician prescribed transmission 

of daily and emergent data reports); CPT 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 transmission, 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 jurisdiction. 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 the PPIS data adopted in the CY 2010 PFS final rule with 

comment period. We refer readers to section II.A.2. of this proposed rule for a 

description of the general PFS PE methodology that is the basis for the following 

discussion of approaches to establishing PE RVUs for these four CPT codes. 

We examined several alternative methods 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 from 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 indirect practice cost index value for each code 

based on the PE/HR survey data of the historical mix of specialties providing these 

services. Establishing payment rates for these 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 services that are nationally priced, these 

decreases would be relative to the lower payment 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 specialties performing these 

services, while continuing to treat the centralized monitoring equipment as an indirect 

cost. We found that establishing payment rates 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 typical 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 the 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 the 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 current contractor’s price for CPT code 93229. 

 Finally, we considered proposing contractor-pricing for all four of these services 

for CY 2011. However, we are cognizant of past public comments on this issue that have 
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requested that all of these services be priced 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 was recently reduced in the area where the 

majority of the billings for this service currently occur. 

After taking all these factors into consideration, 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 responses 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 methodologies. 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 development for the future. Therefore, we are also 

interested in public comments on these current 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 services that did not require a face-to-face 

encounter under the traditional model of medical care. Examples of these services 

included interpretation of an x-ray or electrocardiogram or electroencephalogram tracing, 

and cardiac pacemaker analysis. 

Section 4206 of the BBA provided for coverage of, and payment for, consultation 

services delivered via a telecommunications system to Medicare beneficiaries residing in 

rural health professional shortage areas (HPSAs) as defined by the Public Health Service 

Act. Additionally, the BBA required that a Medicare practitioner (telepresenter) be with 

the patient at the time of a teleconsultation. Further, the BBA specified that payment for 

a teleconsultation had to be shared between the consulting practitioner and the referring 

practitioner and could not exceed the fee schedule payment which would have been made 

to the consultant for the service provided. The BBA prohibited payment for any 

telephone line charges or facility 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 Protection Act of 2000 (Pub. L. 106-554) (BIPA) added a new 

section 1834(m) to the Act which significantly expanded Medicare telehealth services. 

Section 1834(m)(4)(F)(i) of the Act defines Medicare telehealth services to include 

consultations, office visits, office psychiatry 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) required the Secretary to establish a process 
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that provides for annual updates to the list 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 telecommunications 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 mail systems do not meet the 

definition of an interactive telecommunications system. An interactive 

telecommunications system is generally required as a condition of payment; however, 

section 1834(m)(1)of the statute does allow the use of asynchronous "store-and-forward" 

technology in delivering these services when the originating site is a Federal telemedicine 

demonstration program in Alaska or Hawaii. 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 provided 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 specified 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 originating 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 recently, section 149 of the Medicare Improvements 

for Patients and Providers Act 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 December 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 and behavior assessment and intervention (HBAI). 

In general, the practitioner at the distant site may be any of the following, 

provided that the practitioner is licensed under 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 distant 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 equal to the amount that the practitioner would 

have been paid if the service had been furnished without the use of a telecommunications 

system. Distant site practitioners must submit the appropriate HCPCS procedure code for 

a covered professional telehealth 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 certifies 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 individual is located must submit a claim with HCPCS code Q3014 

(Telehealth originating site facility 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 circumstances 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 services are not Medicare telehealth services 

as defined under section 1834(m). Rather, these remote services that utilize 

telecommunications technology are 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 permissible originating sites), and should be reported in the same 

way (that is, without the –GT or –GQ modifier appended). 

B. Requests for Adding Services to the 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 reviewing 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 other practitioner) at the distant site and, if 

necessary, the telepresenter. We also look 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; psychiatric 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-person by a physician, CNS, NP, or PA in order 
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to examine the vascular access site); individual MNT; neurobehavioral 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 proposed rule. Each request for adding a 

service to the list of Medicare telehealth services must include any supporting 

documentation the requester wishes us to consider 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 diabetes 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, including our proposals for additions to the CY 

2011 telehealth list. 

1. Individual KDE Services 

The American Society of Nephrology, Dialysis Patient Citizens, AMGEN, and 

Kidney Care Partners submitted requests to add individual KDE services, reported by 

HCPCS code G0420 (Face-to-face educational services 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 beneficiary receiving individual KDE 

services is similar to the education, assessment, and counseling elements of individual 

MNT services, reported by HCPCS code G0270 (Medical nutrition therapy; reassessment 

and subsequent intervention(s) following second 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 assessment and intervention, individual, face-toface with the patient, each 15 minutes); and CPT code 97803 (Medical nutrition therapy; 

re-assessment and intervention, 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 HCPCS code G0420 to the list of telehealth 

services for CY 2011 on a category 1 basis. Consistent 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 services, 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 believe 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 services 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 presence 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 services 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 are 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 concerned 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 injection training component of 

DSMT services can be addressed by imposing 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 services 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 instruction 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. 
CMS-1503-P 250

 Therefore, we are proposing to add HCPCS 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 self-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 –GT 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-administration of injectable drugs which must be 

furnished to the eligible telehealth individual 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 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. 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, Medicare telehealth services, including 

individual DSMT furnished as a telehealth service, could only be furnished by a licensed 

PA, NP, CNS, certified nurse-midwife, clinical psychologist, clinical social worker, or 

registered dietitian or nutrition professional. 
CMS-1503-P 251

3. Group KDE, MNT, DSMT, and HBAI Services 

The American Society of Nephrology, Dialysis Patient Citizens, AMGEN, Tahoe 

Forest Health Systems, Kidney Care Partners, the American Telemedicine Association, 

and the Marshfield Clinic submitted 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 individual(s)), each 30 minutes); 

● Group DSMT services, reported by HCPCS code G0109 (Diabetes outpatient 

self-management training services, group session (2 or more), per 30 minutes); and/or 

● Group HBAI services, reported by CPT code 96153 (Health and behavior 

intervention, each 15 minutes, face-to-face; group (2 or more patients)) and 96154 

(Health and behavior intervention, each 15 minutes, 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. Furthermore, we are proposing to add individual 

KDE and DSMT services to the list of Medicare telehealth services beginning in 

CY 2011 as described above. 

 In the CY 2007 and CY 2010 PFS rulemaking 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 through telehealth. We have observed that currently there are 

no group services approved as Medicare telehealth 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 previously have considered requests to add various 

group services to the list of Medicare telehealth 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 diagnostic findings or therapeutic interventions 

when services are furnished via telehealth versus when services are furnished in-person. 

 We continue to believe that the group dynamic may 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 psychotherapy, group psychotherapy is fundamentally 

different from other Medicare telehealth services and, therefore, could not be considered 

on a category 1 basis for addition to the telehealth services list. For the same reason, in 

the absence of evidence to the contrary, we do not believe group psychotherapy services 

could be appropriately delivered through telehealth. 

 However, upon further consideration, with regard to the particular group 

education and training services for which we received requests for addition to the 

Medicare telehealth services list, we believe the group dynamic is not central to the core 

education and training components of these 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 DSMT, 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 modifier with HCPCS code G0109, 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 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, DSMT, 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 following 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 DSMT services. 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, Medicare telehealth services, including group DSMT furnished 

as a telehealth service, could only be furnished 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 American Telemedicine 

Association, and Mille Lacs Health System submitted various requests to add initial 

hospital care services (reported by CPT codes 99221 (Level 1 initial hospital care), 99222 

(Level 2 initial hospital care), and 99223 (Level 3 initial hospital care)); subsequent 

hospital care services (reported by CPT codes 99231 (Level 1 subsequent hospital care), 

99232 (Level 2 subsequent hospital care), and 99233 (Level 3 subsequent hospital care)); 

and/or hospital discharge day management services (reported by CPT codes 99238 

(Hospital discharge day management; 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 psychiatric 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 codes for hospital care services are used to 
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report care for hospitalized patients with a variety of diagnoses, including psychiatric 

diagnoses. We do not believe it would be appropriate 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 appropriate 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 management hospital care services to the list of 

approved telehealth services because 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 for 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 resemblance 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 review 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 the first hospital inpatient E/M visit to 

the patient by the admitting or a consulting practitioner when that visit is furnished inperson. In addition, we note that currently 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, specifically HCPCS codes G0406 (Follow-up inpatient 

telehealth consultation, limited, physicians typically spend 15 minutes communicating 

with the patient via telehealth); G0407 (Follow-up inpatient telehealth consultation, 

intermediate, physicians typically spend 25 minutes communicating with the patient via 

telehealth); G0408 (Follow-up inpatient telehealth consultation, complex, physicians 

typically spend 35 minutes or more communicating with the patient via telehealth); 

G0425 (Initial inpatient telehealth consultation, typically 30 minutes communicating with 

the patient via telehealth); G0426 (Initial inpatient telehealth consultation, typically 50 

minutes communicating with the patient via telehealth); and G0427 (Initial inpatient 

telehealth consultation, typically 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 documentation submitted in support 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 between telehealth and 

in-person services. Therefore, we received 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 regarding 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 treatment responsibility comprehensively assesses the patient's 

condition upon admission to the hospital through 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 subsequent hospital care services reported by 

CPT codes 99231 through 99233 to the 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. 
CMS-1503-P 258

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. Therefore, we believe that subsequent hospital care visits by a 

patient's admitting practitioner may sufficiently resemble follow-up inpatient consultation 

services to consider these subsequent hospital 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 order to ensure that hospitalized patients have 

frequent encounters with their admitting practitioner. However, we also continue to 

believe that the majority of these visits 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 subsequent hospital care services, specifically 

CPT codes 99231, 99232, and 99233, be added to the 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 telehealth. Because of our concerns regarding the 

potential acuity of hospital inpatients, we are proposing to limit the provision of 

subsequent hospital care services through telehealth 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 their hospitalization. Consulting practitioners 

should continue to use the inpatient 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 discharge 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 caregivers, and preparation of discharge records, 

prescriptions, and referral forms. These services 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 a 

practitioner 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 Medicare 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-person in light of the acuity of hospitalized 

patients, their typically complex post-hospitalization 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 facility care), 99305 (Level 2 initial nursing 

facility care) and 99306 (Level 3 initial nursing facility care)); subsequent (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 management; 30 minutes or less) and 99316 

(Nursing facility discharge day management; more than 30 minutes)); and other (reported 

by CPT code 99318 (Evaluation and management 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 these services expressed concerns regarding 

limited access to care if we do not allow these services to be furnished through telehealth, 
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and requested that CMS acknowledge the recent 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 final rules (74 FR 33544 and 74 FR 61762), we 

discussed concerns about potential disparities in patient acuity 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 conducted in-person, and not as Medicare 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 Medicare telehealth services list that are used 

exclusively to describe these Federally-mandated visits. These codes include the CPT 

codes for initial nursing facility care (CPT codes 99304 through 99306) that are used to 

report the initial E/M visit that fulfills Federally-mandated requirements 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 Federally-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 nursing 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 assess 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 management service, the service be furnished 

in-person. The practitioner must be able 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 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 equivalent 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 services, reported by CPT codes 99307 through 

99310, may be used to report either a Federally-mandated periodic visit under §483.40(c) 

or another E/M visit, prior to or after the initial 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 believe that many SNF residents have complex 

medical care needs, we believe that it is appropriate to consider the addition of these 

codes to the telehealth list on a category 1 basis. As we state above in the context of our 

discussion 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 facility services are similar to those services. 

These E/M services are furnished to high acuity, complex SNF patients, although not by 

the admitting practitioner himself or herself. Therefore, we believe that subsequent 

nursing facility visits by a patient's admitting 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 frequent encounters with their admitting practitioner, although we 

continue to believe that the Federally-mandated visits should be in-person to facilitate the 

comprehensive, coordinated, and personal care that these complex patients require on an 

ongoing basis. 

 Therefore, we are proposing that subsequent nursing facility care services, 

specifically CPT codes 99307, 99308, 99309 and 99310, be added to the list of Medicare 

telehealth services on a category 1 basis beginning in CY 2011, with some limitations on 

furnishing these services through telehealth. Because of our concerns regarding the 
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potential acuity and complexity of SNF inpatients, 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 quality care and clinical outcomes, regarding 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 for 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 reported for a Federally-mandated periodic visit 

under §483.40(c) may not be furnished through telehealth. In light of this proposal for 

CY 2011, we remain confident that admitting practitioners will continue 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 services 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, described by CPT codes 96119 (Neuropsychological 

testing (eg, Halstead-Reitan Neuropsychological 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 patient and time interpreting these test results 

and preparing the report); and 96119 (Neuropsychological 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-face), to the list of telehealth 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 and data regarding the appropriateness of 

furnishing neuropsychological testing via telehealth. 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 telehealth 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 telehealth 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 approved telehealth services for CY 2011. Speechlanguage pathologists are not permitted under section 1842(b)(18)(C) of the Act to 

furnish and receive payment for Medicare telehealth services. Therefore, we are not 
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proposing to add any speech-language pathology services to the list of Medicare 

telehealth services for CY 2011. For further discussion 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 patient'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 services to the list of Medicare telehealth 

services for CY 2011. 

D. Summary of CY 2011 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 services (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 telehealth visit every 3 days (CPT codes 99231, 99232, and 99233); 

and 

● Subsequent nursing facility care services, with the limitation for the patient's 
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admitting practitioner of one telehealth 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 applicable 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 physician 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 Patient Protection and 

Affordable Care Act (Pub. L. 111-148), enacted on March 23, 2010, as amended by the 

Health Care and Education 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 authorizing incentive payments through 2014, and 

requiring a penalty beginning in 2015, for eligible professionals who do not satisfactorily 

submit quality data. For a more detailed discussion of the provisions of section 3002 of 

the ACA, please refer to section VI.G.1. of this proposed rule. 
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B. Section 3003: Improvements to the Physician Feedback Program and Section 3007: 

Value-based Payment Modifier Under 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) Program for purposes of providing confidential 

reports to physicians that measure the resources involved in furnishing care to Medicare 

beneficiaries. Section 1848(n) of the Act also authorizes CMS to include information on 

the quality of care furnished to Medicare beneficiaries by a physician or group of 

physicians. 

We are continuing a phased implementation 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 about 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 areas1

several hundred reports that contained per capita and episode-based cost information. 

Phase I of the Program focused on providing confidential feedback on resource 

use measures. Section 1848 (n)(1)(A)(iii) of the Act states that the Secretary may also 

include information on the quality of care furnished to Medicare beneficiaries by 

physicians (or groups of physicians) in the feedback 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 Secretary 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, defined 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) formally 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 report to both physician group practices and their 

affiliated practitioners, recognizing that many physicians practice in arrangements other 

than solo practices. We believe that using both group and individual level reporting will 

also allow us to gain experience with the sample size issues that arise when individual 

physicians have too few Medicare beneficiaries with specific conditions to generate 

reliable information. (See the CY 2010 final 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 relevant to the RUR program. Section 3003 

continues the confidential feedback 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 payment 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 for differential payment under the fee 
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schedule to a physician or groups of physicians, and later, possibly to other eligible 

professionals, based upon the 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 implementation 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 ACA 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 foundation for implementing the payment modifier. 

Specifically, throughout future phases of reports under the RUR program, we will 

continue to enhance our measures and methods 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 implementation 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 contain 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 various 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, several changes to the program parameters 

for Phase II that were finalized in prior rules. First, we plan to discontinue our use of 

commercially-available proprietary episode grouping software. In particular, section 

3003 of the ACA requires that the Secretary develop 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 proprietary 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 developed. 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 previous phases of the program had limitations. 

These software products were not intended for use with Medicare claims data, and we 

discovered several problems with 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 referred to as “black boxes,” do not enable 

users to understand the coding to determine how to accomodate these issues. Therefore, 

CMS had to make several decisions about how to pre-process the 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 cost information, we plan to provide overall per capita cost 

information, as well as per capita cost information for those beneficiaries with five 

common chronic diseases: (1) diabetes, (2) congestive 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 beneficiaries with that disease. 

Second, while commenters have been generally supportive of including PQRI 

measures in the reports, we propose not including 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 quite 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 developed 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 incentive 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 electronically in Phase II, by leveraging 

the infrastructure used to distribute PQRI feedback reports. This infrastructure will 

enable groups to utilize an electronic 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 with electronic dissemination that allows for 

easier navigation. We are seeking public comment on the above proposals. 

4. Implementation of Sections 3003 and 3007 of the ACA 

 The Affordable Care Act provisions that we mention above contain several 

important implementation dates. In addition 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 January 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 implementing sections 3003 and 3007 of the ACA, we intend to 

perform extensive data analysis and research, and to seek stakeholder input on issues 

related to cost and quality measures 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 chosen for use in the payment modifier will 

be candidates for inclusion in future phases of the confidential feedback reports. 

As mentioned above, Phase I included reports to several hundred physicians. In 

Phase II we anticipate disseminating reports to about 40 large physician groups and the 

approximately 2,000 physicians 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 applicable 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 important decisions to be made when 

implementing a program that compares physicians 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 identified 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; peer groups; minimum case sizes; cost and quality measures; 

and compositing methods. To date, the public comments we have received have not led 

us to a single methodology to propose for dealing with any of these issues. Therefore, we 

do not make formal proposals in this proposed rule. Specific parameters of the RUR 

program are based on the most current information 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 then predicts costs for beneficiaries based on 

their unique mix of health conditions. Several other socioeconomic 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 above. 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 HCC model will be the only method 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. Beneficiaries 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 adjusting 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 generally used for attributing beneficiaries’ 

costs to physicians for the purposes of measuring and comparing performance. In Phase 

I, we used two different attribution methodologies. Half of the reports used the 

“multiple-proportional” attribution, in which a beneficiary’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” method, 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 services of 30 percent of the E&M services 
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for physician group level reports. These minimum threshold determinations were based 

on our analysis of the claims data. We recognize 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 method 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 attribution 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 challenge that very narrow peer groups are most 

often not large enough to make statistically significant comparisons. 

The individual-level reports in both phases of the program have contained, or will 

contain, two peer group comparisons: (1) physicians in the same specialty in the same 

geographic area; and (2) physicians in the same 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 10th, 50th, and 90th percentiles. These benchmarks were 

finalized on an interim basis in the CY 2010 proposed rule (74 FR 33589). 
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In determining applicability for episode measures 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 compared. There was no minimum peer group size 

requirement. 

The original MIPPA mandate requires CMS to make comparisons among 

physicians on cost, and gives the Secretary the authority to include comparisons on 

quality. The use of quality measures in the 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 cost 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 appropriate and relevant peer groups for 

comparison, including the appropriate minimum case sizes and minimum peer group 

sizes. We are also interested in methodologies that can account for small case sizes. 

d. Cost and Quality Measures and Compositing Methods 

As mentioned above, and in previous rules, 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 mentioned 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 quality and cost measures. Accordingly, we 

will need to devise a methodology in the future for compositing cost measures and 

quality measures, including considering, among other things, possible methodologies to 

develop a single score. In the future, episode-based cost measures developed using the 

public Medicare-specific episode grouper software also may be considered in developing 

a composite score. Other domains 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 composites 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 anticipate continuing to gather feedback from 

stakeholders about the important data-driven policy topics that affect the feedback 

reports. 

C. Section 3102: Extension of the Work Geographic Index Floor and Revisions to the 

Practice Expense Geographic Adjustment under the Medicare Physician Fee Schedule, 

and Protections for Frontier States as amended by Section 10324 

Section 1848(e)(1)(E) of the Act (as amended by section 3102(a) of the ACA) 

extends application of the 1.0 work GPCI floor for services furnished through December 

31, 2010. In addition, section 1848(e)(1) of the 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 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) 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 differences 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 adjustments 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 Exceptions Process for Medicare Therapy Caps

Section 1833(g)(5) of the Act (as amended by section 3103 of the ACA) extends 

the exceptions process for therapy caps through December 31, 2010. Therapy caps are 

discussed in detail in section III.A. of this proposed rule. 

E. Section 3104: Extension of Payment for Technical Component of Certain Physician 

Pathology Services

Section 542(c) of the Medicare, Medicaid, 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 Act of 2003 (MMA) (Pub. 
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L. 108-173), section 104 of division B of the Tax Relief and Health 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 continue payment to independent 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 pathology services refers to the preparation of the slide 

involving tissue or cells that a pathologist interprets. The professional 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 services for hospital patients even though the 

payment for the costs of furnishing the pathology 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 prospective 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 duplicate 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 hospital 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 pathology 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 independent laboratories for the TC of physician 

pathology services for hospital patients through CY 2007, and section 104 of the 

MMSEA further extended such payment through 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 the 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 policy to reflect that for services furnished 

after December 31, 2010, an independent laboratory may not bill the Medicare contractor 

for the TC of physician pathology services furnished to a hospital inpatient or outpatient; 

and (2) reformat this subsection into subparagraphs. 

F. Sections 3105 and 10311: Extension of Ambulance Add-Ons

1. Amendment to Section 1834(l)(13) of the Act 

Section 146(a) of the MIPPA amended section 1834(l)(13)(A) of the Act to 

specify that, effective for ground ambulance services 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 metropolitan 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 ACA further amend section 1834(l)(13)(A) 

of the Act to extend the payment add-ons described above for an additional year, such 

that these add-ons also apply to covered 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 requirement. This statutory requirement is selfimplementing. A plain reading of the statute requires only a ministerial application of the 

mandated rate increase, and does not require any substantive exercise of discretion on the 

part of the Secretary. For further information regarding the extension of these payment 

add-ons, please see Transmittal 706 (Change 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 payments under the ambulance fee schedule for air 

ambulance services furnished on December 31, 2006, shall continue to 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, 2009. Sections 

3105(b) and 10311(b) of the ACA amend 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 were subsequently re-designated as urban, 

we have re-established the “rural” indicator 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 plain 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 Transmittal 706 (Change Request 6972) dated May 

21, 2010. 

3. Amendment to Section 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 ambulance services furnished on or after July 

1, 2004, and before January 1, 2010, for which transportation 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 per 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 transports that originated in a rural area included in 

those areas comprising the lowest 25th percentile of all rural 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 rural 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 manner as in previous years), to ground 

ambulance services with dates of service on or after January 1, 2010 and before 

January 1, 2011 where transportation originates in a qualified rural area. 

We are revising § 414.610(c)(5)(ii) to conform the regulations to this statutory 

requirement. This statutory requirement is self-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 extension of this rural bonus, please see Transmittal 

706 (Change Request 6972) dated May 21, 2010. 

G. Section 3107: Extension of Physician 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, representing “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, Behavior 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, using 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, using 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, using 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, using 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, using 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, using 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, Behavior Modifying and/or Supportive Psychotherapy 

90816 (Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an 

inpatient 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 an 

inpatient 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 an 

inpatient 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 an 

inpatient 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 an 

inpatient 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 an 

inpatient 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, using 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, using 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, using 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, using 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, using 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, using 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 Physician Assistants to Order Post-Hospital Extended Care 

Services

The ACA included a self-implementing provision relating to SNFs. Section 3108 

adds physician assistants (PAs) to the list of practitioners (that is, physicians, nurse 

practitioners (NPs), and clinical nurse specialists) that can perform the required initial 

certification and periodic recertifications under section 1814(a)(2)(B) of the Act with 

respect to the SNF level of care. Accordingly, 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 absorptiometry (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 the 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 (eg, 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 assessment) were deleted 

and replaced with new CPT codes 77080, 77081, and 77082 that have the same 

respective code descriptors as the predecessor codes. Section 1848(b) of the Act (as 
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amended by section 3111 of the ACA) specifies 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 these services when multiplied by the CY 2011 

CF. Specifically, we divided the payment amount based on the statutory requirements by 

the CY 2011 CF for this proposed rule, and distributed the imputed total RVUs across the 

work, PE, and malpractice components proportionately to their CY 2006 distribution. 

Therefore, these imputed RVUs for CPT 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 amended by section 3114 of the ACA) 

increases the amount of Medicare payment 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 section 1833(a)(1)(K) of the Act (as amended by 

section 3114 of the ACA), effective for services 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 Medicare 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 Medicare 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 physician or incident to a physician’s services. 

Additionally, there is no requirement under the CNM benefit for physician oversight or 

supervision. Accordingly, CNMs are authorized to personally furnish diagnostic tests 

that fall under their State scope of practice without regard to the levels of physician 

supervision required under the diagnostic tests benefit. Therefore, we are amending 

§410.32(b)(2) (Exceptions to the levels of physician 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 Medicare 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 reasonable 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 reporting periods beginning during the 2-year 

period beginning on July 1, 2004. 

Section 105 of the Tax Relief and Health Care Act of 2006 (Pub. L. 109-432) 

(TRHCA) extended the 2-year period in section 416(b) of the MMA for an additional 

cost-reporting year. 

 Section 107 of the Medicare, Medicaid, 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 services performed as 

late as June 29, 2009, because this was the date those cost reports would have closed. 

Section 3122 of the ACA reinstitutes reasonable cost payment for clinical 

diagnostic laboratory tests performed by hospitals 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 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. 

L. Section 3134: Misvalued Codes Under the Physician Fee Schedule

Section 1848(c)(2)(K) of the Act (as added by section 3134 of the ACA) requires 

the Secretary to periodically review and identify 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 appropriate 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 validate 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 the issue of potentially misvalued services. 

Our proposed CY 2011 approaches to categories of potentially misvalued codes are 

discussed in section II.C. of this proposed rule. 

M. Section 3135: Modification 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 added 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 proposed rule, effective January 1, 2011 we are 

proposing to assign a 75 percent equipment utilization rate assumption to expensive 

diagnostic imaging equipment used in services described by the HCPCS codes displayed 

in Table 4. 

In the CY 2010 PFS final rule with comment 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 equipment utilization rate 

assumption, applying a 25/75 blend of the new and old PE RVUs, respectively, for the 

associated procedures. Section 1848(b)(4)(C) of the Act (as added by section 3135(a) of 

the ACA) does not provide for any further transition 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 utilization 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 equipment 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 added 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 discussed 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 imaging procedures, applied to the second and 

subsequent services when more than one service 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 apply to professional component (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, payment is made at 50 percent of the TC for 

each additional procedure, consistent with the statutory provision. 

N. Section 3136: Revision for Payment for Power-Driven Wheelchairs

1. Payment Rules for Power Wheelchairs 

Durable medical equipment (DME) is defined at section 1861(n) of the Act and 

includes wheelchairs necessary for use in the 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 wheelchairs 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 Guidelines published by the Durable Medical 

Equipment Regional Carriers (DMERCs) currently called the Durable Medical 

Equipment Medicare Administrative Contractors (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 power wheelchairs classified 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 the 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 rental payments capped at 13 months. After a 

13-month period of continuous use during which 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 section 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 purchase rather than rent the item. Since 1991, 
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over 95 percent of Medicare beneficiaries have exercised this lump-sum purchase option 

for power wheelchairs. 

Consistent with payment for other 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 reasonable useful lifetime for 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 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. Pursuant to section 1834(a)(7)(A)(i)(II) of the 

Act and § 414.229(b), the current rental fee schedule 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. The 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 required by section 1834(a)(14) of the Act and § 414.229(d). 

The current purchase price amount for power wheelchairs acquired on a lump sum 
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purchase basis is 100 percent of the purchase price calculated for the item when rented, as 

discussed above. 

2. Revision of Payment Amounts for Power Wheelchairs 

 Section 3136(a) of the ACA made several 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 purchase 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 the 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 the 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 used 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, section 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 implementation 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 into prior to January 1, 2011 as part of Round 

1 of the DMEPOS CBP will continue to be paid 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” before 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 wheelchairs 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 wheelchairs. We consider 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 the 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-driven wheelchairs furnished on or after 

January 1, 2011. The lump sum purchase payment option will no longer extend to 

standard power driven wheelchairs furnished on or after January 1, 2011. 

Furthermore, section 3136(c)(2) of the ACA 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 entered 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 prior 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 section 1847A of the Act to provide for 

Medicare payment of biosimilar biological products using the average sale price (ASP) 

methodology. 

Section 1847A of the Act, as amended by the ACA, defines a biosimilar 

biological product as a biological 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 biosimilar biological product is 

defined by the statute as the 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 biosimilar 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 pathway for biosimilar biological products, and in accordance 

with the statute, the effective date for Medicare 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 biological drug products are approved, we will 

receive ASP sales data through 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 will be determined in accordance with the provisions in 

section 1847A(c)(4) of the Act. If no manufacturer data is collected, prices will be 

determined by local contractors using any 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/McrPartBDrugAvgSalesPrice/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 Market Basket Updates and Incorporation of 

Productivity Improvements into Market Basket Updates That Do Not Already 

Incorporate Such Improvements.

1. ESRD Market Basket Discussion 

Section 3401(h) of the ACA amended section 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 this proposed rule for a detailed description of 

these provisions. 

2. Productivity Adjustment regarding Ambulatory Surgical Center, Ambulance, Clinical 

Laboratory and DMEPOS Fee Schedules 

Section 3401 of the ACA requires that the 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) amends section 1886(b)(3)(B) of the Act to 

add clause (xi)(II) which sets forth the definition 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 private 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 other 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) historical 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 models. These models take into account a 

very broad range of factors that influence 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 MFP, 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 Component 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 variables, IGI compared the historical growth 

rates of the BLS and IGI components listed above and 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 project BLS’ components of MFP, and derive the 

MFP adjustment that would be used under section 3401 to adjust the updates for the ASC 

payment system, the AFS, and the CLFS. 

As discussed below, for each of these payment 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 shall 

reduce 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 (for 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 timeframe. Since the CPI-U update factor is 

reduced by the MFP adjustment to determine the annual update for these payment 

systems, we believe it is appropriate for the 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 30th 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 percentage point level up or down as applicable 

according to conventional rounding rules (that 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 and apply the MFP adjustment to determine 

the annual updates for ASCs, the AFS, and the CLFS for CY 2011 and each subsequent 

year. We will set forth the final MFP adjustment 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 for 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 CMS instruction and on the CMS website. 

These notifications would set forth both the CPI-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 the 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 involved. 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 the 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 update factor). Section 3401(k) of the ACA 

amends section 1833(i)(2)(D) of the Act by adding a new clause (v) which requires that 

“any annual update under [the ASC payment] system for the year . . . shall be reduced by 

the productivity adjustment described 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 application 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 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 CPI-U update factor 

for the ASC payment system to zero. Section 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 application 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 payment 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 update 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 should 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 previous year. We refer to this update as the 

Ambulance Inflation Factor (AIF). Section 3401(j) of the ACA amends section 

1834(l)(3) of the Act to add a new subparagraph (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 increase, or AIF), the Secretary shall reduce 

such percentage increase by the MFP 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 subparagraph (C) (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. 

In accordance with section 1834(l)(3) of the 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 below 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 the 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 statute 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 resulting 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 Laboratory 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 adjustment 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 described 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 percentage 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 result 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 that 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 points 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 medical equipment defined in section 1834(a)(13) 

of the Act, prosthetic devices, orthotics, and prosthetics 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 increase 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, prosthetic devices, orthotics, and prosthetics and 2003 for 

parenteral and enteral nutrients, equipment, and supplies, these annual fee schedule 

updates have been implemented on an annual basis through program instructions. 

Section 3401(m) of the ACA amends section 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 discussed above). Section 3401(m) of the ACA 

further amends section 1834(a)(14) of the Act to state that the application of 

subparagraph (L) (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(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 the MFP adjustment described in section 

1886(b)(3)(B)(xi)(II) of the Act (as discussed 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 section 1842(s)(1) of the Act to add a new 

subparagraph (B) and clause (ii) 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 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 subparagraph (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 program instructions related to the DMEPOS fees 

schedule updates. 

Q. Section 4103: Medicare Coverage of Annual Wellness Visit Providing a Personalized 

Prevention Plan

1. Background 

a. Medicare Coverage of Preventive Physical 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 furnished 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 include 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 expanded 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 for each individual beneficiary. 

b. Requirements for Coverage of an Annual Wellness Visit 

Section 4103 of the ACA provides for coverage 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 requires 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 establishment of, or update to, the individual’s 

medical and family history, a list of the individual’s current providers 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 appropriate 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 interventions are recommended or underway; and 

furnishing of personalized health advice and referral, 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 wellness visit determined to be appropriate. 

2. Proposed Revisions 

a. Proposed Revisions to §411.15, Particular Services Excluded from Coverage 

To conform the regulations to the statutory 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) and 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 wellness visit is furnished under Medicare Part B only. As 

provided in the statute, this new coverage allows 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 Medicare Part B coverage period, and has not 

received either an IPPE or an annual wellness 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 Plan Services, and §410.15(b), Limitation on 

Coverage of Annual Wellness Visits 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 terms 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 providing personalized prevention plan services. 

Further, the ACA allows the addition of any other element determined 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 screening 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 home 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 medications as provided in the statute, but also supplements such 

as vitamins and calcium that an individual may use or be exposed to. Supplements such 

as these are commonly used by many beneficiaries 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 function 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 medicine 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 Social Security Act); or 

++ A medical professional (including a health educator, registered dietitian, or 

nutritionist) or a team of medical professionals, who are working under the supervision of 

a physician as defined in this definition. 

● Establishment of, or an update to the individual’s medical and family history,

for purposes of this section, means at a minimum the collection and documentation of the 

following: 
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++ Past medical and surgical history, including experiences with illnesses, 

hospital stays, operations, allergies, injuries, and treatments. 

++ Use or exposure to medications and supplements, including calcium and 

vitamins. 

++ Medical events experienced by the beneficiary’s parents and any siblings and 

children, including diseases that may be hereditary 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 received either an initial preventive physical examination or 

an annual wellness visit providing a personalized prevention plan within the past 12 

months. 

(2) Requirements of the First Visit for Personalized Prevention Plan Services 

We are proposing that the first annual wellness visit for purposes of this benefit 

include the following: 

● Establishment of the individual’s medical and family history; 

● Establishment of a list of current providers and suppliers that are regularly 

involved in providing medical care to the individual; 

● Measurement of the individual’s height, weight, body mass index (or waist 

circumference, if appropriate), blood pressure, and other routine measurements as 

deemed appropriate, based on the individual’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 professional as defined in this section may select from 

various available screening questions or standardized 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 appropriate screening questions or a screening 

questionnaire, which the health professional as defined in this section may select from 

various available screening questions or standardized 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 health 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 underway, 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), and a list of treatment 

options and their associated risks and benefits; 

● Furnishing of personalized health advice and a referral, as appropriate, to 

health education or preventive counseling services or programs aimed at reducing 

identified risk factors and improving self management, or community-based lifestyle 

interventions to reduce health risks and promote self-management and wellness, 

including weight loss, physical activity, smoking cessation, fall prevention, and nutrition; 
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and 

● Any other element determined appropriate by the Secretary through the 

National Coverage Determination process. 

(3) Requirements of Subsequent Visits for 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 providers and suppliers that are regularly 

involved in providing medical care to the individual, as that list was developed for the 

first annual wellness visit providing personalized prevention plan services; 

● Measurement of an individual’s weight, blood pressure, and other routine 

measurements as deemed appropriate, based 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 visit providing personalized prevention plan 

services; and 

++ The list of risk factors and conditions for which primary, secondary or tertiary 

interventions are recommended or are underway for the individual as that list was 

developed at the first annual wellness visit providing personalized prevention plan 

services; 

● Furnishing of personalized health advice to the individual and a referral, as 
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appropriate, to health education 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 Determination process. 

Body-mass index (BMI) should be calculated at the first annual wellness visit and may be 

recalculated at subsequent visits, if indicated. Given the general stability of adult height, 

we would not expect the BMI to meaningfully change in the absence of significant 

weight change. We have not in the definition of the subsequent annual visit required 

measurement of the individual’s height. 

We are proposing to add two distinct elements to the definition of the first annual 

wellness visit only: depression screening 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 would be premature and 

beyond the current evidence to require that they be included in the definition of 

subsequent visits, but they may be performed at these visits, if indicated. 

In addition, to facilitate future 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 required elements for those purposes will be 

made through the National Coverage Determination (NCD) process. The NCD process is 

evidence based, transparent and furnishes the opportunity for public comment, and is 

described in sections 1862(l)of the Act. 

While section 4103 of the ACA ultimately requires that an HRA be included in 

the new annual wellness visit benefit beginning January 1, 2011, the HRA guidelines 

(with standards for interactive telephonic and web-based HRAs) and the model HRA tool 
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also required by section 4103 are not yet available. 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 appropriate 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 visits, 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 medical 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 benefit 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 subsection (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 “personalized prevention plan services” and to 

specify who may furnish these services. Finally, 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 visit 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, physician 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 payment 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 establish the following two new HCPCS codes 

for CY 2011: GXXXA (Annual wellness visit; includes 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 practitioner 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 eligible only for an IPPE. After the first 12 

months of Part B coverage, on and after January 1, 2011, beneficiaries will be eligible for 

an annual wellness visit described 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 one initial annual wellness 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 wellness visits that would 

include the required elements for those visits would be reported as subsequent visits, even 

if a different practitioner furnished the subsequent 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 subsequent annual wellness visit would update the 

information in the patient’s medical record based 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 HCPCS code G0402 (Initial preventive physical 

examination; face-to-face visit, 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 annual wellness visit are very similar, given that both represent 

an initial beneficiary visit focused on prevention. 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 and intensity, HCPCS code G0402 was most equivalent to 

CPT code 99204 (Level 4 new patient office or other 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 and, therefore, we are proposing to assign the 

same direct PE inputs to HCPCS codes G0402 and GXXXA as are included for CPT 

code 99204. We note that currently, the direct PE inputs for HCPCS code G0402 also 

include preventive assessment forms, 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 proposed 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 subsequent annual wellness visit described by 

HCPCS code GXXXB is most similar, from the perspectives of physician work and PE, 

to CPT code 99214 (Level 4 established patient office or other outpatient visit). The 

subsequent annual wellness visit is a patient visit for PPPS that includes certain required 

elements, such as updating information regarding 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 physician work and direct PE of a subsequent 

annual wellness visit are similar, 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 visit would typically be for an established patient and, as 

described earlier in this section, we are proposing that certain wellness visit elements 

only must be furnished in the first wellness visit. As a result, we believe it would be most 

appropriate to value the subsequent annual wellness visit based 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 CPT code 99214 to HCPCS code GXXXB. 

Furthermore, we believe the direct PE inputs for these two services are also similar and, 

therefore, we are proposing to assign the same direct PE inputs to HCPCS code GXXXB 

as are assigned to CPT code 99214. We note that 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 furnishes this service in the facility setting. 

While we believe there could 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 wellness visit and another E/M service, 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 through 66290), we do not want to prohibit the 

reporting of an appropriate 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 available 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 medically necessary E/M visit may be reported 

and appended with CPT modifier -25 (Significant, separately identifiable 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 scenario would be uncommon, and 

we expect that no components of an encounter attributable to the 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-sharing, section 4103(c) of the ACA amends 
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section 1833(a)(1) of the Act by adding subparagraph (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 the payment basis determined under section 

1848 of the Act, thereby eliminating coinsurance for the annual wellness visit. Finally, 

section 4103(b)(4) of the ACA amends 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 their 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 section 1861(ddd) of the Act to add paragraph 

(3), which defines the term “preventive services” as follows: 

● The specific services currently listed in section 1861(ww)(2) of the Act with 

the explicit exclusion of electrocardiograms (as specified in section 1861(ww)(2)(M) of 

the Act); 

● The initial preventive physical examination (IPPE) established by section 611 

of the MMA and defined in section 1861(ww)(1) of the Act; and 

● The annual wellness visit, as specified 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 the Act as cross-referenced to section 

1861(ww)(2) of the Act, excluding electrocardiograms, 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 therapy (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 determination (NCD) process. 

We note that currently the only additional preventive service identified for 

coverage through the NCD process is HIV testing. A proposed NCD for smoking 

cessation services for asymptomatic 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 population and that are appropriate for the 

individual. This provision waives any coinsurance that would otherwise be applicable 

under section 1833(a)(1) of the Act for those 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 payment 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 beneficiary 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 particular 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 section 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 annual 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 the Act to waive the deductible for the IPPE effective 

January 1, 2009. 

 Not all preventive services described 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 the 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 provision 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 Act (as amended by section 4104 of the ACA) 

for waiver of the deductible and coinsurance as a preventive service. 

 The following preventive services listed 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 furnished 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. However, 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, described by HCPCS codes G0117 (Glaucoma 

screening for high risk patients furnished by an optometrist or ophthalmologist) and 

G0118 (Glaucoma screening for high risk patient furnished under the direct supervision 

of an optometrist or ophthalmologist), will continue 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 screening; alternative to G0104, screening 

sigmoidoscopy, barium enema) and G0120 (Colorectal 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 
CMS-1503-P 330

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 Act 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, screening 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 both 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 Disease Control and Prevention’s Advisory 

Committee on Immunization Practices. However, the USPSTF’s most recent vaccine 

recommendations gave a grade of B to influenza 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 require 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. 
CMS-1503-P 331

 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 and 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 vaccine and its administration. In addition, in §410.160(b), we are also 

proposing to add exceptions for bone mass measurement, MNT services, and the annual 

wellness visit. 

In §410.152, we are proposing to revise paragraph (l) to establish the amount of 

payment under the applicable payment system for providers and suppliers of the services 

listed in the paragraph and displayed in Table 38. Table 38 displays the HCPCS codes 

that we are proposing as “preventive services” under section 1861(ddd)(3)(A) of the Act 

and identifies the HCPCS codes for the IPPE and 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 the 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 changes 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 and 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 
CMS-1503-P 332

the preventive service for at least one indication and/or population with a grade of A or 

B, we note that all existing Medicare coverage 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 recommendations 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 specific population or indication, 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 there 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 section 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 the definition of Federally Qualified 

Health Center (FQHC) services as defined in section 1861(aa)(3)(A) of the Act by 

replacing the specific references to services provided under section 1861(qq) and (vv) of 

the Act (diabetes outpatient self-management training services and medical nutrition 

therapy services, respectively) with preventive services as defined in section 

1861(ddd)(3) of the Act, as established by section 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 
CMS-1503-P 333

section §405.2449 which would add the new preventive services definition to the 

definition of FQHC services effective for services provided on or after January 1, 2011. 

Section 1861(ddd)(3) of the Act defines “preventive services” as consisting of the 

following three components: 

● Screening and preventive services described in section 1861(ww)(2) of the Act 

(other than electrocardiograms described in subparagraph (M) of that same subsection). 

● An initial preventive physical examination, 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 amended 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 believe we can give both section 1833(a)(1)(Y) 

and (Z) of the Act, and the definition of FQHC services (revised to include the broader 

scope of preventive services) their best effect by permitting a 100 percent reimbursement 
CMS-1503-P 334

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 that the Medicare Part B deductible shall 

not apply to Federally qualified health center services. The ACA makes no change to this 

provision, therefore Medicare shall continue to waive the Part B deductible for all 

Federally qualified health center services, including preventive services added by the 

ACA.
CMS-1503-P 335

TABLE 38: Proposed CY 2011 Deductible and Coinsurance for Preventive Services Under Section 1861(ddd

(Includes the IPPE and the Annual Wellness Visit) 

Preventive 

Service 

CPT/ 

HCPCS 

Code 

Long Descriptor USPSTF Rating1 Payment Method CY 2010 Coins. / Deductible CY 20

Coin

Deduc

G0402 

Initial preventive physical examination; face to face visits, services limited to new beneficiary during the first 12 months of Medicare enrollment 

PFS 

Coins. 

applies & 

ded. is 

waived 

WAIV

G0403 

Electrocardiogram, routine ECG with 12 leads; performed as a screening for the initial preventive physical examination with interpretation and report 

PFS Not Waived No

Waiv

Initial 

Preventive 

Physical 

Examination, 

IPPE 

G0404 

Electrocardiogram, routine ECG with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination 

*Not 

Rated 

PFS Not Waived No

Waiv
CMS-1503-P 336

Preventive 

Service 

CPT/ 

HCPCS 

Code 

Long Descriptor USPSTF Rating1 Payment Method CY 2010 Coins. / Deductible CY 20

Coin

Deduc

G0405 

Electrocardiogram, routine ECG with 12 leads; interpretation and report only, performed as a screening for the initial preventive physical examination 

PFS Not Waived No

Waiv

Ultrasound 

Screening for 

Abdominal 

Aortic 

Aneurysm 

(AAA) 

G0389 

Ultrasound, B-scan and /or real time with image documentation; for abdominal aortic aneurysm (AAA) ultrasound screening 

B PFS 

Coins. 

applies & 

ded. is 

waived 

WAIV

80061 Lipid panel CLFS WAIVED WAIV82465 Cholesterol, serum or whole blood, total CLFS WAIVED WAIV83718 

Lipoprotein, direct measurement; high density cholesterol (hdl cholesterol) 

CLFS WAIVED WAIV

Cardiovascular 

Disease 

Screening 

84478 Triglycerides 

A 

CLFS WAIVED WAIV

82947 

Glucose; quantitative, blood (except reagent strip) 

CLFS WAIVED WAIV

Diabetes 

Screening 

Tests 

82950 Glucose; post glucose dose (includes glucose) 

B 

CLFS WAIVED WAIV
CMS-1503-P 337

Preventive 

Service 

CPT/ 

HCPCS 

Code 

Long Descriptor USPSTF Rating1 Payment Method CY 2010 Coins. / Deductible CY 20

Coin

Deduc

82951 

Glucose; tolerance test (gtt), three specimens (includes glucose) 

*Not 

Rated CLFS WAIVED WAIV

G0108 

Diabetes outpatient selfmanagement training services, individual, per 30 minutes 

PFS Not Waived No

Waiv

Diabetes SelfManagement 

Training 

Services 

(DSMT) G0109 

Diabetes outpatient selfmanagement training services, group session (2 or more), per 30 minutes 

*Not 

Rated 

PFS Not Waived No

Waiv

97802 

Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes 

PFS Not Waived WAIV

97803 

Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes 

PFS Not Waived WAIV

Medical 

Nutrition 

Therapy 

(MNT) 

Services 

97804 

Medical nutrition therapy; group (2 or more individual(s)), each 30 minutes 

B 

PFS Not Waived WAIV
CMS-1503-P 338

Preventive 

Service 

CPT/ 

HCPCS 

Code 

Long Descriptor USPSTF Rating1 Payment Method CY 2010 Coins. / Deductible CY 20

Coin

Deduc

G0270 

Medical nutrition therapy; reassessment and subsequent intervention(s) following second 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 

PFS Not Waived WAIV

G0271 

Medical nutrition therapy, reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), group (2 or more individuals), each 30 minutes 

B 

PFS Not Waived WAIV
CMS-1503-P 339

Preventive 

Service 

CPT/ 

HCPCS 

Code 

Long Descriptor USPSTF Rating1 Payment Method CY 2010 Coins. / Deductible CY 20

Coin

Deduc

G0123 

Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision 

CLFS WAIVED WAIV

G0124 

Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, requiring interpretation by physician

A 

PFS 

Coins. 

applies & 

ded. is 

waived 

WAIV

Screening 

Pap Test 

G0141 

Screening cytopathology smears, cervical or vaginal, performed by automated system, with manual rescreening, requiring interpretation by physician 

A PFS 

Coins. 

applies & 

ded. is 

waived 

WAIV
CMS-1503-P 340

Preventive 

Service 

CPT/ 

HCPCS 

Code 

Long Descriptor USPSTF Rating1 Payment Method CY 2010 Coins. / Deductible CY 20

Coin

Deduc

G0143 

Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with manual screening and rescreening by cytotechnologist under physician supervision 

A CLFS WAIVED WAIV

G0144 

Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system, under physician supervision 

A CLFS WAIVED WAIV

G0145 

Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, with screening by automated system and manual rescreening under physician supervision 

A CLFS WAIVED WAIV
CMS-1503-P 341

Preventive 

Service 

CPT/ 

HCPCS 

Code 

Long Descriptor USPSTF Rating1 Payment Method CY 2010 Coins. / Deductible CY 20

Coin

Deduc

G0147 

Screening cytopathology smears, cervical or vaginal, performed by automated system under physician supervision 

A CLFS WAIVED WAIV

G0148 

Screening cytopathology smears, cervical or vaginal, performed by automated system with manual rescreening 

CLFS WAIVED WAIV

P3000 

Screening papanicolaou smear, cervical or vaginal, up to three smears, by technician under physician supervision 

CLFS WAIVED WAIV

P3001 

Screening papanicolaou smear, cervical or vaginal, up to three smears, requiring interpretation by physician 

A 

PFS 

Coins. 

applies & 

ded. is 

waived 

WAIV
CMS-1503-P 342

Preventive 

Service 

CPT/ 

HCPCS 

Code 

Long Descriptor USPSTF Rating1 Payment Method CY 2010 Coins. / Deductible CY 20

Coin

Deduc

Q0091 

Screening papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory 

PFS 

Coins. 

applies & 

ded. is 

waived 

WAIV

Screening 

Pelvic Exam G0101 

Cervical or vaginal cancer screening; pelvic and clinical breast examination 

A PFS 

Coins. 

applies & 

ded. is 

waived 

WAIV

77052 

Computer-aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; screening mammography (list separately in addition to code for primary procedure) 

B PFS 

Coins. 

applies & 

ded. is 

waived 

WAIV

Screening 

Mammography 

77057 

Screening mammography, bilateral (2-view film study of each breast) 

B PFS 

Coins. 

applies & 

ded. is 

waived 

WAIV
CMS-1503-P 343

Preventive 

Service 

CPT/ 

HCPCS 

Code 

Long Descriptor USPSTF Rating1 Payment Method CY 2010 Coins. / Deductible CY 20

Coin

Deduc

G0202 

Screening mammography, producing direct digital image, bilateral, all views 

PFS 

Coins. 

applies & 

ded. is 

waived 

WAIV

G0130 

Single energy x-ray absorptiometry (sexa) bone density study, one or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel) 

PFS Not Waived WAIV

77078 

Computed tomography, bone mineral density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine) 

PFS Not Waived WAIV

77079 

Computed tomography, bone mineral density study, 1 or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel) 

PFS Not Waived WAIV

Bone Mass 

Measurement

77080 

Dual-energy x-ray absorptiometry (dxa), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine) 

B 

PFS Not Waived WAIV
CMS-1503-P 344

Preventive 

Service 

CPT/ 

HCPCS 

Code 

Long Descriptor USPSTF Rating1 Payment Method CY 2010 Coins. / Deductible CY 20

Coin

Deduc

77081 

Dual-energy x-ray absorptiometry (dxa), bone density study, 1 or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel) 

PFS Not Waived WAIV

77083 

Radiographic absorptiometry (eg, photodensitometry, radiogrammetry), 1 or more sites 

PFS Not Waived WAIV

76977 

Ultrasound bone density measurement and interpretation, peripheral site(s), any method 

B PFS Not Waived WAIV

G0104 

Colorectal cancer screening; flexible sigmoidoscopy 

PFS 

Coins. 

applies & 

ded. Is 

waived 

WAIV

Colorectal 

Cancer 

Screening 

G0105 

Colorectal cancer screening; colonoscopy on individual at high risk 

A 

PFS 

Coins. 

applies & 

ded. is 

waived 

WAIV
CMS-1503-P 345

Preventive 

Service 

CPT/ 

HCPCS 

Code 

Long Descriptor USPSTF Rating1 Payment Method CY 2010 Coins. / Deductible CY 20

Coin

Deduc

G0106 

Colorectal cancer screening; alternative to G0104, screening sigmoidoscopy, barium enema 

PFS 

Coins. 

applies & 

ded. is 

waived 

Coin

applie

ded. 

waiv

G0120 

Colorectal cancer screening; alternative to G0105, screening colonoscopy, barium enema. 

*Not 

Rated 

PFS 

Coins. 

applies & 

ded. is 

waived 

Coin

applie

ded. 

waiv

G0121 

Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk 

PFS 

Coins. 

applies & 

ded. Is 

waived 

WAIV

82270 

Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive 

CLFS WAIVED WAIV

G0328 

Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous 

A 

CLFS 

Coins. 

applies & 

ded. Is 

waived 

WAIV

Prostate 

Cancer 

Screening 

G0102 Prostate cancer screening; digital rectal examination D PFS Not Waived No

Waiv
CMS-1503-P 346

Preventive 

Service 

CPT/ 

HCPCS 

Code 

Long Descriptor USPSTF Rating1 Payment Method CY 2010 Coins. / Deductible CY 20

Coin

Deduc

G0103 

Prostate cancer screening; prostate specific antigen test (PSA) 

CLFS WAIVED WAIV

G0117 

Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist 

PFS Not Waived No

Waiv

Glaucoma 

Screening 

G0118 

Glaucoma screening for high risk patient furnished under the direct supervision of an optometrist or ophthalmologist 

I 

PFS Not Waived No

Waiv

90655 

Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for intramuscular use 

Drug 

Pricing 

File 

WAIVED WAIV

Influenza 

Virus 

Vaccine 

90656 

Influenza virus vaccine, split virus, preservative free, when administered to individuals 3 years and older, for intramuscular use 

B 

Drug 

Pricing 

File 

WAIVED WAIV
CMS-1503-P 347

Preventive 

Service 

CPT/ 

HCPCS 

Code 

Long Descriptor USPSTF Rating1 Payment Method CY 2010 Coins. / Deductible CY 20

Coin

Deduc

90657 

Influenza virus vaccine, split virus, when administered to children 6-35 months of age, for intramuscular use 

Drug 

Pricing 

File 

WAIVED WAIV

90658 

Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use 

Drug 

Pricing 

File 

WAIVED WAIV

90660 Influenza virus vaccine, live, for intranasal use Drug Pricing File WAIVED WAIV90662 

Influenza virus vaccine, split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use 

Drug 

Pricing 

File 

WAIVED WAIV

G0008 Administration of influenza virus vaccine PFS WAIVED WAIVG9141 

Influenza A (H1N1) immunization administration (includes the physician counseling the patient/family) 

PFS WAIVED WAIV
CMS-1503-P 348

Preventive 

Service 

CPT/ 

HCPCS 

Code 

Long Descriptor USPSTF Rating1 Payment Method CY 2010 Coins. / Deductible CY 20

Coin

Deduc

G9142 

Influenza A (H1N1) vaccine, any route of administration 

Drug 

Pricing 

File (if 

not 

supplied 

at no 

cost) 

WAIVED WAIV

90669 

Pneumococcal conjugate vaccine, polyvalent, when administered to children younger than 5 years, for intramuscular use 

Drug 

Pricing 

File 

WAIVED WAIV

90670 

Pneumococcal conjugate vaccine, 13 valent, for intramuscular use. 

Drug 

Pricing 

File 

WAIVED WAIV

90732 

Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use 

Drug 

Pricing 

File 

WAIVED WAIV

Pneumococcal 

Vaccine 

G0009 Administration of pneumococcal vaccine 

B 

PFS WAIVED WAIV
CMS-1503-P 349

Preventive 

Service 

CPT/ 

HCPCS 

Code 

Long Descriptor USPSTF Rating1 Payment Method CY 2010 Coins. / Deductible CY 20

Coin

Deduc

90740 

Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use 

Drug 

Pricing 

File 

Not 

Waived WAIV

90743 

Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use 

Drug 

Pricing 

File 

Not 

Waived WAIV

90744 

Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use 

Drug 

Pricing 

File 

Not 

Waived WAIV

90746 

Hepatitis B vaccine, adult dosage, for intramuscular use 

Drug 

Pricing 

File 

Not 

Waived WAIV

90747 

Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use 

A 

Drug 

Pricing 

File 

Not 

Waived WAIV

Hepatitis B Vaccine 

G0010 Administration of hepatitis B vaccine A PFS Not Waived WAIV

HIV 

Screening 86689 

HTLV or HIV antibody, confirmatory test (eg, Western Blot) 

A CLFS WAIVED WAIV
CMS-1503-P 350

Preventive 

Service 

CPT/ 

HCPCS 

Code 

Long Descriptor USPSTF Rating1 Payment Method CY 2010 Coins. / Deductible CY 20

Coin

Deduc

G0432 

Infectious agent antigen detection by enzyme immunoassay (EIA) technique, qualitative or semi-qualitative, multiplestep method, HIV-1 or HIV-2, screening 

CLFS WAIVED WAIV

G0433 

Infectious agent antigen detection by enzymelinked immunosorbent assay (ELISA) technique, antibody, HIV-1 or HIV2, screening 

CLFS WAIVED WAIV

G0435 

Infectious agent antigen detection by rapid antibody test of oral mucosa transudate, HIV-1 or HIV-2 , screening 

CLFS WAIVED WAIV

GXXXA 

Annual wellness visit, including PPPS, first visit PFS N/A WAIV

Annual 

Wellness 

Visit GXXXB 

Annual wellness visit, including PPPS, subsequent visit 

*Not 

Rated

PFS N/A WAIV

1 U.S. Preventive Services Task Force Recommendations 
CMS-1503-P 351

A -- The USPSTF strongly recommends that clinicians routinely provide [the service] to eligible patients. (The USPSTF found good evidence thimportant 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 important 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 [thhealth 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 fair evidence thaineffective or that harms outweigh benefits.) I -- The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. (Evidence that [the se

lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.) 
CMS-1503-P 352

4. Extension of Waiver of Deductible 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 section 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 appropriateness of this proposed definition of services that are furnished in 

connection with, as a result of, and in the same clinical encounter as the colorectal cancer 

screening test that becomes diagnostic. We also note that the beneficiary’s annual 

deductible would likely be met when any surgical procedure (related or not) is furnished 

on the same day as the scheduled screening test. 

We are proposing to implement this provision by creating a HCPCS modifier that 

providers and practitioners would append to the diagnostic procedure code that is 

reported instead of the screening colonoscopy 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 
CMS-1503-P 353

waiving the deductible for all surgical services on the same date as the diagnostic test. 

Coinsurance would continue to apply to the diagnostic test and to other services furnished 

in connection with, as a result of, and in the same clinical encounter as the screening test. 

S. Section 5501: Expanding Access to Primary Care Services and General Surgery

Services

1. Section 5501(a): Incentive Payment Program for Primary Care Services 

a. Background 

Section 5501(a) of the ACA revises section 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 added 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 accounted 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 section 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): 
CMS-1503-P 354

● 99201 through 99215 for new and established patient office or other outpatient 

evaluation and management (E/M) visits; 

● 99304 through 99340 for 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; and domiciliary, rest home (eg, assisted living 

facility), or home care plan oversight services; and 

● 99341 through 99350 for new and established patient home E/M visits. 

These codes are displayed in Table 39. All 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 management; more than 30 minutes 

99318 

Other nursing facility services; evaluation 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, rest home, or custodial care visit 

99328 Level 5 new patient domiciliary, rest home, or custodial care visit 

99334 Level 1 established patient domiciliary, rest home, or custodial care visit 

99335 Level 2 established patient domiciliary, rest home, or custodial care visit 

99336 Level 3 established patient domiciliary, rest home, or custodial care visit 

99337 Level 4 established patient 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 displayed in Table 39. We commonly use the most 

recent full year of claims data for purposes 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 services (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 that 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/practitioner national provider identifier (NPI) number 

using the most current full year of claims data available. 

Therefore, for determining PCIP practitioner 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 claims to determine practitioner eligibility for 

PCIP payment beginning January 2011. We note that the MMA changed the 

requirements for critical access hospital (CAH) billing for practitioners’ professional 

services and, therefore, modifications 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. However, 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 using only 6 months of CAH data for those 

CAHs paid under the optional method. Thereafter, we would update the list of 

practitioners eligible for the PCIP annually based on the most recent available full year of 

PFS and CAH claims data. 

To the extent practitioners were paid under the PFS during the historical claims 

data year for some primary services and, for other services, CAHs were paid under the 

optional method for those same practitioners’ professional services, 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 practitioners 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 service 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 future year, such as the use of CY 2009 PFS 

utilization data in the establishment of certain aspects of CY 2011 PFS payment rates. 

Under the proposed PCIP eligibility determination method, it would be necessary 

to revise the list of eligible practitioners based on updated claims 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 applicable CY PCIP. Given the statutory requirement 

that a practitioner’s primary care services account 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 Medicare without the 2-year lag in eligibility 

determination that was described previously. However, given our general interest in 

supporting primary care practitioners and entry 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, geriatric medicine, or pediatric 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 designation under Medicare would make such changes 

only so that their primary specialty designation 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 cardiology) in order to take advantage of the 

PCIP payments, we would considering making future revisions to eliminate such an 

outcome. 

Consistent with the established Medicare HPSA physician bonus program 

(Medicare Claims Processing Manual, Pub. 100-04, Chapter 12, Section 90.4.4) and the 

proposed Health Professional Shortage 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 contractors 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 professional services or, where the practitioner 

has reassigned his or her benefits to a CAH 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 rendering practitioner’s NPI must be included 

on the line-item for the primary care service (identified in Table 39 above) in order for a 
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determination to be made regarding whether or not the service is eligible for payment of 

the PCIP. We note that, in order to be eligible 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 historical 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 administrative or judicial review under section 1869, 

1878, or otherwise, respecting the identification of primary care practitioners.” We 

believe that the inclusion of this language is intended to provide 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 opportunity 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 claims 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 identified 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 care practitioner would otherwise be paid for 

their professional services under Part B for furnishing the primary care services. For 

example, primary care practitioners identified 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 care 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 PCIP 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. Therefore, 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 and 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 addition, payments for outpatient CAH services 

under section 1834(g)(2)(B) of the Act (as amended by section 5501(a) of the ACA) are 
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not affected by the PCIP payment amounts made 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 amount that would otherwise be paid for their 

professional services under Part B. Quarterly PCIP payments would be made to eligible 

practitioners or to CAHs paid under the optional method that are billing 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 Professional Shortage Areas. 

a. Background 

Section 1833(m) of the Act provides for an additional 10 percent incentive 

payment for physicians’ services furnished to a covered individual in an area that is 

designated as a geographic Health Professional Shortage Area (HPSA) 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 equal 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 added 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 notice (74 FR 65455 through 65457), we identified 

489 10-day global procedure codes and 3,796 90-day global procedure codes for a total 

of 4,285 surgical procedure codes that would have 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 January 1, 2011 and before January 1, 2016, we 

are proposing to provide a 10 percent incentive 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 procedure 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 change their Medicare specialty 

designation in order to take advantage of the HSIP payments. However, we will monitor 

the specialty designations of enrolled physicians, and if we find that surgeons are 

changing their primary specialty designation to general surgery in order 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 Medicare 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 quarterly 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 his or her benefits to a critical access hospital (CAH) paid 

under the optional method, to the CAH 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 the rendering physician, identified by his or 

her NPI, of 02-general surgery. If the claim is submitted by a physician’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 determination 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 codes for automatic payment of the bonus for eligible services 

furnished by general surgeons. We are also proposing to create a new HCPCS code 

modifier to identify circumstances when general 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 requirement, 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, approximately 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 designated 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 established 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 services 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 procedure.” We are also proposing to revise 

§414.67 to move the existing provisions to paragraph (a) to be grouped as the “Health 

Professional Shortage Area (HPSA) physician bonus program” and adding a new 

paragraph (b) for the “HPSA surgical incentive 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 the amount that would otherwise be paid for 

their professional services under Part B. 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 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 Under the Optional Method 

Section 1834(g) of the Act establishes the 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 furnished by a CAH. Specifically, section 

1834(g)(1) of the Act, as amended by the BBRA, 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 services plus, with respect to the professional 

services, the amount otherwise paid for professional services under Medicare, less the 

applicable Medicare deductible and coinsurance amount. The election made under 

section 1834(g)(2) of the Act is sometimes referred to as "method II" or "the optional 

method." Throughout this section of this preamble, 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 payment for professional services under the 

optional method to 115 percent of the amount otherwise paid for professional services 

under Medicare. In addition, in 2003 section 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 regarding 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 phrase "101 percent of" before "the reasonable 

costs.” 

Section 5501(a) of the ACA amends section 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 services. 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 additional 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 professional services under the optional method, by 

adding at the end of section 1834(g)(2)(B) the following phrase, “Subsections (x) and (y) 

of 1833 shall not be taken into account in determining 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 considering the incentive payments for primary care 

services furnished by primary care practitioners and major surgical procedures furnished 

by general surgeons in HPSAs as these terms 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 optional method, are in §413.70(b)(3)(ii)(B). In 

order to implement the amendments to section 1834(g)(2)(B) of the Act as specified by 

sections 5501(a)(2) and 5501(b)(2) of the ACA, we are proposing to amend the 

regulations in §413.70(b)(3)(ii)(B) to state that, 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 the PFS amount under the optional method would 

not take into account the additional 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 Ancillary Services Exception to 

the Prohibition on Physician Self-Referral for Certain Imaging Services 

1. Background 

Section 1877 of the Act also known as the 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 (ownership 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 those 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 office 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, section 6003 provides that, with respect to referrals 

for magnetic resonance imaging (MRI), computed tomography (CT), positron emission 

tomography (PET), and any other DHS specified under section 1877(h)(6)(D) that the 

Secretary determines appropriate, we must promulgate 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 patient with a list of suppliers who furnish the service in 

the area in which the patient resides. 

2. Proposed Disclosure Requirement 

We are proposing to implement section 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 the 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 considering whether to expand this disclosure 

requirement to other radiology and imaging services. We are not inclined to expand the 

disclosure requirement but we solicit comments 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 Disclosure Requirements 

 In §411.355(b)(7), we are proposing that the disclosure notice should be written in a 

manner sufficient to be reasonably understood 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 obtained from a person other than the referring 

physician or his or her group practice and include a list of other suppliers who provide the 

service being referred (MRI, CT, or PET). 

We believe one purpose of the disclosure requirement is to inform a patient’s 

decision-making regarding his or her own care. 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 indicate 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 specifies that the referring physician must provide a 

written list of “suppliers (as defined 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 services”, which is defined 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 relevant 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 physicians 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 reside. 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 statute, we are proposing that the suppliers 

included in this notice should be located within a 25-mile radius of the 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 we 

have 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 suppliers located within a 25- mile radius of the 
CMS-1503-P 373

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 proposed 25-mile radius requirement. In 

attempting to minimize confusion and burden related to implementing 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 other 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 should be considered in finalizing regulations for 

physicians in both urban and rural areas. 

In order to help a patient make an informed 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 that the list include the 10 closest suppliers, 

but we want to allow physicians some flexibility in drafting the list of suppliers. On the 

other hand, we are concerned 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 burdensome or susceptible to abuse and whether 

there are alternate criteria we should use that 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 referring physician’s office location, including up 

to 10 suppliers as required by these regulations. If no other suppliers of the imaging 

services ordered exist within the 25-mile radius 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 imaging services from another supplier. In 

this last situation, simply providing this disclosure 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 notice be required to include certain 

information about the listed suppliers in order to satisfy this disclosure requirement. The 

list must include the name, address, phone number, and distance from 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 suppliers in order to emphasize to the patient 

the relative convenience of the listed suppliers. 

We are not proposing an exception to the disclosure 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 procedures or circumstances in which it may 

be difficult or impractical to provide the written 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 intended 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 
CMS-1503-P 375

statutory requirements. One possible alternative is to only require a “reasonable” list of 

other suppliers with general requirements 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 other alternative methods of compliance 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 the 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, section 6003(a) of the ACA amends section 1877(b)(2) of the 

Act by instructing that the new disclosure requirement be added as one of the additional 

requirements of the in-office ancillary services 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 disclosure 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 requirement and the regulation becomes effective. 

We considered whether, pursuant to section 6003 of the ACA, the final rule 

setting forth the disclosure requirement should apply retroactively to all services 

furnished on or after January 1, 2010. Given 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 apply only to services furnished on or after the effective date 

of the final regulation implementing section 6003 of the ACA. We are proposing an 

effective date of January 1, 2011 for the regulation implementing this provision. 

U. Section 6404: Maximum Period for Submission 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, providers 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 calendar year to have been furnished in the 

succeeding calendar year) except that, where the Secretary deems that efficient 

administration so requires, such period may 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, and 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 services could be filed with 

Medicare “... no later than the close of the calendar year following the year in which such 

service is furnished (deeming any service furnished 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 sections 1814(a)(1), 1835(a), and 1842(b)(3)(B) of the 

Act. In order to effectively administer the 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 section 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 Department that was performing 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 sections 1814(a)(1), 1835(a), and 

1842(b)(3)(B) of the Act regarding Medicare fee-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 for pre-2010 services, subject to this new 

requirement. The practical effect of this change is that any claims for services furnished 

before October 1, 2009 will follow the current existing 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 only have 12-15 months to file a claim, 

whereas before the ACA amendments, they would have had an additional 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 provided 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 statutory provisions. Therefore, we are proposing that for pre2010 services, the pre-existing regulatory structure will continue to apply. For those 
CMS-1503-P 379

services furnished before January 1, 2010, claims must be filed on or before December 31 

of the following year for services that were furnished during the first 9 months of a 

calendar year, and on or before December 31st 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 Secretary 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 following conditions have been met: 

● At the time the service was furnished the beneficiary was not entitled to 

Medicare; and 

● The beneficiary subsequently received 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 will be extended through 

the last day of the 6th calendar month following the month in which the beneficiary 
CMS-1503-P 380

received notification of Medicare entitlement effective 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 having 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 contractors 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 received notification of Medicare entitlement 

effective retroactively to or before the date of the furnished service; and 

● A State Medicaid agency recovered the Medicaid payment for the furnished 

service from the provider or supplier 11 months or more after the date of service. 

This proposed exception applies to situations where a provider or supplier bills 

(and receives payment from) Medicaid for the services that a dual eligible 

Medicare/Medicaid beneficiary 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 individual was granted Medicare entitlement 

retroactively, the State Medicaid Program recovers its payments from the provider or 

supplier for that individual’s services instructing the provider or supplier that Medicare 

should be billed for the services (not Medicaid). If all three of the conditions outlined 

above occur within 11 months of the date the 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 all 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 6th calendar month following the 

month in which the State Medicaid agency recovered the Medicaid payment for the 

furnished service from the provider or supplier. 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 contractors or agents (see §424.44(b)(1)) that no 

extension of time will be granted beyond 4 years 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 fairness 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 exception 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 four 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 alternative 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 term is very important to providers, suppliers, 

and beneficiaries because the “date of service” 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 many 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 are soliciting comments regarding whether CMS 

should provide a regulatory definition of “date of service” and, 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-physician 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 considered timely. In addition, we want to make 
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clear that the one calendar year timely filing limit in section 424.44(a) does apply to any 

retrospective claims permitted 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 selection for round 2 and beyond we are outlining our proposals 

for implementing the statutory requirements related to MSA selection in both MIPPA and 

the ACA in this section. First, we propose to use the authority provided by the statute at 

section 1847(a)(1)(D)(ii) of the Act, as amended by MIPPA to subdivide Metropolitan 

Statistical Areas (MSAs) with populations 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 additional information regarding changes made by 

both MIPPA and Section 6410 of the ACA. In addition to the changes discussed 
CMS-1503-P 384

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 MIPPA, 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 (MSAs) 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. Section 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 areas; (II) MSAs not selected under Round 1 

or 2 with a population of less than 250,000; and (III) certain areas with low population 

density within a selected MSA. These requirements do not apply to a national mail order 

program. 

Finally, MIPPA required that we implement 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) and (D)(ii) of the Act to expand Round 2 of 

the program from 70 MSAs to 91 MSAs by adding the next 21 largest MSAs by total 

population not already selected for Rounds 1 or 2. 

2. Subdividing Large MSAs under Round 2 
CMS-1503-P 385

We have selected MSAs for Round 1 and for Round 2 consistent with MIPPA’s 

requirement. For round 1 CBAs generally were comparable to MSAs, however, for 

round 2 we are proposing to subdivide MSAs of 8,000,000 or more in population. The 

authority to subdivide MSAs into separate areas for competitive bidding purposes is set 

forth in section 1847(a)(1)(D)(ii)(II) of the 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 identified 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-Joliet, 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 divide 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 considering 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 determine: (1) whether or not to subdivide an 

MSA into separate CBAs, and (2) once the decision is made to subdivide the MSA, how 
CMS-1503-P 386

to subdivide the MSA. We considered the following 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 these highly and densely populated MSAs. We 

believe consideration 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 obstacles, mimic existing supplier service 

patterns, and, to the extent possible, do not cross State lines. We believe the factors we 

have selected will achieve those objectives. 

We found that counties clearly delineate areas within a MSA, and as we have 

done for Round 1 by identifying CBAs by counties and zip codes, we are proposing to 
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subdivide the MSAs at a county level. Since the Office of Management and Budget 

(OMB) defines the MSAs by counties and county-based subdivisions are stable, we use 

counties to subdivide CBAs. When subdividing 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 MSA has 207,106 beneficiaries and $218,161,562 of 

DMEPOS allowed charges subject 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 Metro 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 comprise 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 22,747 702,458

South-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. 
CMS-1503-P 389

FIGURE 1: 

The Indiana-Chicago Metro CBA would include all four of the Indiana counties 

that are part of the MSA. The other CBAs in the MSA would be as follows: 
CMS-1503-P 390

● The South-West-Chicago Metro CBA would include counties in Illinois 

located to the south and west of the Central-Chicago Metro CBA. 

● The Central-Chicago Metro CBA would include the city of Chicago covering 

both Cook and DuPage counties. 

● The Northern-Chicago Metro CBA which is north of the Central-Chicago 

Metro CBA subdivision that encompasses 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 subject 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 allowed amount and beneficiary count subject 

to competitive bidding, and the general population 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. 
CMS-1503-P 391

FIGURE 2: 

As mentioned earlier, we propose to subdivide 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 area that are not competitive. In the final 

rule CMS-1270 F §414.410(c) published in April 2007, we defined the factors we 

consider when determining an area is considered 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 propose 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 the 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 Mountains has one major road and 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 DMEPOS 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 two islands of Santa Catalina and San 

Clemente off the west coast. We are proposing that the two islands be included as a part 

of the Los Angeles County CBA in order to ensure that beneficiaries presently residing 
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on these islands or who move to these islands 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 therefore, 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 comprises 23 counties in three States: New 

York, New Jersey and Pennsylvania. The MSA has 344,879 FFS beneficiaries receiving 

DMEPOS subject to the 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 competitive 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:
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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 Island. 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 York 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 the Program Advisory and Oversight 

Committee (PAOC), we presented these proposals 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 areas 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 Counties 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 when we divide the MSAs into CBAs; 

● In the LA County CBA, exclude the area north of the San Gabriel Mountains 

from the CBA; and 
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● Consider traffic patterns when dividing the Los Angeles MSAs into CBAs. 

We are considering the PAOC’s advice and 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 section 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 selected under Round 1 or Round 2 with a 

population of less than 250,000; and 

● Areas with a low population density within a MSA that is otherwise selected 

consistent with section 1847(a)(3)(A). 

We propose to incorporate these requirements and timeframes in proposed §414.410(c). 

4. Expansion of Round 2 

Section 6410(a) of the ACA expanded the areas 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 the 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 selected Round 2). The 2009 annual population 

estimates from the U.S. Census Bureau are the most recent estimates of population that 

will be available prior to the Round 2 competition mandated to take place in 2011. We 
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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 Collection of HCPCS data for 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 provides 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-Alexandria, 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
CMS-1503-P 398

social worker, psychologist services, and preventive services. FQHCs are “safety net” 

providers (for example, community health centers 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 primary care services in underserved urban and 

rural communities. FQHCs typically enhance the availability of care to vulnerable 

populations, including Medicare, Medicaid, SCHIP, 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 year, an interim all-inclusive per-visit payment 

amount, based upon an estimate of Medicare reasonable costs, is calculated for each 

Medicare FQHC. During the year, this interim 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 beginning on or after October 1, 2014. 

Section 10501(i)(3)(A) of the ACA amended section 1834 of the Act by adding a 

new subsection (o), Development and Implementation of Prospective Payment System. 

This subsection provides the statutory framework for development and implementation of 

a prospective payment system for Medicare FQHCs. Section 1834(o)(1)(B) of the Act, 

as established by the ACA, addresses collection of data necessary to develop and 
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implement the new Medicare FQHC prospective 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 Medicare FQHC prospective payment system, including the 

reporting of services using HCPCS codes. Section 1834(o)(1)(B) of the Act requires that 

the Secretary impose this data collection 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 reporting 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 report on Medicare FQHC claims all pertinent 

service(s) provided for each Medicare FQHC visit (defined in §405.2463). This 

additional reporting would include the information 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 requirements 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 accordance 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. Accordingly, we are not proposing additional 

information collection requirements at this time. However, we invite public comment on 

any additional information FQHCs 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 authorized under section 303(c) of the MMA 

which amends Title XVIII of the Act by adding 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 furnished incident to a physician's service, 

drugs furnished under the durable medical equipment (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 ASP 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) could 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 penalties associated with untimely or false ASP 

reporting. Manufacturers who misrepresent or fail to report manufacturer ASP data will 

remain subject to civil monetary penalties, as applicable and 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, preparation, 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 synthesis; 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 data reporting includes repackagers. 

In accordance with section 1847A of the Act, 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 the 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 applicable and available pricing data from manufacturers for that 

drug. This includes WAC prices from compendia 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 manufacturer 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 weighted calculations described in section 

1847A(b) of the Act. For multisource drugs, such a situation is likely to artificially 

increase or decrease Medicare ASP payment limits, which in turn would affect 

beneficiary cost sharing amounts. Such artificial 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 ASPs, based on the manufacturer's ASP calculated for the 

most recent quarter for which data is available. Specifically, we are proposing to carry 

over the previously reported manufacturer ASP for an NDC(s) when missing 

manufacturer ASP and/or WAC data 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 deadlines 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 process. 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 that this percentage threshold meets the 

definition of significant. We are specifically seeking comments on our use of 10 percent 

as the threshold amount. In order to better represent 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 proposing that the manufacturer ASP payment 

amounts for the individual NDCs that 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 account 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 both single source drugs and multiple source 

drugs. However, we are concerned that including single source drugs in the carry over 

process could create an incentive for non-reporting in situations where ASP prices for a 

single source drug are falling and the manufacturer stops reporting ASP in an effort to 

preserve a higher payment amount despite the risk of significant statutory penalties for 
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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 Example 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 average 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 establish a straightforward and transparent 

solution that minimizes the effect of missing manufacturer ASP data on Medicare ASP 

payment limits. We believe that the availability of a mechanism to minimize non-market 

related price fluctuations is desirable when efforts to obtain manufacturer's ASP data by 

deadlines have not been successful. Our proposed 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 codified 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 policy would be implemented regardless of any efforts by the 

OIG to enforce Civil Monetary Penalties for non-reporting. 

We would also like to remind manufacturers 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 Inside CMS Section of 

the ASP Overview Web page at 

http://www.cms.hhs.gov/McrPartBDrugAvgSalesPrice/01_overview.asp#TopOfPage , 

and the Downloads section of the same webpage 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 addition, 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 current 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 forward 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 calendar 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 methodologies 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 partial quarter status during the first quarter of sales. We are taking 

this opportunity to describe our policy regarding 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 first quarter (unless the date 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 section 1847A(c)(4) of the Act, and we intend to 
CMS-1503-P 407

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 data 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 the 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-weighting methodology. In addition, section 

112(b) of the MMSEA sets forth a special rule for determining the payment amount for 

certain drugs and biologicals. We addressed 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 manufacturers. Manufacturers submit ASP data 

to us at the 11-digit National Drug Code (NDC) 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 manufacturer'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 changes. 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 "intentional overfill" in containers of drugs. We 

understand that this "intentional overfill" is intended to compensate for loss of product 

when a dose is prepared and administered properly. For instance, a hypothetical drug is 

intended to be delivered at a 0.5 mg dose which must be drawn into a syringe from a vial 

labeled for single use only. The vial is labeled to contain 0.5 mg of product but actually 

contains 1.5mg of product. The additional 1.0 mg of product is included, by design, and 

is intended to be available to the provider 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 
CMS-1503-P 409

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 interpret "the amount in one item" to be the 

amount of product in the vial or other container as indicated on the FDA-approved label. 

 It has been longstanding Medicare policy that in order to meet the general 

requirements for coverage under the "incident 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 Manual (Publication # 100-02), Chapter 15, 

Sections 50.3, 60.1.A). Such physicians' services 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 actually purchased and that the cost of the 

product must represent an expense to the physician. 

We further understand that when a provider 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 provided 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 and does not represent an incurred cost to a 
CMS-1503-P 410

provider, we are proposing to update our regulations 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-approved 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 the 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 which this section applies, as the Inspector 

General, in consultation with the Secretary, determines to be appropriate." Section 

1847A (d)(2) of the Act states that, "Based upon such studies and other data for drugs and 

biologicals, the Inspector General shall compare the ASP under this section for drugs and 

biologicals with -- 

● The widely available market price (WAMP) 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 percentage (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 WAMP 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 determined under this section for such drug or 

biological, the lesser of -- (i) the widely available market price for the 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 establishes that the applicable threshold percentage is "the 

percentage applied under this subparagraph subject 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 comment period, we specified an applicable 

threshold percentage of 5 percent for both the 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 inappropriate. 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 operational issues associated with this policy. 

We continue to proceed cautiously in this area. We remain committed to providing 

stakeholders, including providers and manufacturers 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 allows the Secretary to specify adjustments to 

this threshold percentage for years subsequent 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 pricing quarter, or three of the previous four 

quarters immediately prior to the current quarter. 
CMS-1503-P 413

In general, the ASP methodology reflects average market prices for Part B drugs 

for a quarter. The ASP is based, in part, on the 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 Sales Prices and Average manufacturer Prices: 

An Overview of 2008", only 33 of 482 examined 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 underlying market trends. We believe that 

applying this threshold percentage adjusted to reflect data from multiple quarters will 

account for continuing differences between ASP 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 comparisons 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 comparisons based on "partial" 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-weighted AMP calculated by the Inspector General 

is based on fewer NDCs than the volume-weighted 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 calculations, 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 the same set of NDCs. We are proposing to revise 

§414.904(d)(3) to reflect corresponding regulatory 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 Inspector 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 the frequency of when such studies should be 

conducted. The Inspector General has conducted studies comparing AMP to ASP for 
CMS-1503-P 415

essentially each quarter since the ASP system 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 billing codes with volume-weighted ASPs that have exceeded 

their volume-weighted AMPs by the applicable 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 Medicare 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 Average Sales Price and Average 

Manufacturer Prices: Impact on Medicare Reimbursement for Fourth 

Quarter 2009 (OEI-03-09-00640) 

8/2009 

Comparison of First-Quarter 2009 Average Sales Price and Average 

Manufacturer Prices: Impact on Medicare 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 Medicare Reimbursement for Second 

Quarter 2009 (OEI-03-09-00340) 

4/2009 

Comparison of Third Quarter 2008 Average Sales Prices and Average 

Manufacturer Prices: Impact on Medicare Reimbursement for First Quarter 

2009 (OEI-03-09-00150) 

2/2009 

Comparison of Second Quarter 2008 Average Sales Prices and Average 

Manufacturer Prices: Impact on Medicare Reimbursement for Fourth 

Quarter 2008 (OEI-03-09-00050) 

12/2008 

Comparison of First Quarter 2008 Average Sales Price and Average 

Manufacturer Prices: Impact on Medicare 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 Medicare Reimbursement for Second 

Quarter 2008 (OEI -03-08-00340) 

5/2008 

Comparison of Third-Quarter 2007 Average Sales Price and Average 

Manufacturer Prices: Impact on Medicare Reimbursement for First Quarter 

2008 (OEI-03-08-00130) 

12/2007 Comparison of Second-Quarter 2007 Average Sales Price and Average 
CMS-1503-P 416

Date Report Title 

Manufacturer Prices: Impact on Medicare Reimbursement for Fourth 

Quarter 2007 (OEI-03-08-00010) 

9/2007 

Comparison of First-Quarter 2007 Average Sales Price and Average 

Manufacturer Prices: Impact on Medicare Reimbursement for Third 

Quarter 2007 (OEI-03-07-00530) 

7/2007 

Comparison of Third-Quarter 2006 Average Sales Price and Average 

Manufacturer Prices: Impact on Medicare 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 Medicare Reimbursement for Second 

Quarter 2006 (OEI-03-06-00370) 

4/2006 Monitoring Medicare Part B Drug Prices: 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 and Average Manufacturer Prices: Impact on 

Medicare Reimbursement for First Quarter 2010" (OEI-03-10-00150), the Inspector 

General found that of 356 billing codes with complete AMP data in the third quarter of 

2009, 16 met the 5 percent threshold, that is, ASP 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 General 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 legislative 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 
CMS-1503-P 417

definition of AMP (72 FR 39142). On December 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/DeficitReductionAct/Downloads/AMPPIOrder.pdf). 

In 2010, section 2503 of ACA amended the definition of AMP, in part, to reflect 

the average price paid for covered outpatient drugs: (1) by wholesalers for drugs 

distributed to retail community pharmacies; and (2) by retail community pharmacies that 

purchase drugs directly from the manufacturer. The statute defines retail community 

pharmacies, in part, as independent, chain, and supermarket pharmacies. 

(3) Proposal 

Overall, we are cognizant that any policy must reflect market-related pricing 

changes. Additionally, we continue to recognize 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 timing 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 preliminary 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 price 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 threshold 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 quarters. 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 manufacturer'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 opportunity after we receive the data, which is the 

calendar quarter after receipt. 

Section 1847A(d)(3)(C) of the Act indicates that a price substitution would be 

implemented "effective as of the next quarter" after the OIG has informed us that the ASP 
CMS-1503-P 419

for a drug or biological exceeds its AMP by the applicable percentage threshold. The 

OIG does not receive new ASP prices for a given 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. 
CMS-1503-P 420

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 substitution policy should permit a final comparison 

between the OIG's volume-weighted 103 percent AMP for a billing code (calculated from 

the prior quarter's data) and the billing code'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 particularly 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. 
CMS-1503-P 421

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 AMP 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: Policy for Reporting Units when Billing for 

Ambulance Fractional Mileage

Under the ambulance fee schedule, the Medicare program pays for transportation 

services for Medicare beneficiaries when other means of transportation are 

contraindicated and all other applicable medical necessity requirements are met. 

Ambulance services are classified 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 (ALS1) (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 medical condition. The House Ways and Means 

Committee and Senate Finance Committee Reports that accompanied the 1965 Social 

Security Amendments suggest that the Congress intended that-- 

● The ambulance benefit cover transportation services only if other means of 

transportation are contraindicated by the beneficiary's medical condition; and 

● Only ambulance service to local facilities 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, 89th Cong., 1st Sess. 37 and Rep. No. 404, 

89th Cong., 1st 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. 
CMS-1503-P 423

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 services (hereafter referred to 

collectively as “providers and suppliers”) were 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 operational 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 totaling 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 
CMS-1503-P 424

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 whole 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 reporting 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 trips 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 instructions clearly state that providers and 

suppliers should, as a matter of procedure, round up fractional mileage amounts to the 

nearest whole mile, some providers 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 concerns 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 fractional 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 issuance 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 amounts, as with ambulance mileage. 

 We then explored whether a change in our procedure would be: (a) appropriate, 
CMS-1503-P 426

(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 for reporting units of service on provider 

claims for fractional ambulance mileage, we believe that we should make every effort to 

create and implement policies and 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 current procedure for reporting units of service 

to require reporting of fractional 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 currently 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 that 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. This was an important point because if 
CMS-1503-P 427

providers and suppliers are not able to measure 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 within 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 nearest tenth of a mile. Additionally, aircraft 

geographic positioning system (GPS) technology 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 administered; covered miles. Although Medicare currently makes 

payment based on fractional units for some services (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 units 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 previously 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. This 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 cost 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 safeguard 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 equipped onboard their vehicles. We believe 

that requiring ambulance providers and suppliers 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 burdening the ambulance community. 

Based on all of the above considerations, we have decided that our claims 

processing instructions for submission of claims for ambulance mileage 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 submission of the most accurate information on all Medicare 

ambulance claims. Furthermore, since our claims processing systems are currently 

capable of accepting and processing fractional units of service, we believe that 

ambulance mileage should be billed to and paid by Medicare in fractional amounts to 

enhance payment accuracy. Based on all the considerations discussed above, we are 

proposing to require that claims for mileage 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 without 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. Providers and suppliers would submit fractional mileage using a 

decimal in the appropriate place (for example, 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 ambulance 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 paper 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 covered miles continue to be reported in whole 
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number miles on both paper and electronic claims. We propose that providers and 

suppliers would round up fractional mileage to the next whole number for mileage that 

exceeds 100 covered miles and report the resulting 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 paying 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 and soliciting comments 

on the results of our negotiated rulemaking committee tasked to establish national 

coverage and administrative policies 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 ordering 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 diagnostic x-ray tests, diagnostic laboratory 

tests, and other diagnostic tests must be ordered by the physician who is treating the 

beneficiary.” In the November 23, 2001 final rule, we added paragraph (d)(2) to §410.32 

to require that the physician or qualified nonphysician practitioner (NPP) (that is, clinical 

nurse specialists, clinical psychologists, clinical social workers, nurse-midwives, nurse 

practitioners (NPs), and physician assistants (PAs)) who orders the service must maintain 

documentation of medical necessity in the beneficiary's medical record (66 FR 58809). 

In the preamble discussions to the March 10, 2000 proposed rule and November 23, 2001 

final rule (65 FR 13089 and 66 FR 58802, respectively), 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 permissible way of documenting that the test 

has been ordered.” In those preambles, we described the policy of not requiring 

physician signatures on requisitions for clinical diagnostic laboratory tests, but implicitly 

left in place the existing requirements for a written order to be signed by the ordering 

physician or NPP for clinical diagnostic laboratory 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 contractors clarifying that the signature of 

the ordering physician is not required for Medicare purposes on a requisition for a clinical 

diagnostic laboratory test (65 FR 13089 and 66 FR 58802). 

On March 5, 2002, we published a program transmittal implementing the 

administrative policies set forth in the final rule, including the following instruction: 

“Medicare does not require the signature of the ordering physician on a laboratory service 

requisition. While the signature of a physician 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 program transmittal in order to manualize 

the March 5, 2002 Transmittal. (Transmittal 1787, Change Request 2410, dated 

January 24, 2003). The cover note to the transmittal states, “Section 15021, Ordering 

Diagnostic Tests, manualizes Transmittal AB-02-030, dated March 5, 2002. In 

accordance with negotiated rulemaking for outpatient clinical diagnostic laboratory 

services, no signature is required for the ordering 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 clinical diagnostic services paid on the basis of 

the physician fee schedule or for physician pathology services.” The manual instructions 

did not explicitly reference clinical diagnostic 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 clinical diagnostic laboratory tests paid under 

the Clinical Laboratory Fee Schedule (CLFS)) to also apply to clinical diagnostic tests 

paid on the basis of the Physician Fee Schedule (PFS) and physician 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 paper 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 transmittal (Transmittal 94, Change Request 

6100, dated August 29, 2008) to update the BPM to incorporate language that was 

previously contained in section 15021 of the 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 schedule, the physician fee schedule, or for 

physician pathology services.” Based on further 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 surrounding the implementation of the policy in 

2001 and subsequent transmittals, we restated and solicited 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 requisition 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 paragraph (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 medical 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 paid under the CLFS is not the only way of 

documenting that the test has been ordered and, thus, should not be required provided 

such documentation exists in an alternate form. 

This policy regarding requisitions for clinical diagnostic laboratory tests does not 

supersede other applicable Medicare requirements (such as those related to hospital 

Conditions of Participation (CoPs)) which require the medical record to include an order 

signed by the physician who is treating the beneficiary. Nor do we believe that anything 

in our policy regarding signatures on requisitions for clinical diagnostic laboratory tests 

supersedes other requirements mandated by professional standards of practice or 

obligations regarding orders and medical records 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 those 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 applies 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 additional 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 treating 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 defined 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 information, referring institution information, 

information about where to send reports, billing information, specimen information, 

shipping addresses for specimens 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 convenience 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 the public about the distinction between requisitions and 

orders. 

During the proposed and final rulemaking 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 all 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, clear 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 paying particular attention 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 address the concerns raised. We are proposing 

to require a physician’s or NPP’s signature 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 physician’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 requires 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, physicians 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 requested, 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 directive for laboratories to meet. 
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We welcome comments on this proposal. 

D. Discussion of Chiropractic 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 coverage for chiropractic services is limited to manual 

manipulation of the spine to correct a subluxation described in section 1861(r)(5) of the 

Act. The demonstration expanded current Medicare coverage to include "care for 

neuromusculoskeletal conditions typical among eligible beneficiaries and diagnostic and 

other services that a chiropractor is legally 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 two urban regions, with each type including a 

Health Professional Shortage 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 section 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 which the Secretary would have paid under 

the Medicare program if the demonstration 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 demonstration 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 demonstration 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 control 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 comment period (74 FR 61926), we discussed 

the evaluation of this demonstration 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 demonstration, 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 expanded 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 the 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 focus on users of chiropractic services rather 

than all Medicare beneficiaries with neuromusculoskeletal conditions, including those 

who did not use chiropractic services and who would not have become users of 

chiropractic services even with expanded coverage for them (74 FR 61926 through 
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61927). Users of chiropractic services are most likely to have been affected by the 

expanded coverage provided by this 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 demonstration over a 5-year period, that is, 

CYs 2010 through 2014 (74 FR 61927). Specifically, 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 implementation 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 approximately $524 million based on actual 

Medicare spending for chiropractic services for 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 reduced by approximately 2 

percent. We are reflecting this reduction only in the payment files used by the Medicare 

contractors to process Medicare claims rather 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 Payment 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, adjusted 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 that time. As a result of the July 15, 2008 

enactment of MIPPA, we are required to implement 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 updates 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 accordance 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 the 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 transition 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 first 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 blend, 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 published this summer. 

b. Medicare Modernization Act (MMA) – The 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 payments for separately billed drugs and the 

revised drug pricing specified in the statute. In addition, section 1881(b)(12)(A) of the 

Act requires that the composite rate be adjusted for a number of patient characteristics 

(case-mix) and section 1881(b)(12)(D) of the Act gives the Secretary discretion to revise 

the wage indices and the urban and rural definitions used to develop them. Finally, 

section 1881(b)(12)(E) of the Act imposed a budget 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 that were effective 

January 1, 2005, included an update of 1.6 percent 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 payments for separately billable drugs and 

payments based on revised drug 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 facilities, 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 implemented 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 explanation 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 updated to 14.5 percent to reflect the expected growth in 

expenditures for separately billable drugs in CY 2006. 

We also implemented a revised geographic adjustment authorized by section 

1881(b)(12)(D) of the Act. This adjustment revised 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. Effective January 1, 2006, 25 percent of the payment 

was based on the revised geographic adjustments, 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 revised 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 payment 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 comment period, we implemented 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 MIEA-TRHCA (Pub. L. 109-432) established a 

1.6 percent update to the composite rate portion of the payment system, effective April 1, 

2007. The effect of this increase in the composite rate was a reduction in the drug add-on 

adjustment to 14.9 percent, effective April 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 index 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 adjustments, and the remaining 50 percent of 

payment was based on the MSA-based adjustments. 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 PFS 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 add-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 wage 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 implemented 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 MIPPA updated sections 1881(b)(12)(G) 

and 1881(b)(12)(A) of the Act to revise payments 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 composite 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 independent dialysis facilities (53.711). The 1 

percent increase to the independent dialysis facility’s CY 2008 composite rate of $132.49 

resulted in a CY 2009 base composite rate for hospital-based and independent dialysis 

facilities of $133.81. The one percent increase in the composite rate portion of the 

payment system effective January 1, 2009, reduced the drug add-on adjustment from 15.5 
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to 15.2 percent. 

 Also, we updated the wage index adjustments to reflect the latest available wage 

data, including a wage index BN adjustment 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 composite rate system, as well as the wage 

index values used to adjust the labor component of the composite rate. Specifically, to 

update the drug add-on adjustment, we conducted 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 section 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 percent 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 reflect 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 adjustment to the composite rate, using a 

refined methodology for projecting growth 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 basket increase factor 

(that is., the ESRD market basket). As explained in the ESRD PPS proposed rule 

(74 FR 4997), we described how the ESRD Bundled market basket would be used to 

update the composite rate portion of the ESRD payments during the PPS transition. 

Ordinarily in updating the composite payment 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 provision as requiring that the 

composite rate portion of the blended payment amount be increased in CY 2011 by the 

ESRD market basket percentage increase factor (the “ESRD market basket”). 

For purposes of this proposed rule, for 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 adjustment to the composite rate. Also, we 

note that the drug add-on percentage would 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 adjustment 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 specifies that the drug add-on increase must 

reflect “the estimated growth in expenditures for drugs and biologicals (including 

erythropoietin) that are separately billable .......”By referring to “expenditures”, we 

believe the statute contemplates that the update 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 expenditure 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 are proposing to use trend analysis from drug 

expenditure data to update the per treatment drug add-on adjustment. We then removed 

growth in enrollment for the same time period from the expenditure growth, so that the 

residual reflects per patient 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 expenditure growth using trend analysis, we 

looked at the average annual growth in total drug expenditures between 2006 and 2009. 

First, we estimated the total drug expenditures for all ESRD 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 facility claims, updated through December 31, 2009 
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(that is, claims with dates of service from January 1 through December 31, 2009, that 

were received, processed, paid, 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 timeframe. This updated CY 2009 

data file will include claims received, processed, paid, and passed to the National Claims 

History File as of June 30, 2010. 

While the CY 2009 claims file used in this 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 expenditures 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 claims file. We used the 

relationship between the December 2008 and the 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 adjustment 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 additional 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 from 2006 through 2009. This average annual 

change showed an increase of 2.1 percent for this timeframe. We propose to use this 2.1 

percent increase to project drug 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 the 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 approximately 3.6 percent. 

To do this, we divided the total drug expenditure change between 2010 and 2011 (1.021) 

by enrollment growth of 3.6 percent (1.036) for 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 Update to the Drug Add-On Adjustment 

In CY 2006, we applied the projected growth 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 projected 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 growth by the projected growth in total 

dialysis treatments to develop the per treatment growth update amount. This growth 

update amount, combined with the CY 2005 per treatment drug add-on amount, resulted 

in an average drug add-on amount per treatment of $18.88 (or a 14.5 percent adjustment 

to the composite rate) for CY 2006. 

In the CY 2007 PFS final rule with comment period (71 FR 69684), we revised 

our update methodology by applying the growth update to the per treatment drug add-on 

amount. That is, for CY 2007, we applied the growth 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 treatment drug add-on amount was updated to 
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$20.33. In the CY 2009 and 2010 PFS final rule with comment period (73 FR 69755 

through 69757 and 74 FR 61923), we applied a zero 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 drug add-on amount of $20.33 established in 

CY 2008. 

d. Proposed Update to the Drug Add-on Adjustment 

 As discussed previously in this section, 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 described 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 zero 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 the 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 add-on. Therefore, we propose to apply a zero 

update, and to maintain the $20.33 per treatment 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 adjust 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 followed 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 authorized under sections 

1886(d)(8) and (d)(10) of the Act or other provisions 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 hospital data and unadjusted for 

occupational mix. 

f. Proposed Updates to Core-Based Statistical Area (CBSA) 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 rates. 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 regarding 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 geographic 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 the 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 the 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 Unadjusted Wage Index,” describes the 

cost report schedules, line items, data elements, 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 Occupational 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 index floor (74 FR 61924). We also stated that a 

gradual reduction in the floor is needed to support 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 for 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 Puerto 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 determined 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 intend 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 blend, and a wage index value of 1.2844 for the 

ESRD PPS portion of the blend for Barnstable Town, MA (CBSA 12700) and also 

results in a proposed CY 2011 wage index value 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-MA (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, and 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 apply 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 composite 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 urban 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 urban area with not hospital data, that is, 

Hinesville-Fort Stewart, GA (CBSA 25980). Under the methodology used for that area, 

we compute the average of all urban areas within the State of South Carolina. This 

approach would result in a CY 2011 wage index value of 0.9480 for the composite rate 

portion of the blend, and a wage index value 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 the CY 2011 proposed wage index floor of 0.60 to 

facilities that are located in rural Puerto Rico. The proposed reduction to the wage index 

floor of 0.60 remains higher than the actual 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 Statistics, to determine if other methodologies might 

be appropriate for imputing wage index values for areas without hospital wage data for 

CY 2011 and subsequent years. To date, no data 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 payment rates effective beginning January 1, 

2011. 

k. Budget Neutrality Adjustment 

 We have previously interpreted the statute as requiring that the geographic 

adjustment be made in a budget neutral manner. Given our application of the ESRD 

wage index, this means that aggregate payments to ESRD facilities 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 adjustments. A separate BN adjustment was 

developed for the case-mix adjustments 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 index BN adjustment factor (1.057057), 

we used the FY 2007 pre-floor, pre-reclassified, non-occupational mix-adjusted hospital 

data to compute the wage index values, 2009 outpatient 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 Compare 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 Proposed 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 estimated 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 for 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 composite rate expenditures for all ESRD facilities. 

After comparing these two dollar amounts (target amount divided by the new CY 

2011 amount), we calculated an adjustment factor 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 index floor value of 0.6000 is applied whenever 

appropriate. The proposed wage BN adjustment 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 tables 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 index values will be applied under the composite 

rate portion and includes the budget neutrality adjustment of 1057057. The second 

column lists the wage index values that will be applied under the ESRD PPS. 

F. Issues Related to the Medicare Improvements 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 provides an incentive payment to identified EPs 

(EPs) who satisfactorily report data on quality measures for covered professional services 

furnished during a specified reporting period. We propose to add §414.90 to title 42 of 

the Code of Federal Regulations 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 practitioner described in section 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 Health 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 program, related laws, and 

help desk resources, is available 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 data on quality measures in the applicable reporting period for 

the year. 

The various provisions of the ACA, with respect 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 further 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 the applicable reporting period. Section 

1848(m)(1)(B) of the Act, as amended by section 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 qualified 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 satisfactorily 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 section 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 process. 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 ("Additional 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 satisfactorily 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 quality measures for a year and having such 

data submitted on their behalf through a Maintenance of Certification Program (MOCP) 

(as defined under section 1848(m)(7) of the Act) 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 ("Additional 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 successful completion of a qualified MOCP 

practice assessment into the composite of measures 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 Physician Compare Internet web site by 

January 1, 2011, on which information on physicians enrolled in the Medicare program 

and other EPs who participate in the PQRI program would be posted. With respect to 

measures collected under the PQRI program, to the extent practicable, the Secretary will 

implement a plan by January 1, 2013, to report 2012 PQRI information on the Physician 

Compare Web site. 

 Finally, section 1848(m)(7) of the Act ("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 shall 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 PQRI, section 1848(m)(2)(B) of the Act, as 

amended by section 3002(a) of the ACA, authorizes a 1.0 percent incentive, and for 2012 

through 2014, a 0.5 percent incentive, for qualified EPs who satisfactorily submit PQRI 

quality measures data. Regardless of the reporting mechanism, and/or the associated 

reporting period (both discussed in detail below) an EP chooses to report quality data for 
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purposes of PQRI, if the EP meets the respective criteria for satisfactory reporting, the EP 

may receive a 1.0 percent incentive. 

 The PQRI incentive payment amount is calculated using estimated Medicare Part 

B PFS allowed charges for all covered professional 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 incentive 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 EHR-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 percent 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 satisfactorily 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 mechanisms and criteria for satisfactorily 

reporting for group practices are also addressed 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 entire 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 reported, and is consistent with the 

goals of maximizing scientific validity and reducing administrative burden. For the 2011 

PQRI, we propose the following reporting periods: (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 period 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 discussed further below in their respective 

sections, we propose the 12-month reporting 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 years, we received input from stakeholders in 

support of partial year reporting 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 complex, and may facilitate participation in 2011 

PQRI for certain EPs. In an effort to be consistent with prior program 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 implemented 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 Terminology (CPT) Category II codes or Gcodes (where CPT Category II codes are not yet available). CPT Category II codes and 

G-codes are Healthcare Common Procedure Coding System (HCPCS) codes for reporting 

quality data. For the 2008 PQRI, we added registry-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 EHR reporting option by conducting limited testing 

of EHR reporting for the 2008 and 2009 PQRI. This 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 identified in Table 14 of the CY 2010 PFS final 

rule with comment period(74 FR 61831), contingent upon the successful completion of 

our 2009 EHR data submission testing process and a determination 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, following the successful completion of the 

2009 EHR data submission testing 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 mechanism. We also propose to retain the 

2010 EHR-based reporting mechanism, by which we will continue to accept quality 

measures data extracted from a qualified 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 PQRI by EPs. However, we seek public comment on these 

proposals and invite suggestions as to other options 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 quality data. Claims submission, however, is 

available to all EPs. We have observed 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 furnished during the reporting period to which 

the measure applies) and qualified 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 may 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 means that claims-based reporting must be 

concurrent with billing. 

By contrast, our experience with the registry-based reporting mechanism 

continues to be a favorable option, as the drawbacks discussed above do not apply. Data 

has shown that not only have the participation rates for registry-based reporting 

increased, but also satisfactory reporting, resulting in an incentive payment for EPs, has 

also increased. Furthermore, the available 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 anticiapte continuing to expand this option in future years. 

We also believe that EHR-based reporting continues 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 mechanism for 2011 PQRI will continue to promote 
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the adoption and use of EHRs and further align 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 detail 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 qualified 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 requirements 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 measures or measures groups an EP selects, 

one or more of the proposed reporting mechanisms may not be available for reporting a 

particular 2011 PQRI individual quality measure or measures group. For example, the 

EHR reporting mechanism currently is not available 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 complex for claims-based reporting. The 

proposed 2011 reporting mechanisms through which each proposed 2011 PQRI 

individual quality measure and measures group could be reported are identified 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 reporting 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 sophisticated 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 alternative 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_AlternativeReportingMechanisms.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 the 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 for participation through a specific reporting 
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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. and 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 required 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 may 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 EPs 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 arrangement 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 
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to CMS. Thus, the registry would act as a Health Insurance Portability and 

Accountability Act of 1996 (Pub. L. 104-191) (HIPAA) Business Associate and agent of 

the EP. Such agents are referred to as "data submission vendors." The "data submission 

vendors" would have the requisite legal authority to provide clinical quality measures 

results and numerator and denominator data on individual quality 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 registry-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 transmitting data. EPs that conduct HIPAA covered transactions 

also would need to maintain compliance with the HIPAA requirements. 

We propose that EPs choosing to participate in PQRI through the registry-based 

reporting mechanism for 2011 would need to select a qualified PQRI registry and submit 

information on PQRI individual quality measures 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 measure(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 post the names of the 2011 PQRI qualified 

registries in 3 phases, which are discussed below. In any event, even though a registry is 

listed as "qualified," we cannot guarantee or assume responsibility for the registry's 
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successful submission of the required PQRI quality 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 based 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 numerator 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. The 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 the 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 final step in the qualification process and a 

necessary requirement if the registry desires to continue to participate in PQRI in 

subsequent years. We propose that these registries also must meet any new 2011 

requirements and will also undergo testing, which will be completed by the end of the 

first quarter of 2011 at the latest. 

In the third phase, we propose to complete posting of the list of qualified 2011 

registries as soon as we have completed vetting the additional registries interested in and 

capable of participating in the 2011 PQRI. We anticipate this will be completed no later 
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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 denominator data on PQRI individual quality 

measures or measures group through the registry-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 satisfactory 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 measure (or measures groups) 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 assuming that the measure was not applicable to 
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the EP and was likely reported from EHR-derived data (or from data 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 Individual 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 associated 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 proposed requirements are identical to the 2010 

requirements for individual EPs who choose the EHR-based requirements. We are 

proposing to retain the 2010 requirements 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 immediately 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 through 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 self-nominated EHR vendor products 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. 
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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 the first time we have an 

opportunity to receive direct EHR data submission for quality reporting and to calculate 

the results, we believe it is best not to add 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 addition to meeting the criteria for satisfactory 

reporting of individual measures)-- 

● Have a qualified EHR product; 

● Have an active Individuals Authorized Access to CMS Computer Services 

(IACS) user account with a data submission role 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 information 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 
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December 31, 2011) via IACS or an acceptable 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 complete 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 qualified EHR vendors available for 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 PQRI 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 product is qualified and has been 

updated to facilitate PQRI quality measures data submission. Such professionals also 

should begin attempting submission soon after the 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 problems 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 the electronic transmission of the 2011 PQRI measures, 

identified in Tables 55 and 56 of this proposed 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 Requirements 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 qualified for 2009 did not need to be "requalified" for 2010 unless they were unsuccessful at submitting 2009 PQRI data (that is, 

failed to submit 2009 PQRI data per the 2009 PQRI registry requirements). Registries 

that were "qualified" for 2009 and wished to continue to participate in 2010 were only 

required to communicate their desire to continue participation for 2010 by submitting a 

letter to CMS indicating their continued interest 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 require 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 applicable reporting periods in 2011. We propose 

that the registry self-nomination process for the 2011 PQRI would be based on a registry 

meeting specific technical and other requirements, as discussed below. 

To be considered a qualified registry for purposes of submitting individual quality 

measures and measures groups on behalf of EPs 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 report per year to participating EPs; 
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● Not be owned and managed by an individual locally-owned single-specialty 

group (in other words, single-specialty practices with only 1 practice location or solo 

practitioner practices would be prohibited from self-nominating to become a qualified 

PQRI registry); 

● Participate in ongoing 2011 PQRI mandatory 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 report 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; 
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● 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 quality service performed (numerator); 

● Report the number of performance exclusions; 

● Report the number of reported instances, 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 level 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 (national health information network) if 

technically feasible; 

● Submit an acceptable "validation strategy" to CMS by March 31, 2011. A 

validation strategy ascertains whether EPs have 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 strategies often include such provisions as the 

registry being able to conduct random sampling 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; 
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● 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 documentation 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 contractual 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 CMS are accurate and complete; 

● Indicate the reporting period chosen for each EP who chooses to submit data 

on measures groups; 
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● Base reported information on measures 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 applicable 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 qualification requirements for 2011 registries are similar to the 

PQRI qualification requirements for registries for previous years. However, we note, 

that registries would no longer 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 reporting 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 members. 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 performance rates unless otherwise stated if 
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aggregated measures data is continued for 2011 PQRI registry reporting. CMS will 

provide registries a calculation 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 program, 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 performance rates) using the CMS-supplied 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. Registries 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 recalculate the registries' reported results. 

Validation will be conducted for several measures 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 PQRI and despite their apparent success as a 

vehicle for quality reporting (over 90.0 percent 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 registry data against claims. Even though 

qualified registries go through a thorough vetting and testing process, we have found 

differences in measure results (that is, performance rates) reported by the registries when 

compared to measure results calculated from claims data for the same EP. This makes it 
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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 algorithms by registries to calculate measures. 

We believe the proposed new requirements for registries discussed above will help us in 

validating the registry data we receive by addressing some of the reasons leading to the 

inconsistencies. The proposal for 2011 to retain many of the 2010 requirements while 

introducing some new requirements 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 denominator data on PQRI individual quality measures or 

measures groups to CMS, and discouraging small physicians' offices or an individual EP 

from self-nominating to become a qualified registry. 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 groups 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 
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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 aggregated data), which means there is less 

data for CMS to analyze. 

 Another option that we considered was changing 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 beneficiary-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 variation that occurs when registries try to 

aggregate their data and calculate the measure results themselves. Reducing the variation 

would facilitate comparison 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 registry to make fewer systems changes. The 

registry would not need to update the algorithms used to calculate the measure's results. 

We invite comments on this alternative that was considered. 

We propose to post the final 2011 PQRI registry requirements, including the exact 

date by which registries that wish to qualify 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 
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new registries that wish to self-nominate for 2011 would be required to do so by 

January 31, 2011. 

Similar to 2010 PQRI, we propose that registries that were "qualified" for 2010 

and wish to continue to participate in 2011 will not need to be "re-qualified" for 2011 

except to the extent that the requirements change 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 requirements. 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 requirements) 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 their 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 procedures 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 registry 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 
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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 propose that the above registry requirements 

would apply not only for the purpose of a registry qualifying to report 2011 PQRI quality 

measure results and numerator and denominator data on PQRI individual quality 

measures or measures groups, but also for the 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 Requirements 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 product (that is, the name of 

the vendor software product and the version that was qualified), and were available for 

the product's users to submit quality data on Medicare beneficiaries to CMS directly from 

their system for the 2010 PQRI. This list of qualified EHR vendors and products was 

posted upon completion of the 2009 EHR Testing Program in January 2010. 

Vendors' EHR products that were listed as "qualified" products for the 2010 PQRI 

were selected because the vendor self-nominated to participate in the 2009 EHR Testing 

Program and demonstrated that their products met the "Requirements for Electronic 

Health Record (EHR) Vendors to Participate 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_AlternativeReportingMechanisms.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 specifications, 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 qualification 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 the EHR vendor vetting process for the 2011 PQRI will be 

complete in early 2011. At the conclusion of the 2011 PQRI EHR vendor vetting 

process, those EHR products that meet all 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 may 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. However, 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 self-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_AlternativeReportingMechanisms.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 having one or more of their EHR products 
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"qualified" to submit quality data extracted from their EHR products to the CMS clinical 

quality data warehouse for 2012 and subsequent years will be required to submit their 

self-nomination letter by January 31, 2011. Instructions for submitting the selfnomination letter will be provided in the 2012 EHR vendor requirements, which we 

expect to post in the 4th 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 qualified 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 required data elements according to the 2012 

EHR Specifications. 

● Be able to separate out and report 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 previously qualified PQRI EHR vendors and 2012 

EHR test vendors must also participate in ongoing PQRI mandatory support conference 

calls hosted by CMS (approximately one call per month). These requirements would 

apply not only for the purpose of a vendor's EHR product being qualified 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 
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measure for the 2012 eRx Incentive Program in 2013. We propose that if a vendor 

misses more than one mandatory support call or meeting, the vendor and their product 

would be disqualified for the PQRI reporting year, which is covered by the call. 

 We propose that previously qualified 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 maintain their PQRI qualification, as well as update 

their electronic measure specifications and data transmission schema should either or 

both change. This proposed requirement ensures 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 EHR Vendors and their products for the 2012 

PQRI. 

e. Proposed Criteria for Satisfactory Reporting of Individual Quality Measures for 

Individual EPs 

 Section 1848(m)(3)(A) of the Act established 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 professional, 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 establishes the presumption that if an EP submits 

quality data codes for a particular measure the measure applies to the EP. 

 For years after 2009, section 1848(m)(3)(D) of the Act provides additional 

authority to the Secretary, in consultation with stakeholders and experts, to revise the 

criteria for satisfactorily reporting data on quality measures. Based on this authority and 
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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 apply 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 furnished 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 able 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 the 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 furnished during the reporting period to which the 

measure applies. 

We also propose for 2011 the requirement that an EP who reports on fewer than 3 

measures through the claims-based reporting mechanism may be subject to the Measure 

Applicability Validation (MAV) process, which would allow us to determine whether an 

EP should have reported quality data codes for additional 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 whether 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 
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cluster of closely related measures and did not report on any other measure that is part of 

that identified cluster of closely related measures, 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-based reporting mechanism only. 

We note that the proposed 2011 criteria for 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 reporting 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, approximately half of PQRI participants (defined as 

submitting at least one QDC), qualified for the PQRI incentive payment. Following the 

2007 program completion, we performed 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 requirement. As a result 

of our review of the 2007 and 2008 program results, we believe that we can reduce the 

reporting sample requirement to 50 percent for claims-based submission without 

increasing the likelihood that professionals will selectively report based on whether the 
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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 percent 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 professionals who qualify for the PQRI incentive. Thus, we believe we can 

encourage significantly broader participation 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 reporting 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 for registry-based and EHR-based reporting: 

● Report on at least 3 measures that apply 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 furnished during the reporting period to which the 

measure applies. 

We do not believe that reducing the reporting sample to 50 percent for registrybased reporting or EHR-based reporting would substantially impact the portion of 

participating professionals who qualify for the PQRI incentive. As stated previously, 

over 90.0 percent of EPs submitting data through registries were incentive eligible. 
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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 comments on our proposal to lower the reporting 

criteria for claims-based reporting of individual measures from 80 percent to 50 percent. 

We seek input on whether 50 percent is an appropriate 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 percent) but we found that differences in the 

performance rates at 50 percent and 80 percent reporting were not substantial while 

differences in the proportion of EPs satisfactorily 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 total of 5 proposed reporting options for 2011, 

or ways in which an EP may meet the criteria 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 reporting individual quality measures under more 

than one of the proposed reporting criteria, proposed reporting mechanism, and or for 

more than one proposed reporting period; however, only one incentive payment will be 

made to an EP based on the longest reporting period for which the EP satisfactorily 

reports. 

f. Proposed Criteria for Satisfactory Reporting 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 previously, we do not propose to make the EHR-based 

reporting mechanism available for reporting on measures groups in 2011. The criteria 

that we propose for 2011 for satisfactory reporting 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, the reporting of at least 1 measures group for 

at least 50 percent of patients to whom the measures group applies, during the reporting 

period; or (2) for registry-based reporting, the reporting of at least 1 measures group for 

at least 80 percent of patients to whom the measures group applies during the reporting 
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period. EPs, for both claims-based and registry-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 and 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 sample 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 reporting period, based on reporting 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 would 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 propose 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 claims data with registry 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 
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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 given 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 the 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 reporting period for which the EP satisfactorily 

reports. Similarly, an EP could also potentially qualify for the PQRI incentive payment 

by satisfactorily reporting both individual measures 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. 
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g. Proposed Reporting Option for Satisfactory Reporting on Quality Measures by Group 

Practices 

(1) Background and Authority 

 Section 1848(m)(3)(C)(i) of the Act requires 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 that 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) demonstration project under section 

1866A of the Act. A group practice reporting 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 practice 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 group 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 
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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 group 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 propose 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 demonstration while concurrently expanding the 

availability of the GPRO to more group practices. Since the PGP demonstration is a 

demonstration program for large group practices, 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 propose one GPRO process, 

which we refer to as "GPRO I" that would 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 process which we refer to as "GPRO II". We 

invite comments on the proposed definition of "group practice" and our proposal to 

expand the definition of group practice to include groups with 2 or more members. 
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In order to participate in the 2011 PQRI through the GPRO, we propose to require 

group practices to complete a self-nomination process and to meet certain technical and 

other requirements. The proposed self-nomination process and participation 

requirements for GPRO I and GPRO II are separately discussed below. 

As discussed further in section VI.F.2. of this proposed rule , participation in the 

Electronic Prescribing (eRx) Incentive Program is voluntary for group practices selected 

to participate in the PQRI group practice reporting option. However, for 2011, we 

propose that group practices must participate 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 electronic 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 approved by the Secretary, would also be considered group 

practices for purposes of the 2011 PQRI GPRO. Specifically, for the 2011 PQRI we 

propose to deem group practices participating in the PGP, Medicare Care Management 

Performance (MCMP), and EHR demonstrations to be participating in the PQRI GPRO 

since many of the measures being reported under these demonstration programs are 

similar 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 incentive qualification under their respective 

approved demonstration project. For example, the MCMP demonstration sites would be 
CMS-1503-P 500

required to meet the requirements for earning 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 demonstration projects discussed above would 

be required to meet the proposed 2011 eRx Incentive Program GPRO requirements or the 

proposed 2011 eRx Incentive Program requirements 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 approved demonstration project since there is no 

eRx requirement under these demonstrations. 

(3) Proposed Process for Physician Group Practices to Participate as Group Practices and 

Criteria for Satisfactory Reporting 

(i) Group Practice Reporting Option for physician group practices with 200 or more 

NPIs-GPRO I 

As stated above, we propose that group practices interested in participating in 

GPRO I must self-nominate to do so. Specifically, 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 electronic 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 single point of contact for 

handling administrative issues, as well as the name and email address of a single point of 

contact for technical support purposes. This information 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 group practice's compliance with the following 

requirements: 

● Have an active IACS user account; 

● Agree to attend and participate in all mandatory GPRO training 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 participation 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 wish to self-nominate for 2011 would be 

required to do so by January 31, 2011. Upon receipt of the self-nomination letters we 

propose to assess whether the participation requirements were met by each selfnominated group practice using 2010 Medicare claims data. We do not propose to 

preclude a group practice from participating 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 who are not established Medicare providers, 

however, would not be included in our incentive 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 participate in the PQRI GPRO I for 2011, we 

propose to retain the existing 12-month reporting period beginning January 1, 2011. We 

propose that group practices participating in GPRO I submit information on these 

measures using a data collection tool based on the GPRO Tool used in 2010 PQRI GPRO 

by 36 participating group practices to report quality measures under PQRI. The 2010 

PQRI GPRO Tool will be updated as needed 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 performance 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 PQRI GPRO. We believe these measures 

target high-cost chronic conditions and preventive 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 measures set developed under the direction of 

CMS and were used in the PGP and/or MCMP demonstration programs, and have 

subsequently been used in 2010 PQRI GPRO. Contributors to the development of the 

DOQ measures set included the American Medical 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 reporting 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 preventive 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 for 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 identified in Table 71 for inclusion in 2011 PQRI 

GPRO I. We specifically request comments on whether these measures can and/or 

should be expanded for the group practice reporting option for future program years. 

Disease modules and measures should address high cost conditions and/or a gap in care. 

Further detail on criteria for measure selection can be found in section VI.F.1.h. below. 

 The proposed process that group practices will be required to use 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 required 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 sample 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 practice using a patient assignment methodology 
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modeled after the patient assignment methodology used in the PGP demonstration. 

Based on our desire to model the PQRI GPRO I after the PGP demonstration, 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 payer. Assigned beneficiaries would not 

include Medicare Advantage enrollees. A beneficiary would be assigned to the physician 

group that provides the plurality of a beneficiary's office or other outpatient evaluation 

and management allowed charges (based on Medicare Part B claims submitted for the 

beneficiary for dates of services between 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 assigned patient sample 

for purposes of 2011 PQRI GPRO I. For inclusion in the sample, assigned beneficiaries 

would be required to have at least 2 visits 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 provide the selected physician groups with access to this prepopulated database by no later than the first quarter of 2012. The physician group would 

be required to populate the remaining data fields 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 beneficiaries 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 quality measure. All of the assigned patients' 

inpatient, outpatient, and physician claims would be used in determining clinical 

eligibility for each module, regardless if they were submitted by the group practice or 

other providers. Identical to the sampling method used in the PGP demonstration, we 

propose that the random sample must consist of at least 411 assigned beneficiaries. If the 

pool of eligible assigned beneficiaries is less than 411, then the group practice must 

report on 100 percent, or all, of the assigned beneficiaries to satisfactorily participate in 

the group practice reporting option. For each disease module or preventive care measure, 

the physician group would be required 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 already 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 Period 

A 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 qualify as individual EPs 

with respect to the other practice (TIN). As discussed above, we propose that each 

physician group selected to participate in the PQRI GPRO I would have access to a data 

base (that is a data collection tool) that would include the assigned beneficiary sample 

and the quality measures. This data collection tool was originally developed for use in 

the PGP demonstration, updated for use in the MCMP demonstration, and will continue 

to be updated as needed for use in the PQRI. The assigned beneficiaries' demographic 

and utilization information is pre-populated based 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 each of the quality measures would include all 

beneficiaries 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 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 data should we choose to do so in future 

program years. 
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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" for 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 characteristics 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 significant potential benefits to allowing 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. Additionally, 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 raises 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 patients for any one physician to meaningfully 

differentiate performance results. Finally, we believe that many process-of-care 

measures depend on general functioning of the practice, such as in coordinating and 

tracking care, as opposed to a quality of a particular professional in the group, 

particularly for measures related to prevention and care of chronic illnesses. 

As a result, based on our authority under 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 processes 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 propose 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 report as a group to self-nominate. The 

self-nomination process would consist 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 least 2 established Medicare providers. 

NPIs who are not established Medicare providers, 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 process available to groups in 2011, we propose 

to initially pilot the GPRO II process with a limited number of groups. We propose to 
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select the first 500 groups that meet the proposed eligibility requirements to participate in 

the 2011 GPRO II. We propose to use the postmark to determine the order in which 

groups self-nominated for GPRO II. We propose 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 January 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 reviewing 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 detail below, we propose that in addition to 

reporting a specific number of individual measures, the group would have to report one 

or more proposed 2011 PQRI measures groups identified 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 individual 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 professionals. 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 requirements 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 would 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 from among any of the 2011 PQRI measures 

on which to submit data, provided the measures 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 (percentage) 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 measures, 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 concerned 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 measures 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 applies to patients of the group. 

A second alternative that we considered was to require group practices, as part of 

the self-nomination process, to designate whether 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 specialty-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 measures or requiring all groups, regardless of 

specialty, to report on the same core set of measures. 

Table 50 sets forth the proposed criteria 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 professional's data to see if they satisfactorily reported at the 

individual TIN/NPI level. If the EP satisfactorily reported at the individual 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 Program as a small group, we propose that the 

group would need to indicate that preference in their self-nomination letter and would 

need to report on the number of unique encounters 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 individual 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 measure and the group would need to use an 

electronic prescribing system that meets the requirements 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 members 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 Group 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 visits 

where 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 prescriber 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 assumed 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 denominator codes, and thus, would not have an 

opportunity to report the electronic prescribing measure. For the remaining EPs within 

the group who do have an opportunity to report 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 required 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 quality 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 option that we considered for expanding the 

GPRO for 2011 was to expand GPRO I to include smaller group practices. Specifically, 

we considered allowing groups of 100 or more EPs to participate in the PQRI under 

GPRO using the same reporting mechanism 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. 
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h. Statutory Requirements and Other Considerations 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 under 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 endorsed 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 measures is identified for each measure. The 

basis for including certain measures that are 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 generally 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 refinement 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 System 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 process (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 measures and measures groups for possible 

inclusion in the proposed set of quality measures 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. Accordingly, 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 measures be selected from measures that 

have been endorsed by the entity with a contract 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 submission of the measures for 

endorsement may be carried out by a variety of different organizations. We do not 

believe there needs to be any special restrictions on the type or make up of the 
CMS-1503-P 516

organizations carrying out this basic development of physician measures, such as 

restricting the initial development to physician-controlled organizations. Any such 

restriction would unduly limit the basic development of quality measures and the scope 

and utility of measures that may be considered 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 received in response to the CY 2010 PFS 

proposed rule and final rule with comment period. Additionally, 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 list 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 Listening Session participants. The Listening 

Session background paper is posted on CMS Sponsored Calls page of the PQRI section 

of the CMS Web site at: 

http://www.cms.gov/PQRI/04_CMSSponsoredCalls.asp#TopOfPage. 

With respect to the selection of new measures (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 considerations, 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 and support CMS and HHS priorities for 

improved quality and efficiency of care for Medicare beneficiaries. These current and 

long term priority topics include the following: prevention; chronic conditions; high cost 

and high volume conditions; elimination of health disparities; healthcare-associated 

infections and other conditions; improved care coordination; 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 measure set except as provided under section 

1848(k)(2)(C)(ii) of the Act. 

++ Section 1848(k)(2)(C)(ii) of the Act provides an exception to the requirement 

that the Secretary select measures that have been endorsed by the entity with a contract 

under section 1890(a) of the Act (that is, the NQF). As long as an area or medical topic 

for which a feasible and practical NQF-endorsed measure is not available has been 

identified and due consideration has been given to measures that have been adopted by 

the AQA or other consensus organization identified by Secretary. As discussed above, 

we anticipate not including measures which only have AQA adoption for future program 

years. 
CMS-1503-P 518

++ The statutory requirements 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 contract 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. The basic steps for developing measures 

applicable to physicians and other EPs prior to submission of the measures for 

endorsement may be carried out by a variety of different organizations. We do not 

believe there needs to be any special restrictions on the type or make up of the 

organizations carrying out this basic development of physician measures, such as 

restricting the initial development to physician-controlled organizations. Any such 

restriction would unduly limit the basic development of quality measures and the scope 

and utility of measures that may be considered 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 Medicare beneficiaries and expand 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 clinical quality including outcome measures, 

where appropriate and feasible, process measures, structural measures, efficiency 

measures, and measures of patient 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 rates. This leads to preference for measures 

that reflect readiness for implementation, such 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 collection and submission. Therefore, any measures that have 

previously been found to be technically impractical 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 example, in some cases, we are proposing to 

replace existing 2010 PQRI measures with updated and improved measures that are less 

technically challenging to report. For example, we are proposing to replace existing 2010 

PQRI measures #114 and #115 with updated and 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 challenging 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 proposing. While we welcome all constructive 

comments and suggestions, and may consider such recommended measures for inclusion 

in future measure sets for PQRI and/or other 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 selection 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 via notice and comment rulemaking. Measures 

that were not included in this proposed rule for inclusion in the 2011 PQRI that are 

recommended to CMS via comments on this proposed 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 selection 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 via notice and comment rulemaking. Measures 

that were not included in this proposed rule for inclusion in the 2011 PQRI that are 

recommended to CMS via comments on this proposed 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 measures, such publication does not provide true 

opportunity for public comment on those measures' 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 the 2011 measure set. However, as discussed 

above, we will consider comments and recommendations for measures, which may not be 

applicable to the final set of 2011 PQRI measures, for purposes of identifying measures 

for possible use in future years' PQRI or other initiatives to which those measures may be 

pertinent. 

In addition, as in prior years, we again 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 process 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 owner, developer, or maintainer to make changes 

to a measure. Therefore, comments requesting changes to a specific proposed PQRI 

measure's title, definition, and detailed 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 measures 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 may 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 consideration 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 reporting PQRI quality 

measures data on either individual quality measures or on measures groups for 2011 

PQRI. 

Consistent with statutory requirements for 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 and will ultimately be finalized as of the date 

the CY 2011 PFS final rule with comment period is available for public inspection at the 

Office of the Federal Register. No changes (that is, additions or deletions of measures) 

will be made after publication of the CY 2011 PFS final rule with comment period. 

However, as was the case in previous program 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 specifications for individual quality measures will 

be available on the PQRI section of the CMS Web site at http://www.cms.gov/PQRI

when they are sufficiently developed or finalized. We are targeting 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 specifications will include 

instructions for reporting and will identify the 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 measures groups suggestions, one of which 

included modifications to an existing measures group, for possible inclusion in the 2011 

PQRI. 

We propose to include a total of 198 measures (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 Tables 52 through 56 and fall 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 Available for EHR-based Reporting. 

In addition, we are also proposing the inclusion 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 more of the considerations for selection of 

proposed 2011 measures discussed in section 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 ultimately were not 

NQF-endorsed. In addition we propose to replace existing 2010 PQRI measures #114 

and #115 with an updated and improved measure (#TBD "Preventive Care and 

Screening: Tobacco Use: Screening and Cessation Intervention"), which is less 

technically challenging to report. We invite 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 registry-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 would not be reportable as individual measures 

through claims-based reporting or registry-based reporting. 

The 125 individual 2010 PQRI measures proposed 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 Title in Table 52, along 

with the name of the measure's developer/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 available 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 identified 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 the 

Physician 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 0420 

134 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 of 

Anti-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 0056 

172 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 0454 

194 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 measures #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 measures 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 have 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 individual quality measure may, therefore, be 
CMS-1503-P 532

different from specifications for the same quality 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 specifications 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 guarantee 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 Table 53 can be found in the "2010 PQRI Quality 
CMS-1503-P 533

Measures List," which is available on the Measures 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 0393 

118 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 0383 

159 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 

Number 

168 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 0409 

206 HIV/AIDS: Screening for High Risk Sexual Behaviors AMAPCPI/NCQA 0413 

207 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 quality 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 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 specifications 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 development 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) all 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 January 1, 2011. The titles of these proposed 

additional, or new, measures are listed in Table 54 along with the name of the measure 

developer and the proposed reporting mechanism (that is, whether the measure is 

proposed to be reportable using claims, registries, 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 registry-only measures for the 2011 PQRI. The 

remaining 15 measures are proposed to be available 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 discussed in section VI.F.1.h. of this proposed 

rule. 

(4) Proposed 2011 Measures Available 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 submission process and a determination that accepting data from 

EHRs on quality measures for the 2011 PQRI continues 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 Recovery and Reinvestment Act (ARRA). Again, 

this year, we propose to make these measures available for electronic submission via an 

EHR because these measures target preventive 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 Pain; (8) CAD; (9) Heart Failure; (10) IVD; 

(11) Hepatitis C; (12) HIV/AIDS; and (13) CAP. We are proposing to include these 

measures groups in 2011 PQRI because they each contain at least 4 PQRI quality 

measures that share a common 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 groups 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 high impact on HHS and CMS priority topics 

for improved quality and efficiency for Medicare beneficiaries (such as prevention, 

chronic conditions, improved care coordination, 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 included in the Back Pain measures group, the measures included 

in any proposed 2011 measures group be reportable 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 continue to be reportable only as part of a 

measures group and not as individual measures in 2011. We propose that measures 

selected for inclusion in all 2011 PQRI measuresgroups (except for the Back Pain 
CMS-1503-P 541

measures group) are reportable either as individual 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 PQRI 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 inclusion 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 measures 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 
CMS-1503-P 542

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: Discontinuation 

of 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 

Developer 

159 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/NCQA 

207 HIV/AIDS: Screening for Injection Drug Use 0415 AMAPCPI/NCQA 
CMS-1503-P 546

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 measures 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 instructions for measures groups will again be 

provided separately from the specifications and 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. 
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Additionally, the detailed measure specifications and instructions for submitting 

data on those 2011 measures groups that were also included as 2010 PQRI measures 

groups may be updated or modified prior to 2011. Therefore, the 2011 PQRI measure 

specifications for any given measures group could be different from specifications and 

submission instructions for the same measures 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 Physician 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 existing PQRI measure and will be added to the 2011 

PQRI for purposes of the GPRO I. Measures 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 measures specifications manual and other 

supporting documents will be available for group practices participating in the 2011 

PQRI GPRO I. We anticipate that the group practice measures specifications manual will 
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be available by November 15, 2010 on the PQRI 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 0055 

118 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 
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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 requires the Secretary to post on the CMS Web 

site, in an easily understandable format, a list 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 prescribers. 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 information on physicians enrolled in the 

Medicare program and other EPs who participate 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, for 2011 PQRI, to use the current Physician 

and Other Health Care Professional Directory as a foundation for the Physician Compare 

Web site. As in 2010 PQRI, we propose to continue 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 Physician and Other Health Care Professionals Directory. Our 

intent for the 2011 PQRI is to post the information 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 PQRI quality measures through one of the 
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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 furnished 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 reporting the names of group practices, on the 

Physician Compare Web site, for 2011, we propose to post the names of group practices 

that: (1) submit data on the 2011 PQRI quality 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 services furnished during the applicable 2011 

PQRI reporting period for purposes of satisfying 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 available 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, and 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 physician performance, including measures 

collected under PQRI. Consistent with section 10331 of the ACA, we expect, in the 

future, to publicly report performance information based on PQRI. 

We will be working on a plan to expand the information that is publicly posted on 

the Physician Compare in future years. This will be further described in future 
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rulemaking. We solicit comments on our plan 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 Act, 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 quality reporting period for the year, the fee 

schedule amount for services furnished by such professionals during 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 Certification Programs and Section 10327 

Improvements to the Physician Quality Reporting System 

 Section 3002(c) of the ACA amends section 1848(k)(4) of the Act to require a 

mechanism whereby an EP may provide data 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 ("Additional 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 requirements are met. In accordance with section 

1848(m)(7)(B) of the Act, in order to qualify for the additional incentive payment, an EP 
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must-- 

• Satisfactorily submit data on quality measures 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 defines "Maintenance of Certification 

Program" as a continuous assessment program, such as a qualified ABMS MOCP, or an 

equivalent program (as determined by the Secretary), that advances quality and the 

lifelong learning and self-assessment of board certified specialty physicians by focusing 

on the competencies of patient care, medical knowledge, practice-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 educational and self-assessment programs that require an 

assessment of what was learned. 

• Demonstrate, through a formalized, secure examination, that the physician has 

the fundamental diagnostic skills, medical knowledge, and clinical judgment to provide 

quality care in their respective specialty. 
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• Successful completion of a qualified MOCP practice assessment. 

 As defined in section 1848(m)(7)(C)(ii) of the Act, a "qualified Maintenance of 

Certification Program practice assessment" means 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 payment, 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, information on the survey of patient experience 

with care; and 

 (3) As the Secretary may require, on the methods, measures, and data used under 

the MOCP and the qualified MOCP practice assessment. 

 Section 10327(b) of the ACA amends section 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 assessment into the composite of measures of 
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quality for care furnished pursuant to the physician fee schedule payment modifier. 

 To implement the provisions under sections 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 requirements for satisfactory PQRI reporting, for 

program year 2011, based on the 12-month reporting 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 month 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 may 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 participate under one of the GPRO options (I or II),. 

Alternatively, EPs may satisfactorily report 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 satisfactory reporting under PQRI. 

• In addition to meeting the proposed requirements 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 the 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 submission of the MOCP data as specified below. 

• An EP must, more frequently than is required to qualify for or maintain board 
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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 practice assessment. With regard to the 

elements other than completing a qualified 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 requirement. 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 educational and self-assessment programs that require an 

assessment of what was learned; demonstrate, through a formalized, secure examination, 

that the physician has the fundamental diagnostic skills, medical knowledge, and clinical 

judgment to provide quality care in their respective specialty; and successfully complete a 

qualified MOCP practice assessment. 

With respect to the MOCP practice assessment, which is specifically delineated 

in section 1848(m)(7)(B)(ii) of the Act as being 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 “more frequently.” Additionally, we are 
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aware that some specialty boards have varying 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 specialty board. We interpret the statutory 

provisions as requiring participation in and successful completion of at least one MOCP 

practice assessment. Therefore, we propose, as a basic requirement, participation in 

and successful completion in at least one MOCP practice assessment. For physicians 

who are not required to participate in an MOCP to maintain board certification, "more 

often" would be more than 0, and therefore 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 order 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 complete 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 MOCP, EPs who do not have available, through 

their boards or otherwise, an MOCP practice assessment are not eligible for the 0.5 

percent incentive. 

• We believe that the experience of care survey provides particularly valuable 
CMS-1503-P 557

information and propose that a qualified MOCP practice assessment must include a 

survey of patient experience with care. The Secretary may request information on the 

survey of patient experience with care, under section 1848(m)(7)(B)(iii) of the Act. In 

view of the importance of this information, and 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 whom information is being submitted by the 

MOCP. 

We propose that MOCPs, who wish to enable their members to be eligible for an 

additional PQRI incentive payment for the 2011 PQRI, will need to go through a selfnomination process by January 31, 2011. We propose 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 the MOCP, and whether the MOCP is 

sponsored by an ABMS board. If not an ABMS 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 under 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 specifications of the measures, 

or an electronic file containing the detailed 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 the 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 maintain 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 
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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 should 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 registry. 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) – Integration of PQRI and EHR Reporting 

Section 1848(m)(7) of the Act ("Integration of Physician Quality Reporting and 

EHR Reporting), as added by section 3002(d) of the ACA requires us to move towards 

the integration of EHR measures with respect 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 measures under PQRI with reporting requirements 

under subsection (o) relating to the meaningful use of EHRs. Such integration shall 

consist of the following: 

(A) The selection of measures, the reporting of which would both demonstrate— 

 (i) Meaningful use of an EHR for purposes of the EHR incentive program; and 

(ii) Quality of care furnished to an individual; and 
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(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 requirements of planning the integration of PQRI 

and EHR reporting. We are working towards 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 align 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 section 1848(m)(5) of the Act by adding 

subparagraph (H), which requires 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 feedback report. We will continue to provide 

feedback reports to individuals and group practices that satisfactorily submit PQRI 

quality measure and thus qualify to earn a PQRI incentive. 
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 We believe that the requirements 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 feedback reports that are similar in content and format to the 

reports that we currently provide for such EPs 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 available 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 would not be required to report on a certain 

percentage of eligible cases to satisfactorily report the 2011 PQRI measures groups. EPs 

could just report on 30 eligible cases to satisfactorily report using measures groups. 

Interim feedback regarding the number of cases reported as of February 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 feedback from the 2011 PQRI Listening Session that 

was held on February 2, 2010, we are considering a process by which we could respond 

to interim feedback report requests at the individual level for claims-based submission, 
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based upon first quarter claims data for the applicable 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 prior 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 amended 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 later 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 section 1869, section 1878, or otherwise, of: 

 (1) The determination of measures applicable to services furnished by EPs under 

PQRI; 

 (2) The determination of satisfactory reporting under PQRI; and 

 (3) The determination of any PQRI incentive payment and PQRI payment 

adjustment. 

 We propose to base the informal process 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, information on PQRI feedback report availability 

and access, and/or information on PQRI Portal password issues. We believe that the 
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current inquiry process provides a good basis for an informal review process because EPs 

currently can utilize the inquiry process if they have questions on whether they qualified 

for an incentive. However, the current inquiry process does not have timelines nor is it 

restricted to questions solely on whether the 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 concern(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 evidence submission process, although the EP 

may submit information to assist in the review. 

• Based on our informal review, we will provide a written response. 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. 
CMS-1503-P 564

• By December 31, 2011, we propose to post on the CMS PQRI Web site, further 

information regarding the operational aspects of the informal review process for 2011 

PQRI. We invite public comment on this proposed process. 

2. Section 132: Incentives for Electronic Prescribing (eRx)– The Electronic Prescribing 

Incentive Program 

a. Program Background and Statutory Authority 

 As defined in §423.159(a), eRx is the transmission using electronic media, of 

prescription or prescription-related information between prescriber, dispenser, pharmacy 

benefit manager (PBM), or health 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 use of electronic prescribing by authorizing 

incentive payments to EPs or group practices who 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 payment 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 Federal 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 electronic prescribers, as defined in section 

1848(m)(3)(B) of the Act and further discussed below in this section, an incentive 
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payment equal to 1.0 percent of the total estimated 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 furnished during the 2011 reporting period. Covered 

professional services are defined under the statute to be services for which payment is 

made under, or is based on, the PFS and which are furnished by an EP. The applicable 

electronic prescribing percent (1.0 percent) 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 Recovery and Reinvestment Act of 2009(Pub.L. 

111-5) (ARRA-HITECH), specifies that the eRx incentive does not apply to an EP (or 

group practice), if, for the EHR reporting period, 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 respect 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 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 professional does not have general 
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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 are 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 apply 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 underlying 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 volume prescribers. On the other hand, we 

believe that a payment adjustment should be applied primarily to assure that those who 

have a large volume of prescribing do so electronically, without penalizing those for 

whom the adoption and use of an electronic prescribing 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. 
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Under section 1848(m)(6)(A) of the Act, the 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 described 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 prescribing authority. Detailed information about the types of 

professionals that are eligible to participate 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 professional level, based 

on the NPI. Inasmuch as some individuals (identified by NPIs) may be associated with 

more than one practice or TIN, the determination of whether an EP is a successful 

electronic prescriber will be made to the 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 Secretary 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 professional services for a reporting period (or, 
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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 reporting the electronic prescribing measure, 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. Therefore, in addition to making 

incentive payments for 2011 to individual EPs based on separately analyzing whether the 

individual EPs are successful electronic prescribers, we propose to also make incentive 

payments to group practices based on the determination that the group practice, as a 

whole, is a successful electronic prescriber 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 measures reported, and 

is consistent with the goals of maximizing scientific validity and reducing administrative 

burden. We propose the 2011 eRx Incentive Program reporting period to be the entire 

calendar year (January 1, 2011 through December 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 will help to further maintain program 

stability and be less confusing for EPs. 
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 Accordingly, we propose that successful electronic prescribers would be eligible 

to receive an incentive payment equal to 1.0 percent of the total 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 Determination of Successful Electronic 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 possible 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 physician reporting system, under subsection 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 after 2009, section 1848(m)(3)(D) of the Act 

permits the Secretary in consultation with stakeholders 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 reporting 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 submitted by EPs. However, under section 
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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 prescriptions is applied for a particular reporting 

period, then the standard based on the reporting on electronic prescribing measures would 

no longer apply. 

For 2011, we propose to continue to require 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 specifications 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 the 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 prescription 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, prescription 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 reporting 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 reporting mechanisms available to individual 

EPs to report the electronic prescribing measure in 2010 to maintain program stability. 

First, we propose to again retain the claims-based 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 data 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 quality 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 reporting at each eligible visit. Registries 

need to indicate their desire to qualify to submit measure results and numerator and 

denominator data on the electronic prescribing 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 electronic 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 submit 2011 measure results and numerator and 

denominator data on the electronic prescribing 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 and 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 Program 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 for the 2011 PQRI on the PQRI section of the 

CMS Web site. 

Similarly, we continue to propose that 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 prescribing measure for the 2011 eRx Incentive 

Program. The self-nomination process and requirements for EHR vendors for the PQRI, 

which would apply to the EHR vendors for the 2011 eRx Incentive Program were 

discussed in the CY 2010 PFS final rule with comment period (74 FR 61801 through 
CMS-1503-P 573

61802). EHR vendors were required to indicate their desire to have one or more of their 

EHR products qualified for the purpose of an EP potentially being able to submit data on 

the electronic prescribing measure for the 2011 eRx Incentive Program at the time that 

they submitted their self-nomination letter for the 2011 PQRI. A list of qualified EHR 

vendors and their products (including the version 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 section 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 submitting 2011 data on the electronic prescribing 

measure in 2012, as described in section VI.F.1. above, such EPs would need to submit 

2011 data on the electronic prescribing 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 denominator that defines the circumstances 

when the measure is reportable; and (2) a reporting numerator. 

The denominator for the electronic prescribing measure consists of specific billing 

codes for covered professional services. The 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 electronic prescribing measure. As such, we 
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expanded the scope of the denominator codes for 2010 to covered professional 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 CPT 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 opportunities for EPs to participate in the eRx Incentive Program. 

Thus far, our experience in the 2010 eRx Incentive 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 denominator 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 patient to be included in the measure's 

denominator (that is, reporting of the electronic prescribing measure is not further limited 

to certain ages or a specific gender). EPs are 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 electronic prescribing measure. 
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We further propose that 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. 

(iii) Qualified Electronic Prescribing System – Required Functionalities and Part D eRx 

Standards 

To report the electronic prescribing measure 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 professional 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 certain required functionalities that the system 

can perform. We propose that for 2011, a "qualified" 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, print prescriptions, electronically transmit 

prescriptions, and conduct alerts (written or acoustic signals to warn the prescriber of 

possible undesirable or unsafe situations including potentially inappropriate dose or route 
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of administration of a drug, drug-drug interactions, allergy concerns, or warnings and 

cautions). This functionality must be enabled. 

• Provide information related to lower 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 electronically 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 ensure that EPs utilize electronic prescribing 

systems in compliance with standards established for such systems pursuant to the Part D 

Electronic Prescribing Program under section 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 individuals. To be a qualified electronic prescribing 

system under the current eRx Incentive Program, electronic systems must convey the 

information listed above under (a) through (d) using the standards currently in effect for 

the Part D electronic prescribing program. Additional Part D electronic prescribing 

standards were implemented April 1, 2009. These 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 prescribing system utilize the adopted Part D 

electronic prescribing standards. The Part D electronic prescribing standards relevant to 

the four functionalities for a "qualified" system in the electronic prescribing measure 

described above and listed as (a), (b), (c), and (d), currently are as follows: 

(a) Generate medication list – Use the National Council for Prescription Drug 

Programs (NCPDP) Prescriber/Pharmacist Interface SCRIPT Standard, Implementation 

Guide, Version 8, Release 1, October 2005 (hereinafter "NCPDP SCRIPT 8.1") 

Medication History Standard. 

(b) Transmit prescriptions electronically – 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 Guide, 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 electronically 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 Addenda to Health Care Eligibility Benefit 

Inquiry and Response, Version 4010A1, October 2002, Washington Publishing 
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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 equivalent NCPDP Batch Standard Batch 

Implementation Guide, Version 1, Release 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" system under the eRx Incentive Program. One 

example is Rx Fill Notification, which is discussed in the Part D electronic prescribing 

final rule (73 FR 18918, 18926). For purposes of the 2011 Electronic Prescribing 

Program, we again are not proposing to require that an electronic prescribing system 

contain all functionalities for which there are available Part D electronic prescribing 

standards. For those required functionalities described above, we propose that a 

"qualified" system must use the adopted Part D electronic prescribing standards for 

electronic messaging. 

There are other aspects of the functionalities for a "qualified" system that are not 

dependent on electronic messaging and are part of the software of the electronic 

prescribing system, for which Part D standards for electronic prescribing do not pertain 

and are not required for purposes of the eRx Incentive Program. For example, the 

requirements in qualification (b) listed above that require the system to allow 

professionals to select medications, print prescriptions, and conduct alerts are functions 

included in the particular software, for which Part D standards for electronic messaging 

do not apply. 
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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 transmission network; only that the system be a "qualified" system 

having the functionalities described above based on Part D electronic prescribing 

standards. As in 2010, if the professional does not have general 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 participate in the 2011 eRx Incentive Program he 

or she may be subject to the 2012 eRx penalty 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 system and actually used the system in a 

substantial way to electronically prescribe. In this context, the reporting of information 

in circumstances where a professional did not electronically prescribe is not pertinent. 

Additionally, although it may be of interest 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 high 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 professionals to specifically report such details.

 Accordingly, for the 2011 electronic prescribing measure, we propose to retain 

the following numerator G-code from the 2010 electronic prescribing measure's 
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numerator: G8553 (At least 1 prescription created during the encounter was generated 

and transmitted electronically using a qualified electronic prescribing system.) 

 We propose to post the final 2011 electronic prescribing measure specifications 

on the "eRx Measure" page of the eRx Incentive 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 measure 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 Medicare Part B claim containing one of the 

electronic prescribing measure's denominator codes, 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 electronically 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 cases in which the measure is reportable. In 
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2010, we revised the criteria for successful electronic 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 measure by generating and reporting one or more 

prescriptions associated with a patient visit electronically, a minimum of 25 unique visits 

per year in 2010 of applicable cases in the 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 prescription 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 electronic 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 once an EP has invested in an eRx system, integrated the use 

of the eRx system into the practice's work flows, and has used the system to some extent, 

he or she is likely to continue to use the eRx 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 integrated use of an eRx system into his or her 

practice's work flow, we believe that requiring the EP to continue 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 required to report that at least 1 prescription 

for a Medicare Part B FFS patient created during an encounter that is represented by 1 of 
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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 into consideration that prescriptions are 

not generated with every Medicare Part B FFS patient encounter, some prescriptions, 

such as narcotics, cannot be prescribed electronically, and that not all Medicare Part B 

FFS encounters are represented by the electronic prescribing measure's denominator 

codes. 

As stated previously, we propose that 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 Secretary is authorized to choose 1 of 2 possible 

criteria for determining whether or not the limitation applies to a successful electronic 

prescriber. The first criterion, under section 1848(m)(2)(B)(i) of the Act, is based upon 

whether the Medicare Part B allowed charges for 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 second 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 determined by the Secretary) of prescriptions 

under Part D (which can, again, be assessed using Part D drug claims data). If the 
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Secretary decides to use the latter criterion, then, in accordance with section 

1848(m)(2)(B) of the Act, the criterion based 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 determination of whether an EP is a 

"successful electronic prescriber" based on submission of the electronic prescribing 

measure, we propose to again apply the criterion 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 retaining for 2011 our proposal to make the 

determination of whether an EP is a "successful electronic prescriber" based on 

submission of the electronic prescribing measure, 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 assessed 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 prescribing 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 least 25 times for those eligible cases that 
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occur during the 2011 reporting period. Although an individual EP may decide to 

conduct his or her own assessment of how likely this statutory limitation is expected to 

apply to him or her before deciding whether or not to report the electronic prescribing 

measure, an individual EP may report the electronic prescribing measure without regard 

to the statutory limitation for the incentive payment. 

(4) Proposed Reporting Option for Satisfactory 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 EPs in a group practice shall be treated as a 

successful electronic prescriber. In addition, 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 incentive 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 successfully meets the proposed requirements for 

group practices would not be eligible to earn a separate eRx incentive payment for 2011 

on the basis of his or her successfully reporting the electronic prescribing measure at the 

individual level. 

(i) Definition of "Group Practice" 

 Section 1848(m)(3)(C)(i) of the Act authorizes the Secretary to define "group 

practice." For purposes of determining whether a group practice is a successful 
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electronic prescriber for 2011, we propose that consistent with the definition of group 

practice proposed for the PQRI group practice reporting option (GPRO) discussed in 

section VI.F.1. of this proposed rule, a "group 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 participation 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 participating in the 2011 PQRI GPRO (that is, 

group practices participating in a CMS-approved Medicare demonstration) that have 

indicated their desire to participate 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 prescribing group practice reporting option will be 

required to participate in the PQRI group practice 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 practices that are participating in PQRI 

under the group practice reporting option. If a group practice wishes to participate in the 

2011 eRx Incentive Program under the group practice reporting option, it must indicate 

its desire to do so at the time that the group practice self-nominates to participate in the 
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2011 PQRI group practice reporting option. There is no need for group practices to 

indicate their intent to participate in the 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 participating 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 practice that wishes to participate in the eRx 

Incentive Program group practice reporting option will be notified of the selection 

decision to participate in the eRx Incentive Program 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 eligibility 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 electronic prescribing measure. That is, the 

group practice will need to indicate in its self-nomination letter which reporting 

mechanism the group practice intends to use for purposes of participating in the 2011 eRx 

Incentive Program group practice reporting option. 

(2) Process for Group Practices to Participate as Group Practices and Criteria for 

Successful Reporting of the Electronic Prescribing Measure by Group Practices 

 For group practices selected to participate in the electronic prescribing group 

practice reporting option for 2011, we propose the reporting period would be 

January 1, 2011, to December 31, 2011. 
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 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 that 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 electronic presciber, we propose that 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 

for the number of instances specified in Table 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 patient 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 specifies that the limitation on the applicability 

of the electronic prescribing incentive applies to group practices as well as individual 

EPs. Therefore, in determining whether a group practice will receive an electronic 

prescribing incentive payment for 2011 by meeting the proposed reporting criteria 

described above, we would determine whether the 10 percent threshold is met based on 

the claims submitted by the group practice. 
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This calculation is expected to take place in the first quarter of 2012 and will be 

determined by dividing the group practice'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 charges 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 furnished 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 shall 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 incentive program still must meet the relevant 

eRx penalty criteria for being a successful electronic prescriber. 

(1) The eRx Penalty Reporting Period 
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 For purposes of the 2012 eRx penalty, we propose to make a determination of 

whether an EP or a group practice is a successful 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 rather than a 12-month reporting period so 

that we may be able to complete the analysis of 2011 data to determine 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 penalty applies sufficiently in advance of 2012. We believe 

that establishing a 6-month reporting period for 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 application of a penalty. 

 For EPs and group practices using the claims-based reporting mechanism, we 

propose that all claims for services furnished 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 whether 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 require 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 individual EP unless one of the following 

conditions is met: 
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• The EP is not a physician (includes MDs, DOs, and podiatrists), nurse 

practitioner, or physician assistant as of June 30, 2011. We believe 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 may 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 within the denominator of the eRx measure for 

dates of service between January 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 successful electronic prescriber. In addition, we 

seek to prevent EPs who are new to Medicare from being subject to the eRx penalty.

• The EP is a successful electronic prescriber 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 patients created during an encounter that is 

represented by 1 of the codes in the denominator 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 reporting 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 
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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 electronic prescribing measures required under 

section 1848(m)(2)(B)(i) of the Act also applies 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 period are comprised of services which 

appear in the denominator of the 2011 electronic 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 reduction 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 and 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 individual 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 the 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 payment adjustment would not be applied to a a 

group practice participating in the 2011 eRx GPRO if the group practice is participating 

in either the 2011 PQRI GPRO I or the 2011 PQRI GPRO II and meets the proposed 
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2011 criteria for successful electronic prescribing described in sections 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 would need to be satisfied during the 2012 eRx 

penalty reporting period of January 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 proposed criteria for being a successful electronic 

prescriber for the 2011 incentive in 6 months rather than 12 months to avoid the penalty. 

When compared to the criteria for individual 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 section 1848(m)(2)(B)(i) of the Act, we also 

propose that the 2012 eRx penalty would not apply to an eRx GPRO in which less than 

10 percent of the group practice's estimated total allowed charges for the January 1, 2011 

through June 30, 2011 reporting period are comprised of services which appear in the 

denominator of the 2011 electronic prescribing measure. To be consistent with how this 
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limitation is applied to group practices for purposes 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 furnished 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 criteria for determining applicability of the 

2012 eRx penalty to group practices, including the proposed criteria for successful 

reporting of the electronic prescribing measure for group practices, and our proposed 

analytical approach. 

(4) Significant Hardship Exemption 

 Section 1848(a)(5)(B) of the Act provides 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 that in addition to meeting the criteria for 
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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 penalty, if during the 2012 eRx penalty 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 circumstances apply would be required to report the 

appropriate G-code at least once between January 1, 2011 and June 30, 2011 using their 

selected 2011 eRx reporting mechanism. Reporting 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 the significant hardship exception. We 

invite comments on the proposed process for the significant hardship exception as well as 

comments regarding other circumstances that should be considered a significant hardship. 

d. The 2013 eRx Penalty 

 Section 1848(a)(5) of the Act also requires 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 year, the fee schedule amount for such services 

furnishd by such professional during 2013 shall be equal to 98.5 percent of the fee 

schedule amount that would otherwise apply to such PFS services. Under section 
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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 practice shall be treated as a successful 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 electronic prescriber for purposes of the 2013 eRx penalty. In 

addition, we propose that the reporting period 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 criteria 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 requires the Secretary to post on the CMS Web 

site, in an easily understandable format, a list 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 electronic prescribers. As required by 

section 1848(m)(5)(G) of the Act, we are proposing to make public the names of EPs and 

group practices who are successful electronic 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 Physician and Other Health Care Professionals 

directory as the foundation for the Physician Compare Web site. 
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We anticipate that the names of individual 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 EPs are not required to participate in both 

programs to earn an incentive under either program, 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. Likewise, 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 reporting 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 included 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 participating in the eRx Incentive Program under 
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the group practice reporting option would also have to participate in a PQRI group 

practice reporting option, the criteria for satisfactory reporting of PQRI measures for 

group practices are different from the criteria for successful reporting of the electronic 

prescribing measure by group practices. Therefore, it is possible for a group practice to 

be listed as a group practice that satisfactorily submits data on quality measures for the 

PQRI but not as a successful electronic prescriber under the 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 furnished 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), set 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 purchased items (section 1834(a)(2) of the Act 

and §414.220 of the regulations); 
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● Items requiring frequent and substantial 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 (section 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 for 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 section 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 Medicare 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 applicable SPA, unless any unmet Part B deductible 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 total amounts that would otherwise be paid under 

the fee schedule methodologies set forth in section 1834(a) of the Act. This requirement 

guarantees savings to both the Medicare program and beneficiaries under the program. 

The fee schedule methodologies will continue to set payment amounts for 

noncompetitively bid DMEPOS items and services. The program also includes 

provisions to ensure beneficiary access to quality DMEPOS items and services. Section 

1847 of the Act limits participation in the program to suppliers 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, section 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 metropolitan statistical areas (MSAs) in 2007. The 

program was to be expanded into 70 additional 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 proposals. In the April 10, 2007 Federal Register

(72 FR 17992), we issued a final rule addressing 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 implementation 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 diabetic supplies. The bidding window opened 

on May 15, 2007 and was extended to allow bidders adequate time to prepare and submit 

their bids. We then evaluated each submission 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 DMEPOS 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 enacted. Section 154 of the MIPPA amended 

section 1847 of the Act to make certain limited 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 the 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, Puerto 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 Act. 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 competitions may be phased in after 2010. 

b. Implementation of a National Mail Order DMEPOS Competitive Bidding Program 

(CBP) for Diabetic Testing Supplies 

 We conducted competitions for mail order diabetic testing supplies in the 10 

CBAs selected for Round 1. In the Round 1 rebid we conducted competition for mail 

order diabetic testing supplies 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 residence in a CBA”. We clarified in program 

instructions that “mail order” means items ordered remotely (that is, by phone, email, 

Internet, or mail) and delivered to a beneficiary’s residence by common carriers (for 

example, U.S. Postal Service, Federal Express, United Parcel Service, or other shipping 

or courier service companies) but not items obtained by beneficiaries from local retail 

storefronts. 
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 Due to the inclusion of mail order diabetic supplies as a product category in 

Round 1 of the program, Medicare beneficiaries 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 program’s regulations. Beneficiaries who do not 

obtain their testing supplies through mail order may purchase these products from any 

enrolled Medicare supplier and Medicare payment for these items will be at the fee 

schedule amount. The home blood glucose monitor (diabetic testing equipment) itself is 

not included in the Round 1 DMEPOS CBP for mail order diabetic supplies. 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 medical needs. The supplier of 

the glucose monitor is responsible for training the beneficiary on how to use the monitor 

and for answering all follow up questions and providing all services required by the 

DMEPOS quality standards and supplier standards , 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 supplier whose contract requires them to ship 

the replacement diabetic supplies directly to the beneficiary’s home. If the beneficiary 

wants to continue receiving their replacement 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 testing their blood glucose levels, this choice is 

preserved. However, if they choose the convenience 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 for 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 rulemaking 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 furnished 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 the May 1, 2006 proposed rule (71 FR 25669) and 

April 10, 2007 final rule (72 FR 18018). A national mail order program 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 delivery 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 supplies 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. Manufacturers and suppliers have stated to CMS at different meetings 

on numerous occasions that the choice for beneficiaries 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 implementation of Round 1 of the 

program; required CMS to conduct a second Round 1 competition 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 indicated that we would be considering 

alternatives for competition of diabetic testing supplies in future notice and comment 

rulemaking. We explained that we believed it was consistent with section 1847(a) to 

employ competitive bidding for diabetic suppliers 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 supplies. 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 have 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 supplies would be based on 

the SPA determined from the bids submitted and accepted for the furnishing of diabetic 

testing supplies by mail order throughout the national CBA. 

 As part of our proposal to implement the national mail order DMEPOS CBP, we 

are also proposing a revised definition in regulation of “mail order” so that there would 

be a clear distinction between mail order items and non-mail order items. 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 that their bid covers at least 50 percent of 

all types of diabetic testing strips furnished by suppliers. If the supplier is not able to 

satisfy this requirement, the Secretary must reject 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 mandates the establishment of DMEPOS CBP 

for items described in section 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 replacement diabetic testing supplies from mail 

order suppliers. Mail order diabetic testing supplies account for approximately one 

billion dollars in allowed charges per year and are therefore high volume items. We 

believe that a national mail order 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 referenced above as long as certain refinements discussed 

below are made to the program to address concerns about the mail order/non-mail order 

bifurcation. 

We have heard from industry groups and suppliers that furnish diabetic testing 

supplies on a national mail order basis of their concerns that national chain pharmacies 

that furnish diabetic testing supplies through both a national mail order 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 program 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 supplier that furnishes diabetic supplies, while 

clarifying the definition of mail order will provide significant savings potential for 

beneficiaries and the program. Savings would 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 supplies as a result of the requirement 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 order bifurcation and 

associated concerns. These alternatives include: 

● A national competition among all types of suppliers for all replacement 

diabetic supplies. Under this alternative, all beneficiaries would receive their 

replacement diabetic supplies from contract suppliers 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 contract 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 the supplies are delivered on a timely basis. 

● Competitions in local CBAs among all types of suppliers for all replacement 

diabetic supplies. Under this alternative, all beneficiaries would receive their 

replacement diabetic supplies from contract suppliers 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 supplies 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 any 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 beneficiary. We believe the other two options 

would also diminish this choice. In addition, 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 mail order supplies. Suppliers participating in a national 

program may be able to obtain volume purchasing 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 establish 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 refinements described below. We note that the decision to proceed 

with a national mail order competition after 2010 does not prevent us from phasing in 

competitions for non-mail order 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 order 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 delivery. 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 pharmacy 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 definitions of mail order item and non-mail order item 

are intended to clearly identify which items are 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 the 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 Parcel Service) and does not include items 

obtained by beneficiaries from local storefronts.” The intent of the Round 1 definition 

was to distinguish between mail order supplies (supplies furnished directly to the 

beneficiary’s home) and non-mail order supplies (supplies picked up at a local 

pharmacy). Manufacturers and suppliers of blood 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 the 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 considered 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 services 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 order (home delivery option) and non-mail order (pharmacy 

pickup option), suppliers could continue to attempt to make arrangements as they did in 

the initial Round 1 competition to circumvent the DMEPOS CBP. We consider these 

practices to be inconsistent with the DMEPOS 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 furnishing supplies to the home delivery market. 

This proposed definition of mail order item would not apply to the Round 1 

competition because of the specific requirement 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 the new definition of mail 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 will continue to take 

appropriate and necessary action against suppliers that do not comply with the revised 

definition. 

As mentioned above, an alternative DMEPOS CBP for replacement diabetic 

supplies would be to hold a national competition 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 and non-mail order supplies; however, it would 

likely eliminate the pharmacy pickup choice since most local pharmacies would not be 

able to service the entire CBA if they did not also operate a national mail order service. 

We invite comments on our proposed definition 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 competition for diabetic testing strips, 

such as the national mail order program for diabetic testing supplies proposed in this rule, 

must include the special rule set forth in section 1847(b)(10)(A) of the Act. Under that 

section, a supplier must demonstrate that their bid to furnish diabetic testing strips covers 

the furnishing of a sufficient number of different types of diabetic testing strip products 

that, in the aggregate and taking into account 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 volume 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 different brands of monitors. Therefore, when 

replacement test strips are furnished, the supplier must ensure that the specific brand and 

model of test strips that the patient requires for use with their purchased monitor is 

furnished. 
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Section 1847(b)(10)(B) of the Act mandates 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 share (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 additional information from suppliers such as 

invoices or purchase orders to verify that the requirements in the statute have been met. 

 We are proposing that suppliers be required to demonstrate that its bid covers the 

minimum 50 percent threshold provided in the 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 testing products to generate a wider 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 contract suppliers would not be able to carry a limited variety of 

products and switch beneficiaries to those products. 

For purposes of implementing the special rule in section 1847(b)(10)(A), we are 

proposing to define “diabetic testing strip product” 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 diabetic 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 mandated 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 competitions and/or local 

competitions conducted for diabetic 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 glucose monitor and testing supplies than they 

and/or their physician or clinician 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 was 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 awarded 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 brand 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 order 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 beneficiary’s selection of the type of 

monitor and supplies. This requires the supplier to furnish the brand of testing supplies 

that work with the blood glucose monitor product 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 needs to replace their existing blood glucose 

monitor, and neither the beneficiary nor their physician has determined 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 beneficiary has selected. We believe this proposal 

would preserve the integrity of the clinical decision regarding choice of glucose 

monitoring system and would result in contract suppliers offering a wide variety of 

diabetic testing supply products. 

We are proposing to amend §414.422 to add the anti-switching o requirement to the 

terms of the contract for a supplier of diabetic 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. The 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, the treating practitioner 

(if possible), or a group practice to which the physician or treating practitioner has 

reassigned the right to receive Medicare payment. 

The April 10, 2007 final rule also established 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 awarded 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 section 1847(a) of the Act by adding 

paragraph (7), which expands the exemptions from the DMEPOS 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) 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 final 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 other practitioners in future rulemaking. 

In this proposed rule, we are proposing 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 orthotics 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 admission or on the date of discharge. 

d. Grandfathering Rules Resulting 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 establish a “grandfathering” process. This 

requirement was implemented through regulations 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 noncontract supplier if that supplier chooses to 

become a grandfathered supplier. Under §414.408(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 
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payments for taking over the furnishing of oxygen and oxygen equipment. When a 

beneficiary decides to use a contract supplier 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 near 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, the 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 standard 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 items generally would not be affected by the 

grandfathering rules. However, as discussed 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. 
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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 the 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 amounts. 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 mentioned 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 coinsurance 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 noncontract supplier to a contract supplier at the 

beginning of a DMEPOS CBP. In another example, 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 noncontract supplier to a contract supplier at the 

beginning of a DMEPOS CBP. As stated above, we expect that most noncontract 
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suppliers will choose to become grandfathered suppliers, therefore limiting the number of 

instances where these rules would apply. However, 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 longer lose title to the equipment after 

receiving the 36th payment and this may warrant reconsideration 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 DMEPOS CBP. In addition, we 

believe it is important to reevaluate the policy 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 DMEPOS 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 would 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 determine that a contract supplier’s actions 

constitute a breach of contract, §414.422(g)(2) authorizes us to take one or more of the 

following actions: 
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● 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 process 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 suppliers whose contract(s) may be terminated due to a breach of 

contract to have access to an appeal process that will reconsider that termination. In 

establishing this process we reviewed other appeals processes, such as the appeals 

process under Part D located at 42 CFR §423.641 through §423.668, Subpart N – 

Medicare Contract Determinations and Appeals, to consider essential steps to ensure 

suppliers have access to an appropriate 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 contract is actually terminated. This proposal 

would avoid the necessity to reinstate retroactively suppliers because the contracts would 
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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 corrective action plan (CAP) depending upon the 

nature of the breach. We believe 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 would be terminated for a breach of contract. 

● Breach of contract means any deviation from contract requirements, including 

a failure to comply with a governmental agency or licensing organization requirements. 

● Corrective Action Plan (CAP) means a contract supplier’s written document 

with supporting information that describes the actions the contract supplier would take 

within a specified timeframe to remedy the breach of contract. 

● Competitive Bidding Implementation Contractor (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 determination 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 regulation would allow contract suppliers 

the opportunity for a review of the following: 
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● A CMS determination under §414.422(g)(1) that the contract supplier breached 

its contract entered into as part 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 appeals processes preclude us from terminating a 

DMEPOS CBP contract. In other words, the 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 revoked 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 would continue to appeal the inactivation or 

revocation of its supplier number through the NSC’s appeals process, and we would 

postpone the termination decision until the supplier completes the NSC appeals process. 

Under our proposal, when we issue a termination decision, it would be final and 

binding unless a postponement of the termination 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 termination. A contract may be terminated for any 

violation of the terms of the contract. Examples of violations include, but are not limited 

to, situations where the contract supplier -- 
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● Has committed or participated in false, 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 proposed 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 contract 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 recommendation to terminate the supplier’s 

contract. If we find that a breach occurred, 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 
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contract, either in part or in whole, we would notify the contract supplier of the 

termination by certified mail. The notice would 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 date of the notification of termination. The 

notice would be sent by the CBIC using certified mail on the same date as the date on the 

notification of termination. The date of the notification 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 the 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 regarding 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 
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rounds of competitive bidding. An appeal of the termination would include the appeal of 

any other results from the termination that 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 whether to appeal the notice of termination. 

(5) Corrective Action Plan 

We are also proposing a process by which 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 example, 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 would result in negative consequences to the 

beneficiaries or the program caused by delaying the termination of the contract. 

We are proposing timelines related 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 termination. While the CAP is being evaluated, the 

termination determination would be postponed. We believe that 30 days is a sufficient 

amount of time for suppliers to prepare and submit a CAP and this would also ensure that 

there are no unnecessary delays in the appeals process. 

Under the proposed rule, we would require 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. 
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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 identified the CBIC and CMS would make a case-bycase determination concerning what constitutes a timely manner for correcting the 

deficiency. However, we expect most deficiencies 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 part of the review process. 

As part of the review process, the CBIC would provide guidance, in accordance 

with CMS instructions, regarding the type of documentation that the CAP and the follow 

up report must provide to substantiate that the deficiencies have been corrected. To make 

a determination if a CAP would 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 process. Suppliers may only revise their CAP one 

time during the review process. The timeframe 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 consistent with the supplier’s original 

submission and its contract would be terminated within 45 calendar days. Every supplier 

would have a one time opportunity to revise their CAP based upon deficiencies identified 

by the CBIC. Failure to develop and implement 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 this termination. Under the proposed rule, 

once an acceptable CAP has been completed the contract supplier must provide a follow-
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up report within 5 days of the agreed upon date 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 has 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 consider this process to 

be a reconsideration of the original decision, and, consistent with other Medicare appeals 

provisions, we believe it is important that an individual not involved in making the initial 

recommendation conduct the reconsideration of the initial decision. As mentioned 

previously, the HO would be an individual who is designated by CMS to review and to 

make an unbiased and independent recommendation of whether to terminate the 

supplier’s DMEPOS CBP contract. The notice to the contract supplier would also 

identify the location to which a request for hearing must be sent. 

Under the proposed rule, a contract supplier 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 appeal. 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 the 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 believe suppliers have sufficient time to decide whether 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 hearing 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 authorized 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 other than the authorized official to be a 

representative for them at the hearing. However, the representative may not be an 

individual who has been disqualified or suspended from acting as a representative by the 

Secretary or otherwise prohibited by law. The 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 process for requesting a hearing by a 

HO. 

(7) Scheduling of the Hearing 

The proposed rule also addresses scheduling 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 the 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 would be terminated immediately. In the hearing 
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request the contract supplier may ask for the hearing 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 the 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 provides 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 notice and the procedures for scheduling a 

hearing. 

(8) Burden of Proof 

We propose that the contract supplier would 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 that it is not in breach of its contract and 

that the termination action is not appropriate. The supplier’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 termination. 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 opportunity to submit evidence to the HO within 

30 days of receiving the notice announcing the 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 documentation 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 addition 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. 
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● 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 regulations issued by the Secretary, and manual 

instructions issued by CMS. 

The HO would make a recommendation based 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 CMS 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 recommendation 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 based upon on the record of the 

hearing, evidence, and documents considered by the HO as part of the HO 

recommendation. Information submitted after the hearing would 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, the 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. 
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We welcome comments on our proposal relating to CMS’s final determination of 

a supplier’s contract termination. 

(11) Effective Date of the Contract Termination 

Under the proposed rule, suppliers who submit a CAP or request a hearing would 

have the termination date identified on the notice 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 effective 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 related 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 supplier is no longer a DMEPOS CBP contract 

supplier for any DMEPOS CBP product category 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 product categories for which the supplier was 
CMS-1503-P 634

awarded a contract. We would not make payment and would reject claims for DMEPOS 

competitive bid items and services furnished by a supplier whose contract has been 

terminated after the effective date of the termination for the remainder of the contract 

period. 

We recognize that a supplier’s termination would impact beneficiaries within the 

CBA. Therefore, we therefore propose that terminated suppliers must notify all 

beneficiaries within the CBA who are receiving 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 determination 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 prevented from participating in future rounds of 

DMEPOS CBP. We also propose that rental 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 proposing 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 section 1834(a)(5) of the Act and §414.226 of our 

regulations. Suppliers are paid a monthly payment amount for furnishing medically 

necessary oxygen contents (for both stationary and portable) and stationary oxygen 

equipment described under the 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, which use oxygen stored as a very cold liquid 

in cylinders and tanks; and gaseous oxygen 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). Equipment in these classes includes traditional portable 

equipment, that is, portable liquid oxygen systems and portable gaseous oxygen systems, 

and oxygen generating portable equipment (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 oxygen systems (for stationary and traditional 

portable systems) require on-going delivery of oxygen contents. 

Section 1834(a)(5)(F) of the Act, as amended 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 equipment rental cap is reached for gaseous or 

liquid systems. In the CY 2009 PFS final 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 equipment to the beneficiary at 

the end of the 36-month rental period. Section 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 requirements 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 continuous use by the patient for the equipment’s 

reasonable useful lifetime or if the original equipment is lost, stolen, or irreparably 

damaged, the patient may elect to obtain a new piece of equipment. In such 

circumstances, §414.420(f)(2) authorizes payment 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 elects 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). 
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We are proposing to revise the payment rule for oxygen and oxygen equipment at 

§414.226(g)(1) to address situations where beneficiaries relocate outside the service area 

of a supplier during the 36-month rental payment 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 30th

rental month, the new supplier would be entitled to only 6 months of rental payments and 

then would have to continue to furnish the oxygen and oxygen equipment during any 

period of medical need for the remainder of the reasonable useful lifetime of the 

equipment. This creates a financial disincentive for oxygen suppliers to furnish oxygen 

and oxygen equipment to beneficiaries in these situations. 

 The proposed changes to the payment rules for oxygen and oxygen equipment 

would apply to oxygen and oxygen equipment furnished under Part B and would also 

apply to oxygen and oxygen equipment furnished under programs implemented in 

accordance with section 1847(a) of the Act. 

b. Furnishing Oxygen Equipment after 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 required 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 finalizing 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 after the 36-month rental period but before 

the end of the reasonable useful lifetime of the equipment, the supplier must make 

arrangements for the beneficiary to continue receiving the equipment at his or her new 

place of residence. This responsibility for furnishing 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 equipment. 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 supplier’s normal service area during the 36-month 

rental period. 

c. Furnishing Oxygen Equipment during the 36-Month Rental Period (Cap) 

Section §414.226(g)(1) contains the requirement that the supplier that furnishes 

oxygen and oxygen equipment for the first month of the 36th month of the rental cap 

period must continue to furnish the equipment 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 normal service area. This exception was proposed 

in the “Home Health Prospective Payment System Rate Update for Calendar Year 2007 

and Deficit Reduction Act of 2005 Changes to Medicare Payment for Oxygen Equipment 

and Capped Rental Durable Medical 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 addressed 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 since the implementation of the capped rental 

payment methodology on January 1, 1989, we received 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 Reconciliation Act of 1987 (Pub. L. 100-203), 

representatives of the DME industry indicated 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 beneficiaries 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 payment 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 where there are a few number of months left in 

the 36-month rental payment period. 

We do not believe that beneficiaries 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 after the 36-month rental period). Section 
CMS-1503-P 640

1834(a)(5)(F)(ii) of the Act requires the supplier that furnishes the oxygen equipment 

during the 36-month rental payment period to continue furnishing the equipment after the 

36-month rental payment period. Consistent with this requirement, we established 

regulations at §414.226(f)(1) that require the supplier to furnish the equipment or make 

arrangements for furnishing the equipment in situations where the beneficiary relocates 

outside the supplier’s normal service area. Since no such requirement currently applies in 

situations where the beneficiary relocates prior 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 equipment 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 requirement 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 36th paid 

rental month was repealed. The exception 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 revise the exception at §414.226(g)(1)(ii) to apply 

only to situations where the beneficiary relocates before the 18th 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 the 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 18th paid rental month during a period of continuous use. Under the current 

rule, a supplier does not have to furnish the oxygen equipment if the beneficiary relocated 

before the 36th paid rental month during a period of continuous use. The current rule was 

established based on the long term, demonstrated 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 either 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 statutory payment rule for oxygen equipment. 

We believe this approach would 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 equipment, 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 relocate to furnish oxygen equipment in these 

situations. We also believe that this proposal 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 payments. Most of the cases that have been 

reported regarding problems encountered by beneficiaries 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-month 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 equipment during the second half of the 36-month 

rental cap period. 

H. Provider and Supplier Enrollment Issue: Air Ambulance Provision

The National Transportation Safety Board (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 from 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 FAA-approved terrain awareness warning systems, night vision 

imaging systems, flight data recording systems for monitoring and autopilots if a second 

pilot is not used. 

In response to the NTSB concerns, the Secretary noted that the recommendations 

to CMS were similar to those being made to the Federal Aviation Administration (FAA). 

While we have expertise to regulate health and safety requirements that suppliers and 

providers of healthcare should meet, we do not have the expertise to determine aircraft 

safety requirements. The Secretary stated that, "we believe the FAA should determine 

the minimum level of safety that HEMS operators 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 service 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 supplier form designated by CMS and provide 

Medicare carrier with documentation of compliance 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 Federal 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 Paperwork 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 transportation, air ambulances 

remain subject to Federal laws and regulations. In accordance with §424.516(a)(2), 

providers and suppliers must adhere to all Federal 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 clarify that ambulance suppliers and other 

providers and suppliers include documentation regarding all applicable Federal and State 

certifications. Accordingly we are propsing to revise §424.510(d)(iii) from "Submission 
CMS-1503-P 645

of all documentation, including all applicable Federal and State 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 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," to "Submission of all documentation, including all applicable Federal and 

State licenses,certifications (including, but not limited to Federal Aviation Administration 

and Clinical Laboratory Improvement 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 statutory or regulatory authority, or under the 

Paperwork 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." 

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. Moreover, fixed-wing ambulance operators and 

HEMS operators must maintain 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 beneficiaries. In addition, since the FAA is 

responsible for the issuance and enforcement of regulations and minimum standards 

covering manufacturing, operating, and maintaining aircraft, we will work with the FAA 

to confirm that fixed-wing ambulance operators and HEMS operators remain in 

compliance with FAA safety regulations. 

(including, but not limited to Federal Aviation Administration and certifications) to the 

Medicare contractor within 30 days of the revocation or suspension of the license or 

certification, the provider or supplier 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 certification requirements for their provider or supplier 

type. We believe that allowing providers and suppliers to self-report licensure or 

certification revocations and 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 requirements 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, see §424.535(c). Thus, by complying with the 

reporting responsibilities found 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 licensure 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 throughout 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 ambulance 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 ambulance supplier does not meet their reporting 

responsibilities and notify the Medicare program of a Federal or State licensure or 

certification revocation or suspension within 30 days of the reportable event, we believe 

that it is appropriate to that CMS or the Medicare contractor 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 making a minor technical correction to 

remove an extraneous cross-reference which 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 finalized. 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 (along 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" policies 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 payment 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 Reduction 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 Paperwork Reduction Act of 

1995 requires that we solicit comment on the following issues: 
CMS-1503-P 649

● The need for the information collection and its usefulness in carrying out the 

proper functions of our agency. 

● The accuracy of our estimate of the information collection burden. 

● The quality, utility, and clarity of the information to be collected. 

● Recommendations to minimize the information collection burden on the 

affected public, including automated collection techniques. 

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 beneficiary’s medical record. In addition, both 

the medical record and the laboratory requisition (or order) would be required to be 

signed by the physician or qualified nonphysician practitioner (as defined in 

§410.32(a)(2) of this section) who orders the service. The burden associated with these 

requirements would be the time and effort necessary for a physician or qualified 

nonphysician practitioner to sign the medical record 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 the time, effort, and 

financial resources necessary to comply with 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 usual 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 with respect to magnetic resonance 

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 

§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 for 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 supplier’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 the 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, including up to 10 suppliers. Provision of the 

written list of alternate suppliers 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 record of the disclosure notification, signed 

by the patient and the referring physician, shall be maintained as a part of the patient’s 

medical record. 

 The burden associated with the requirements 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 obtain 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 develop 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 standard 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 obtain 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 requirement 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 CMS 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 supplier 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 requirement annually. Similarly, 

we estimate that it will take a supplier an average of 3 hours 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 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. The burden associated 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 believe 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 supplier 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 proposes that a supplier who wishes to 

appeal the termination notice must submit 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 are receiving rented competitive 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 notice 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 distribute notification of its termination to all beneficiaries 

receiving rented competitive bid items or competitive bid items received on a recurring 

basis. We estimate that it will take a supplier 3 hours to develop and distribute a notice 

announcing its termination to all of its beneficiaries receiving rented competitive bid 

items or competitive bid items received on a recurring basis. We believe 2 suppliers will 

be subject to this requirement on an annual 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)
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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 program, the provider or supplier must report 

voluntary withdraw or involuntary termination to the applicable Medicare contractor. 

The burden associated with the requirements 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 program, the provider or supplier must report 

voluntary withdraw or involuntary termination to the applicable Medicare contractor. 

The burden associated with the requirements 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 disclosure = 

$148.40 a year per physician x 71,000 physicians = $10,536,400. 

If you comment on these information collection 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 Information 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 (ASP) issues in section VI.A.1 of this 

proposed rule does not contain any new information 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 measures and reporting mechanisms to be 

available to eligible professionals (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 described in section 1842(b)(18)(c) of the Act, 

physical and occupational therapists, qualified speech-language pathologists, and 

qualified audiologists. EPs may choose whether 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 one 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 PQRI in CY 2011. Information from the “PQRI 

2007 Reporting Experience Report,” which is available 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 submit 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 necessary information, collecting the necessary 

information, and reporting the information needed 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 applicable to his or her patients 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 participation by EPs who are participating in PQRI for the first 

time in 2011, we will assign 5 hours as the amount of time needed for EPs to review the 

2011 PQRI Measures List, review the various reporting options, select the most 
CMS-1503-P 658

appropriate reporting option, identify the applicable measures or measures groups for 

which they can report the necessary information, 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 hours 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 specifications for up to 3 selected measures or 

up to 1 selected measures group and to develop a mechanism for incorporating reporting 

of the selected measures or measures group into the office work flows. 

Information from the Physician Voluntary Reporting Program (PVRP), which was 

a predecessor to the PQRI, indicated an average 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 approximately $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 increased efforts by CMS and stakeholders to 

disseminate useful educational resources and best practices. 

We believe the burden associated with 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, select 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 modifications 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 measure) 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, with 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 required 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 reporting 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 population and the types of measures on which the 

EP chooses to report (each measure’s specifications includes a required reporting 

frequency). 

Based on the assumptions discussed above, we estimate the total annual reporting 

burden per EP associated with claims-based reporting to range from 4.5 minutes (0.25 
CMS-1503-P 660

minutes per measure X 3 measures X 6 cases per measure) to 180 minutes (12 minutes 

per measure X 3 measures X 6 cases per measure), 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-based 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 measures 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 registry-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 for purposes of participation in the 2011 PQRI. 

However, EPs would need to authorize or instruct the registry to submit quality measures 

results and numerator and denominator data on quality measures 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 CMS 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 self-nomination. It is 

estimated that each self-nominated entity will also spend 2 hours for the interview with 

CMS officials and 2 hours calculating numerators, denominators, and measure results for 
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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 self-nomination process involves the 

completion of an XML submission by the registry, which is estimated to take 

approximately 5 hours, but may vary depending on the registry’s experience. We 

estimate that the registry staff involved in the registry self-nomination process have an 

average labor cost of $50 per hour. Therefore, assuming the total burden hours per 

registry associated with the registry self-nomination process 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 applicable measures. However, we believe that 

registries already perform many of these activities 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 have 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 file 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 have 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 their product(s) be used by EPs to submit 

PQRI quality measures data to CMS were required to complete a self-nomination process 

in order for the vendor’s product(s) to be considered “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 similar to the time required for 

registries to self-nominate that is approximately 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 vendor programming its EHR product(s) to 

extract the clinical data that the EP needs to submit to CMS for purposes of reporting 
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2010 PQRI quality measures will be dependent on the EHR vendor’s familiarity with 

PQRI, the vendor’s system capabilities, as well as the vendor’s programming capabilities. 

Some vendors already have these necessary capabilities and for such vendors, we 

estimate the total burden 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 vendors 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 practices 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 reporting 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, approximately 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 associated with the self-nomination process. 

Assuming that the group practice staff involved 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 practice self-nomination process to be 

approximately $348 ($58 per hour x 6 hours per group practice). 
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The burden associated with the group practice reporting requirements of this 

voluntary reporting initiative is the time and effort associated with the group practice 

submitting the quality measures data. For practices participating under the proposed 

GPRO I process, this would be the time associated with the physician group completing 

the data collection tool. The information collection 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 December 31, 2011, for use in the Physician Group 

Practice, Medicare Care Management Performance (MCMP), and EHR demonstrations. 

Based on burden estimates for the PGP demonstration, which uses the same data 

submission methods, we estimate the burden associated with a physician group 

completing the data collection tool would 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 associated 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 the 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 claims or registry. We believe it would be 

appropriate to multiply the appropriate burden 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 example, based on our estimate of 15.75 minutes 

per EP under claims-based reporting, we would expect that a 2-person group would have 

a burden of 31.50 minutes for claims-based submission under GPRO II. 
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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 participation numbers from 

the first year of the eRx Incentive Program (2009) are not available. Information from 

the “PQRI 2007 Reporting Experience Report,” which 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 assume that as many EPs 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 qualify to be considered a successful 

electronic prescriber in 2011 in order to earn an incentive payment. For 2011, EPs and 

group practices may choose whether to participate 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 rule, they can qualify to receive an incentive payment for 

2011 and/or avoid being subject to a penalty 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 need 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 expect 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 through 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 measure 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 individual EPs to be approximately $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 required information, selecting the appropriate 

quality data codes (QDCs), and including the appropriate QDCs on the claims they 
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submit for payment. For claims-based reporting, the QDCs will be collected as 

additional (optional) line items on the existing HIPAA transaction 837-P and/or CMS 

Form 1500. We do not anticipate any new forms and no modifications to the existing 

transaction or form. We also do not anticipate 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 the measure 25 times, we estimate the burden 

associated with claims-based data submission 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 report data to a registry as EPs opting for 

registry-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 

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 prescribing measure to CMS on their behalf. We 

estimate that the time and effort associated with this would be approximately 5 minutes 
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for each EP that wishes to authorize or instruct the registry to submit quality measures 

results and numerator and denominator data on the electronic prescribing measure to 

CMS on their behalf. 

Based on our proposal to consider only registries qualified to submit PQRI quality 

measures results and numerator and denominator 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 electronic prescribing measure for the 2010 eRx 

Incentive Program, there would be no need for a registry to undergo a separate selfnomination process for the eRx Incentive Program 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 their 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-Prescribing 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 participants 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 quality data to CMS was first added to the 

eRx Incentive Program in 2010 and EPs are not required 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 submission to CMS, the burden to the EP associated with 

submission of data on the electronic prescribing measure should be minimal. 

Since we are considering only EHR products 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 EHR vendor associated with the EHR vendor 

programming its EHR product(s) to extract the clinical 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 product to enable EPs to submit data on the measure to the 

CMS-designated clinical data warehouse will be dependent on the EHR vendor’s 

familiarity with the electronic prescribing measure, the vendor’s system capabilities, as 

well as the vendor’s programming capabilities. Since only EHR products qualified for 

the 2011 PQRI would be qualified for the 2011 eRx Incentive Program and the eRx 

Incentive Program consists of only one measure, we believe that any burden associated 

with the EHR vendor to program its product(s) to enable EPs to submit data on the 
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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 Incentive Program discussed 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 manner 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 individual 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 burden 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 need 

to 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 prescribing 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 number of reporting instances that would be required if each 

member of the group separately reported the electronic prescribing measure. Thus, we 
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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 measure) for a GPRO I group who chooses to report the 

electronic prescribing measures through claims 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 measure 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 authorizing 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 registry to submit quality measures results and 

numerator and denominator data on the electronic 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 electronic 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 public comments we normally receive on Federal 

Register documents, we are not able to acknowledge or respond to them individually. 

We will consider all comments we receive by the date and time specified in the "DATES" 

section of this preamble, and, when we proceed with a subsequent document, 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 Review (September 30, 1993), the Regulatory Flexibility Act 

(RFA) (September 19, 1980, Pub. L. 96-354), section 1102(b) of the Social Security Act, 

section 202 of the Unfunded Mandates Reform 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 alternatives and, if regulation is necessary, to select regulatory 

approaches that maximize net benefits (including potential economic, environmental, 

public health and safety effects, distributive impacts, and equity). A regulatory impact 

analysis (RIA) must be prepared for major rules with economically significant effects 

($100 million or more in any 1 year). We estimate, as discussed below 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 threshold, and hence also a major rule under 
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the Congressional Review Act. Accordingly, we have prepared a Regulatory Impact 

Analysis that to the best of our ability presents 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 the RFA (including small businesses, nonprofit 

organizations, and small governmental jurisdictions). The great majority of hospitals and 

most other health care providers and suppliers are small entities, either by being nonprofit 

organizations or by meeting the SBA definition of a small business (having revenues of 

less than $34.5 million in any 1 year) (for details see the SBA’s Web site at 

http://sba.gov/idc/groups/public/documents/sba_homepage/serv_sstd_tablepdf.pdf (refer 

to the 620000 series). Individuals and States are not included 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 concerning the reason action is being taken, the 

kinds and number of small entities the rule affects, 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, NPPs, and suppliers including IDTFs are 

considered small businesses if they generate revenues of $10 million or less based on 

SBA size standards. Approximately 95 percent of physicians are considered to be small 

entities. There are over 1 million physicians, other practitioners, and medical suppliers 

that receive Medicare payment under the PFS. 
CMS-1503-P 674

 For purposes of the RFA approximately 85 percent of suppliers of durable 

medical equipment, prosthetics, orthotics, and supplies (DMEPOS) are considered small 

businesses according to the SBA size standards. Our most recent claims information 

includes 47,000 entities billing Medicare for DMEPOS each year. Total annual estimated 

Medicare expenditures for DMEPOS suppliers are approximately $10.1 billion in CY 

2009, for which $8.1 billion was fee-for-service (FFS) and $2 billion was for managed 

care. 

 For purposes of the RFA, approximately 80 percent of clinical diagnostic 

laboratories are considered small businesses according to the SBA size standards. 

Ambulance providers and suppliers for purposes of the RFA are also considered 

to be small entities. 

In addition, most ESRD facilities 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 year 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 the 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 
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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 the affected entities are small entities, the 

analysis discussed throughout the preamble 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 requires us to prepare a regulatory impact 

analysis, if a rule may have a significant impact on the operations of a substantial number 

of small rural hospitals. 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 this 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 many of them are based at hospitals with fewer than 100 

beds. However, overall, the 184 rural hospital-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. Therefore, the Secretary has determined that 

this proposed rule will not have a significant impact on the operations of a substantial 

number of small rural hospitals. 

Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) also 
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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 threshold is approximately $135 million. This 

proposed rule will not mandate any requirements for State, local, or tribal governments in 

the aggregate, or by the private sector, of $135 million. Medicare beneficiaries are 

considered to be part of the private sector and as a result a more detailed discussion is 

presented on the Impact of Beneficiaries in section IX.G. of this regulatory impact 

analysis. 

Executive Order 13132 establishes certain requirements that an agency must meet 

when it promulgates a proposed rule (and subsequent final rule) that imposes substantial 

direct requirement costs on State and local governments, preempts State law, or otherwise 

has Federalism implications. We have examined this proposed rule in accordance with 

Executive Order 13132 and have determined that this regulation would not have any 

substantial direct effect on State or local governments, preempt States, or otherwise have 

a Federalism implication. 

We have prepared the following analysis, which together with the information 

provided in the rest of this preamble, meets 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 presents 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, payments, 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 relevant 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 requires 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 adjustments 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 physicians, 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 would be less than the 

impact displayed here because physicians furnish services to both Medicare and 

non-Medicare patients and specialties may receive substantial Medicare revenues for 

services that are not paid under the PFS. For instance, independent laboratories receive 

approximately 85 percent of their 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 current law -6.1 percent CY 2011 PFS update. 

The following is an explanation of the information represented in Table 73: 
CMS-1503-P 678

● 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 utilization and CY 2010 rates. That is, allowed 

charges are the PFS amounts for covered services and include coinsurance and 

deductibles (which are the financial responsibility of the beneficiary). These amounts 

have been summed across all services furnished by physicians, practitioners, or suppliers 

within a specialty to arrive at the total allowed charges for the specialty. 

● Column C (Impact of Work and Malpractice (MP) RVU Changes): This 

column shows the estimated CY 2011 impact on total 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 estimated 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 allowed charges of the changes in the PE 

RVUs under the second year of the 4-year transition 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 proposed CY 2011 rescaling of the RVUs so 
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that the proportions of total payments based 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 charges 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 charges 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 

Specialty Allowed Combined Impact 

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% 
CMS-1503-P 680

 (A) (B) (C) (D) (E) (F) (G) (H) 

Impact of PE RVU 

and MPPR Changes 

Specialty Allowed Combined Impact 

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% 
CMS-1503-P 681

 (A) (B) (C) (D) (E) (F) (G) (H) 

Impact of PE RVU 

and MPPR Changes 

Specialty Allowed Combined Impact 

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 section 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 data are generally consistent with the 

impacts discussed in the CY 2010 PFS final 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 malpractice 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 malpractice and PE and, correspondingly, 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 generally represents a small proportion of total 
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payments and the rescaling of the malpractice RVUs is not the primary driver of the 

specialty impacts. As discussed in section II.E.1. of this proposed rule, the proposed 

rescaling of the RVUs to match the proposed 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 order 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 payment rates and policies for physical therapy 

services, we estimate that this proposal would reduce (not redistribute) payments in those 

settings for therapy services by approximately 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 include noncontiguous body areas. We estimate 

that this change would primarily reduce payments to the specialties of IDTF and 

radiology. In order to maintain 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 further discussed in section II.C.4. of this 

proposed rule, while the discussions of the 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 and 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 estimated CY 2011 combined impact on total 

allowed charges by specialty of all 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 specialties, such as family practice, internal 

medicine, and geriatrics. Again, these impacts are estimated prior to the application of 

the negative CY 2011 CF update specified under the current statute. 

Table 74 shows the estimated impact on total payments for selected high-volume 

procedures of all of the changes discussed previously, including the effect of the CY 

2011 negative PFS CF update. We selected these 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 facility 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 684

TABLE 74: Impact of Proposed Rule and Estimated Physician Update on CY 2011 Payment for Sele

Facility Nonfa

CPT1/ 

HCPCS 

Code 

MOD Short Descriptor CT 2010 2 CY 2011 3 Percent Change CY 2010 2 CY 2

11721 Debride nail, 6 or more $ 20.72 $ 18.41 -11% $ 31.23 $ 17000 Destruct premalg lesion $ 40.88 $ 39.04 -4% $ 57.91 $ 27130 Total hip arthroplasty $ 1,084.09 $ 1,005.16 -7% NA 27244 Treat thigh fracture $ 918.31 $ 854.90 -7% NA 27447 Total knee arthroplasty $ 1,159.32 $ 1,074.64 -7% NA 33533 CABG, arterial, single $ 1,536.01 $ 1,374.42 -11% NA 35301 Rechanneling of artery $ 869.49 $ 783.95 -10% NA 43239 Upper GI endoscopy, biopsy $ 133.42 $ 122.76 -8% $ 256.05 $ 66821 After cataract laser surgery $ 216.59 $ 210.41 -3% $ 228.80 $ 66984 Cataract surg w/iol, 1 stage $ 549.57 $ 524.43 -5% NA 67210 Treatment of retinal lesion $ 479.17 $ 457.89 -4% $ 494.21 $ 71010 Chest x-ray NA NA NA $ 18.17 $ 71010 26 Chest x-ray $ 7.10 $ 6.38 -10% $ 7.10 $ 77056 Mammogram, both breasts NA NA NA $ 82.61 $ 77056 26 Mammogram, both breasts $ 34.63 $ 30.69 -11% $ 34.63 $ 77057 Mammogram, screening NA NA NA $ 61.60 $ 77057 26 Mammogram, screening $ 27.82 $ 24.80 -11% $ 27.82 $ 77427 Radiation tx management, x5 $ 153.00 $ 141.17 -8% $ 153.00 $ 88305 26 Tissue exam by pathologist $ 28.67 $ 26.03 -9% $ 28.67 $ 90801 Psy dx interview $ 100.21 $ 88.14 -12% $ 120.93 $ 90862 Medication management $ 35.77 $ 32.16 -10% $ 44.28 $ 90935 Hemodialysis, one evaluation $ 53.08 $ 48.37 -9% NA 92012 Eye exam established pat $ 38.32 $ 36.09 -6% $ 58.48 $ 92014 Eye exam & treatment $ 58.48 $ 55.00 -6% $ 85.44 $ 92980 Insert intracoronary stent $ 689.80 $ 608.64 -12% NA 93000 Electrocardiogram, complete NA NA NA $ 15.61 $ 93010 Electrocardiogram report $ 7.10 $ 6.38 -10% $ 7.10 $ 
CMS-1503-P 685

Facility Nonfa

CPT1/ 

HCPCS 

Code 

MOD Short Descriptor CT 2010 2 CY 2011 3 Percent Change CY 2010 2 CY 2

93015 Cardiovascular stress test NA NA NA $ 72.67 $ 93307 26 Echo exam of heart $ 38.32 $ 34.13 -11% $ 38.32 $ 93510 26 Left heart catheterization $ 198.71 $ 174.81 -12% $ 198.71 $ 98941 Chiropractic manipulation $ 24.13 $ 21.85 -9% $ 27.25 $ 99203 Office/outpatient visit, new $ 57.34 $ 52.79 -8% $ 76.93 $ 99213 Office/outpatient visit, est $ 38.04 $ 35.11 -8% $ 51.38 $ 99214 Office/outpatient visit, est $ 58.48 $ 53.77 -8% $ 76.93 $ 99222 Initial hospital care $ 101.62 $ 93.54 -8% NA 99223 Initial hospital care $ 149.60 $ 137.25 -8% NA 99231 Subsequent hospital care $ 29.81 $ 27.25 -9% NA 99232 Subsequent hospital care $ 53.93 $ 49.35 -9% NA 99233 Subsequent hospital care $ 77.50 $ 70.96 -8% NA 99236 Observ/hosp same date $ 166.06 $ 151.73 -9% NA 99239 Hospital discharge day $ 77.78 $ 71.94 -8% NA 99283 Emergency dept visit $ 48.26 $ 43.21 -10% NA 99284 Emergency dept visit $ 91.41 $ 81.76 -11% NA 99291 Critical care, first hour $ 170.04 $ 153.94 -9% $ 203.25 $ 99292 Critical care, addÏl 30 min $ 85.16 $ 77.09 -9% $ 91.97 $ 99348 Home visit, est patient NA NA NA $ 63.59 $ 99350 Home visit, est patient NA NA NA $ 130.58 $ 

G0008 Admin influenza virus vac NA NA NA $ 16.75 $ 

1 CPT codes and descriptions are copyright 2010 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply. 2 Payments based upon corrected CY 2010 conversion factor of $28.3868 under the statute as of October 30, 2009 that would be in effect on December 31, 2010 under cu3 Payments based upon the projected CY 2011 conversion factor of $26.6574 adjusted by the proposed MEI rescaling factor of 0.921.
CMS-1503-P 686

B. Geographic Practice Cost Indices (GPCIs) 

As discussed in section II.D. of this proposed 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 data for determining the relative cost 

differences in the office rent component of the PE GPCIs, as well as the 2006 through 

2007 professional malpractice premium data for determining the malpractice GPCIs. The 

2006 through 2008 Bureau of Labor and Statistics (BLS) Occupational Employment 

Statistics (OES) data were used as a replacement for 2000 Census 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, reflect the same proportions determined for the 

proposed 2006-based MEI. 

Additionally, the proposed GPCIs reflect several 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 and 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 
CMS-1503-P 687

work GPCI floor in Alaska, beginning January 1, 2009 and, therefore, the 1.500 work 

GPCI floor in Alaska will remain in place 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 frontier states effective January 1, 2011. OACT estimates the 

combined impact of these provisions on a fiscal 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 year (CY 2011) in descending order. The 

GAFs reflect the use of updated underlying GPCI 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 for 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 service would deviate from the estimated payment 

based on the GAF to the extent that the proportions 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 GPCI data, updated cost share weights, and 

provisions of the ACA, are reflected in the CY 2012 GPCI values that are displayed in 

Addendum E to this proposed rule. 

C. Rebasing and Revising of the MEI 
CMS-1503-P 688

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 inpatients 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 
CMS-1503-P 689

of certain rural area designations for purposes 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 alternatives 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 GAO’s September 2003 Report titled 

“Ambulance Services: Medicare Payments Can Be Better Targeted to Trips in Less 

Densely Populated Rural Areas” (GAO report 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 lowest 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 increase is applied to the base rate for ground 

ambulance transports that originate in qualified 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 determined that ground ambulance transports 

originating in 7,842 zip code areas (which were 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 Office of the Actuary (OACT) estimates the 
CMS-1503-P 690

impact of all these provisions to be $10 million for FY 2011. 

4. Section 3107: Extension of Physician 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 estimates 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 proposed 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 paid 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 Reasonable 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 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 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: Modification of Equipment Utilization Factor For Advanced Imaging 

Services 

As discussed in section V.M. of this proposed 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 parts within families of codes 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 for expensive diagnostic imaging equipment, 

changing the CY 2011 transitional utilization rate 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 capped rental fee schedule amounts for all power wheelchairs 

effective for power wheelchairs furnished 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 first 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 total payments per standard power wheelchair 

being less than 100 percent of the purchase 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 monthly 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 the lump sum payment method for standard 

power-driven wheelchairs and by decreasing payments 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 Market 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 2011 ESRD composite rate Market Basket 
CMS-1503-P 693

minus one increase to a Market Basket increase. 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 proposed 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 coverage, with no coinsurance or deductible, for an annual 

wellness visit. The annual wellness visit entails the creation of a personalized prevention 

plan for an individual that includes a health risk assessment and may include other 

elements, such as updating the family history, identifying providers that regularly provide 

medical care to the individual, body mass 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 proposed rule, for services furnished on or 

after January 1, 2011, sections 1833(a)(1) and 1833(b)of the Act (as amended by section 

4104 of the ACA) waive the deductible and 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 coinsurance 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. 
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12. Section 5501: Expanding Access to Primary Care Services and General Surgery 

Services 

As discussed in section V.S. of this proposed 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 primary care practitioners, as well as general 

surgeons practicing in geographic health professional 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-referral 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 requirement created by section 6003 of the 

ACA and related to the in-office ancillary services exception to the physician self-referral 

prohibition. Specifically, the statute requires that, with respect 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 another supplier. In addition, the statute requires 

physicians to provide a written 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 include a list of at least 10 other suppliers 

who provide the services for which the individual is being referred and which are located 

within a 25-mile radius of the referring physician’s office location. If there are fewer 

than 10 other suppliers located within a 25-mile radius of the physician’s office location, 
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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, including up to 10 

suppliers. Provision of the written list of alternate suppliers will not be required if no 

other suppliers provide the services for which the individual is being referred within a 

25-mile radius. We also propose that 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 supplier’s name, address, 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 and 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 Statistics 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 
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burden associated with disclosing the information, 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 disclosure requirement would present a 

negligible economic impact on the physician or group practice required to create the 

disclosure notice. The physician or group 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 supplier and also lists other suppliers located 

within a 25-mile radius of the physician’s office 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 beneficiaries would be impacted positively by this new provision. 

The disclosure that the patient may receive the referred imaging services from another 

supplier contributes to informed decision-making about the availability of such imaging 

services from other suppliers. We also believe 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 Submission 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 law, claims for services furnished on or after 

January 1, 2010, must be filed within 1 calendar 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 later than December 31, 2010. 

Section 6404 of the ACA also permits the Secretary 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 provision 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 provision is non-economically significant, as to the 

interest lost on money now required to pay 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 believe providers and suppliers would 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 and Part B claims are 

filed in 12 months or less. In addition, some providers and suppliers 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 availability 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 discussed 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 which 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-related 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 for the Medicare program and its beneficiaries 

since any substituted prices would be for amounts less than the calculated 106 percent of 

the ASP. 

2. Ambulance Fee Schedule: Proposed Policy for Reporting Units when Billing for 

Ambulance Fractional Mileage 

As discussed in section VI.B. of this proposed rule, we are proposing to 

implement fractional mileage billing for all providers and suppliers of ambulance 

services. For all claims for mileage totaling up to 100 covered miles, we are proposing to 

require all providers and suppliers 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 providers and suppliers round up to the nearest 

tenth of a mile rather than the nearest whole 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 requiring 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 using 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 per year when considering other types of 

ambulance mileage payments such as those for rural mileage and those made to 

institutional providers. 

3. Chiropractic Services 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 second year. As discussed in the CY 2010 

PFS final rule with comment 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 adjustment, 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 the changes affecting payments to different 

categories of ESRD facilities, it is necessary to compare estimated payments under the 

current year (CY 2010 payments) to estimated 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 ESRD facilities, it is 

imperative that the estimates of current payments and estimates of proposed payments 

contain similar inputs. Therefore, we simulated payments only for those ESRD facilities 
CMS-1503-P 701

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 PPS, and section 1881(b)(14)(E)(ii) allows 

ESRD facilities to make a one-time election to be excluded 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 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. Therefore, these proposed rates listed in the impact table below reflect only the 

composite rate portion of the blended payment 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 the categories based on characteristics 

provided in the Online Survey and Certification 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 updated 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 figure for treatments. This was an increase of 12.4 percent. 
CMS-1503-P 702

Due to data limitations, we are unable to estimate current and proposed payments for 32 

of the 5318 ESRD facilities that bill for 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 second 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 payments 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 aggregate 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 index revisions be done in a manner that results 

in the same aggregate amount of expenditures 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 blended payment amount under the payment system. 

We anticipate an estimated ESRD market basket 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 composite 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 current payment is the composite rate for 

each provider (with the current 15.0 percent drug 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 increase 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 increase 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 percent and payments to hospital-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) increase to the composite rate. This 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: Physician 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 participate in the 2011 PQRI. Although there may 

be some cost incurred in the PQRI and their associated code sets, and for expanding an 

existing clinical data warehouse to accommodate 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 individual EPs is voluntary and individual 

EPs and group practices may have different processes 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 accurately estimate the impact of the PQRI on 

providers. Furthermore, we believe 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 addition, for many EPs, the cost 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 approximately $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 furnished during the 2011 reporting period. Although we expect 

that the lower incentive payment amount for 2011 would reduce the total outlay by 
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approximately one-third, we also expect more EPs to participate in the 2011 PQRI as 

there are more methods of data submission and additional alternative 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 reporting option. This burden will vary with each individual 

EP by the number of applicable measures, the EP’s familiarity and understanding of the 

PQRI, experience with PQRI participation, and the method(s) selected by the EP for 

reporting of the measures, and incorporating the 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 quality 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 individual EP approximately 5 hours to review the PQRI quality 

measures, review the various reporting options, 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 into their office work 

flows, we estimate that the cost to EPs associated with preparing to report PQRI quality 

measures would be approximately $290 per individual EP ($58 per hour X 5 hours). 

Another factor that influences 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 
CMS-1503-P 707

codes (QDCs) for 1 measure on a claim ranges 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 reporting 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 approximately $4.35 (0.25 

min per reporting instance x 6 reporting instances 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 satisfactorily 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, the mean incentive amount was close to $700 

for an individual EP and the median incentive 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 costs associated with PQRI reporting, which 

we believe are minimal. Many EPs who select registry-based reporting were already 

utilizing the registry for other purposes and would not need to report additional data to 
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the registry specifically for PQRI. The registries 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 authorized 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 Part III secure examination, but most Boards 

do not have additional charges 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 data for the CY 2011 PQRI discussed in 

section VI.F.1 of this proposed rule, group practices interested in participating in the CY 
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2011 PQRI through the group practice reporting option (GPRO) I or GPRO II may also 

incur a cost. However, for groups that satisfactorily report for 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 for staff involved with the 

claims-based reporting option for individual EPs, we also estimate that the group practice 

staff involved in the group practice self-nomination process has an average labor cost of 

$58 per hour. Therefore, assuming 2 hours for 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 GPRO I process, another factor in the 

cost to the group would be the time and effort associated with the group practice 

completing and submitting the proposed data collection tool. The information collection 

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 

December 31, 2011. Based on the Physician Group Practice (PGP) demonstration’s 

estimate that it takes approximately 79 hours for a group practice to complete the data 

collection tool, which uses the same data submission methods as those we have proposed, 
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we estimate the cost associated with a physician 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 the 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 costs for a group practice reporting via claims 

should also be similar to the costs associated with claims-based reporting for an 

individual EP. Overall, there is significantly 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 whole 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 those shared patients. Therefore, assuming that 

an average group practice would spend 20 hours 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 groups 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 measures 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 
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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 denominator data on quality measures to CMS on 

behalf of their participants. We estimate the 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 estimate of $50 per hour average labor cost for 

registries is based on the assumption that registry 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 PQRI results, they wish to be qualified to 

submit additional measures or for additional methods, or we finalize new requirements 

for 2011. We do not believe that there are any additional costs for registries 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 participants. We believe 

that the majority of registries already perform 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 data that the EP needs to 

submit to CMS for purposes of reporting 2012 quality measures as well. We propose that 

previously qualified vendors would need to only update their electronic measure 
CMS-1503-P 712

specifications and data transmission schema to incorporate 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 officials, 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-level 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 the 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 programming 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 approximately $10,000 per vendor ($50 per hour X 

200 hours per EHR vendor). 

6. Section 132 of the MIPPA: Incentives for 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 maintaining 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 have 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 provide, it is difficult to accurately estimate 

the impact of the eRx Incentive Program on providers. 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 cost 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 prior 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 year 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 based 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 charges for covered professional services in 
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2011, more EPs (and groups) will choose to participate in the 2011 eRx Incentive 

Program to avoid a prospective 1 percent payment penalty in 2012 for not demonstrating 

that they are successful electronic prescribers. 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 incentive 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 order 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 technology in his or her practice and the 

training needed. One study indicated that a midrange complete electronic medical record 

with electronic prescribing functionality costs $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, and problem list system may cost $1,200 per 

physician per year after setup costs. Hardware costs and setup fees substantially add to 

the final cost of any software package. (Corley, 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 incorporating reporting of the measure into 

their office work flows. Since the eRx Incentive Program consists of only 1 quality 

measure, we propose to estimate 2 hours as the amount of time needed for individual EPs 

to prepare for participation in the eRx Incentive Program. 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 quality 

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. At an average cost of approximately $58 per hour, we estimate 

the total preparation costs to individual EPs 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 reporting 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 report 25 electronic prescribing events during 

2011, we estimate the annual estimated cost per individual EP to report the electronic 

prescribing measure via claims-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 comparable 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 Program. 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 practices 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 qualified 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) the 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 Program 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-nomination process since we propose to limit the 

group practices to those selected to participate 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 associated 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 GPRO II to $4,229.17 (1.75 min per case x 2500 

cases per measure x $58 per hour) for the groups participating under GPRO I. 

We believe that the costs to individual EPs and group practices associated with 

avoiding the eRx penalty that goes into effect in 2012 would be similar to the costs of an 

EP or group practice reporting the electronic prescribing measure for purposes of the 

2011 eRx incentive. The proposed requirements for avoiding the 2012 eRx penalty, 

including the reporting period, essentially overlaps with the proposed requirements for 

the 2011 eRx incentive. 
CMS-1503-P 718

 Based on our proposal to consider only registries qualified to submit quality 

measures results and numerator and denominator 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 measures 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 already be required to perform these activities 

for PQRI. 

 Likewise, based on our proposal to consider only EHR products qualified for the 

CY 2011 PQRI to be qualified to submit results and numerator 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 separate self-nomination process for the eRx 

Incentive Program. Therefore, there would be no additional cost associated with the selfnomination process. 

 The cost to the EHR vendor associated 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 reporting 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 associated 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-implementing 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 the Act, as added by section 

154(d) of MIPPA, also expanded the exemption from CBP for certain OTS DME items 

(crutches, canes, walkers, folding manual 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 oxygen equipment in section VI.G. of this 

proposed rule reflect changes made by section 144(b) of MIPPA and regulations 

implementing that provision. In §414.226(g), exceptions are listed to the requirement 

that the supplier that furnishes oxygen equipment in the 1st month of the 36-month period 

must continue to furnish it until medical necessity ends or the 36-month of continuous 

use ends. Section VI.G. changes one exception (§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 supplier, 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 18th 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 beneficiaries using oxygen equipment. In addition, between the 

32nd and 35th month, relocation happens with the beneficiaries in about 0.06 percent of 

the time on average. 

c. Diabetic Testing Supplies
CMS-1503-P 721

We are establishing requirements for conducting a national competition for 

furnishing diabetic supplies on a mail order basis. 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 percent of all of the different 

types of diabetic testing products on the market by brand and model name; and a 

prohibition against influencing and incentivizing 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 supplies 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 storefront. We do not expect this rule to have 

any adverse affects on beneficiaries because the new definition of mail order is reflective 

of the way that beneficiaries currently get their testing supplies. However, we believe 

that by clarifying this definition we will protect beneficiaries from paying higher copayment amounts and we anticipate program savings that would have been eroded by 

suppliers circumventing our definition 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 regardless of how the items were obtained. We 

rejected this approach because it would force 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 national mail order competition for 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 into 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 diabetic test strip products from every contract 

supplier. We plan to use the information that bidding suppliers provide on their bidding 

Form B where suppliers list the products they plan to furnish. We believe this 

requirement will have a minimal 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 least 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 brand provided by the supplier. 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 rather by the beneficiary and 

their physician. We believe that this provision will have a minimal impact on suppliers 
CMS-1503-P 723

because suppliers currently offer a variety 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 provisions pertaining to subdividing metropolitan statistical 

areas (MSAs) with populations of at least 8,000,000 for the purpose of establishing 

competitive bidding areas (CBAs) under Round 2 of the DMEPOS Competitive Bidding 

Program will have a positive impact on most suppliers, 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 when furnishing items. More importantly, it 

should ensure more timely delivery 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 being 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 attractive to suppliers for bidding purposes. 

Table 76 considers FY cash impact on the entire Medicare program, including 

Medicare Advantage for FYs 2011 thru 2015 of the provisions of this proposed rule 

related to the establishment of CBAs during Round 2 and prior to calendar year 2015. 

The FY–CY distinction is an important one when 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 include beneficiary coinsurance. Finally, the estimates in 

Table 76 incorporate spillover effects from the competitive acquisition program onto the 

Medicare Advantage program. The expectation 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 considered to have little 

to no impact because the baseline never considered 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 some provisions related 

to specific MIPPA and ACA provisions. The preceding preamble provides descriptions 

of the statutory provisions that are addressed, 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 proposed 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 furnished 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 and improve the quality and value of care 

provided to Medicare beneficiaries. 

 The regulatory provisions may affect beneficiary liability in some cases. For 

example, the waiver of the deductible and coinsurance 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 function 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 responsible 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 Table 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/circulars/a004/a-4.pdf), in Table 77, we have prepared 

an accounting statement showing the estimated expenditures associated with this 

proposed rule. This estimate includes the estimated FY 2011 cash benefit impact 

associated with certain ACA and MIPPA provisions, 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 expenditures of $5.7 billion 

for PFS conversion factor update 

From Whom To Whom? Federal Government to physicians, other 

practitioners and providers and suppliers who 

receive payment under Medicare. 

FY 2011 Annualized Monetized 

Transfers 

Estimated increase in expenditures of $2 billion for 

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 recordkeeping requirements, 

Rural areas, X-rays. 

42 CFR Part 409 

Health facilities, Medicare. 

42 CFR Part 410 

Health facilities, Health professions, Kidney diseases, Laboratories, Medicare, 

Reporting and recordkeeping requirements, 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 facilities, Health professions, Medicare, 

Reporting and recordkeeping requirements. 
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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 January 1, 2011, preventive services covered 

under the Medicare Federally qualified health center benefit are those preventive services 

defined in section 1861(ddd)(3) of the Act, and § 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 section 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 prospective payment system for FQHCs including, 

but not limited to all pertinent HCPCS (Healthcare Common Procedure Coding System) 

code(s) corresponding to the service(s) provided 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 phrase “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 meets 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 section 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 function 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 wellness visit providing a personalized prevention plan within 

the past 12 months. 

Establishment of, or an update to the individual’s medical and family history for 

purposes of this section means, at a minimum, 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 personalized prevention plan services for 

purposes of this section means the following services furnished an eligible beneficiary by 

a health professional as those terms are defined in this section: 

(i) Establishment of an individual’s medical and family history. 

(ii) Establishment of a list of current providers 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 pressure, and other routine measurements as 

deemed appropriate, based on the beneficiary’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 professional may select from various available standardized 

screening tests designed for this purpose and recognized by national medical professional 

organizations. 

(vi) Review of the individual’s functional ability and level of safety, based on 

direct observation or the use of appropriate screening questions or a screening 

questionnaire, which the health professional as defined in this section may select from 

various available screening questions or standardized 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 recommendations of the United States Preventive 

Services Task Force and the Advisory Committee on Immunization Practices, and the 

individual’s health status, screening history, 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 underway 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 options and their associated risks and benefits. 

(viii) Furnishing of personalized health advice and a referral, as appropriate, to 

health education or preventive 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 and promote self-management and wellness, 

including weight loss, physical activity, smoking cessation, fall prevention and nutrition. 

(ix) Any other element determined appropriate through the National Coverage 

Determination process. 

Health professional for purposes of this section means: 

(i) A physician who is a doctor of medicine or osteopathy (as defined in section 

1861(r)(1) of the Social Security Act); or 

(ii) A physician assistant, nurse practitioner, 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 medical professionals, who are working 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 wellness 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 providers and suppliers that are regularly 

involved in providing medical care to the individual as that list was developed for the 

first annual wellness visit providing personalized prevention plan services. 

(iii) Measurement of an individual’s weight (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 first 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 underway for the individual as that list was 

developed at the first annual wellness visit providing personalized prevention plan 

services. 

(vi) Furnishing of personalized health advice to the individual and a referral, as 

appropriate, to health education 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 appropriate through the National Coverage 

Determination process. 

(b) Conditions for coverage of annual wellness visits providing personalized 

prevention plan services. Medicare Part B pays for first and subsequent annual wellness 

visits providing personalized prevention plan services 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 services that is performed for an individual 

who is not an eligible beneficiary 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 services 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 specified in section 410.16 of this subpart or 

either a first or a subsequent annual wellness visit providing personalized prevention plan 

services performed within the past 12 months. 

(d) Effective date. Coverage for an annual wellness visit providing personalized 

prevention plan services is effective for services 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 tests, 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. 

* * * * * 
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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 office 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 telehealth visit every 

30 days), professional consultations, psychiatric diagnostic interview examination, 

neurobehavioral status exam, 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 group 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 individual and group health and 

behavior assessment and intervention services furnished by an interactive 

telecommunications system if the following conditions are met: 

* * * * * 

Subpart I--Payment for SMI Benefits 

14. Section 410.150 is amended by adding paragraph (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 settings and for services and supplies furnished incident to 

those services. Payment is made only if no facility or other provider charges or is paid 

any amount for the furnishing of the professional 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 established under the applicable payment methodology 

for the service setting for providers and suppliers for the following preventive services: 

(1) Pneumococcal (as specified in paragraph (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 (excluding digital rectal examinations). 

(5) Colorectal cancer screening tests (excluding barium enemas). 

(6) Bone mass measurement. 

(7) Medical nutrition therapy (MNT) services. 

(8) Cardiovascular screening blood tests. 

(9) Diabetes screening tests. 

(10) Ultrasound screening for abdominal aortic aneurysm (AAA). 

(11) Additional preventive services identified for coverage through the national 

coverage determination (NCD) process. 

(12) Initial Preventive Physical Examination (IPPE). 
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(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 hepatitis 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 identified for coverage through the national 

coverage determination (NCD) process. 

* * * * * 

PART 411—EXCLUSIONS FROM MEDICARE 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 other 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 screening for abdominal aortic screening for 

abdominal aortic aneurysms (AAA), cardiovascular disease screening tests, diabetes 

screening tests, a screening electrocardiogram, initial preventive physical examinations 

that meet the criteria specified in paragraphs (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 personalized prevention plan services 

* * * * * 

(k) * * * 

(16) In the case of an annual wellness visit providing a personalized prevention 

plan, subject to the conditions and limitations specified in §410.15 of this chapter. 

* * * * * 

Subpart J--Financial Relationships Between Physicians and Entities Furnishing 

Designated Health Services 

19. Section 411.355 is amended by adding paragraph (b)(7) to read as follows: 
CMS-1503-P 743

§411.355 General exceptions to the referral prohibition related to both 

ownership/investment and compensation. 

* * * * * 

(b) * * * 

(7) Disclosure requirement for certain imaging services. 

(i) With respect to magnetic resonance 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 written 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 which are located 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 supplier’s name, address, 

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. 

(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, including up to 10 suppliers. Provision of the 

written list of alternate suppliers 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 REASONABLE 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 shortage 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 chapter shall not be included 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 the 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 the definitions of “Health Professional 

Shortage Area” and “Major surgical procedure” in alphabetical order to read as follows: 

§414.2 Definitions. 

* * * * * 

Health Professional Shortage Area (HPSA) means an area designated under 

section 332(a)(1)(A) of the Public Health Service 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 under 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 furnished in qualifying States to recognize the 

practice expense index floor established for Frontier 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 related share adjustment determined by 

the Secretary to take into account the unique circumstances 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 analysis 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 attributable 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 telehealth 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 under §483.40(c) and with the limitation of one 

telehealth nursing facility care service every 30 days), professional consultations, 

psychiatric diagnostic interview examination, neurobehavioral status exam, 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 group kidney disease education 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 behavior assessment and 

intervention furnished via an interactive telecommunications system is equal to the 

current fee schedule amount applicable 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 Professional 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 defined 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 year 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 for 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 payments 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 program under paragraph (a)(1) of this 

section. 

(2) Payment will be made on a quarterly basis in an amount equal to 10 percent of 

the Part B payment amount for major surgical 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 receive 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 method, to the CAH based on an institutional 

claim. 

28. Section 414.80 is added to subpart B to read as follows: 

§414.80 Incentive payment 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 primary 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 meets 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 practitioner’s allowed charges during a reference 

period specified by the Secretary are for primary care services. 

Primary care services means new and established patient 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 payment amount for the primary care services 

under Part B, in addition to the amount the primary care practitioner 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 reporting 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 section, unless otherwise indicated— 

 Covered professional services means services for which payment is made under, 

or is based on, the Medicare physician fee schedule as provided under section 1848(k)(3) 

of the Act and which are furnished 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 therapist or a qualified speech-language 

pathologist. 

(iv) A qualified audiologist (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 participating in Medicare demonstration 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 program (as determined by the Secretary), that advances quality 

and the lifelong learning and self-assessment of board certified 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 has the fundamental diagnostic skills, medical 

knowledge, and clinical judgment to provide quality care in their respective specialty. 

(iv) The program requires successful completion 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 patient experience with care; and 

(iii) Requires a physician to implement a quality improvement intervention to 

address a practice weakness identified in the initial assessment under 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 denominator 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 professionals 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 particular 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, has 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, which has the requisite legal authority 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 performed divided by the total number of 
CMS-1503-P 754

patients in the denominator of the measure. 

 (c) Incentive payments. With respect to covered professional services furnished 

during a reporting period by an eligible professional, if -- 

(1) There are any quality measures that have 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 section, such group practice) for such reporting 

period; and 

 (2) The eligible professional (or in the case of a group practice under paragraph 

(h) of this section, the group practice) satisfactorily submits (as determined under 

paragraph (g) of this section for eligible professionals and paragraph (h) of this section 

for group practices) to the Secretary data on such 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 the eligible professional (or 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 professional’s (or, in the case of a group practice under paragraph 

(h) of this section, the group practice’s) total estimated allowed charges 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) total estimated allowed charges for covered 
CMS-1503-P 755

professional services furnished 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 professional 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 section, 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 paragraph (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 professional 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 defined 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 determined appropriate by the Secretary. 

(ii) The eligible professional, more frequently 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 Maintenance of Certification Program 

practice assessment (as defined in paragraph (b) of this section) for such year. 

(iii) A Maintenance of Certification program submits to the Secretary, on behalf 

of the eligible professional, 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 Certification Program and the qualified Maintenance of Certification 

Program practice assessment. 

 (e) Incentive payment adjustment. (1) With respect to covered professional 

services furnished by an eligible professional 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 reporting period for the year (as determined under 

paragraph (g) for eligible professionals and 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 schedule amount for purposes of determining a 

payment based on such amount) must be equal 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 services furnished during a year, subject to 

paragraph (g) of this section, the quality measures 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 Secretary 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 selection 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 professional, as identified by a unique TIN/NPI 

combination, must meet the criteria for satisfactory 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 specified in paragraph (g)(1) of this section 

and using one of the reporting mechanisms specified in paragraph (g)(2) of this section. 

Although an eligible professional may attempt to qualify for the PQRI incentive payment 

by reporting on both individual PQRI quality measures 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 quality 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 professional who 

wishes to participate in the PQRI must report information on the individual PQRI quality 

measures or PQRI measures groups identified 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 eligible professional’s behalf; or 

 (iii) Reporting the individual PQRI quality measures to CMS by extracting 

clinical data using a secure data submission 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 services furnished by the eligible professional 

during the applicable reporting period. 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 qualified EHR 

product selected by the eligible professional 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 section) 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 requirements 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 otherwise 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 identified by an individual 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 professional cannot individually qualify for a PQRI 

incentive payment by meeting the requirements specified in paragraph (g) of this section. 

 (ii) If, for the program year, the eligible professional participates in the PQRI 

under another TIN that is not selected to participate 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 paragraph (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 judicial review under section 1869, section 1879, or 

otherwise of-- 
CMS-1503-P 761

(i) The determination of measures applicable 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 paragraph (i) of this section eligible 

professionals (or in the case of reporting 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 section, group practices) must submit a written 

request to CMS within 90 days of the release of the feedback reports. The request must 

summarize the concern(s) and reasons for requesting an informal review and may also 

include information to assist in the review. 

 (2) CMS will provide a written response within 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 professional’s or group practice’s PQRI data. 

For each program year, CMS will post on a public website, in an easily understandable 

format, a list of the names of eligible professionals (or in the case of reporting under 

paragraph (h), group practices) who satisfactorily submitted PQRI quality measures. 

 30. A new §414.92 is added to subpart B to read as follows: 

§ 414.92 Electronic prescribing incentive program 
CMS-1503-P 762

 (a) Basis and scope. This part implements the following 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 provided under section 1848(k)(3) 

of the Act and which are furnished by an eligible professional. 

 Electronic prescribing (eRx) incentive program means the incentive payment 

program established under section 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 therapist or a qualified speech-language 

pathologist. 

 (iv) A qualified audiologist (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 product 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 furnished during a reporting period by an eligible 

professional, if the eligible professional is a successful electronic prescriber for such 

reporting period, in addition to the amount otherwise 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 group practice, from the Federal Supplementary 

Medical Insurance Trust Fund established under 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) total estimated allowed charges for all covered professional 

services furnished by the eligible professional (or, in the case of a group practice under 

paragraph (e) of this section, by the group practice) during the applicable reporting 

period. 

(i) For purposes of this paragraph, 

(A) The eligible professional’s (or, in the case of a group practice under paragraph 
CMS-1503-P 764

(e) of this section, the group practice’s) total estimated allowed charges for covered 

professional services furnished 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 professional 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 section, 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 practice) receives an incentive 

payment under section 1848(o)(1)(A) of the Act with respect to a certified EHR 

technology (as defined in section 1848(o)(4) of the 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 covered professional services furnished by an 

eligible professional during 2012, 2013, or 2014, if the eligible 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 period (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 amount for purposes of determining a payment 

based on such amount) is equal to the applicable percent (as specified in paragraph 

(c)(2)(i) of this section) of the fee schedule 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 professional (or in the case of a 

group practice under paragraph (e) of this section, 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. For purposes of this paragraph, any of the 

following circumstances constitute a “significant hardship:” 

 (A) An eligible professional (or group practice) 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 practice under paragraph (e) of this section, a 

group practice) if for the reporting period the allowed charges under section 1848 of the 

Act for all covered professional services furnished by the eligible professional (or group, 

as applicable) for the codes to which the electronic 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 covered 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 (subject to paragraph (c)(3) of this section), 

an individual eligible professional, 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 after the end of the applicable reporting 

period, on the eligible professional’s Medicare Part B claims for covered professional 
CMS-1503-P 767

services furnished by the eligible professional during the reporting period specified in 

paragraph (d)(1) of this section; 

 (ii) A qualified registry (as 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 information, as required by CMS, for covered 

professional services furnished 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 clinical data using a secure data submission 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 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 qualified EHR product selected 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 successful electronic prescriber 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 group practice for being a successful electronic 
CMS-1503-P 768

prescriber. 

 (i) If an eligible professional, as identified by an individual 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 Incentive Program GPRO, the eligible professional 

cannot individually qualify for an eRx incentive payment by meeting the requirements 

specified in paragraph (d) of this section. 

 (ii) If, for the program year, the eligible 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 year, 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 professional’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 professionals (or in the case of 

reporting under paragraph (e) of this section, 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 alphabetical 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 power 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 period 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 18th month of continuous use, the beneficiary 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 the 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 equipment-capped rental items. 

(a) * * * 

(3) For power-driven wheelchairs 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 paragraphs (f) or (h) of this section. 

(b) * * *

(3) For power-driven wheelchairs furnished on or after January 1, 2011, the 

monthly fee schedule amount for 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 price for each of the remaining months. 

* * * * * 

(d) * * * 

(1) Suppliers must offer beneficiaries the option of purchasing power-driven 

wheelchairs at the time the supplier 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 amount established in paragraph (c) of this 

section. 

* * * * * 

(h) Purchase of power-driven wheelchairs furnished on or after January 1, 2006. 

(1) Suppliers must offer beneficiaries the option to purchase power-driven 

wheelchairs at the time the equipment is initially furnished. 

(2) Payment is made on a lump-sum purchase 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 program,” “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 terminated for a breach of contract. 

* * * * * 
CMS-1503-P 772

Breach of contract means any deviation from contract requirements, including a 

failure to comply with a governmental agency 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 independent 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 contracts 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 infusion 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 wheelchairs equals 15 percent of the single 

payment amounts calculated for new durable medical equipment under paragraph (f)(1) 

of this section for each of the first 3 months, 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 largest MSAs by total population based on 2009 

population estimates, and not already 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 testing 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 paragraph (e)(3) to read as follows: 

§414.422 Term of contracts. 

* * * * * 

(e) * * * 
CMS-1503-P 776

(3) Contract suppliers for diabetic testing supplies must furnish the brand of 

diabetic testing supplies that work with the home blood glucose monitor selected by the 

beneficiary. The contract supplier is prohibited from influencing or incentivizing the 

beneficiary by persuading, pressuring, or advising them to switch from their current 

brand or for new beneficiaries from their preferred brand of glucose monitor and testing 

supplies. The contract supplier may not furnish information about alternative brands to 

the beneficiary unless the beneficiary requests such information. 

* * * * * 

40. Section 414.423 is added to read as follows: 

§414.423 Appeals process for termination of competitive bidding contract.

This section implements an appeals process for suppliers that CMS has 

determined are in breach of their Medicare DMEPOS Competitive Bidding Program 

contracts and where CMS has taken action to terminate the supplier’s contract. Except as 

specified in this regulation termination decisions 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 notify the Medicare DMEPOS 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 termination, 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 Corrective 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 termination 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 submit a CAP or if CMS determines that a 

supplier's CAP is insufficient, the supplier 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, suppliers 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 involved with the original determination.

(2) A supplier who wishes to appeal the termination notice must submit 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. 

(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 accordance 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 give the parties to the hearing 30 day notice 

of the change. 

(5) The HO’s scheduling notice must provide 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 burden to prove it is not in violation of the contract. 

(iv) The opportunity for parties to the hearing 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 evidence 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 supplier 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 affected parties within 15 days prior to the 

scheduled date of the hearing. 

(i) Role of the Hearing Officer. The HO will conduct a thorough 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 the 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 regulations 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 recommendation will not allow the supplier to submit 

new information. 

(2) After reviewing the HO recommendation, CMS’ decision will be made within 

30 days from the date of receipt 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 has 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 competitive 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 termination. The notification to the beneficiaries 
CMS-1503-P 783

must inform the beneficiaries that they are going 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 supplier 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 recommendation terminates the supplier’s 

contract, the effective date of the termination 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 otherwise 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 otherwise 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 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 rural area determined to be in the lowest 25 

percent of rural population arrayed by population density. The amount of this 

increase is based on CMS’s estimate of the ratio of the average cost per trip for the 

rural areas in the lowest quartile of population 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 inflation factor established by law. The inflation factor is 

based on the consumer price index for all 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 business multi-factor productivity (MFP) (as 

projected by the Secretary for the 10-year period ending with the applicable fiscal 

year, year, cost reporting period, 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 services 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 adjustment 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 Manufacturer’s Average Sales Price Data 

41. Section 414.804 is amended by-- 

A. Redesignating paragraph (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 container 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 adding 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 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) as defined at section 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 the biosimilar biological 

product as defined at section 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 price 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 contained 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 Inspector 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 manufacturer 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 drugs 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 manufacturer price for a billing code 

will be applied at such times when: 

(A) The threshold for making price substitutions, 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 manufacturer 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 WAMP 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 States District of Columbia in National 

Association of Chain Drug Stores et al. v. Health and Human Services, Civil Action No. 

1:07-cv-02017 (RCL), is vacated. 

* * * * * 
CMS-1503-P 789

(i) If manufacturer ASP data is not available 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 (as 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 the 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 TEACHING 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: Physician pathology services. 

* * * * * 

(d) Physician pathology services furnished by an independent laboratory.
CMS-1503-P 790

(1) The technical component of physician pathology services furnished by an 

independent laboratory to a hospital inpatient or outpatient on or before 

December 31, 2010, may be paid to the laboratory by the contractor under the physician 

fee schedule if the Medicare beneficiary is a patient of a covered hospital as defined in 

paragraph (a)(1) of this section. 

(2) For services furnished after December 31, 2010, an independent laboratory 

may not bill the Medicare contractor for the technical component of physician pathology 

services furnished to a hospital 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 practitioner, a clinical nurse specialist, or 

a physician assistant as those terms are defined in section 1861(aa)(5) of the Act) who 

does not have a direct or indirect employment relationship with the facility but who is 

working in collaboration with a physician. 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 medical direction and appropriate supervision as provided for 

in guidelines jointly developed by the physician 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 facility 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 employment 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 paragraphs (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 claim 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 were furnished during the first 9 months of a 

calendar year, and on or before December 31st 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 extended 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 extended 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 received notification of Medicare entitlement 

effective retroactively to or before the date of the furnished service. 

(3) The time for filing a claim will be extended 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 received 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 following 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 that 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 6th
CMS-1503-P 794

calendar month following the month in which 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 6th calendar month following the month 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-physician practitioner organizations. 

(2) Physicians. 

(3) Nonphysician practitioners. 

 (4) Independent diagnostic testing facilities. 

* * * * * 

Subpart P--Requirements for Establishing and Maintaining Medicare Billing 

Privileges 

49. Section 424.502 is amended by adding 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 practitioner, submits written confirmation 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 documentation, including all applicable Federal and State 

licenses,certifications (including, but not limited to Federal Aviation Administration and 

Clinical Laboratory Improvement 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 statutory or regulatory authority, or under the 

Paperwork 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. 

* * * * * 

51. Section 424.516 is amended by adding paragraph (e)(3) to read as follows: 

§424.516 Additional provider and supplier requirements for enrolling and 

maintaining active enrollment status in the Medicare program. 

* * * * * 

(e) * * * 

(3) Within 30 days any revocation or suspension of a Federal or State license or 

certification (including Federal Aviation Administration and Clinical Laboratory 
CMS-1503-P 796

Improvement Act certifications), an air ambulance 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 Assistance Program No. 93.773, Medicare--

Hospital Insurance; and Program No. 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 provide various data pertaining to the 

Medicare fee schedule for physicians’ services furnished in CY 2011. Addendum B 

contains the RVUs for work, nonfacility PE, facility PE, and malpractice 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 information for each CPT code and alphanumeric HCPCS code, except for: alpha-numeric codes beginning with B (enteral and 

parenteral therapy); “E” (durable medical equipment); “K” (temporary codes for 

nonphysicians’ services or items); or “L” (orthotics); and codes for anesthesiology. 

Please also note the following: 

• An “NA” in the “Nonfacility PE RVUs” column of Addendum B means that 

CMS has not developed PE RVUs in the nonfacility setting for the service because it is 

typically performed in the hospital (for example, an open heart surgery is generally 

performed in the hospital setting and not a physician’s office). If there is an “NA” in the 

nonfacility PE RVU column, and the contractor determines that this service can be 

performed in the nonfacility setting, the service will be paid at the facility PE RVU rate. 

• Services that have an “NA” in the “Facility PE RVUs” column of Addendum B 

are typically not paid under the PFS when provided in a facility setting. These services 

(which include “incident to” services and the technical portion of diagnostic tests) are 
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 component (modifier TC) 

and a professional component (PC) (modifier-26) for the service. If there is a PC and a 

TC for the service, Addendum B contains three entries for the code, specifically a code 

for: the global values (both professional and technical); modifier -26 (PC); and modifier 

-TC. The global service is not designated by a modifier, and physicians must bill using 

the code without a modifier if the physician furnishes both the PC and the TC of the 

service. Modifier-53 is shown for a discontinued procedure, for example a colonoscopy 

that is not completed. There will be RVUs for a code with this modifier. 

3. Status indicator. This indicator shows whether the CPT/HCPCS code is included 

in the PFS and whether it is separately payable if the service is covered. 

A = Active code. These codes are separately payable under the PFS if covered. 

There will be RVUs for codes with this status. The presence of an “A” indicator does not 

mean that Medicare has made a national coverage determination regarding the service. 

Contractors remain responsible for coverage decisions in the absence of a national 

Medicare policy. 

B = Bundled code. Payments for covered services are always bundled into 

payment for other services not specified. If RVUs are shown, they are not used for 
CMS-1503-P 800

Medicare payment. If these services are covered, 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 individual case basis following review of 

documentation, such as an operative report. 

E = Excluded from the PFS by regulation. These codes are for items and services 

that CMS chose to exclude from the PFS by regulation. No RVUs are shown, and no 

payment may be made under the PFS for these codes. Payment for them, when covered, 

continues under reasonable charge procedures. 

I = Not valid for Medicare purposes. Medicare uses another code for the 

reporting of, and the payment for these services. (Codes not subject to a 90-day grace 

period.) 

M = Measurement codes, used for reporting purposes only. There are no RVUs 

and no payment amounts for these codes. CMS uses them to aid with performance 

measurement. No separate payment is made. These codes should be billed with a zero 

(($0.00) charge and are denied) on the MPFSDB. 

N = 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 shown, 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 are billed on the same date by the same 

provider, these services are bundled into the service(s) for which payment is made. 

X = Statutory exclusion. These codes represent an item or service that is not 

within the statutory definition of “physicians’ services” for PFS payment purposes. No 

RVUs are shown for these codes, and no payment may be made under the PFS. 

(Examples are ambulance services and clinical diagnostic laboratory services.) 

4. Description of code. This is an abbreviated version of the narrative description 

of the code. 

5. Physician work RVUs. These are the RVUs for the physician work in CY 

2011. 

6. Fully implemented nonfacility PE RVUs. These are the fully implemented 

resource-based PE RVUs for nonfacility settings. 

7. CY 2011 transitional nonfacility PE RVUs. These are the CY 2011 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 furnished in uncomplicated maternity cases, 

including antepartum care, delivery, and postpartum care. The usual global surgical 

concept does not apply. See the Physicians’ Current Procedural Terminology for specific 

definitions. 

XXX = The global concept does not apply. 

YYY = The global period is to be set by the contractor (for example, unlisted 

surgery codes). 

ZZZ = Code related to another service that is always included in the global period 

of the other service. (Note: Physician work and PE are associated with intra-service time 

and, in some instances, with the post-service time.) 
CMS-1503-P 803

ADDENDUM B: Proposed Relative Value Units and Related Information Used in Determining Medicare Paym

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

0016T C Thermotx choroid vasc lesion 0.00 0.00 0.00 0.00 0.00 0017T C Photocoagulat macular drusen 0.00 0.00 0.00 0.00 0.00 0019T C Extracorp shock wv tx,ms nos 0.00 0.00 0.00 0.00 0.00 0030T C Antiprothrombin antibody 0.00 0.00 0.00 0.00 0.00 0042T C Ct perfusion w/contrast, cbf 0.00 0.00 0.00 0.00 0.00 0048T C Implant ventricular device 0.00 0.00 0.00 0.00 0.00 0050T C Removal circulation assist 0.00 0.00 0.00 0.00 0.00 0051T C Implant total heart system 0.00 0.00 0.00 0.00 0.00 0052T C Replace component heart syst 0.00 0.00 0.00 0.00 0.00 0053T C Replace component heart syst 0.00 0.00 0.00 0.00 0.00 0054T C Bone surgery using computer 0.00 0.00 0.00 0.00 0.00 0055T C Bone surgery using computer 0.00 0.00 0.00 0.00 0.00 0071T C U/s leiomyomata ablate <200 0.00 0.00 0.00 0.00 0.00 0072T C U/s leiomyomata ablate >200 0.00 0.00 0.00 0.00 0.00 0073T A Delivery, comp imrt 0.00 13.68 15.38 NA NA 0075T C Perq stent/chest vert art 0.00 0.00 0.00 NA NA 0075T TC C Perq stent/chest vert art 0.00 0.00 0.00 NA NA 0075T 26 C Perq stent/chest vert art 0.00 0.00 0.00 0.00 0.00 0076T C S&i stent/chest vert art 0.00 0.00 0.00 NA NA 0076T TC C S&i stent/chest vert art 0.00 0.00 0.00 NA NA 0076T 26 C S&i stent/chest vert art 0.00 0.00 0.00 0.00 0.00 0078T C Endovasc aort repr w/device 0.00 0.00 0.00 0.00 0.00 0079T C Endovasc visc extnsn repr 0.00 0.00 0.00 0.00 0.00 0080T C Endovasc aort repr rad s&i 0.00 0.00 0.00 0.00 0.00 
CMS-1503-P 804

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

0081T C Endovasc visc extnsn s&i 0.00 0.00 0.00 0.00 0.00 0085T N Breath test heart reject 0.00 0.00 0.00 0.00 0.00 0092T C Artific disc addl 0.00 0.00 0.00 0.00 0.00 0095T C Artific diskectomy addl 0.00 0.00 0.00 0.00 0.00 0098T C Rev artific disc addl 0.00 0.00 0.00 0.00 0.00 0099T C Implant corneal ring 0.00 0.00 0.00 0.00 0.00 0100T C Prosth retina receive&gen 0.00 0.00 0.00 0.00 0.00 0101T C Extracorp shockwv tx,hi enrg 0.00 0.00 0.00 0.00 0.00 0102T C Extracorp shockwv tx,anesth 0.00 0.00 0.00 0.00 0.00 0103T C Holotranscobalamin 0.00 0.00 0.00 0.00 0.00 0104T C At rest cardio gas rebreathe 0.00 0.00 0.00 0.00 0.00 0105T C Exerc cardio gas rebreathe 0.00 0.00 0.00 0.00 0.00 0106T C Touch quant sensory test 0.00 0.00 0.00 0.00 0.00 0107T C Vibrate quant sensory test 0.00 0.00 0.00 0.00 0.00 0108T C Cool quant sensory test 0.00 0.00 0.00 0.00 0.00 0109T C Heat quant sensory test 0.00 0.00 0.00 0.00 0.00 0110T C Nos quant sensory test 0.00 0.00 0.00 0.00 0.00 0111T C Rbc membranes fatty acids 0.00 0.00 0.00 0.00 0.00 0123T C Scleral fistulization 0.00 0.00 0.00 0.00 0.00 0124T C Conjunctival drug placement 0.00 0.00 0.00 0.00 0.00 0126T C Chd risk imt study 0.00 0.00 0.00 0.00 0.00 0130T C Chron care drug investigatn 0.00 0.00 0.00 0.00 0.00 0140T C Exhaled breath condensate ph 0.00 0.00 0.00 0.00 0.00 0141T I Perq islet transplant 0.00 0.00 0.00 0.00 0.00 0142T I Open islet transplant 0.00 0.00 0.00 0.00 0.00 0143T I Laparoscopic islet transplnt 0.00 0.00 0.00 0.00 0.00 
CMS-1503-P 805

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

0155T C Lap impl gast curve electrd 0.00 0.00 0.00 0.00 0.00 0156T C Lap remv gast curve electrd 0.00 0.00 0.00 0.00 0.00 0157T C Open impl gast curve electrd 0.00 0.00 0.00 0.00 0.00 0158T C Open remv gast curve electrd 0.00 0.00 0.00 0.00 0.00 0159T C Cad breast mri 0.00 0.00 0.00 NA NA 0159T TC C Cad breast mri 0.00 0.00 0.00 NA NA 0159T 26 C Cad breast mri 0.00 0.00 0.00 0.00 0.00 0160T C Tcranial magn stim tx plan 0.00 0.00 0.00 0.00 0.00 0161T C Tcranial magn stim tx deliv 0.00 0.00 0.00 0.00 0.00 0163T C Lumb artif diskectomy addl 0.00 0.00 0.00 0.00 0.00 0164T C Remove lumb artif disc addl 0.00 0.00 0.00 0.00 0.00 0165T C Revise lumb artif disc addl 0.00 0.00 0.00 0.00 0.00 0166T C Tcath vsd close w/o bypass 0.00 0.00 0.00 0.00 0.00 0167T C Tcath vsd close w bypass 0.00 0.00 0.00 0.00 0.00 0168T C Rhinophototx light app bilat 0.00 0.00 0.00 0.00 0.00 0169T C Place stereo cath brain 0.00 0.00 0.00 0.00 0.00 0171T C Lumbar spine proces distract 0.00 0.00 0.00 0.00 0.00 0172T C Lumbar spine process addl 0.00 0.00 0.00 0.00 0.00 0173T C Iop monit io pressure 0.00 0.00 0.00 0.00 0.00 0174T C Cad cxr with interp 0.00 0.00 0.00 0.00 0.00 0175T C Cad cxr remote 0.00 0.00 0.00 0.00 0.00 0176T C Aqu canal dilat w/o retent 0.00 0.00 0.00 0.00 0.00 0177T C Aqu canal dilat w retent 0.00 0.00 0.00 0.00 0.00 0178T C 64 lead ecg w i&r 0.00 0.00 0.00 0.00 0.00 0179T C 64 lead ecg w tracing 0.00 0.00 0.00 0.00 0.00 0180T C 64 lead ecg w i&r only 0.00 0.00 0.00 0.00 0.00 
CMS-1503-P 806

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

0181T C Corneal hysteresis 0.00 0.00 0.00 0.00 0.00 0182T C Hdr elect brachytherapy 0.00 0.00 0.00 NA NA 0182T TC C Hdr elect brachytherapy 0.00 0.00 0.00 NA NA 0182T 26 C Hdr elect brachytherapy 0.00 0.00 0.00 0.00 0.00 0183T C Wound ultrasound 0.00 0.00 0.00 0.00 0.00 0184T C Exc rectal tumor endoscopic 0.00 0.00 0.00 0.00 0.00 0185T C Comptr probability analysis 0.00 0.00 0.00 0.00 0.00 0186T C Suprachoroidal drug delivery 0.00 0.00 0.00 0.00 0.00 0187T C Ophthalmic dx image anterior 0.00 0.00 0.00 0.00 0.00 0188T N Videoconf crit care 74 min 0.00 0.00 0.00 0.00 0.00 0189T N Videoconf crit care addl 30 0.00 0.00 0.00 0.00 0.00 0190T C Place intraoc radiation src 0.00 0.00 0.00 0.00 0.00 0191T C Insert ant segment drain int 0.00 0.00 0.00 0.00 0.00 0192T C Insert ant segment drain ext 0.00 0.00 0.00 0.00 0.00 0193T C Rf bladder neck microremodel 0.00 0.00 0.00 0.00 0.00 0195T C Arthrod presac interbody 0.00 0.00 0.00 0.00 0.00 0196T C Arthrod presac interbody eac 0.00 0.00 0.00 0.00 0.00 0197T C Intrafraction track motion 0.00 0.00 0.00 0.00 0.00 0198T C Ocular blood flow measure 0.00 0.00 0.00 0.00 0.00 0199T C Physiologic tremor record 0.00 0.00 0.00 0.00 0.00 0200T C Perq sacral augmt unilat inj 0.00 0.00 0.00 0.00 0.00 0201T C Perq sacral augmt bilat inj 0.00 0.00 0.00 0.00 0.00 0202T C Post vert arthrplst 1 lumbar 0.00 0.00 0.00 0.00 0.00 0203T C Unattend sleep study w/time 0.00 0.00 0.00 NA NA 0203T TC C Unattend sleep study w/time 0.00 0.00 0.00 NA NA 0203T 26 C Unattend sleep study w/time 0.00 0.00 0.00 0.00 0.00 
CMS-1503-P 807

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

0204T C Unattended sleep study 0.00 0.00 0.00 NA NA 0204T TC C Unattended sleep study 0.00 0.00 0.00 NA NA 0204T 26 C Unattended sleep study 0.00 0.00 0.00 0.00 0.00 0205T C Inirs each vessel add-on 0.00 0.00 0.00 0.00 0.00 0206T C Remote algorithm analys ecg 0.00 0.00 0.00 0.00 0.00 0207T C Clear eyelid gland w/heat 0.00 0.00 0.00 0.00 0.00 0208T C Automated audiometry air 0.00 0.00 0.00 0.00 0.00 0209T C Auto audiometry air/bone 0.00 0.00 0.00 0.00 0.00 0210T C Auto audiometry sp thresh 0.00 0.00 0.00 0.00 0.00 0211T C Auto audiometry sp thresh 0.00 0.00 0.00 0.00 0.00 0212T C Comprehen auto audiometry 0.00 0.00 0.00 0.00 0.00 0213T C Us facet jt inj cerv/t 1 lev 0.00 0.00 0.00 0.00 0.00 0214T C Us facet jt inj cerv/t 2 lev 0.00 0.00 0.00 0.00 0.00 0215T C Us facet jt inj cerv/t 3 lev 0.00 0.00 0.00 0.00 0.00 0216T C Us facet jt inj ls 1 level 0.00 0.00 0.00 0.00 0.00 0217T C Us facet jt inj ls 2 level 0.00 0.00 0.00 0.00 0.00 0218T C Us facet jt inj ls 3 level 0.00 0.00 0.00 0.00 0.00 0219T C Fuse spine facet jt cerv 0.00 0.00 0.00 0.00 0.00 0220T C Fuse spine facet jt thor 0.00 0.00 0.00 0.00 0.00 0221T C Fuse spine facet jt lumbar 0.00 0.00 0.00 0.00 0.00 0222T C Fuse spine facet jt add seg 0.00 0.00 0.00 0.00 0.00 

0528F I Rcmnd flw-up 10 yrs docd 0.00 0.00 0.00 0.00 0.00 0535F I Dyspnea mngmnt plan docd 0.00 0.00 0.00 0.00 0.00 0545F I Follow up care plan mdd docd 0.00 0.00 0.00 0.00 0.00 

10021 A Fna w/o image 1.27 2.70 2.64 0.62 0.57 10022 A Fna w/image 1.27 2.37 2.54 0.49 0.51 
CMS-1503-P 808

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

10040 A Acne surgery 1.21 1.60 1.56 1.25 1.20 10060 A Drainage of skin abscess 1.22 1.96 1.83 1.43 1.34 10061 A Drainage of skin abscess 2.45 2.69 2.55 1.99 1.90 10080 A Drainage of pilonidal cyst 1.22 3.52 3.41 1.54 1.43 10081 A Drainage of pilonidal cyst 2.50 4.66 4.52 2.09 1.94 10120 A Remove foreign body 1.25 2.60 2.49 1.31 1.23 10121 A Remove foreign body 2.74 4.71 4.44 2.32 2.18 10140 A Drainage of hematoma/fluid 1.58 2.87 2.70 1.66 1.60 10160 A Puncture drainage of lesion 1.25 2.31 2.21 1.37 1.33 10180 A Complex drainage, wound 2.30 4.26 4.04 2.45 2.34 11000 A Debride infected skin 0.60 0.91 0.86 0.21 0.21 11001 A Debride infected skin add-on 0.30 0.29 0.28 0.10 0.11 11004 A Debride genitalia & perineum 10.80 NA NA 4.67 4.48 11005 A Debride abdom wall 14.24 NA NA 6.23 5.79 11006 A Debride genit/per/abdom wall 13.10 NA NA 5.77 5.50 11008 A Remove mesh from abd wall 5.00 NA NA 2.18 2.03 11010 A Debride skin, fx 4.19 9.20 8.73 3.41 3.21 11011 A Debride skin/muscle, fx 4.94 9.39 9.12 3.05 2.86 11012 A Debride skin/muscle/bone, fx 6.87 12.17 12.00 4.57 4.36 11040 A Debride skin, partial 0.50 0.84 0.79 0.20 0.20 11041 A Debride skin, full 0.60 0.90 0.87 0.24 0.25 11042 A Debride skin/tissue 0.80 1.25 1.20 0.35 0.35 11043 A Debride tissue/muscle 3.14 4.72 4.44 3.57 3.35 11044 A Debride tissue/muscle/bone 4.26 6.53 6.13 4.92 4.66 11055 R Trim skin lesion 0.43 0.99 0.93 0.13 0.14 11056 R Trim skin lesions, 2 to 4 0.61 1.07 1.02 0.18 0.20 
CMS-1503-P 809

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

11057 R Trim skin lesions, over 4 0.79 1.21 1.15 0.23 0.26 11100 A Biopsy, skin lesion 0.81 2.04 2.05 0.57 0.53 11101 A Biopsy, skin add-on 0.41 0.50 0.49 0.29 0.27 11200 A Removal of skin tags 0.82 1.57 1.50 1.19 1.12 11201 A Remove skin tags add-on 0.29 0.23 0.21 0.18 0.16 11300 A Shave skin lesion 0.51 1.41 1.38 0.33 0.30 11301 A Shave skin lesion 0.85 1.73 1.71 0.58 0.53 11302 A Shave skin lesion 1.05 2.02 2.00 0.73 0.66 11303 A Shave skin lesion 1.24 2.38 2.34 0.85 0.77 11305 A Shave skin lesion 0.67 1.30 1.25 0.26 0.27 11306 A Shave skin lesion 0.99 1.67 1.63 0.51 0.50 11307 A Shave skin lesion 1.14 1.99 1.96 0.67 0.64 11308 A Shave skin lesion 1.41 2.10 2.03 0.69 0.67 11310 A Shave skin lesion 0.73 1.62 1.60 0.48 0.44 11311 A Shave skin lesion 1.05 1.90 1.88 0.72 0.67 11312 A Shave skin lesion 1.20 2.21 2.18 0.84 0.78 11313 A Shave skin lesion 1.62 2.62 2.57 1.12 1.02 11400 A Exc tr-ext b9+marg 0.5 < cm 0.90 2.44 2.37 1.29 1.20 11401 A Exc tr-ext b9+marg 0.6-1 cm 1.28 2.76 2.68 1.57 1.47 11402 A Exc tr-ext b9+marg 1.1-2 cm 1.45 3.03 2.94 1.66 1.56 11403 A Exc tr-ext b9+marg 2.1-3 cm 1.84 3.32 3.18 2.15 1.99 11404 A Exc tr-ext b9+marg 3.1-4 cm 2.11 3.73 3.58 2.27 2.11 11406 A Exc tr-ext b9+marg > 4.0 cm 3.52 4.80 4.47 3.04 2.75 11420 A Exc h-f-nk-sp b9+marg 0.5 < 1.03 2.33 2.24 1.23 1.18 11421 A Exc h-f-nk-sp b9+marg 0.6-1 1.47 2.82 2.72 1.58 1.49 11422 A Exc h-f-nk-sp b9+marg 1.1-2 1.68 3.09 2.97 2.04 1.92 
CMS-1503-P 810

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

11423 A Exc h-f-nk-sp b9+marg 2.1-3 2.06 3.43 3.31 2.25 2.10 11424 A Exc h-f-nk-sp b9+marg 3.1-4 2.48 3.81 3.66 2.40 2.25 11426 A Exc h-f-nk-sp b9+marg > 4 cm 4.09 4.85 4.59 3.31 3.05 11440 A Exc face-mm b9+marg 0.5 < cm 1.05 2.61 2.54 1.78 1.69 11441 A Exc face-mm b9+marg 0.6-1 cm 1.53 3.05 2.95 2.09 1.98 11442 A Exc face-mm b9+marg 1.1-2 cm 1.77 3.36 3.26 2.24 2.12 11443 A Exc face-mm b9+marg 2.1-3 cm 2.34 3.77 3.63 2.57 2.41 11444 A Exc face-mm b9+marg 3.1-4 cm 3.19 4.47 4.27 3.05 2.84 11446 A Exc face-mm b9+marg > 4 cm 4.80 5.82 5.40 4.12 3.74 11450 A Removal, sweat gland lesion 3.22 6.91 6.52 3.46 3.15 11451 A Removal, sweat gland lesion 4.43 8.27 7.96 4.10 3.76 11462 A Removal, sweat gland lesion 3.00 6.90 6.60 3.42 3.13 11463 A Removal, sweat gland lesion 4.43 8.47 8.25 4.24 3.92 11470 A Removal, sweat gland lesion 3.74 7.38 6.91 3.84 3.47 11471 A Removal, sweat gland lesion 4.89 8.73 8.26 4.42 4.01 

1150F I Doc pt rsk death w/in 1yr 0.00 0.00 0.00 0.00 0.00 1151F I Doc no pt rsk death w/in 1yr 0.00 0.00 0.00 0.00 0.00 1152F I Doc advncd dis comfort 1st 0.00 0.00 0.00 0.00 0.00 1153F I Doc advncd dis cmfrt not 1st 0.00 0.00 0.00 0.00 0.00 1157F I Advnc care plan in rcrd 0.00 0.00 0.00 0.00 0.00 1158F I Advnc care plan tlk docd 0.00 0.00 0.00 0.00 0.00 1159F I Med list docd in rcrd 0.00 0.00 0.00 0.00 0.00 

11600 A Exc tr-ext mlg+marg 0.5 < cm 1.63 3.56 3.40 1.64 1.49 11601 A Exc tr-ext mlg+marg 0.6-1 cm 2.07 4.18 4.05 2.07 1.92 11602 A Exc tr-ext mlg+marg 1.1-2 cm 2.27 4.54 4.43 2.29 2.13 11603 A Exc tr-ext mlg+marg 2.1-3 cm 2.82 4.94 4.77 2.62 2.39 
CMS-1503-P 811

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

11604 A Exc tr-ext mlg+marg 3.1-4 cm 3.17 5.40 5.19 2.76 2.51 11606 A Exc tr-ext mlg+marg > 4 cm 5.02 7.15 6.69 3.69 3.28 

1160F I Rvw meds by rx/dr in rcrd 0.00 0.00 0.00 0.00 0.00 

11620 A Exc h-f-nk-sp mlg+marg 0.5 < 1.64 3.62 3.49 1.69 1.54 11621 A Exc h-f-nk-sp mlg+marg 0.6-1 2.08 4.22 4.10 2.10 1.95 11622 A Exc h-f-nk-sp mlg+marg 1.1-2 2.41 4.63 4.53 2.38 2.22 11623 A Exc h-f-nk-sp mlg+marg 2.1-3 3.11 5.14 4.95 2.79 2.56 11624 A Exc h-f-nk-sp mlg+marg 3.1-4 3.62 5.63 5.40 3.02 2.76 11626 A Exc h-f-nk-sp mlg+mar > 4 cm 4.61 6.51 6.22 3.48 3.20 11640 A Exc face-mm malig+marg 0.5 < 1.67 3.80 3.67 1.80 1.66 11641 A Exc face-mm malig+marg 0.6-1 2.17 4.37 4.27 2.20 2.08 11642 A Exc face-mm malig+marg 1.1-2 2.62 4.85 4.76 2.53 2.38 11643 A Exc face-mm malig+marg 2.1-3 3.42 5.38 5.20 3.01 2.79 11644 A Exc face-mm malig+marg 3.1-4 4.34 6.49 6.25 3.59 3.32 11646 A Exc face-mm mlg+marg > 4 cm 6.26 7.87 7.50 4.72 4.36 11719 R Trim nail(s) 0.17 0.46 0.44 0.05 0.06 11720 A Debride nail, 1-5 0.32 0.57 0.54 0.09 0.10 11721 A Debride nail, 6 or more 0.54 0.66 0.64 0.16 0.18 11730 A Removal of nail plate 1.10 1.63 1.56 0.33 0.36 11732 A Remove nail plate, add-on 0.57 0.67 0.64 0.17 0.19 11740 A Drain blood from under nail 0.37 0.99 0.92 0.53 0.51 11750 A Removal of nail bed 2.50 3.68 3.47 2.34 2.27 11752 A Remove nail bed/finger tip 3.63 5.27 4.90 3.63 3.52 11755 A Biopsy, nail unit 1.31 2.44 2.35 0.92 0.92 11760 A Repair of nail bed 1.63 4.60 4.22 1.99 1.91 11762 A Reconstruction of nail bed 2.94 4.79 4.47 2.19 2.21 
CMS-1503-P 812

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

11765 A Excision of nail fold, toe 0.74 3.31 3.09 1.25 1.18 11770 A Removal of pilonidal lesion 2.66 4.68 4.42 2.22 2.03 11771 A Removal of pilonidal lesion 6.09 9.10 8.44 5.37 4.91 11772 A Removal of pilonidal lesion 7.35 10.71 10.09 7.68 7.13 

1180F I Thromboemb risk assessed 0.00 0.00 0.00 0.00 0.00 

11900 A Injection into skin lesions 0.52 1.03 1.03 0.37 0.34 11901 A Added skin lesions injection 0.80 1.17 1.15 0.58 0.53 11920 R Correct skin color defects 1.61 3.06 3.15 1.56 1.45 11921 R Correct skin color defects 1.93 3.52 3.54 1.81 1.68 11922 R Correct skin color defects 0.49 1.20 1.18 0.34 0.31 11950 R Therapy for contour defects 0.84 1.02 1.10 0.47 0.48 11951 R Therapy for contour defects 1.19 1.47 1.47 0.73 0.68 11952 R Therapy for contour defects 1.69 1.58 1.81 0.79 0.86 11954 R Therapy for contour defects 1.85 2.52 2.45 1.36 1.21 11960 A Insert tissue expander(s) 11.49 NA NA 12.79 12.82 11970 A Replace tissue expander 8.01 NA NA 8.88 8.20 11971 A Remove tissue expander(s) 3.41 9.31 9.29 5.27 5.00 11975 N Insert contraceptive cap 1.48 2.09 2.08 0.64 0.63 11976 R Removal of contraceptive cap 1.78 2.07 2.11 0.80 0.73 11977 N Removal/reinsert contra cap 3.30 2.91 2.91 1.43 1.41 11980 A Implant hormone pellet(s) 1.48 1.34 1.31 0.72 0.67 11981 A Insert drug implant device 1.48 2.13 2.18 0.70 0.73 11982 A Remove drug implant device 1.78 2.20 2.32 0.83 0.89 11983 A Remove/insert drug implant 3.30 2.53 2.83 1.36 1.54 12001 A Repair superficial wound(s) 1.75 2.39 2.26 1.08 0.99 12002 A Repair superficial wound(s) 1.91 2.48 2.35 1.22 1.12 
CMS-1503-P 813

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

12004 A Repair superficial wound(s) 2.29 2.85 2.70 1.33 1.23 12005 A Repair superficial wound(s) 2.91 3.44 3.26 1.54 1.43 12006 A Repair superficial wound(s) 3.71 4.11 3.90 1.87 1.74 12007 A Repair superficial wound(s) 4.16 4.51 4.34 2.00 1.95 

1200F I Seizure type(s)+ frq docd 0.00 0.00 0.00 0.00 0.00 

12011 A Repair superficial wound(s) 1.81 2.58 2.45 1.08 1.00 12013 A Repair superficial wound(s) 2.04 2.79 2.65 1.25 1.16 12014 A Repair superficial wound(s) 2.51 3.12 2.97 1.39 1.30 12015 A Repair superficial wound(s) 3.24 3.76 3.59 1.57 1.48 12016 A Repair superficial wound(s) 3.97 4.36 4.14 1.85 1.75 12017 A Repair superficial wound(s) 4.75 NA NA 1.78 1.84 12018 A Repair superficial wound(s) 5.57 NA NA 1.93 2.31 12020 A Closure of split wound 2.67 4.82 4.63 2.42 2.30 12021 A Closure of split wound 1.89 2.58 2.40 1.91 1.77 12031 A Intmd wnd repair s/tr/ext 2.20 4.63 4.42 2.35 2.15 12032 A Intmd wnd repair s/tr/ext 2.52 5.90 5.87 2.90 2.78 12034 A Intmd wnd repair s/tr/ext 2.97 5.51 5.30 2.65 2.47 12035 A Intmd wnd repair s/tr/ext 3.47 6.74 6.53 2.92 2.76 12036 A Intmd wnd repair s/tr/ext 4.09 7.07 6.77 3.19 3.00 12037 A Intmd wnd repair s/tr/ext 4.71 7.71 7.43 3.70 3.51 12041 A Intmd wnd repair n-hf/genit 2.42 4.73 4.49 2.41 2.20 12042 A Intmd wnd repair n-hg/genit 2.79 5.24 5.14 2.79 2.60 12044 A Intmd wnd repair n-hg/genit 3.19 6.55 6.17 2.65 2.47 12045 A Intmd wnd repair n-hg/genit 3.68 6.45 6.29 2.86 2.73 12046 A Intmd wnd repair n-hg/genit 4.29 7.59 7.44 3.38 3.23 12047 A Intmd wnd repair n-hg/genit 4.69 8.43 8.08 3.46 3.41 
CMS-1503-P 814

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

12051 A Intmd wnd repair face/mm 2.52 4.91 4.79 2.56 2.39 12052 A Intmd wnd repair face/mm 2.87 5.64 5.50 3.27 3.03 12053 A Intmd wnd repair face/mm 3.17 6.28 6.04 2.82 2.63 12054 A Intmd wnd repair, face/mm 3.50 6.53 6.22 2.70 2.54 12055 A Intmd wnd repair face/mm 4.47 7.63 7.18 2.92 2.74 12056 A Intmd wnd repair face/mm 5.28 9.78 8.84 4.79 4.06 12057 A Intmd wnd repair face/mm 6.00 11.35 10.07 4.67 4.31 

1205F I EPI etiol synd rvwd and docd 0.00 0.00 0.00 0.00 0.00 

13100 A Repair of wound or lesion 3.17 5.38 5.34 3.29 3.17 13101 A Repair of wound or lesion 3.96 6.95 6.87 3.94 3.77 13102 A Repair wound/lesion add-on 1.24 1.73 1.65 0.82 0.75 13120 A Repair of wound or lesion 3.35 5.56 5.50 3.45 3.29 13121 A Repair of wound or lesion 4.42 7.79 7.67 4.71 4.47 13122 A Repair wound/lesion add-on 1.44 1.80 1.75 0.92 0.83 13131 A Repair of wound or lesion 3.83 6.01 5.94 3.82 3.66 13132 A Repair of wound or lesion 6.58 9.45 9.22 6.54 6.22 13133 A Repair wound/lesion add-on 2.19 2.44 2.34 1.50 1.38 13150 A Repair of wound or lesion 3.85 5.95 5.84 3.77 3.57 13151 A Repair of wound or lesion 4.49 6.68 6.57 4.33 4.15 13152 A Repair of wound or lesion 6.37 9.10 8.90 5.44 5.19 13153 A Repair wound/lesion add-on 2.38 2.73 2.60 1.60 1.46 13160 A Late closure of wound 12.04 NA NA 9.85 9.26 14000 A Skin tissue rearrangement 6.37 10.75 10.46 7.58 7.25 14001 A Skin tissue rearrangement 8.78 13.25 12.88 9.41 9.06 14020 A Skin tissue rearrangement 7.22 12.04 11.72 8.66 8.34 14021 A Skin tissue rearrangement 9.72 14.44 14.06 10.47 10.15 
CMS-1503-P 815

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

14040 A Skin tissue rearrangement 8.60 12.65 12.30 9.26 8.96 14041 A Skin tissue rearrangement 10.83 15.45 15.10 11.15 10.81 14060 A Skin tissue rearrangement 9.23 12.39 11.96 9.74 9.33 14061 A Skin tissue rearrangement 11.48 16.75 16.37 12.00 11.64 14301 A Skin tissue rearrangement 12.65 16.91 16.91 11.82 11.82 14302 A Skin tissue rearrange add-on 3.73 2.49 2.49 2.49 2.49 14350 A Skin tissue rearrangement 11.05 NA NA 8.56 8.46 15002 A Wound prep, trk/arm/leg 3.65 5.74 5.39 2.56 2.32 15003 A Wound prep, addl 100 cm 0.80 1.21 1.15 0.42 0.38 15004 A Wound prep, f/n/hf/g 4.58 6.39 6.15 2.95 2.76 15005 A Wnd prep, f/n/hf/g, addl cm 1.60 1.70 1.59 0.84 0.75 15040 A Harvest cultured skin graft 2.00 4.94 4.91 1.44 1.35 15050 A Skin pinch graft 5.57 10.28 9.61 6.98 6.53 15100 A Skin splt grft, trnk/arm/leg 9.90 13.40 13.03 9.63 9.08 15101 A Skin splt grft t/a/l, add-on 1.72 3.27 3.31 1.26 1.20 15110 A Epidrm autogrft trnk/arm/leg 10.97 11.93 11.43 8.93 8.33 15111 A Epidrm autogrft t/a/l add-on 1.85 1.20 1.21 0.89 0.87 15115 A Epidrm a-grft face/nck/hf/g 11.28 12.63 11.81 9.67 8.98 15116 A Epidrm a-grft f/n/hf/g addl 2.50 2.20 1.95 1.78 1.52 15120 A Skn splt a-grft fac/nck/hf/g 11.16 15.26 14.38 10.70 9.95 15121 A Skn splt a-grft f/n/hf/g add 2.67 4.61 4.50 1.98 1.85 15130 A Derm autograft, trnk/arm/leg 7.53 10.82 10.45 7.88 7.41 15131 A Derm autograft t/a/l add-on 1.50 1.29 1.15 1.07 0.89 15135 A Derm autograft face/nck/hf/g 11.03 13.03 12.19 10.10 9.42 15136 A Derm autograft, f/n/hf/g add 1.50 1.16 0.97 0.98 0.78 15150 A Cult epiderm grft t/arm/leg 9.39 8.81 8.68 7.19 7.04 
CMS-1503-P 816

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

15151 A Cult epiderm grft t/a/l addl 2.00 1.11 1.16 0.86 0.89 15152 A Cult epiderm graft t/a/l +% 2.50 1.35 1.54 1.10 1.24 15155 A Cult epiderm graft, f/n/hf/g 10.14 6.82 7.80 5.49 6.44 15156 A Cult epidrm grft f/n/hfg add 2.75 1.44 1.59 1.18 1.33 15157 A Cult epiderm grft f/n/hfg +% 3.00 1.19 1.58 0.89 1.23 15170 A Acell graft trunk/arms/legs 5.99 6.00 5.48 4.22 3.75 15171 A Acell graft t/arm/leg add-on 1.55 0.97 0.89 0.81 0.74 15175 A Acellular graft, f/n/hf/g 7.99 6.12 5.94 4.46 4.31 15176 A Acell graft, f/n/hf/g add-on 2.45 1.55 1.44 1.24 1.16 15200 A Skin full graft, trunk 9.15 13.59 12.81 9.41 8.66 15201 A Skin full graft trunk add-on 1.32 2.75 2.69 0.89 0.79 15220 A Skin full graft sclp/arm/leg 8.09 13.20 12.72 9.08 8.64 15221 A Skin full graft add-on 1.19 2.56 2.54 0.78 0.72 15240 A Skin full grft face/genit/hf 10.41 15.45 14.74 12.02 11.32 15241 A Skin full graft add-on 1.86 3.26 3.14 1.28 1.16 15260 A Skin full graft een & lips 11.64 16.43 15.71 12.59 11.93 15261 A Skin full graft add-on 2.23 3.76 3.62 1.74 1.63 15300 A Apply skinallogrft, t/arm/lg 4.65 4.96 4.55 3.31 3.01 15301 A Apply sknallogrft t/a/l addl 1.00 0.67 0.63 0.50 0.47 15320 A Apply skin allogrft f/n/hf/g 5.36 4.89 4.69 3.13 3.02 15321 A Aply sknallogrft f/n/hfg add 1.50 1.02 0.94 0.80 0.74 15330 A Aply acell alogrft t/arm/leg 3.99 5.02 4.60 3.32 3.01 15331 A Aply acell grft t/a/l add-on 1.00 0.74 0.66 0.58 0.52 15335 A Apply acell graft, f/n/hf/g 4.50 4.38 4.19 2.76 2.66 15336 A Aply acell grft f/n/hf/g add 1.43 1.31 1.04 1.02 0.79 15340 A Apply cult skin substitute 3.82 4.83 4.68 3.51 3.36 
CMS-1503-P 817

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

15341 A Apply cult skin sub add-on 0.50 0.81 0.78 0.19 0.19 15360 A Apply cult derm sub, t/a/l 4.02 5.76 5.66 4.27 4.15 15361 A Aply cult derm sub t/a/l add 1.15 0.51 0.57 0.36 0.40 15365 A Apply cult derm sub f/n/hf/g 4.30 5.23 5.12 3.85 3.74 15366 A Apply cult derm f/hf/g add 1.45 0.74 0.74 0.51 0.53 15400 A Apply skin xenograft, t/a/l 4.47 6.96 6.47 5.41 5.13 15401 A Apply skn xenogrft t/a/l add 1.00 1.34 1.41 0.50 0.47 15420 A Apply skin xgraft, f/n/hf/g 4.98 7.14 6.97 5.66 5.50 15421 A Apply skn xgrft f/n/hf/g add 1.50 1.65 1.55 0.80 0.72 15430 A Apply acellular xenograft 6.20 8.86 8.32 8.16 7.69 15431 C Apply acellular xgraft add 0.00 0.00 0.00 0.00 0.00 15570 A Form skin pedicle flap 10.21 14.16 13.50 9.49 8.83 15572 A Form skin pedicle flap 10.12 14.10 13.18 10.43 9.52 15574 A Form skin pedicle flap 10.70 14.55 13.75 10.68 9.91 15576 A Form skin pedicle flap 9.37 13.05 12.42 9.49 8.83 15600 A Skin graft 2.01 6.84 6.93 3.71 3.55 15610 A Skin graft 2.52 7.22 6.81 4.16 3.98 15620 A Skin graft 3.75 8.32 8.23 5.29 5.00 15630 A Skin graft 4.08 8.68 8.57 5.64 5.41 15650 A Transfer skin pedicle flap 4.77 9.17 9.15 5.93 5.75 15731 A Forehead flap w/vasc pedicle 14.38 17.26 16.34 14.14 13.21 15732 A Muscle-skin graft, head/neck 19.90 21.63 20.28 17.35 15.72 15734 A Muscle-skin graft, trunk 19.86 21.30 20.53 16.59 15.64 15736 A Muscle-skin graft, arm 17.04 19.32 18.64 14.65 13.60 15738 A Muscle-skin graft, leg 19.04 19.43 18.76 15.01 14.05 15740 A Island pedicle flap graft 11.80 16.68 16.09 12.49 11.89 
CMS-1503-P 818

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

15750 A Neurovascular pedicle graft 12.96 NA NA 12.28 11.53 15756 A Free myo/skin flap microvasc 36.94 NA NA 28.48 26.11 15757 A Free skin flap, microvasc 37.15 NA NA 27.91 25.63 15758 A Free fascial flap, microvasc 36.90 NA NA 27.69 25.56 15760 A Composite skin graft 9.86 13.91 13.21 10.09 9.41 15770 A Derma-fat-fascia graft 8.96 NA NA 9.62 8.89 15775 R Hair transplant punch grafts 3.95 4.74 4.59 2.51 2.22 15776 R Hair transplant punch grafts 5.53 6.48 6.28 3.30 3.10 15780 A Abrasion treatment of skin 8.73 13.81 13.76 8.40 8.45 15781 A Abrasion treatment of skin 5.02 10.19 9.86 7.02 6.77 15782 A Abrasion treatment of skin 4.44 10.52 10.82 6.22 6.45 15783 A Abrasion treatment of skin 4.41 9.07 8.97 6.14 5.86 15786 A Abrasion, lesion, single 2.08 4.59 4.53 1.71 1.64 15787 A Abrasion, lesions, add-on 0.33 0.98 1.00 0.16 0.15 15788 R Chemical peel, face, epiderm 2.09 10.87 10.39 4.96 4.69 15789 R Chemical peel, face, dermal 4.91 10.45 10.53 6.94 6.77 15792 R Chemical peel, nonfacial 1.86 10.33 10.15 5.50 5.44 15793 A Chemical peel, nonfacial 3.96 9.70 9.42 6.33 6.05 15819 A Plastic surgery, neck 10.65 NA NA 7.46 8.01 15820 A Revision of lower eyelid 6.27 9.44 8.74 8.00 7.28 15821 A Revision of lower eyelid 6.84 9.99 9.15 8.36 7.52 15822 A Revision of upper eyelid 4.62 7.70 7.14 6.28 5.72 15823 A Revision of upper eyelid 8.32 11.43 10.34 9.83 8.76 15824 R Removal of forehead wrinkles 0.00 0.00 0.00 0.00 0.00 15825 R Removal of neck wrinkles 0.00 0.00 0.00 0.00 0.00 15826 R Removal of brow wrinkles 0.00 0.00 0.00 0.00 0.00 
CMS-1503-P 819

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

15828 R Removal of face wrinkles 0.00 0.00 0.00 0.00 0.00 15829 R Removal of skin wrinkles 0.00 0.00 0.00 0.00 0.00 15830 R Exc skin abd 17.11 NA NA 14.87 13.55 15832 A Excise excessive skin tissue 12.85 NA NA 13.05 11.52 15833 A Excise excessive skin tissue 11.90 NA NA 11.37 10.57 15834 A Excise excessive skin tissue 12.17 NA NA 12.57 10.90 15835 A Excise excessive skin tissue 12.99 NA NA 13.12 11.40 15836 A Excise excessive skin tissue 10.61 NA NA 8.39 8.37 15837 A Excise excessive skin tissue 9.55 14.13 12.35 9.79 8.73 15838 A Excise excessive skin tissue 8.25 NA NA 7.99 7.47 15839 A Excise excessive skin tissue 10.50 13.21 12.50 9.34 8.73 15840 A Graft for face nerve palsy 14.99 NA NA 13.60 12.49 15841 A Graft for face nerve palsy 25.99 NA NA 22.37 19.96 15842 A Flap for face nerve palsy 41.01 NA NA 28.66 27.73 15845 A Skin and muscle repair, face 14.32 NA NA 14.18 12.48 15847 C Exc skin abd add-on 0.00 0.00 0.00 0.00 0.00 15850 B Removal of sutures 0.78 1.58 1.65 0.34 0.33 15851 A Removal of sutures 0.86 1.80 1.74 0.41 0.36 15852 A Dressing change not for burn 0.86 NA NA 0.41 0.38 15860 A Test for blood flow in graft 1.95 NA NA 0.89 0.88 15876 R Suction assisted lipectomy 0.00 0.00 0.00 0.00 0.00 15877 R Suction assisted lipectomy 0.00 0.00 0.00 0.00 0.00 15878 R Suction assisted lipectomy 0.00 0.00 0.00 0.00 0.00 15879 R Suction assisted lipectomy 0.00 0.00 0.00 0.00 0.00 15920 A Removal of tail bone ulcer 8.29 NA NA 8.05 7.41 15922 A Removal of tail bone ulcer 10.38 NA NA 11.36 10.02 
CMS-1503-P 820

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

15931 A Remove sacrum pressure sore 10.07 NA NA 7.92 7.37 15933 A Remove sacrum pressure sore 11.77 NA NA 10.75 9.99 15934 A Remove sacrum pressure sore 13.68 NA NA 11.35 10.41 15935 A Remove sacrum pressure sore 15.78 NA NA 13.78 12.86 15936 A Remove sacrum pressure sore 13.16 NA NA 10.95 10.10 15937 A Remove sacrum pressure sore 15.14 NA NA 13.17 12.15 15940 A Remove hip pressure sore 10.20 NA NA 8.51 7.83 15941 A Remove hip pressure sore 12.41 NA NA 11.91 11.17 15944 A Remove hip pressure sore 12.44 NA NA 11.96 10.98 15945 A Remove hip pressure sore 13.75 NA NA 13.44 12.31 15946 A Remove hip pressure sore 24.12 NA NA 20.59 18.92 15950 A Remove thigh pressure sore 8.03 NA NA 7.26 6.90 15951 A Remove thigh pressure sore 11.58 NA NA 12.86 11.02 15952 A Remove thigh pressure sore 12.31 NA NA 9.39 9.40 15953 A Remove thigh pressure sore 13.57 NA NA 10.31 10.47 15956 A Remove thigh pressure sore 16.79 NA NA 14.67 13.43 15958 A Remove thigh pressure sore 16.75 NA NA 15.43 14.17 15999 C Removal of pressure sore 0.00 0.00 0.00 0.00 0.00 16000 A Initial treatment of burn(s) 0.89 1.00 0.95 0.38 0.33 16020 A Dress/debrid p-thick burn, s 0.80 1.53 1.45 0.80 0.74 16025 A Dress/debrid p-thick burn, m 1.85 2.21 2.09 1.30 1.20 16030 A Dress/debrid p-thick burn, l 2.08 2.81 2.66 1.50 1.38 16035 A Incision of burn scab, initi 3.74 NA NA 1.56 1.60 16036 A Escharotomy; addl incision 1.50 NA NA 0.66 0.64 17000 A Destruct premalg lesion 0.65 1.59 1.57 0.92 0.88 17003 A Destruct premalg les, 2-14 0.07 0.12 0.13 0.05 0.05 
CMS-1503-P 821

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

17004 A Destroy premlg lesions 15+ 1.85 2.85 2.88 1.81 1.79 17106 A Destruction of skin lesions 3.69 5.72 5.65 3.93 3.84 17107 A Destruction of skin lesions 4.79 7.22 7.30 4.85 4.89 17108 A Destruction of skin lesions 7.49 9.88 9.53 6.73 6.54 17110 A Destruct b9 lesion, 1-14 0.70 2.35 2.37 1.25 1.21 17111 A Destruct lesion, 15 or more 0.97 2.65 2.66 1.43 1.38 17250 A Chemical cautery, tissue 0.50 1.65 1.60 0.50 0.48 17260 A Destruction of skin lesions 0.96 1.65 1.65 0.95 0.90 17261 A Destruction of skin lesions 1.22 2.73 2.72 1.35 1.30 17262 A Destruction of skin lesions 1.63 3.15 3.13 1.65 1.57 17263 A Destruction of skin lesions 1.84 3.42 3.40 1.79 1.70 17264 A Destruction of skin lesions 1.99 3.64 3.61 1.87 1.77 17266 A Destruction of skin lesions 2.39 4.00 3.96 2.12 1.99 17270 A Destruction of skin lesions 1.37 2.76 2.72 1.43 1.35 17271 A Destruction of skin lesions 1.54 2.97 2.95 1.58 1.51 17272 A Destruction of skin lesions 1.82 3.33 3.30 1.78 1.70 17273 A Destruction of skin lesions 2.10 3.63 3.60 1.97 1.87 17274 A Destruction of skin lesions 2.64 4.11 4.07 2.31 2.19 17276 A Destruction of skin lesions 3.25 4.56 4.47 2.66 2.51 17280 A Destruction of skin lesions 1.22 2.64 2.62 1.33 1.26 17281 A Destruction of skin lesions 1.77 3.10 3.08 1.74 1.66 17282 A Destruction of skin lesions 2.09 3.57 3.52 1.97 1.87 17283 A Destruction of skin lesions 2.69 4.11 4.05 2.38 2.25 17284 A Destruction of skin lesions 3.26 4.62 4.55 2.74 2.59 17286 A Destruction of skin lesions 4.48 5.47 5.32 3.49 3.30 17311 A Mohs, 1 stage, h/n/hf/g 6.20 11.87 12.34 4.54 4.24 
CMS-1503-P 822

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

17312 A Mohs addl stage 3.30 7.46 7.83 2.41 2.25 17313 A Mohs, 1 stage, t/a/l 5.56 10.92 11.37 4.08 3.81 17314 A Mohs, addl stage, t/a/l 3.06 6.91 7.25 2.24 2.09 17315 A Mohs surg, addl block 0.87 1.32 1.35 0.64 0.60 17340 A Cryotherapy of skin 0.77 0.64 0.57 0.58 0.51 17360 A Skin peel therapy 1.46 2.15 2.14 1.35 1.28 17380 R Hair removal by electrolysis 0.00 0.00 0.00 0.00 0.00 17999 C Skin tissue procedure 0.00 0.00 0.00 0.00 0.00 19000 A Drainage of breast lesion 0.84 2.06 2.19 0.32 0.34 19001 A Drain breast lesion add-on 0.42 0.28 0.30 0.16 0.17 19020 A Incision of breast lesion 3.83 8.70 8.27 4.23 3.90 19030 A Injection for breast x-ray 1.53 2.68 2.99 0.53 0.61 19100 A Bx breast percut w/o image 1.27 2.71 2.60 0.54 0.50 19101 A Biopsy of breast, open 3.23 5.78 5.54 2.57 2.40 19102 A Bx breast percut w/image 2.00 3.55 3.93 0.71 0.79 19103 A Bx breast percut w/device 3.69 10.68 11.60 1.36 1.46 19105 A Cryosurg ablate fa, each 3.69 48.12 54.84 1.58 1.57 19110 A Nipple exploration 4.44 8.57 8.03 4.61 4.22 19112 A Excise breast duct fistula 3.81 8.44 7.95 4.43 4.06 19120 A Removal of breast lesion 5.92 7.03 6.51 4.89 4.47 19125 A Excision, breast lesion 6.69 7.68 7.09 5.31 4.84 19126 A Excision, addl breast lesion 2.93 NA NA 1.26 1.14 19260 A Removal of chest wall lesion 17.78 NA NA 13.92 13.34 19271 A Revision of chest wall 22.19 NA NA 20.51 20.28 19272 A Extensive chest wall surgery 25.17 NA NA 21.62 21.51 19290 A Place needle wire, breast 1.27 2.93 3.20 0.44 0.50 
CMS-1503-P 823

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

19291 A Place needle wire, breast 0.63 1.15 1.27 0.22 0.25 19295 A Place breast clip, percut 0.00 2.34 2.59 NA NA 19296 A Place po breast cath for rad 3.63 106.59 110.18 1.87 1.73 19297 A Place breast cath for rad 1.72 NA NA 0.74 0.68 19298 A Place breast rad tube/caths 6.00 25.46 29.02 3.07 2.90 19300 A Removal of breast tissue 5.31 8.40 8.06 5.45 4.99 19301 A Partical mastectomy 10.13 NA NA 6.92 6.14 19302 A P-mastectomy w/ln removal 13.99 NA NA 9.20 8.43 19303 A Mast, simple, complete 15.85 NA NA 10.52 9.29 19304 A Mast, subq 7.95 NA NA 7.14 6.55 19305 A Mast, radical 17.46 NA NA 12.12 11.02 19306 A Mast, rad, urban type 18.13 NA NA 13.24 11.92 19307 A Mast, mod rad 18.23 NA NA 13.04 11.84 19316 A Suspension of breast 11.09 NA NA 10.03 9.32 19318 A Reduction of large breast 16.03 NA NA 14.65 13.61 19324 A Enlarge breast 6.80 NA NA 6.06 5.75 19325 A Enlarge breast with implant 8.64 NA NA 9.28 8.58 19328 A Removal of breast implant 6.48 NA NA 7.21 6.66 19330 A Removal of implant material 8.54 NA NA 8.94 8.22 19340 A Immediate breast prosthesis 13.99 NA NA 13.86 8.78 19342 A Delayed breast prosthesis 12.63 NA NA 13.05 12.01 19350 A Breast reconstruction 9.11 13.59 13.34 9.55 8.88 19355 A Correct inverted nipple(s) 8.52 9.94 9.94 6.40 6.12 19357 A Breast reconstruction 21.07 NA NA 22.41 20.64 19361 A Breast reconstr w/lat flap 23.36 NA NA 24.02 21.59 19364 A Breast reconstruction 42.58 NA NA 34.17 31.19 
CMS-1503-P 824

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

19366 A Breast reconstruction 21.84 NA NA 15.49 14.15 19367 A Breast reconstruction 26.80 NA NA 22.89 21.08 19368 A Breast reconstruction 33.90 NA NA 27.67 25.16 19369 A Breast reconstruction 31.31 NA NA 25.83 23.22 19370 A Surgery of breast capsule 9.17 NA NA 9.86 9.09 19371 A Removal of breast capsule 10.62 NA NA 11.18 10.31 19380 A Revise breast reconstruction 10.41 NA NA 11.02 10.17 19396 A Design custom breast implant 2.17 5.03 4.34 1.56 1.37 19499 C Breast surgery procedure 0.00 0.00 0.00 0.00 0.00 20000 A Incision of abscess 2.17 3.40 3.35 1.92 1.91 20005 A Incision of deep abscess 3.58 4.89 4.63 2.80 2.67 20100 A Explore wound, neck 10.38 NA NA 5.64 5.04 20101 A Explore wound, chest 3.23 7.72 7.56 2.00 1.94 20102 A Explore wound, abdomen 3.98 9.11 8.79 2.75 2.53 20103 A Explore wound, extremity 5.34 10.39 10.00 4.07 3.85 20150 A Excise epiphyseal bar 14.75 NA NA 12.26 11.04 20200 A Muscle biopsy 1.46 4.02 3.87 1.01 0.95 20205 A Deep muscle biopsy 2.35 5.16 4.89 1.64 1.52 20206 A Needle biopsy, muscle 0.99 5.41 6.02 0.60 0.66 20220 A Bone biopsy, trocar/needle 1.27 2.82 3.32 0.71 0.79 20225 A Bone biopsy, trocar/needle 1.87 12.76 15.44 1.09 1.20 20240 A Bone biopsy, excisional 3.28 NA NA 2.79 2.72 20245 A Bone biopsy, excisional 8.95 NA NA 8.15 7.70 20250 A Open bone biopsy 5.19 NA NA 4.87 4.60 20251 A Open bone biopsy 5.72 NA NA 5.18 5.00 20500 A Injection of sinus tract 1.28 1.62 1.76 1.07 1.17 
CMS-1503-P 825

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

20501 A Inject sinus tract for x-ray 0.76 2.41 2.71 0.26 0.31 

2050F I Wound char size etc docd 0.00 0.00 0.00 0.00 0.00 

20520 A Removal of foreign body 1.90 3.53 3.37 2.05 1.95 20525 A Removal of foreign body 3.54 9.46 9.29 3.18 3.01 20526 A Ther injection, carp tunnel 0.94 1.10 1.07 0.61 0.58 

20550 A Inj tendon sheath/ligament 0.75 0.83 0.81 0.39 0.36 20551 A Inj tendon origin/insertion 0.75 0.89 0.83 0.44 0.40 20552 A Inj trigger point, 1/2 muscl 0.66 0.84 0.79 0.39 0.34 20553 A Inject trigger points, =/> 3 0.75 0.99 0.91 0.44 0.38 20555 A Place ndl musc/tis for rt 6.00 NA NA 2.91 2.86 20600 A Drain/inject, joint/bursa 0.66 0.84 0.82 0.41 0.40 20605 A Drain/inject, joint/bursa 0.68 0.96 0.92 0.45 0.43 

2060F I Pt talk eval hlthwkr re mdd 0.00 0.00 0.00 0.00 0.00 

20610 A Drain/inject, joint/bursa 0.79 1.39 1.32 0.57 0.54 20612 A Aspirate/inj ganglion cyst 0.70 0.94 0.89 0.45 0.43 20615 A Treatment of bone cyst 2.33 3.67 3.60 2.02 1.95 20650 A Insert and remove bone pin 2.28 3.24 3.08 1.92 1.85 20660 A Apply, rem fixation device 4.00 NA NA 2.18 2.06 20661 A Application of head brace 5.26 NA NA 7.58 7.20 20662 A Application of pelvis brace 6.38 NA NA 4.71 5.55 20663 A Application of thigh brace 5.74 NA NA 6.80 6.30 20664 A Halo brace application 10.06 NA NA 10.36 9.92 20665 A Removal of fixation device 1.36 1.64 1.77 1.24 1.27 20670 A Removal of support implant 1.79 8.59 8.96 2.24 2.19 20680 A Removal of support implant 5.96 10.89 10.43 5.61 5.24 20690 A Apply bone fixation device 8.78 NA NA 7.09 6.26 
CMS-1503-P 826

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

20692 A Apply bone fixation device 16.27 NA NA 14.05 12.25 20693 A Adjust bone fixation device 6.06 NA NA 6.23 6.03 20694 A Remove bone fixation device 4.28 7.22 7.09 4.88 4.67 20696 A Comp multiplane ext fixation 17.56 NA NA 15.12 12.38 20697 A Comp ext fixate strut change 0.00 56.39 48.20 NA NA 20802 A Replantation, arm, complete 42.62 NA NA 22.68 21.70 20805 A Replant forearm, complete 51.46 NA NA 17.56 21.78 20808 A Replantation hand, complete 63.09 NA NA 49.13 46.17 20816 A Replantation digit, complete 31.95 NA NA 26.30 26.63 20822 A Replantation digit, complete 26.66 NA NA 23.70 23.46 20824 A Replantation thumb, complete 31.95 NA NA 23.54 25.07 20827 A Replantation thumb, complete 27.48 NA NA 24.28 24.62 20838 A Replantation foot, complete 42.88 NA NA 23.08 23.21 20900 A Removal of bone for graft 3.00 8.40 8.30 2.71 3.18 20902 A Removal of bone for graft 4.58 NA NA 3.66 4.08 20910 A Remove cartilage for graft 5.53 NA NA 6.14 6.02 20912 A Remove cartilage for graft 6.54 NA NA 7.07 6.67 20920 A Removal of fascia for graft 5.51 NA NA 5.74 5.47 20922 A Removal of fascia for graft 6.93 8.79 9.08 6.08 6.15 20924 A Removal of tendon for graft 6.68 NA NA 7.03 6.72 20926 A Removal of tissue for graft 5.79 NA NA 5.85 5.70 20930 B Sp bone algrft morsel add-on 0.00 0.00 0.00 0.00 0.00 20931 A Sp bone algrft struct add-on 1.81 NA NA 1.00 0.97 20936 B Sp bone agrft local add-on 0.00 0.00 0.00 0.00 0.00 20937 A Sp bone agrft morsel add-on 2.79 NA NA 1.58 1.53 20938 A Sp bone agrft struct add-on 3.02 NA NA 1.70 1.64 
CMS-1503-P 827

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

20950 A Fluid pressure, muscle 1.26 5.47 5.55 1.19 1.14 20955 A Fibula bone graft, microvasc 40.26 NA NA 30.36 28.00 20956 A Iliac bone graft, microvasc 41.18 NA NA 29.90 28.07 20957 A Mt bone graft, microvasc 42.61 NA NA 27.65 24.20 20962 A Other bone graft, microvasc 39.21 NA NA 32.35 29.73 20969 A Bone/skin graft, microvasc 45.43 NA NA 33.09 30.51 20970 A Bone/skin graft, iliac crest 44.58 NA NA 30.61 29.27 20972 A Bone/skin graft, metatarsal 44.51 NA NA 23.39 22.38 20973 A Bone/skin graft, great toe 47.27 NA NA 33.77 27.80 20974 A Electrical bone stimulation 0.62 1.39 1.26 0.70 0.66 20975 A Electrical bone stimulation 2.60 NA NA 2.04 1.97 20979 A Us bone stimulation 0.62 0.82 0.80 0.28 0.29 20982 A Ablate, bone tumor(s) perq 7.27 85.61 94.84 2.92 3.21 20985 A Cptr-asst dir ms px 2.50 NA NA 1.46 1.37 20999 C Musculoskeletal surgery 0.00 0.00 0.00 0.00 0.00 21010 A Incision of jaw joint 11.04 NA NA 9.31 8.59 21011 A Exc face les sc < 2 cm 2.99 6.10 6.10 3.85 3.85 21012 A Exc face les sc = 2 cm 4.45 NA NA 4.91 4.91 21013 A Exc face tum deep < 2 cm 5.42 8.52 8.52 5.52 5.52 21014 A Exc face tum deep = 2 cm 7.13 NA NA 7.30 7.30 21015 A Resect face tum < 2 cm 9.89 NA NA 9.32 7.43 21016 A Resect face tum = 2 cm 15.26 NA NA 12.82 12.82 21025 A Excision of bone, lower jaw 10.03 14.85 14.13 11.07 10.29 21026 A Excision of facial bone(s) 5.70 11.48 10.89 8.23 7.76 21029 A Contour of face bone lesion 8.39 12.93 12.22 9.37 8.74 21030 A Excise max/zygoma b9 tumor 4.91 9.50 8.94 6.73 6.26 
CMS-1503-P 828

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

21031 A Remove exostosis, mandible 3.30 7.64 7.29 4.96 4.63 21032 A Remove exostosis, maxilla 3.34 7.81 7.44 4.85 4.50 21034 A Excise max/zygoma mlg tumor 17.38 20.12 18.87 15.69 14.48 21040 A Excise mandible lesion 4.91 9.63 9.07 6.81 6.27 21044 A Removal of jaw bone lesion 12.80 NA NA 12.11 11.23 21045 A Extensive jaw surgery 18.37 NA NA 16.33 15.06 21046 A Remove mandible cyst complex 14.21 NA NA 17.08 15.71 21047 A Excise lwr jaw cyst w/repair 20.07 NA NA 16.88 15.33 21048 A Remove maxilla cyst complex 14.71 NA NA 17.45 15.84 21049 A Excis uppr jaw cyst w/repair 19.32 NA NA 15.42 14.62 21050 A Removal of jaw joint 11.76 NA NA 12.14 11.52 21060 A Remove jaw joint cartilage 11.07 NA NA 11.95 10.71 21070 A Remove coronoid process 8.62 NA NA 8.89 8.46 21073 A Mnpj of tmj w/anesth 3.45 7.50 7.01 3.63 3.22 21076 A Prepare face/oral prosthesis 13.40 13.89 12.60 10.30 8.97 21077 A Prepare face/oral prosthesis 33.70 33.11 30.23 26.05 22.98 21079 A Prepare face/oral prosthesis 22.31 23.73 21.66 17.40 15.24 21080 A Prepare face/oral prosthesis 25.06 26.92 24.69 19.26 16.93 21081 A Prepare face/oral prosthesis 22.85 24.80 22.75 17.55 15.48 21082 A Prepare face/oral prosthesis 20.84 24.27 21.98 17.25 14.99 21083 A Prepare face/oral prosthesis 19.27 23.63 21.52 16.10 13.96 21084 A Prepare face/oral prosthesis 22.48 26.71 24.52 18.45 16.19 21085 A Prepare face/oral prosthesis 8.99 10.82 9.84 7.11 6.26 21086 A Prepare face/oral prosthesis 24.88 23.80 21.55 19.03 16.55 21087 A Prepare face/oral prosthesis 24.88 23.51 21.41 18.67 16.40 21088 C Prepare face/oral prosthesis 0.00 0.00 0.00 0.00 0.00 
CMS-1503-P 829

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

21089 C Prepare face/oral prosthesis 0.00 0.00 0.00 0.00 0.00 21100 A Maxillofacial fixation 4.73 11.55 13.39 4.59 5.35 21110 A Interdental fixation 5.99 16.37 15.46 12.81 12.04 21116 A Injection, jaw joint x-ray 0.81 3.24 3.34 0.37 0.34 21120 A Reconstruction of chin 5.10 12.68 12.28 9.22 8.75 21121 A Reconstruction of chin 7.81 14.78 13.83 11.02 10.28 21122 A Reconstruction of chin 8.71 NA NA 11.47 10.90 21123 A Reconstruction of chin 11.34 NA NA 15.27 13.20 21125 A Augmentation, lower jaw bone 10.80 72.64 74.63 11.26 10.12 21127 A Augmentation, lower jaw bone 12.44 94.29 92.85 12.98 11.64 21137 A Reduction of forehead 10.24 NA NA 9.01 8.70 21138 A Reduction of forehead 12.87 NA NA 12.36 11.33 21139 A Reduction of forehead 15.02 NA NA 10.82 11.11 21141 A Reconstruct midface, lefort 19.57 NA NA 17.94 16.76 21142 A Reconstruct midface, lefort 20.28 NA NA 18.28 16.23 21143 A Reconstruct midface, lefort 21.05 NA NA 20.66 18.02 21145 A Reconstruct midface, lefort 23.94 NA NA 20.09 18.00 21146 A Reconstruct midface, lefort 24.87 NA NA 22.78 20.31 21147 A Reconstruct midface, lefort 26.47 NA NA 20.46 19.39 21150 A Reconstruct midface, lefort 25.96 NA NA 22.17 20.00 21151 A Reconstruct midface, lefort 29.02 NA NA 23.91 24.50 21154 A Reconstruct midface, lefort 31.29 NA NA 30.79 26.84 21155 A Reconstruct midface, lefort 35.22 NA NA 27.89 25.49 21159 A Reconstruct midface, lefort 43.14 NA NA 39.22 33.18 21160 A Reconstruct midface, lefort 47.19 NA NA 28.17 27.96 21172 A Reconstruct orbit/forehead 28.20 NA NA 24.01 20.66 
CMS-1503-P 830

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

21175 A Reconstruct orbit/forehead 33.56 NA NA 28.35 24.71 21179 A Reconstruct entire forehead 22.65 NA NA 19.85 17.58 21180 A Reconstruct entire forehead 25.58 NA NA 22.03 19.77 21181 A Contour cranial bone lesion 10.28 NA NA 10.40 9.21 21182 A Reconstruct cranial bone 32.58 NA NA 22.12 21.33 21183 A Reconstruct cranial bone 35.70 NA NA 23.92 23.36 21184 A Reconstruct cranial bone 38.62 NA NA 30.69 26.90 21188 A Reconstruction of midface 23.15 NA NA 21.65 20.91 21193 A Reconst lwr jaw w/o graft 18.90 NA NA 16.31 14.79 21194 A Reconst lwr jaw w/graft 21.82 NA NA 17.13 16.20 21195 A Reconst lwr jaw w/o fixation 19.16 NA NA 18.91 17.59 21196 A Reconst lwr jaw w/fixation 20.83 NA NA 21.42 19.48 21198 A Reconstr lwr jaw segment 15.71 NA NA 17.19 16.00 21199 A Reconstr lwr jaw w/advance 16.73 NA NA 12.01 11.03 21206 A Reconstruct upper jaw bone 15.59 NA NA 19.16 16.85 21208 A Augmentation of facial bones 11.42 40.02 38.42 11.19 10.84 21209 A Reduction of facial bones 7.82 15.39 14.86 10.48 9.87 21210 A Face bone graft 11.69 51.85 49.16 12.63 11.31 21215 A Lower jaw bone graft 12.23 99.07 93.97 12.88 11.55 21230 A Rib cartilage graft 11.17 NA NA 10.04 9.38 21235 A Ear cartilage graft 7.50 13.01 12.58 8.58 8.12 21240 A Reconstruction of jaw joint 16.07 NA NA 15.34 13.97 21242 A Reconstruction of jaw joint 14.59 NA NA 14.01 12.96 21243 A Reconstruction of jaw joint 24.53 NA NA 22.87 20.76 21244 A Reconstruction of lower jaw 13.62 NA NA 16.43 15.34 21245 A Reconstruction of jaw 13.12 18.58 17.97 12.21 11.65 
CMS-1503-P 831

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

21246 A Reconstruction of jaw 12.92 NA NA 10.52 9.87 21247 A Reconstruct lower jaw bone 24.37 NA NA 19.26 18.40 21248 A Reconstruction of jaw 12.74 18.47 16.99 12.85 11.47 21249 A Reconstruction of jaw 18.77 23.91 21.84 17.57 15.35 21255 A Reconstruct lower jaw bone 18.46 NA NA 19.29 19.42 21256 A Reconstruction of orbit 17.66 NA NA 16.58 14.83 21260 A Revise eye sockets 17.90 NA NA 21.40 19.56 21261 A Revise eye sockets 34.07 NA NA 23.21 23.84 21263 A Revise eye sockets 31.01 NA NA 21.88 21.94 21267 A Revise eye sockets 20.69 NA NA 24.09 22.30 21268 A Revise eye sockets 27.07 NA NA 20.18 21.31 21270 A Augmentation, cheek bone 10.63 16.83 15.31 10.35 9.07 21275 A Revision, orbitofacial bones 11.76 NA NA 11.64 10.42 21280 A Revision of eyelid 7.13 NA NA 8.85 7.93 21282 A Revision of eyelid 4.27 NA NA 6.30 5.76 21295 A Revision of jaw muscle/bone 1.90 NA NA 2.84 2.86 21296 A Revision of jaw muscle/bone 4.78 NA NA 5.81 6.27 21299 C Cranio/maxillofacial surgery 0.00 0.00 0.00 0.00 0.00 21310 A Treatment of nose fracture 0.58 2.65 2.53 0.16 0.15 21315 A Treatment of nose fracture 1.83 5.88 5.66 2.39 2.27 21320 A Treatment of nose fracture 1.88 5.37 5.19 1.95 1.84 21325 A Treatment of nose fracture 4.18 NA NA 8.94 8.86 21330 A Treatment of nose fracture 5.79 NA NA 10.30 10.04 21335 A Treatment of nose fracture 9.02 NA NA 11.56 11.12 21336 A Treat nasal septal fracture 6.77 NA NA 11.63 11.17 21337 A Treat nasal septal fracture 3.39 7.92 7.64 4.89 4.61 
CMS-1503-P 832

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

21338 A Treat nasoethmoid fracture 6.87 NA NA 13.99 13.52 21339 A Treat nasoethmoid fracture 8.50 NA NA 13.06 13.25 21340 A Treatment of nose fracture 11.49 NA NA 9.89 9.75 21343 A Treatment of sinus fracture 14.32 NA NA 16.68 16.45 21344 A Treatment of sinus fracture 21.57 NA NA 21.71 19.58 21345 A Treat nose/jaw fracture 9.06 12.77 12.57 8.54 8.37 21346 A Treat nose/jaw fracture 11.45 NA NA 14.43 14.18 21347 A Treat nose/jaw fracture 13.53 NA NA 15.41 15.58 21348 A Treat nose/jaw fracture 17.52 NA NA 16.29 14.18 21355 A Treat cheek bone fracture 4.45 8.32 7.88 5.07 4.64 21356 A Treat cheek bone fracture 4.83 9.10 8.77 5.72 5.41 21360 A Treat cheek bone fracture 7.19 NA NA 7.97 7.37 21365 A Treat cheek bone fracture 16.77 NA NA 14.39 13.13 21366 A Treat cheek bone fracture 18.60 NA NA 17.07 14.84 21385 A Treat eye socket fracture 9.57 NA NA 9.92 9.56 21386 A Treat eye socket fracture 9.57 NA NA 8.26 8.00 21387 A Treat eye socket fracture 10.11 NA NA 10.22 9.80 21390 A Treat eye socket fracture 11.23 NA NA 11.16 10.08 21395 A Treat eye socket fracture 14.70 NA NA 13.51 11.90 21400 A Treat eye socket fracture 1.50 3.71 3.53 2.73 2.58 21401 A Treat eye socket fracture 3.68 9.31 9.29 4.49 4.33 21406 A Treat eye socket fracture 7.42 NA NA 8.57 7.67 21407 A Treat eye socket fracture 9.02 NA NA 9.10 8.36 21408 A Treat eye socket fracture 12.78 NA NA 12.39 11.13 21421 A Treat mouth roof fracture 6.02 14.95 14.41 11.73 11.24 21422 A Treat mouth roof fracture 8.73 NA NA 10.07 9.46 
CMS-1503-P 833

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

21423 A Treat mouth roof fracture 10.85 NA NA 12.18 11.03 21431 A Treat craniofacial fracture 7.90 NA NA 12.20 12.12 21432 A Treat craniofacial fracture 8.82 NA NA 11.13 9.96 21433 A Treat craniofacial fracture 26.29 NA NA 18.47 17.97 21435 A Treat craniofacial fracture 20.26 NA NA 15.80 15.24 21436 A Treat craniofacial fracture 30.30 NA NA 26.90 23.86 21440 A Treat dental ridge fracture 3.44 12.29 11.82 9.38 9.05 21445 A Treat dental ridge fracture 6.26 15.23 14.74 11.29 10.84 21450 A Treat lower jaw fracture 3.71 12.98 12.35 9.71 9.38 21451 A Treat lower jaw fracture 5.65 16.18 15.28 12.39 11.79 21452 A Treat lower jaw fracture 2.40 15.93 15.32 8.36 7.61 21453 A Treat lower jaw fracture 6.64 18.78 17.66 15.19 14.47 21454 A Treat lower jaw fracture 7.36 NA NA 8.60 7.90 21461 A Treat lower jaw fracture 9.31 50.62 47.65 17.16 16.34 21462 A Treat lower jaw fracture 11.01 52.11 49.52 18.36 17.26 21465 A Treat lower jaw fracture 13.12 NA NA 13.50 12.06 21470 A Treat lower jaw fracture 17.54 NA NA 16.37 14.84 21480 A Reset dislocated jaw 0.61 1.96 1.93 0.26 0.24 21485 A Reset dislocated jaw 4.77 14.95 14.11 11.70 11.08 21490 A Repair dislocated jaw 12.95 NA NA 12.67 11.74 21495 A Treat hyoid bone fracture 6.79 NA NA 13.46 12.72 21497 A Interdental wiring 4.64 14.40 14.01 11.46 11.14 21499 C Head surgery procedure 0.00 0.00 0.00 0.00 0.00 21501 A Drain neck/chest lesion 3.98 8.43 8.13 4.77 4.57 21502 A Drain chest lesion 7.55 NA NA 5.60 5.75 21510 A Drainage of bone lesion 6.20 NA NA 6.23 6.06 
CMS-1503-P 834

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

21550 A Biopsy of neck/chest 2.11 5.05 4.98 2.23 2.18 21552 A Exc neck les sc = 3 cm 6.49 NA NA 5.53 5.53 21554 A Exc neck tum deep = 5 cm 11.13 NA NA 8.61 8.61 21555 A Exc neck les sc < 3 cm 3.96 7.29 7.10 4.29 4.20 21556 A Exc neck tum deep < 5 cm 7.66 NA NA 6.78 5.92 21557 A Resect neck tum < 5 cm 14.75 NA NA 11.17 8.53 21558 A Resect neck tum = 5 cm 21.58 NA NA 14.95 14.95 21600 A Partial removal of rib 7.26 NA NA 7.93 7.54 21610 A Partial removal of rib 15.91 NA NA 13.75 12.21 21615 A Removal of rib 10.45 NA NA 6.47 6.58 21616 A Removal of rib and nerves 12.69 NA NA 7.06 8.16 21620 A Partial removal of sternum 7.28 NA NA 6.60 6.44 21627 A Sternal debridement 7.30 NA NA 7.21 7.12 21630 A Extensive sternum surgery 19.18 NA NA 14.61 14.00 21632 A Extensive sternum surgery 19.68 NA NA 12.60 12.44 21685 A Hyoid myotomy & suspension 15.26 NA NA 13.20 12.19 21700 A Revision of neck muscle 6.31 NA NA 3.61 4.28 21705 A Revision of neck muscle/rib 9.92 NA NA 4.81 5.68 21720 A Revision of neck muscle 5.80 NA NA 5.72 5.20 21725 A Revision of neck muscle 7.19 NA NA 7.26 6.85 21740 A Reconstruction of sternum 17.57 NA NA 9.15 9.60 21742 C Repair stern/nuss w/o scope 0.00 0.00 0.00 0.00 0.00 21743 C Repair sternum/nuss w/scope 0.00 0.00 0.00 0.00 0.00 21750 A Repair of sternum separation 11.40 NA NA 6.54 6.73 21800 A Treatment of rib fracture 1.01 1.86 1.74 1.95 1.81 21805 A Treatment of rib fracture 2.88 NA NA 4.12 4.06 
CMS-1503-P 835

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

21810 A Treatment of rib fracture(s) 7.03 NA NA 7.13 6.52 21820 A Treat sternum fracture 1.36 2.43 2.27 2.51 2.34 21825 A Treat sternum fracture 7.76 NA NA 6.97 6.95 21899 C Neck/chest surgery procedure 0.00 0.00 0.00 0.00 0.00 21920 A Biopsy soft tissue of back 2.11 5.01 4.96 2.35 2.25 21925 A Biopsy soft tissue of back 4.63 7.19 6.81 4.73 4.40 21930 A Exc back les sc < 3 cm 4.94 7.63 7.41 4.69 4.59 21931 A Exc back les sc = 3 cm 6.88 NA NA 5.60 5.60 21932 A Exc back tum deep < 5 cm 9.82 NA NA 7.89 7.89 21933 A Exc back tum deep = 5 cm 11.13 NA NA 8.35 8.35 21935 A Resect back tum < 5 cm 15.72 NA NA 11.50 11.19 21936 A Resect back tum = 5 cm 22.55 NA NA 15.22 15.22 22010 A I&d, p-spine, c/t/cerv-thor 12.75 NA NA 11.74 11.11 22015 A I&d, p-spine, l/s/ls 12.64 NA NA 11.51 10.99 22100 A Remove part of neck vertebra 11.00 NA NA 11.05 10.37 22101 A Remove part, thorax vertebra 11.08 NA NA 9.83 9.76 22102 A Remove part, lumbar vertebra 11.08 NA NA 10.55 10.09 22103 A Remove extra spine segment 2.34 NA NA 1.34 1.29 22110 A Remove part of neck vertebra 14.00 NA NA 12.78 12.13 22112 A Remove part, thorax vertebra 14.07 NA NA 12.60 11.61 22114 A Remove part, lumbar vertebra 14.07 NA NA 12.50 11.89 22116 A Remove extra spine segment 2.32 NA NA 1.30 1.24 22206 A Cut spine 3 col, thor 37.18 NA NA 25.80 24.14 22207 A Cut spine 3 col, lumb 36.68 NA NA 25.50 23.89 22208 A Cut spine 3 col, addl seg 9.66 NA NA 5.49 5.15 22210 A Revision of neck spine 25.38 NA NA 20.23 19.28 
CMS-1503-P 836

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

22212 A Revision of thorax spine 20.99 NA NA 17.57 16.64 22214 A Revision of lumbar spine 21.02 NA NA 17.53 16.74 22216 A Revise, extra spine segment 6.03 NA NA 3.43 3.32 22220 A Revision of neck spine 22.94 NA NA 18.58 17.44 22222 A Revision of thorax spine 23.09 NA NA 18.85 15.77 22224 A Revision of lumbar spine 23.09 NA NA 18.42 17.38 22226 A Revise, extra spine segment 6.03 NA NA 3.40 3.28 22305 A Treat spine process fracture 2.13 2.99 2.82 2.53 2.38 22310 A Treat spine fracture 3.89 4.26 3.93 3.62 3.33 22315 A Treat spine fracture 10.11 13.22 12.52 10.21 9.61 22318 A Treat odontoid fx w/o graft 22.72 NA NA 17.85 17.05 22319 A Treat odontoid fx w/graft 25.33 NA NA 19.66 18.43 22325 A Treat spine fracture 19.87 NA NA 16.75 15.88 22326 A Treat neck spine fracture 20.84 NA NA 16.75 15.92 22327 A Treat thorax spine fracture 20.77 NA NA 17.49 16.37 22328 A Treat each add spine fx 4.60 NA NA 2.56 2.47 22505 A Manipulation of spine 1.87 NA NA 1.40 1.28 22520 A Percut vertebroplasty thor 9.22 51.31 54.01 4.59 4.99 22521 A Percut vertebroplasty lumb 8.65 51.12 53.41 4.41 4.78 22522 A Percut vertebroplasty addl 4.30 NA NA 1.81 1.91 22523 A Percut kyphoplasty, thor 9.26 NA NA 5.93 6.06 22524 A Percut kyphoplasty, lumbar 8.86 NA NA 5.78 5.88 22525 A Percut kyphoplasty, add-on 4.47 NA NA 2.26 2.29 22526 N Idet, single level 6.10 57.67 53.91 3.43 2.87 22527 N Idet, 1 or more levels 3.03 49.50 45.38 1.31 1.00 22532 A Lat thorax spine fusion 25.99 NA NA 19.41 18.40 
CMS-1503-P 837

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

22533 A Lat lumbar spine fusion 24.79 NA NA 18.77 17.78 22534 A Lat thor/lumb, addl seg 5.99 NA NA 3.35 3.24 22548 A Neck spine fusion 27.06 NA NA 21.32 19.89 22554 A Neck spine fusion 17.69 NA NA 14.35 13.96 22556 A Thorax spine fusion 24.70 NA NA 18.20 17.38 22558 A Lumbar spine fusion 23.53 NA NA 16.79 15.85 22585 A Additional spinal fusion 5.52 NA NA 3.03 2.93 22590 A Spine & skull spinal fusion 21.76 NA NA 17.81 16.99 22595 A Neck spinal fusion 20.64 NA NA 17.13 16.32 22600 A Neck spine fusion 17.40 NA NA 15.16 14.44 22610 A Thorax spine fusion 17.28 NA NA 14.97 14.26 22612 A Lumbar spine fusion 23.53 NA NA 17.61 16.84 22614 A Spine fusion, extra segment 6.43 NA NA 3.61 3.50 22630 A Lumbar spine fusion 22.09 NA NA 17.25 16.53 22632 A Spine fusion, extra segment 5.22 NA NA 2.92 2.82 22800 A Fusion of spine 19.50 NA NA 15.68 15.03 22802 A Fusion of spine 32.11 NA NA 23.08 22.14 22804 A Fusion of spine 37.50 NA NA 26.26 25.16 22808 A Fusion of spine 27.51 NA NA 19.76 18.93 22810 A Fusion of spine 31.50 NA NA 21.22 20.33 22812 A Fusion of spine 34.25 NA NA 25.20 23.54 22818 A Kyphectomy, 1-2 segments 34.33 NA NA 24.29 22.76 22819 A Kyphectomy, 3 or more 39.38 NA NA 28.06 26.29 22830 A Exploration of spinal fusion 11.22 NA NA 9.74 9.36 22840 A Insert spine fixation device 12.52 NA NA 7.00 6.79 22841 B Insert spine fixation device 0.00 0.00 0.00 0.00 0.00 
CMS-1503-P 838

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

22842 A Insert spine fixation device 12.56 NA NA 7.04 6.83 22843 A Insert spine fixation device 13.44 NA NA 7.60 7.30 22844 A Insert spine fixation device 16.42 NA NA 9.40 9.15 22845 A Insert spine fixation device 11.94 NA NA 6.61 6.39 22846 A Insert spine fixation device 12.40 NA NA 6.87 6.64 22847 A Insert spine fixation device 13.78 NA NA 7.55 7.36 22848 A Insert pelv fixation device 5.99 NA NA 3.43 3.34 22849 A Reinsert spinal fixation 19.17 NA NA 14.30 13.73 22850 A Remove spine fixation device 9.82 NA NA 8.77 8.42 22851 A Apply spine prosth device 6.70 NA NA 3.74 3.60 22852 A Remove spine fixation device 9.37 NA NA 8.51 8.15 22855 A Remove spine fixation device 15.86 NA NA 12.49 11.97 22856 A Cerv artific diskectomy 24.05 NA NA 17.70 17.07 22857 R Lumbar artif diskectomy 27.13 NA NA 15.92 16.24 22861 A Revise cerv artific disc 33.36 NA NA 17.11 16.72 22862 R Revise lumbar artif disc 32.63 NA NA 17.28 16.91 22864 A Remove cerv artif disc 29.40 NA NA 21.23 18.01 22865 R Remove lumb artif disc 31.75 NA NA 20.60 21.27 22899 C Spine surgery procedure 0.00 0.00 0.00 0.00 0.00 22900 A Exc back tum deep < 5 cm 8.32 NA NA 6.49 5.37 22901 A Exc back tum deep = 5 cm 10.11 NA NA 7.26 7.26 22902 A Exc abd les sc < 3 cm 4.42 7.55 7.55 4.82 4.82 22903 A Exc abd les sc > 3 cm 6.39 NA NA 5.45 5.45 22904 A Resect abd tum < 5 cm 16.69 NA NA 10.14 10.14 22905 A Resect abd tum > 5 cm 21.58 NA NA 13.45 13.45 22999 C Abdomen surgery procedure 0.00 0.00 0.00 0.00 0.00 
CMS-1503-P 839

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

23000 A Removal of calcium deposits 4.48 11.06 10.41 5.44 5.12 23020 A Release shoulder joint 9.36 NA NA 9.01 8.66 23030 A Drain shoulder lesion 3.47 8.37 8.11 3.38 3.24 23031 A Drain shoulder bursa 2.79 8.45 8.07 3.03 2.86 23035 A Drain shoulder bone lesion 9.16 NA NA 8.97 8.71 23040 A Exploratory shoulder surgery 9.75 NA NA 9.50 9.08 23044 A Exploratory shoulder surgery 7.59 NA NA 7.64 7.36 23065 A Biopsy shoulder tissues 2.30 3.61 3.51 2.30 2.18 23066 A Biopsy shoulder tissues 4.30 10.25 9.75 5.03 4.76 23071 A Exc shoulder les sc > 3 cm 5.91 NA NA 5.25 5.25 23073 A Exc shoulder tum deep > 5 cm 10.13 NA NA 8.33 8.33 23075 A Exc shoulder les sc < 3 cm 4.21 8.30 6.38 4.44 3.29 23076 A Exc shoulder tum deep < 5 cm 7.41 NA NA 6.87 6.71 23077 A Resect shoulder tum < 5 cm 17.66 NA NA 12.90 12.46 23078 A Resect shoulder tum > 5 cm 22.55 NA NA 13.86 13.86 23100 A Biopsy of shoulder joint 6.20 NA NA 7.18 6.77 23101 A Shoulder joint surgery 5.72 NA NA 6.28 6.05 23105 A Remove shoulder joint lining 8.48 NA NA 8.55 8.20 23106 A Incision of collarbone joint 6.13 NA NA 7.14 6.64 23107 A Explore treat shoulder joint 8.87 NA NA 8.80 8.43 23120 A Partial removal, collar bone 7.39 NA NA 8.23 7.83 23125 A Removal of collar bone 9.64 NA NA 9.33 8.81 23130 A Remove shoulder bone, part 7.77 NA NA 8.53 8.15 23140 A Removal of bone lesion 7.12 NA NA 6.86 6.44 23145 A Removal of bone lesion 9.40 NA NA 9.19 8.74 23146 A Removal of bone lesion 8.08 NA NA 8.52 7.91 
CMS-1503-P 840

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

23150 A Removal of humerus lesion 8.91 NA NA 8.68 8.30 23155 A Removal of humerus lesion 10.86 NA NA 10.36 9.85 23156 A Removal of humerus lesion 9.11 NA NA 9.02 8.56 23170 A Remove collar bone lesion 7.21 NA NA 7.77 7.07 23172 A Remove shoulder blade lesion 7.31 NA NA 7.83 7.29 23174 A Remove humerus lesion 10.05 NA NA 10.24 9.76 23180 A Remove collar bone lesion 8.99 NA NA 8.90 8.77 23182 A Remove shoulder blade lesion 8.61 NA NA 9.15 8.82 23184 A Remove humerus lesion 9.90 NA NA 9.74 9.50 23190 A Partial removal of scapula 7.47 NA NA 7.81 7.32 23195 A Removal of head of humerus 10.36 NA NA 9.86 9.35 23200 A Resect clavicle tumor 22.71 NA NA 17.96 13.89 23210 A Resect scapula tumor 27.21 NA NA 20.59 15.51 23220 A Resect prox humerus tumor 30.21 NA NA 22.03 16.93 23330 A Remove shoulder foreign body 1.90 4.42 4.27 2.13 2.05 23331 A Remove shoulder foreign body 7.63 NA NA 8.19 7.83 23332 A Remove shoulder foreign body 12.37 NA NA 11.23 10.75 23350 A Injection for shoulder x-ray 1.00 2.85 3.17 0.38 0.41 23395 A Muscle transfer,shoulder/arm 18.54 NA NA 15.88 15.15 23397 A Muscle transfers 16.76 NA NA 13.81 13.17 23400 A Fixation of shoulder blade 13.87 NA NA 12.12 11.59 23405 A Incision of tendon & muscle 8.54 NA NA 8.20 7.91 23406 A Incise tendon(s) & muscle(s) 11.01 NA NA 9.77 9.40 23410 A Repair rotator cuff, acute 11.39 NA NA 10.59 10.22 23412 A Repair rotator cuff, chronic 11.93 NA NA 10.90 10.56 23415 A Release of shoulder ligament 9.23 NA NA 9.39 8.99 
CMS-1503-P 841

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

23420 A Repair of shoulder 13.54 NA NA 12.41 11.94 23430 A Repair biceps tendon 10.17 NA NA 9.48 9.12 23440 A Remove/transplant tendon 10.64 NA NA 9.54 9.18 23450 A Repair shoulder capsule 13.70 NA NA 11.62 11.10 23455 A Repair shoulder capsule 14.67 NA NA 12.20 11.70 23460 A Repair shoulder capsule 15.82 NA NA 13.37 12.80 23462 A Repair shoulder capsule 15.72 NA NA 12.99 12.37 23465 A Repair shoulder capsule 16.30 NA NA 13.57 12.96 23466 A Repair shoulder capsule 15.80 NA NA 14.16 13.51 23470 A Reconstruct shoulder joint 17.89 NA NA 14.44 13.85 23472 A Reconstruct shoulder joint 22.65 NA NA 17.39 16.62 23480 A Revision of collar bone 11.54 NA NA 10.44 9.94 23485 A Revision of collar bone 13.91 NA NA 11.76 11.26 23490 A Reinforce clavicle 12.16 NA NA 11.93 10.77 23491 A Reinforce shoulder bones 14.54 NA NA 12.56 12.02 23500 A Treat clavicle fracture 2.21 3.57 3.41 3.67 3.44 23505 A Treat clavicle fracture 3.83 5.53 5.26 5.02 4.74 23515 A Treat clavicle fracture 9.69 NA NA 9.84 9.18 23520 A Treat clavicle dislocation 2.29 3.88 3.61 3.97 3.68 23525 A Treat clavicle dislocation 3.79 6.72 5.85 5.68 5.02 23530 A Treat clavicle dislocation 7.48 NA NA 7.82 7.04 23532 A Treat clavicle dislocation 8.20 NA NA 8.49 8.09 23540 A Treat clavicle dislocation 2.36 3.53 3.38 3.62 3.38 23545 A Treat clavicle dislocation 3.43 5.25 4.97 4.45 4.22 23550 A Treat clavicle dislocation 7.59 NA NA 7.67 7.38 23552 A Treat clavicle dislocation 8.82 NA NA 8.81 8.42 
CMS-1503-P 842

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

23570 A Treat shoulder blade fx 2.36 3.80 3.62 3.99 3.76 23575 A Treat shoulder blade fx 4.23 6.47 6.05 5.79 5.39 23585 A Treat scapula fracture 14.23 NA NA 12.09 11.21 23600 A Treat humerus fracture 3.11 5.53 5.29 4.98 4.68 23605 A Treat humerus fracture 5.06 7.37 7.06 6.34 6.04 23615 A Treat humerus fracture 12.30 NA NA 11.42 10.82 23616 A Treat humerus fracture 18.37 NA NA 14.93 14.53 23620 A Treat humerus fracture 2.55 4.63 4.40 4.28 4.02 23625 A Treat humerus fracture 4.10 6.05 5.77 5.35 5.10 23630 A Treat humerus fracture 10.57 NA NA 10.41 9.65 23650 A Treat shoulder dislocation 3.53 4.45 4.24 3.82 3.57 23655 A Treat shoulder dislocation 4.76 NA NA 5.85 5.46 23660 A Treat shoulder dislocation 7.66 NA NA 7.95 7.57 23665 A Treat dislocation/fracture 4.66 6.65 6.34 5.88 5.61 23670 A Treat dislocation/fracture 12.28 NA NA 11.15 10.33 23675 A Treat dislocation/fracture 6.27 8.45 8.01 7.15 6.79 23680 A Treat dislocation/fracture 13.15 NA NA 11.70 10.96 23700 A Fixation of shoulder 2.57 NA NA 2.63 2.52 23800 A Fusion of shoulder joint 14.73 NA NA 12.73 12.13 23802 A Fusion of shoulder joint 18.42 NA NA 15.99 14.79 23900 A Amputation of arm & girdle 20.72 NA NA 16.48 14.67 23920 A Amputation at shoulder joint 16.23 NA NA 13.97 12.62 23921 A Amputation follow-up surgery 5.72 NA NA 6.79 5.61 23929 C Shoulder surgery procedure 0.00 0.00 0.00 0.00 0.00 23930 A Drainage of arm lesion 2.99 6.54 6.48 2.77 2.66 23931 A Drainage of arm bursa 1.84 5.87 5.77 2.46 2.36 
CMS-1503-P 843

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

23935 A Drain arm/elbow bone lesion 6.38 NA NA 7.24 6.81 24000 A Exploratory elbow surgery 6.08 NA NA 6.73 6.39 24006 A Release elbow joint 9.74 NA NA 9.40 8.94 24065 A Biopsy arm/elbow soft tissue 2.13 4.92 4.82 2.50 2.40 24066 A Biopsy arm/elbow soft tissue 5.35 11.17 10.66 5.61 5.23 24071 A Exc arm/elbow les sc = 3 cm 5.70 NA NA 5.20 5.20 24073 A Ex arm/elbow tum deep > 5 cm 10.13 NA NA 8.43 8.43 24075 A Exc arm/elbow les sc < 3 cm 4.24 8.94 8.80 4.56 4.30 24076 A Ex arm/elbow tum deep < 5 cm 7.41 NA NA 7.02 6.36 24077 A Resect arm/elbow tum < 5 cm 15.72 NA NA 11.93 10.30 24079 A Resect arm/elbow tum > 5 cm 20.61 NA NA 13.03 13.03 24100 A Biopsy elbow joint lining 5.07 NA NA 6.09 5.70 24101 A Explore/treat elbow joint 6.30 NA NA 7.13 6.81 24102 A Remove elbow joint lining 8.26 NA NA 8.27 7.86 24105 A Removal of elbow bursa 3.78 NA NA 5.61 5.31 24110 A Remove humerus lesion 7.58 NA NA 8.12 7.73 24115 A Remove/graft bone lesion 10.12 NA NA 9.61 9.06 24116 A Remove/graft bone lesion 12.23 NA NA 10.84 10.31 24120 A Remove elbow lesion 6.82 NA NA 7.37 6.96 24125 A Remove/graft bone lesion 8.14 NA NA 8.45 7.94 24126 A Remove/graft bone lesion 8.62 NA NA 8.73 8.30 24130 A Removal of head of radius 6.42 NA NA 7.22 6.89 24134 A Removal of arm bone lesion 10.22 NA NA 9.77 9.42 24136 A Remove radius bone lesion 8.40 NA NA 8.46 7.60 24138 A Remove elbow bone lesion 8.50 NA NA 9.55 9.07 24140 A Partial removal of arm bone 9.55 NA NA 9.40 9.15 
CMS-1503-P 844

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

24145 A Partial removal of radius 7.81 NA NA 8.01 7.87 24147 A Partial removal of elbow 7.84 NA NA 8.89 8.65 24149 A Radical resection of elbow 16.22 NA NA 15.56 14.56 24150 A Resect distal humerus tumor 23.46 NA NA 18.29 14.66 24152 A Resect radius tumor 19.99 NA NA 16.26 12.43 24155 A Removal of elbow joint 12.09 NA NA 10.75 10.16 24160 A Remove elbow joint implant 8.00 NA NA 8.33 7.92 24164 A Remove radius head implant 6.43 NA NA 6.87 6.58 24200 A Removal of arm foreign body 1.81 3.76 3.61 1.98 1.85 24201 A Removal of arm foreign body 4.70 10.32 10.13 5.11 4.88 24220 A Injection for elbow x-ray 1.31 2.88 3.23 0.55 0.57 24300 A Manipulate elbow w/anesth 4.04 NA NA 7.04 6.71 24301 A Muscle/tendon transfer 10.38 NA NA 9.70 9.30 24305 A Arm tendon lengthening 7.62 NA NA 8.07 7.67 24310 A Revision of arm tendon 6.12 NA NA 6.67 6.37 24320 A Repair of arm tendon 10.86 NA NA 10.03 9.49 24330 A Revision of arm muscles 9.79 NA NA 9.41 8.97 24331 A Revision of arm muscles 10.95 NA NA 10.98 10.13 24332 A Tenolysis, triceps 7.91 NA NA 8.47 8.06 24340 A Repair of biceps tendon 8.08 NA NA 8.35 7.98 24341 A Repair arm tendon/muscle 9.49 NA NA 10.55 9.94 24342 A Repair of ruptured tendon 10.86 NA NA 10.02 9.60 24343 A Repr elbow lat ligmnt w/tiss 9.16 NA NA 9.83 9.40 24344 A Reconstruct elbow lat ligmnt 15.21 NA NA 14.20 13.47 24345 A Repr elbw med ligmnt w/tissu 9.16 NA NA 9.74 9.28 24346 A Reconstruct elbow med ligmnt 15.21 NA NA 14.20 13.51 
CMS-1503-P 845

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

24357 A Repair elbow, perc 5.44 NA NA 6.53 6.27 24358 A Repair elbow w/deb, open 6.66 NA NA 7.45 7.10 24359 A Repair elbow deb/attch open 8.98 NA NA 8.82 8.25 24360 A Reconstruct elbow joint 12.67 NA NA 11.40 10.90 24361 A Reconstruct elbow joint 14.41 NA NA 12.52 12.01 24362 A Reconstruct elbow joint 15.32 NA NA 13.05 12.44 24363 A Replace elbow joint 22.65 NA NA 17.74 16.70 24365 A Reconstruct head of radius 8.62 NA NA 8.47 8.12 24366 A Reconstruct head of radius 9.36 NA NA 8.97 8.56 24400 A Revision of humerus 11.33 NA NA 10.60 10.17 24410 A Revision of humerus 15.11 NA NA 13.19 12.38 24420 A Revision of humerus 13.73 NA NA 12.80 12.21 24430 A Repair of humerus 15.25 NA NA 13.19 12.41 24435 A Repair humerus with graft 14.99 NA NA 13.96 13.21 24470 A Revision of elbow joint 8.93 NA NA 9.01 8.05 24495 A Decompression of forearm 8.41 NA NA 9.07 8.88 24498 A Reinforce humerus 12.28 NA NA 10.88 10.44 24500 A Treat humerus fracture 3.41 6.06 5.78 5.22 4.90 24505 A Treat humerus fracture 5.39 7.95 7.62 6.69 6.39 24515 A Treat humerus fracture 12.12 NA NA 11.37 10.85 24516 A Treat humerus fracture 12.19 NA NA 10.84 10.38 24530 A Treat humerus fracture 3.69 6.45 6.15 5.50 5.18 24535 A Treat humerus fracture 7.11 9.36 8.98 8.12 7.75 24538 A Treat humerus fracture 9.77 NA NA 10.13 9.73 24545 A Treat humerus fracture 13.15 NA NA 11.79 11.06 24546 A Treat humerus fracture 14.91 NA NA 13.00 12.48 
CMS-1503-P 846

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

24560 A Treat humerus fracture 2.98 5.53 5.29 4.65 4.35 24565 A Treat humerus fracture 5.78 8.45 7.83 7.27 6.70 24566 A Treat humerus fracture 9.06 NA NA 10.12 9.62 24575 A Treat humerus fracture 9.71 NA NA 9.93 9.52 24576 A Treat humerus fracture 3.06 6.01 5.71 5.09 4.78 24577 A Treat humerus fracture 6.01 8.65 8.08 7.41 6.87 24579 A Treat humerus fracture 11.44 NA NA 10.97 10.43 24582 A Treat humerus fracture 10.14 NA NA 11.49 10.82 24586 A Treat elbow fracture 15.78 NA NA 13.35 12.78 24587 A Treat elbow fracture 15.79 NA NA 13.50 12.82 24600 A Treat elbow dislocation 4.37 5.11 4.97 4.35 4.13 24605 A Treat elbow dislocation 5.64 NA NA 6.86 6.50 24615 A Treat elbow dislocation 9.83 NA NA 9.30 8.90 24620 A Treat elbow fracture 7.22 NA NA 7.58 7.24 24635 A Treat elbow fracture 8.80 NA NA 9.27 9.80 24640 A Treat elbow dislocation 1.25 2.29 2.08 1.15 1.05 24650 A Treat radius fracture 2.31 4.65 4.44 4.09 3.82 24655 A Treat radius fracture 4.62 6.94 6.70 5.95 5.69 24665 A Treat radius fracture 8.36 NA NA 9.16 8.73 24666 A Treat radius fracture 9.86 NA NA 9.83 9.37 24670 A Treat ulnar fracture 2.69 5.05 4.83 4.30 4.05 24675 A Treat ulnar fracture 4.91 7.28 6.99 6.24 5.96 24685 A Treat ulnar fracture 8.37 NA NA 9.15 8.73 24800 A Fusion of elbow joint 11.41 NA NA 10.78 9.87 24802 A Fusion/graft of elbow joint 14.32 NA NA 12.48 11.85 24900 A Amputation of upper arm 10.18 NA NA 9.42 8.82 
CMS-1503-P 847

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

24920 A Amputation of upper arm 10.13 NA NA 9.47 8.75 24925 A Amputation follow-up surgery 7.30 NA NA 7.81 7.42 24930 A Amputation follow-up surgery 10.83 NA NA 9.88 9.16 24931 A Amputate upper arm & implant 13.44 NA NA 8.26 8.02 24935 A Revision of amputation 16.45 NA NA 7.72 8.55 24940 C Revision of upper arm 0.00 0.00 0.00 0.00 0.00 24999 C Upper arm/elbow surgery 0.00 0.00 0.00 0.00 0.00 25000 A Incision of tendon sheath 3.55 NA NA 5.53 5.62 25001 A Incise flexor carpi radialis 3.79 NA NA 5.55 5.21 25020 A Decompress forearm 1 space 6.06 NA NA 9.64 9.38 25023 A Decompress forearm 1 space 13.83 NA NA 15.83 15.26 25024 A Decompress forearm 2 spaces 10.79 NA NA 10.01 9.53 25025 A Decompress forearm 2 spaces 17.94 NA NA 14.90 13.70 25028 A Drainage of forearm lesion 5.39 NA NA 8.61 8.39 25031 A Drainage of forearm bursa 4.26 NA NA 5.02 5.32 25035 A Treat forearm bone lesion 7.65 NA NA 7.98 8.60 25040 A Explore/treat wrist joint 7.50 NA NA 7.65 7.44 25065 A Biopsy forearm soft tissues 2.04 4.98 4.88 2.51 2.43 25066 A Biopsy forearm soft tissues 4.27 NA NA 5.36 5.50 25071 A Exc forearm les sc > 3 cm 5.91 NA NA 5.59 5.59 25073 A Exc forearm tum deep = 3 cm 7.13 NA NA 7.33 7.33 25075 A Exc forearm les sc < 3 cm 3.96 8.99 6.91 4.55 4.67 25076 A Exc forearm tum deep < 3 cm 6.74 NA NA 7.11 6.88 25077 A Resect forearm/wrist tum<3cm 12.93 NA NA 10.70 10.03 25078 A Resect forearm/wrist tum=3cm 17.69 NA NA 11.77 11.77 25085 A Incision of wrist capsule 5.64 NA NA 6.45 6.43 
CMS-1503-P 848

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

25100 A Biopsy of wrist joint 4.02 NA NA 5.22 5.11 25101 A Explore/treat wrist joint 4.83 NA NA 6.05 5.90 25105 A Remove wrist joint lining 6.02 NA NA 7.01 6.90 25107 A Remove wrist joint cartilage 7.70 NA NA 9.03 8.70 25109 A Excise tendon forearm/wrist 6.94 NA NA 7.65 7.11 25110 A Remove wrist tendon lesion 4.04 NA NA 5.09 5.27 25111 A Remove wrist tendon lesion 3.53 NA NA 5.07 4.90 25112 A Reremove wrist tendon lesion 4.67 NA NA 5.74 5.51 25115 A Remove wrist/forearm lesion 10.09 NA NA 10.57 10.80 25116 A Remove wrist/forearm lesion 7.56 NA NA 8.73 9.18 25118 A Excise wrist tendon sheath 4.51 NA NA 5.82 5.67 25119 A Partial removal of ulna 6.21 NA NA 7.10 7.03 25120 A Removal of forearm lesion 6.27 NA NA 7.14 7.74 25125 A Remove/graft forearm lesion 7.67 NA NA 8.18 8.75 25126 A Remove/graft forearm lesion 7.74 NA NA 8.22 8.74 25130 A Removal of wrist lesion 5.43 NA NA 6.71 6.51 25135 A Remove & graft wrist lesion 7.08 NA NA 7.82 7.65 25136 A Remove & graft wrist lesion 6.14 NA NA 7.03 6.85 25145 A Remove forearm bone lesion 6.54 NA NA 7.27 7.86 25150 A Partial removal of ulna 7.38 NA NA 7.84 7.73 25151 A Partial removal of radius 7.68 NA NA 7.98 8.52 25170 A Resect radius/ulnar tumor 22.21 NA NA 17.45 14.53 25210 A Removal of wrist bone 6.12 NA NA 7.14 6.92 25215 A Removal of wrist bones 8.14 NA NA 8.64 8.45 25230 A Partial removal of radius 5.37 NA NA 6.36 6.17 25240 A Partial removal of ulna 5.31 NA NA 6.29 6.25 
CMS-1503-P 849

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

25246 A Injection for wrist x-ray 1.45 2.81 3.14 0.56 0.60 25248 A Remove forearm foreign body 5.31 NA NA 5.69 5.97 25250 A Removal of wrist prosthesis 6.77 NA NA 7.39 7.06 25251 A Removal of wrist prosthesis 9.82 NA NA 9.42 8.99 25259 A Manipulate wrist w/anesthes 4.04 NA NA 7.12 6.77 25260 A Repair forearm tendon/muscle 8.04 NA NA 9.03 9.44 25263 A Repair forearm tendon/muscle 8.04 NA NA 8.74 9.27 25265 A Repair forearm tendon/muscle 10.10 NA NA 9.92 10.40 25270 A Repair forearm tendon/muscle 6.17 NA NA 7.12 7.68 25272 A Repair forearm tendon/muscle 7.21 NA NA 7.74 8.32 25274 A Repair forearm tendon/muscle 8.94 NA NA 8.92 9.47 25275 A Repair forearm tendon sheath 8.96 NA NA 9.08 8.72 25280 A Revise wrist/forearm tendon 7.39 NA NA 7.89 8.42 25290 A Incise wrist/forearm tendon 5.43 NA NA 6.37 7.51 25295 A Release wrist/forearm tendon 6.72 NA NA 7.47 8.01 25300 A Fusion of tendons at wrist 9.02 NA NA 9.28 8.99 25301 A Fusion of tendons at wrist 8.59 NA NA 8.79 8.49 25310 A Transplant forearm tendon 8.08 NA NA 8.72 9.16 25312 A Transplant forearm tendon 9.82 NA NA 9.60 10.04 25315 A Revise palsy hand tendon(s) 10.68 NA NA 9.93 10.46 25316 A Revise palsy hand tendon(s) 12.90 NA NA 11.55 11.83 25320 A Repair/revise wrist joint 12.75 NA NA 14.11 13.33 25332 A Revise wrist joint 11.74 NA NA 11.08 10.50 25335 A Realignment of hand 13.39 NA NA 8.45 9.86 25337 A Reconstruct ulna/radioulnar 11.73 NA NA 12.49 11.94 25350 A Revision of radius 9.09 NA NA 9.11 9.65 
CMS-1503-P 850

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

25355 A Revision of radius 10.53 NA NA 9.96 10.47 25360 A Revision of ulna 8.74 NA NA 8.81 9.40 25365 A Revise radius & ulna 12.91 NA NA 11.56 11.85 25370 A Revise radius or ulna 14.10 NA NA 12.82 13.05 25375 A Revise radius & ulna 13.55 NA NA 11.93 12.37 25390 A Shorten radius or ulna 10.70 NA NA 10.16 10.57 25391 A Lengthen radius or ulna 14.28 NA NA 12.36 12.69 25392 A Shorten radius & ulna 14.58 NA NA 12.53 12.88 25393 A Lengthen radius & ulna 16.56 NA NA 15.11 14.72 25394 A Repair carpal bone, shorten 10.85 NA NA 10.10 9.62 25400 A Repair radius or ulna 11.28 NA NA 10.39 10.88 25405 A Repair/graft radius or ulna 15.01 NA NA 12.93 13.28 25415 A Repair radius & ulna 13.80 NA NA 12.57 12.88 25420 A Repair/graft radius & ulna 17.04 NA NA 14.22 14.57 25425 A Repair/graft radius or ulna 13.72 NA NA 12.03 13.15 25426 A Repair/graft radius & ulna 16.45 NA NA 13.63 12.88 25430 A Vasc graft into carpal bone 9.71 NA NA 9.84 9.28 25431 A Repair nonunion carpal bone 10.89 NA NA 10.21 9.63 25440 A Repair/graft wrist bone 10.68 NA NA 10.04 9.71 25441 A Reconstruct wrist joint 13.29 NA NA 12.86 11.86 25442 A Reconstruct wrist joint 11.12 NA NA 10.81 10.26 25443 A Reconstruct wrist joint 10.66 NA NA 10.22 9.81 25444 A Reconstruct wrist joint 11.42 NA NA 11.66 10.71 25445 A Reconstruct wrist joint 9.88 NA NA 9.58 9.11 25446 A Wrist replacement 17.30 NA NA 14.58 13.78 25447 A Repair wrist joint(s) 11.14 NA NA 11.30 10.63 
CMS-1503-P 851

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

25449 A Remove wrist joint implant 14.94 NA NA 13.18 12.40 25450 A Revision of wrist joint 8.06 NA NA 5.93 6.70 25455 A Revision of wrist joint 9.71 NA NA 6.86 7.60 25490 A Reinforce radius 9.73 NA NA 8.61 9.34 25491 A Reinforce ulna 10.15 NA NA 9.63 10.16 25492 A Reinforce radius and ulna 12.66 NA NA 11.52 11.86 25500 A Treat fracture of radius 2.60 4.62 4.34 4.03 3.72 25505 A Treat fracture of radius 5.45 7.93 7.61 6.84 6.52 25515 A Treat fracture of radius 8.80 NA NA 9.13 8.71 25520 A Treat fracture of radius 6.50 8.65 8.01 7.87 7.25 25525 A Treat fracture of radius 10.55 NA NA 10.49 10.21 25526 A Treat fracture of radius 13.15 NA NA 12.39 12.32 25530 A Treat fracture of ulna 2.24 4.73 4.51 4.08 3.82 25535 A Treat fracture of ulna 5.36 7.73 7.34 6.78 6.43 25545 A Treat fracture of ulna 7.94 NA NA 8.77 8.43 25560 A Treat fracture radius & ulna 2.59 4.70 4.44 4.02 3.70 25565 A Treat fracture radius & ulna 5.85 8.08 7.76 6.79 6.49 25574 A Treat fracture radius & ulna 8.80 NA NA 9.20 8.73 25575 A Treat fracture radius/ulna 12.29 NA NA 11.82 11.25 25600 A Treat fracture radius/ulna 2.78 5.00 4.78 4.34 4.06 25605 A Treat fracture radius/ulna 7.25 9.41 8.92 8.45 7.98 25606 A Treat fx distal radial 8.31 NA NA 9.45 9.18 25607 A Treat fx rad extra-articul 9.56 NA NA 10.18 9.54 25608 A Treat fx rad intra-articul 11.07 NA NA 11.08 10.38 25609 A Treat fx radial 3+ frag 14.38 NA NA 13.84 12.93 25622 A Treat wrist bone fracture 2.79 5.32 5.05 4.60 4.28 
CMS-1503-P 852

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

25624 A Treat wrist bone fracture 4.77 7.52 7.27 6.42 6.16 25628 A Treat wrist bone fracture 9.67 NA NA 9.77 9.28 25630 A Treat wrist bone fracture 3.03 5.12 4.88 4.46 4.14 25635 A Treat wrist bone fracture 4.61 7.54 7.03 6.48 5.84 25645 A Treat wrist bone fracture 7.42 NA NA 7.78 7.42 25650 A Treat wrist bone fracture 3.23 5.32 5.05 4.79 4.44 25651 A Pin ulnar styloid fracture 5.82 NA NA 7.26 6.83 25652 A Treat fracture ulnar styloid 8.06 NA NA 8.74 8.29 25660 A Treat wrist dislocation 4.98 NA NA 5.78 5.56 25670 A Treat wrist dislocation 8.09 NA NA 8.12 7.82 25671 A Pin radioulnar dislocation 6.46 NA NA 7.80 7.36 25675 A Treat wrist dislocation 4.89 6.64 6.36 5.67 5.40 25676 A Treat wrist dislocation 8.29 NA NA 8.72 8.31 25680 A Treat wrist fracture 6.23 NA NA 6.20 5.84 25685 A Treat wrist fracture 10.09 NA NA 9.58 9.09 25690 A Treat wrist dislocation 5.72 NA NA 7.11 6.64 25695 A Treat wrist dislocation 8.51 NA NA 8.41 8.05 25800 A Fusion of wrist joint 10.07 NA NA 9.70 9.39 25805 A Fusion/graft of wrist joint 11.73 NA NA 10.86 10.59 25810 A Fusion/graft of wrist joint 11.95 NA NA 11.57 11.03 25820 A Fusion of hand bones 7.64 NA NA 8.97 8.60 25825 A Fuse hand bones with graft 9.69 NA NA 10.85 10.36 25830 A Fusion, radioulnar jnt/ulna 10.88 NA NA 14.61 14.32 25900 A Amputation of forearm 9.61 NA NA 9.57 9.77 25905 A Amputation of forearm 9.59 NA NA 9.16 9.38 25907 A Amputation follow-up surgery 8.09 NA NA 8.28 8.57 
CMS-1503-P 853

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

25909 A Amputation follow-up surgery 9.31 NA NA 9.00 9.27 25915 A Amputation of forearm 17.52 NA NA 9.98 12.37 25920 A Amputate hand at wrist 9.03 NA NA 9.59 9.13 25922 A Amputate hand at wrist 7.65 NA NA 6.10 6.71 25924 A Amputation follow-up surgery 8.81 NA NA 7.52 7.99 25927 A Amputation of hand 9.09 NA NA 12.58 12.01 25929 A Amputation follow-up surgery 7.82 NA NA 8.72 7.63 25931 A Amputation follow-up surgery 8.04 NA NA 11.86 11.30 25999 C Forearm or wrist surgery 0.00 0.00 0.00 0.00 0.00 26010 A Drainage of finger abscess 1.59 5.37 5.34 2.11 1.99 26011 A Drainage of finger abscess 2.24 8.29 8.27 2.77 2.64 26020 A Drain hand tendon sheath 5.08 NA NA 6.68 6.32 26025 A Drainage of palm bursa 5.08 NA NA 6.32 5.98 26030 A Drainage of palm bursa(s) 6.25 NA NA 7.08 6.70 26034 A Treat hand bone lesion 6.63 NA NA 7.87 7.47 26035 A Decompress fingers/hand 11.37 NA NA 11.57 10.71 26037 A Decompress fingers/hand 7.57 NA NA 7.84 7.41 26040 A Release palm contracture 3.46 NA NA 5.03 4.76 26045 A Release palm contracture 5.73 NA NA 6.83 6.51 26055 A Incise finger tendon sheath 3.11 11.99 12.18 5.28 4.97 26060 A Incision of finger tendon 2.91 NA NA 4.34 4.12 26070 A Explore/treat hand joint 3.81 NA NA 4.55 4.22 26075 A Explore/treat finger joint 3.91 NA NA 4.83 4.54 26080 A Explore/treat finger joint 4.47 NA NA 6.09 5.76 26100 A Biopsy hand joint lining 3.79 NA NA 5.15 4.83 26105 A Biopsy finger joint lining 3.83 NA NA 5.17 4.91 
CMS-1503-P 854

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

26110 A Biopsy finger joint lining 3.65 NA NA 5.08 4.80 26111 A Exc hand les sc > 1.5 cm 5.42 NA NA 5.95 5.95 26113 A Exc hand tum deep > 1.5 cm 7.13 NA NA 7.81 7.81 26115 A Exc hand les sc < 1.5 cm 3.96 9.67 11.19 5.05 5.17 26116 A Exc hand tum deep < 1.5 cm 6.74 NA NA 7.56 7.12 26117 A Exc hand tum ra < 3 cm 10.13 NA NA 10.29 9.08 26118 A Exc hand tum ra > 3 cm 14.81 NA NA 13.92 13.92 26121 A Release palm contracture 7.73 NA NA 8.45 8.02 26123 A Release palm contracture 10.88 NA NA 11.78 11.03 26125 A Release palm contracture 4.60 NA NA 2.89 2.72 26130 A Remove wrist joint lining 5.59 NA NA 6.87 6.47 26135 A Revise finger joint, each 7.13 NA NA 7.80 7.40 26140 A Revise finger joint, each 6.34 NA NA 7.34 6.97 26145 A Tendon excision, palm/finger 6.49 NA NA 7.37 6.99 26160 A Remove tendon sheath lesion 3.57 11.96 11.88 5.47 5.15 26170 A Removal of palm tendon, each 4.91 NA NA 6.12 5.81 26180 A Removal of finger tendon 5.35 NA NA 6.60 6.32 26185 A Remove finger bone 6.52 NA NA 8.19 7.71 26200 A Remove hand bone lesion 5.65 NA NA 6.52 6.21 26205 A Remove/graft bone lesion 7.93 NA NA 8.15 7.82 26210 A Removal of finger lesion 5.32 NA NA 6.66 6.33 26215 A Remove/graft finger lesion 7.27 NA NA 7.76 7.37 26230 A Partial removal of hand bone 6.47 NA NA 7.05 6.73 26235 A Partial removal, finger bone 6.33 NA NA 7.11 6.74 26236 A Partial removal, finger bone 5.46 NA NA 6.48 6.16 26250 A Extensive hand surgery 15.21 NA NA 13.47 10.39 
CMS-1503-P 855

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

26260 A Resect prox finger tumor 11.16 NA NA 11.26 9.07 26262 A Resect distal finger tumor 8.29 NA NA 8.67 7.31 26320 A Removal of implant from hand 4.10 NA NA 5.34 5.06 26340 A Manipulate finger w/anesth 2.80 NA NA 6.26 5.94 26350 A Repair finger/hand tendon 6.21 NA NA 12.80 12.88 26352 A Repair/graft hand tendon 7.87 NA NA 13.70 13.68 26356 A Repair finger/hand tendon 10.62 NA NA 18.73 18.34 26357 A Repair finger/hand tendon 8.77 NA NA 14.23 14.20 26358 A Repair/graft hand tendon 9.36 NA NA 15.40 15.16 26370 A Repair finger/hand tendon 7.28 NA NA 13.07 13.14 26372 A Repair/graft hand tendon 9.01 NA NA 14.37 14.45 26373 A Repair finger/hand tendon 8.41 NA NA 14.02 14.06 26390 A Revise hand/finger tendon 9.43 NA NA 12.67 12.46 26392 A Repair/graft hand tendon 10.50 NA NA 15.24 15.12 26410 A Repair hand tendon 4.77 NA NA 10.33 10.41 26412 A Repair/graft hand tendon 6.48 NA NA 11.80 11.82 26415 A Excision, hand/finger tendon 8.51 NA NA 9.99 10.20 26416 A Graft hand or finger tendon 9.56 NA NA 14.10 12.48 26418 A Repair finger tendon 4.47 NA NA 10.95 10.99 26420 A Repair/graft finger tendon 6.94 NA NA 11.80 11.90 26426 A Repair finger/hand tendon 6.32 NA NA 7.25 7.98 26428 A Repair/graft finger tendon 7.40 NA NA 12.58 12.55 26432 A Repair finger tendon 4.16 NA NA 9.16 9.18 26433 A Repair finger tendon 4.70 NA NA 9.47 9.51 26434 A Repair/graft finger tendon 6.26 NA NA 10.82 10.74 26437 A Realignment of tendons 5.99 NA NA 10.68 10.61 
CMS-1503-P 856

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

26440 A Release palm/finger tendon 5.16 NA NA 11.44 11.58 26442 A Release palm & finger tendon 9.75 NA NA 16.16 15.83 26445 A Release hand/finger tendon 4.45 NA NA 11.01 11.17 26449 A Release forearm/hand tendon 8.59 NA NA 10.43 10.96 26450 A Incision of palm tendon 3.79 NA NA 7.04 6.97 26455 A Incision of finger tendon 3.76 NA NA 7.04 6.95 26460 A Incise hand/finger tendon 3.58 NA NA 6.99 6.88 26471 A Fusion of finger tendons 5.90 NA NA 10.60 10.49 26474 A Fusion of finger tendons 5.49 NA NA 10.59 10.42 26476 A Tendon lengthening 5.35 NA NA 10.50 10.22 26477 A Tendon shortening 5.32 NA NA 10.24 10.17 26478 A Lengthening of hand tendon 5.97 NA NA 10.64 10.67 26479 A Shortening of hand tendon 5.91 NA NA 10.61 10.58 26480 A Transplant hand tendon 6.90 NA NA 13.23 13.25 26483 A Transplant/graft hand tendon 8.48 NA NA 13.97 13.99 26485 A Transplant palm tendon 7.89 NA NA 13.69 13.73 26489 A Transplant/graft palm tendon 9.86 NA NA 14.87 14.07 26490 A Revise thumb tendon 8.60 NA NA 12.59 12.32 26492 A Tendon transfer with graft 9.84 NA NA 13.48 13.28 26494 A Hand tendon/muscle transfer 8.66 NA NA 12.47 12.34 26496 A Revise thumb tendon 9.78 NA NA 13.23 12.97 26497 A Finger tendon transfer 9.76 NA NA 13.11 12.95 26498 A Finger tendon transfer 14.21 NA NA 16.03 15.75 26499 A Revision of finger 9.17 NA NA 12.76 12.59 26500 A Hand tendon reconstruction 6.13 NA NA 10.66 10.57 26502 A Hand tendon reconstruction 7.31 NA NA 11.83 11.54 
CMS-1503-P 857

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

26508 A Release thumb contracture 6.18 NA NA 10.77 10.61 26510 A Thumb tendon transfer 5.60 NA NA 10.32 10.33 26516 A Fusion of knuckle joint 7.32 NA NA 11.40 11.30 26517 A Fusion of knuckle joints 9.08 NA NA 12.71 12.62 26518 A Fusion of knuckle joints 9.27 NA NA 13.14 12.86 26520 A Release knuckle contracture 5.47 NA NA 11.96 12.06 26525 A Release finger contracture 5.50 NA NA 11.97 12.08 26530 A Revise knuckle joint 6.88 NA NA 7.65 7.25 26531 A Revise knuckle with implant 8.13 NA NA 8.83 8.35 26535 A Revise finger joint 5.41 NA NA 5.96 5.44 26536 A Revise/implant finger joint 6.56 NA NA 12.62 11.95 26540 A Repair hand joint 6.60 NA NA 11.01 10.94 26541 A Repair hand joint with graft 8.81 NA NA 12.50 12.41 26542 A Repair hand joint with graft 6.95 NA NA 11.26 11.18 26545 A Reconstruct finger joint 7.11 NA NA 11.56 11.41 26546 A Repair nonunion hand 10.83 NA NA 15.76 15.37 26548 A Reconstruct finger joint 8.22 NA NA 12.23 12.05 26550 A Construct thumb replacement 21.68 NA NA 21.94 19.26 26551 A Great toe-hand transfer 48.48 NA NA 28.34 30.29 26553 A Single transfer, toe-hand 48.17 NA NA 44.03 34.58 26554 A Double transfer, toe-hand 57.01 NA NA 32.34 33.56 26555 A Positional change of finger 17.08 NA NA 19.26 18.86 26556 A Toe joint transfer 49.75 NA NA 31.98 28.92 26560 A Repair of web finger 5.52 NA NA 10.31 9.94 26561 A Repair of web finger 11.10 NA NA 14.64 13.59 26562 A Repair of web finger 16.68 NA NA 18.89 18.26 
CMS-1503-P 858

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

26565 A Correct metacarpal flaw 6.91 NA NA 11.12 11.05 26567 A Correct finger deformity 6.99 NA NA 11.16 11.11 26568 A Lengthen metacarpal/finger 9.27 NA NA 14.52 14.43 26580 A Repair hand deformity 19.75 NA NA 15.35 15.80 26587 A Reconstruct extra finger 14.50 NA NA 14.57 12.28 26590 A Repair finger deformity 18.67 NA NA 14.91 14.12 26591 A Repair muscles of hand 3.38 NA NA 8.28 8.39 26593 A Release muscles of hand 5.50 NA NA 10.59 10.51 26596 A Excision constricting tissue 9.14 NA NA 11.05 10.39 26600 A Treat metacarpal fracture 2.60 5.23 4.89 4.78 4.37 26605 A Treat metacarpal fracture 3.03 5.58 5.32 4.82 4.55 26607 A Treat metacarpal fracture 5.48 NA NA 6.80 6.24 26608 A Treat metacarpal fracture 5.55 NA NA 7.32 7.01 26615 A Treat metacarpal fracture 7.07 NA NA 8.53 7.85 26641 A Treat thumb dislocation 4.13 5.34 5.25 4.58 4.43 26645 A Treat thumb fracture 4.58 6.82 6.34 5.89 5.42 26650 A Treat thumb fracture 5.35 NA NA 7.52 7.23 26665 A Treat thumb fracture 7.94 NA NA 8.97 8.41 26670 A Treat hand dislocation 3.83 4.92 4.70 4.15 3.87 26675 A Treat hand dislocation 4.83 7.29 6.78 6.31 5.82 26676 A Pin hand dislocation 5.74 NA NA 7.72 7.43 26685 A Treat hand dislocation 7.07 NA NA 8.43 7.91 26686 A Treat hand dislocation 8.17 NA NA 8.49 8.09 26700 A Treat knuckle dislocation 3.83 4.56 4.32 4.07 3.78 

26705 A Treat knuckle dislocation 4.38 6.87 6.37 5.92 5.43 

26706 A Pin knuckle dislocation 5.31 NA NA 6.62 6.19 
CMS-1503-P 859

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

26715 A Treat knuckle dislocation 7.03 NA NA 8.40 7.80 

26720 A Treat finger fracture, each 1.76 3.47 3.31 3.12 2.90 26725 A Treat finger fracture, each 3.48 5.55 5.34 4.68 4.42 26727 A Treat finger fracture, each 5.42 NA NA 7.28 6.96 26735 A Treat finger fracture, each 7.42 NA NA 8.72 8.04 26740 A Treat finger fracture, each 2.07 4.10 3.87 3.73 3.49 26742 A Treat finger fracture, each 3.99 5.78 5.58 4.88 4.66 26746 A Treat finger fracture, each 9.80 NA NA 10.28 9.32 26750 A Treat finger fracture, each 1.80 3.04 2.90 3.05 2.84 26755 A Treat finger fracture, each 3.23 5.06 4.89 4.02 3.80 26756 A Pin finger fracture, each 4.58 NA NA 6.74 6.44 26765 A Treat finger fracture, each 5.86 NA NA 7.72 7.02 26770 A Treat finger dislocation 3.15 3.99 3.80 3.49 3.24 26775 A Treat finger dislocation 3.90 6.32 6.04 5.36 5.02 26776 A Pin finger dislocation 4.99 NA NA 6.95 6.66 26785 A Treat finger dislocation 6.60 NA NA 8.20 7.43 26820 A Thumb fusion with graft 8.45 NA NA 12.34 12.27 26841 A Fusion of thumb 7.35 NA NA 12.05 11.99 26842 A Thumb fusion with graft 8.49 NA NA 12.41 12.34 26843 A Fusion of hand joint 7.78 NA NA 11.71 11.61 26844 A Fusion/graft of hand joint 8.98 NA NA 12.65 12.55 26850 A Fusion of knuckle 7.14 NA NA 11.40 11.31 26852 A Fusion of knuckle with graft 8.71 NA NA 12.63 12.43 26860 A Fusion of finger joint 4.88 NA NA 10.22 10.19 26861 A Fusion of finger jnt, add-on 1.74 NA NA 1.08 1.02 26862 A Fusion/graft of finger joint 7.56 NA NA 11.89 11.74 
CMS-1503-P 860

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

26863 A Fuse/graft added joint 3.89 NA NA 2.27 2.21 26910 A Amputate metacarpal bone 7.79 NA NA 11.33 11.12 26951 A Amputation of finger/thumb 6.04 NA NA 11.39 11.01 26952 A Amputation of finger/thumb 6.48 NA NA 10.82 10.75 26989 C Hand/finger surgery 0.00 0.00 0.00 0.00 0.00 26990 A Drainage of pelvis lesion 7.95 NA NA 8.73 8.33 26991 A Drainage of pelvis bursa 7.06 11.92 11.58 7.01 6.61 26992 A Drainage of bone lesion 13.48 NA NA 12.23 11.66 27000 A Incision of hip tendon 5.74 NA NA 5.91 5.82 27001 A Incision of hip tendon 7.14 NA NA 7.31 6.99 27003 A Incision of hip tendon 7.81 NA NA 8.12 7.65 27005 A Incision of hip tendon 10.07 NA NA 9.37 8.95 27006 A Incision of hip tendons 10.11 NA NA 9.65 9.20 27025 A Incision of hip/thigh fascia 12.89 NA NA 11.55 10.83 27027 A Buttock fasciotomy 13.04 NA NA 11.16 10.15 27030 A Drainage of hip joint 13.65 NA NA 11.28 10.89 27033 A Exploration of hip joint 14.11 NA NA 11.93 11.42 27035 A Denervation of hip joint 17.37 NA NA 14.16 12.42 27036 A Excision of hip joint/muscle 14.38 NA NA 12.58 11.99 27040 A Biopsy of soft tissues 2.92 6.17 6.25 2.37 2.38 27041 A Biopsy of soft tissues 10.18 NA NA 7.77 7.63 27043 A Exc hip pelvis les sc > 3 cm 6.88 NA NA 5.59 5.59 27045 A Exc hip/pelv tum deep > 5 cm 11.13 NA NA 8.64 8.64 27047 A Exc hip/pelvis les sc < 3 cm 4.94 7.57 8.03 4.69 5.12 27048 A Exc hip/pelv tum deep < 5 cm 8.85 NA NA 7.38 6.55 27049 A Resect hip/pelv tum < 5 cm 21.55 NA NA 14.66 12.41 
CMS-1503-P 861

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

27050 A Biopsy of sacroiliac joint 4.74 NA NA 6.01 5.16 27052 A Biopsy of hip joint 7.42 NA NA 7.97 7.47 27054 A Removal of hip joint lining 9.21 NA NA 9.10 8.67 27057 A Buttock fasciotomy w/dbrdmt 14.91 NA NA 12.26 11.15 27059 A Resect hip/pelv tum > 5 cm 29.35 NA NA 18.88 18.88 27060 A Removal of ischial bursa 5.87 NA NA 6.56 5.89 27062 A Remove femur lesion/bursa 5.75 NA NA 6.47 6.15 27065 A Removal of hip bone lesion 6.55 NA NA 6.96 6.66 27066 A Removal of hip bone lesion 11.20 NA NA 10.53 10.02 27067 A Remove/graft hip bone lesion 14.72 NA NA 12.97 12.37 27070 A Partial removal of hip bone 11.56 NA NA 11.25 10.75 27071 A Partial removal of hip bone 12.39 NA NA 11.98 11.49 27075 A Resect hip tumor 32.71 NA NA 22.82 22.15 27076 A Resect hip tum incl acetabul 40.21 NA NA 27.55 21.99 27077 A Resect hip tum w/innom bone 45.21 NA NA 31.00 28.06 27078 A Rsect hip tum incl femur 32.21 NA NA 23.40 17.43 27080 A Removal of tail bone 6.89 NA NA 6.70 6.25 27086 A Remove hip foreign body 1.92 4.36 4.53 1.92 1.93 27087 A Remove hip foreign body 8.83 NA NA 7.94 7.66 27090 A Removal of hip prosthesis 11.69 NA NA 10.52 10.06 27091 A Removal of hip prosthesis 24.35 NA NA 18.49 17.47 27093 A Injection for hip x-ray 1.30 3.91 4.05 0.64 0.62 27095 A Injection for hip x-ray 1.50 4.93 5.04 0.76 0.72 27096 A Inject sacroiliac joint 1.40 4.09 3.85 0.68 0.55 27097 A Revision of hip tendon 9.27 NA NA 8.97 8.34 27098 A Transfer tendon to pelvis 9.32 NA NA 9.24 8.04 
CMS-1503-P 862

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

27100 A Transfer of abdominal muscle 11.35 NA NA 10.75 10.22 27105 A Transfer of spinal muscle 12.04 NA NA 11.15 10.63 27110 A Transfer of iliopsoas muscle 13.77 NA NA 12.16 11.43 27111 A Transfer of iliopsoas muscle 12.60 NA NA 11.48 10.33 27120 A Reconstruction of hip socket 19.25 NA NA 15.59 14.63 27122 A Reconstruction of hip socket 16.09 NA NA 13.42 12.81 27125 A Partial hip replacement 16.64 NA NA 13.73 12.99 27130 A Total hip arthroplasty 21.79 NA NA 16.83 16.00 27132 A Total hip arthroplasty 25.69 NA NA 19.28 18.38 27134 A Revise hip joint replacement 30.28 NA NA 21.18 20.30 27137 A Revise hip joint replacement 22.70 NA NA 16.84 16.10 27138 A Revise hip joint replacement 23.70 NA NA 17.43 16.65 27140 A Transplant femur ridge 12.78 NA NA 11.11 10.68 27146 A Incision of hip bone 18.92 NA NA 15.53 14.49 27147 A Revision of hip bone 22.07 NA NA 17.37 16.44 27151 A Incision of hip bones 24.12 NA NA 18.57 16.61 27156 A Revision of hip bones 26.23 NA NA 19.80 18.62 27158 A Revision of pelvis 21.04 NA NA 16.55 15.39 27161 A Incision of neck of femur 17.89 NA NA 14.62 14.00 27165 A Incision/fixation of femur 20.29 NA NA 16.57 15.68 27170 A Repair/graft femur head/neck 17.61 NA NA 13.93 13.27 27175 A Treat slipped epiphysis 9.38 NA NA 8.47 8.03 27176 A Treat slipped epiphysis 12.92 NA NA 11.67 11.04 27177 A Treat slipped epiphysis 16.09 NA NA 13.76 13.06 27178 A Treat slipped epiphysis 12.92 NA NA 11.67 10.95 27179 A Revise head/neck of femur 13.97 NA NA 12.17 11.56 
CMS-1503-P 863

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

27181 A Treat slipped epiphysis 16.18 NA NA 13.93 13.09 27185 A Revision of femur epiphysis 9.79 NA NA 6.68 6.94 27187 A Reinforce hip bones 14.23 NA NA 12.30 11.79 27193 A Treat pelvic ring fracture 6.09 6.50 6.16 6.67 6.31 27194 A Treat pelvic ring fracture 10.20 NA NA 8.36 8.20 27200 A Treat tail bone fracture 1.92 2.89 2.71 3.09 2.87 27202 A Treat tail bone fracture 7.31 NA NA 7.67 8.60 27215 I Treat pelvic fracture(s) 10.45 NA NA 6.46 7.26 27216 I Treat pelvic ring fracture 15.73 NA NA 9.35 10.40 27217 I Treat pelvic ring fracture 14.65 NA NA 8.88 10.04 27218 I Treat pelvic ring fracture 20.93 NA NA 11.59 12.82 27220 A Treat hip socket fracture 6.83 7.36 6.98 7.23 6.86 27222 A Treat hip socket fracture 14.11 NA NA 11.95 11.46 27226 A Treat hip wall fracture 15.57 NA NA 12.85 11.85 27227 A Treat hip fracture(s) 25.41 NA NA 19.23 18.28 27228 A Treat hip fracture(s) 29.33 NA NA 21.47 20.50 27230 A Treat thigh fracture 5.81 6.84 6.53 6.75 6.40 27232 A Treat thigh fracture 11.72 NA NA 8.65 8.29 27235 A Treat thigh fracture 13.00 NA NA 11.39 10.87 27236 A Treat thigh fracture 17.61 NA NA 14.47 13.69 27238 A Treat thigh fracture 5.75 NA NA 6.48 6.18 27240 A Treat thigh fracture 13.81 NA NA 11.76 11.21 27244 A Treat thigh fracture 18.18 NA NA 14.83 14.02 27245 A Treat thigh fracture 18.18 NA NA 14.86 14.41 27246 A Treat thigh fracture 4.83 5.45 5.20 5.50 5.24 27248 A Treat thigh fracture 10.78 NA NA 9.11 8.80 
CMS-1503-P 864

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

27250 A Treat hip dislocation 3.82 NA NA 0.95 1.51 27252 A Treat hip dislocation 11.03 NA NA 9.13 8.71 27253 A Treat hip dislocation 13.58 NA NA 11.62 11.13 27254 A Treat hip dislocation 18.94 NA NA 14.94 14.24 27256 A Treat hip dislocation 4.28 3.43 3.34 1.73 1.82 27257 A Treat hip dislocation 5.38 NA NA 3.48 3.32 27258 A Treat hip dislocation 16.18 NA NA 13.57 12.86 27259 A Treat hip dislocation 23.26 NA NA 18.39 17.39 27265 A Treat hip dislocation 5.24 NA NA 5.15 5.04 27266 A Treat hip dislocation 7.78 NA NA 7.78 7.41 27267 A Cltx thigh fx 5.50 NA NA 6.09 5.63 27268 A Cltx thigh fx w/mnpj 7.12 NA NA 7.28 6.62 27269 A Optx thigh fx 18.89 NA NA 14.25 13.10 27275 A Manipulation of hip joint 2.32 NA NA 2.48 2.39 27280 A Fusion of sacroiliac joint 14.64 NA NA 12.79 12.20 27282 A Fusion of pubic bones 11.85 NA NA 11.04 9.90 27284 A Fusion of hip joint 25.06 NA NA 18.38 16.28 27286 A Fusion of hip joint 25.17 NA NA 19.18 18.29 27290 A Amputation of leg at hip 24.55 NA NA 19.03 17.33 27295 A Amputation of leg at hip 19.66 NA NA 14.16 13.40 27299 C Pelvis/hip joint surgery 0.00 0.00 0.00 0.00 0.00 27301 A Drain thigh/knee lesion 6.78 11.18 10.84 6.60 6.24 27303 A Drainage of bone lesion 8.63 NA NA 8.48 8.09 27305 A Incise thigh tendon & fascia 6.18 NA NA 6.64 6.22 27306 A Incision of thigh tendon 4.74 NA NA 5.23 5.10 27307 A Incision of thigh tendons 6.06 NA NA 6.77 6.32 
CMS-1503-P 865

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

27310 A Exploration of knee joint 10.00 NA NA 9.58 9.09 27323 A Biopsy, thigh soft tissues 2.33 5.10 4.97 2.53 2.44 27324 A Biopsy, thigh soft tissues 5.04 NA NA 5.42 5.10 27325 A Neurectomy, hamstring 7.20 NA NA 7.69 7.01 27326 A Neurectomy, popliteal 6.47 NA NA 7.26 6.64 27327 A Exc thigh/knee les sc < 3 cm 3.96 8.29 7.78 4.35 4.38 27328 A Exc thigh/knee tum deep <5cm 8.85 NA NA 7.62 6.36 27329 A Resect thigh/knee tum < 5 cm 15.72 NA NA 12.05 11.36 27330 A Biopsy, knee joint lining 5.11 NA NA 5.97 5.57 27331 A Explore/treat knee joint 6.02 NA NA 6.70 6.40 27332 A Removal of knee cartilage 8.46 NA NA 8.69 8.29 27333 A Removal of knee cartilage 7.55 NA NA 8.11 7.72 27334 A Remove knee joint lining 9.19 NA NA 9.11 8.65 27335 A Remove knee joint lining 10.55 NA NA 9.87 9.45 27337 A Exc thigh/knee les sc > 3 cm 5.91 NA NA 5.30 5.30 27339 A Exc thigh/knee tum deep >5cm 11.13 NA NA 8.94 8.94 27340 A Removal of kneecap bursa 4.32 NA NA 5.64 5.36 27345 A Removal of knee cyst 6.09 NA NA 6.76 6.50 27347 A Remove knee cyst 6.73 NA NA 7.41 6.98 27350 A Removal of kneecap 8.66 NA NA 8.78 8.40 27355 A Remove femur lesion 8.00 NA NA 8.10 7.77 27356 A Remove femur lesion/graft 10.09 NA NA 9.60 9.18 27357 A Remove femur lesion/graft 11.16 NA NA 10.62 10.14 27358 A Remove femur lesion/fixation 4.73 NA NA 2.76 2.67 27360 A Partial removal, leg bone(s) 11.46 NA NA 11.32 10.84 27364 A Resect thigh/knee tum >5 cm 24.49 NA NA 16.94 16.94 
CMS-1503-P 866

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

27365 A Resect femur/knee tumor 32.21 NA NA 23.28 18.34 27370 A Injection for knee x-ray 0.96 3.75 3.77 0.50 0.46 27372 A Removal of foreign body 5.21 11.12 10.85 5.65 5.40 27380 A Repair of kneecap tendon 7.45 NA NA 8.39 8.09 27381 A Repair/graft kneecap tendon 10.76 NA NA 10.56 10.18 27385 A Repair of thigh muscle 8.11 NA NA 8.81 8.48 27386 A Repair/graft of thigh muscle 11.13 NA NA 11.09 10.65 27390 A Incision of thigh tendon 5.53 NA NA 6.46 6.12 27391 A Incision of thigh tendons 7.49 NA NA 7.93 7.54 27392 A Incision of thigh tendons 9.63 NA NA 9.42 8.86 27393 A Lengthening of thigh tendon 6.59 NA NA 6.91 6.65 27394 A Lengthening of thigh tendons 8.79 NA NA 8.55 8.22 27395 A Lengthening of thigh tendons 12.24 NA NA 11.27 10.76 27396 A Transplant of thigh tendon 8.15 NA NA 8.31 7.95 27397 A Transplants of thigh tendons 12.66 NA NA 11.87 11.23 27400 A Revise thigh muscles/tendons 9.33 NA NA 9.25 8.78 27403 A Repair of knee cartilage 8.62 NA NA 8.51 8.16 27405 A Repair of knee ligament 9.08 NA NA 9.01 8.63 27407 A Repair of knee ligament 10.85 NA NA 10.35 9.58 27409 A Repair of knee ligaments 13.71 NA NA 12.13 11.54 27412 A Autochondrocyte implant knee 24.74 NA NA 19.52 18.46 27415 A Osteochondral knee allograft 20.00 NA NA 16.86 15.88 27416 A Osteochondral knee autograft 14.16 NA NA 12.10 11.28 27418 A Repair degenerated kneecap 11.60 NA NA 10.63 10.21 27420 A Revision of unstable kneecap 10.26 NA NA 9.70 9.29 27422 A Revision of unstable kneecap 10.21 NA NA 9.67 9.26 
CMS-1503-P 867

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

27424 A Revision/removal of kneecap 10.24 NA NA 9.61 9.25 27425 A Lat retinacular release open 5.39 NA NA 6.59 6.29 27427 A Reconstruction, knee 9.79 NA NA 9.39 8.99 27428 A Reconstruction, knee 15.58 NA NA 14.22 13.51 27429 A Reconstruction, knee 17.54 NA NA 15.72 14.99 27430 A Revision of thigh muscles 10.16 NA NA 9.63 9.21 27435 A Incision of knee joint 10.88 NA NA 10.69 10.16 27437 A Revise kneecap 8.93 NA NA 8.75 8.35 27438 A Revise kneecap with implant 11.89 NA NA 10.60 10.11 27440 A Revision of knee joint 11.09 NA NA 10.26 9.38 27441 A Revision of knee joint 11.54 NA NA 10.53 9.59 27442 A Revision of knee joint 12.37 NA NA 10.91 10.37 27443 A Revision of knee joint 11.41 NA NA 10.45 9.96 27445 A Revision of knee joint 18.66 NA NA 14.87 14.22 27446 A Revision of knee joint 16.38 NA NA 13.20 12.68 27447 A Total knee arthroplasty 23.25 NA NA 17.99 17.16 27448 A Incision of thigh 11.60 NA NA 10.29 9.84 27450 A Incision of thigh 14.61 NA NA 12.49 11.99 27454 A Realignment of thigh bone 19.17 NA NA 15.68 14.65 27455 A Realignment of knee 13.36 NA NA 11.87 11.33 27457 A Realignment of knee 14.03 NA NA 11.75 11.25 27465 A Shortening of thigh bone 18.60 NA NA 15.00 13.92 27466 A Lengthening of thigh bone 17.28 NA NA 14.20 13.63 27468 A Shorten/lengthen thighs 19.97 NA NA 16.03 15.10 27470 A Repair of thigh 17.14 NA NA 14.44 13.79 27472 A Repair/graft of thigh 18.72 NA NA 15.13 14.51 
CMS-1503-P 868

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

27475 A Surgery to stop leg growth 8.93 NA NA 6.22 7.08 27477 A Surgery to stop leg growth 10.14 NA NA 9.47 9.03 27479 A Surgery to stop leg growth 13.16 NA NA 11.48 10.98 27485 A Surgery to stop leg growth 9.13 NA NA 8.81 8.43 27486 A Revise/replace knee joint 21.12 NA NA 16.62 15.85 27487 A Revise/replace knee joint 27.11 NA NA 20.08 19.19 27488 A Removal of knee prosthesis 17.60 NA NA 14.59 13.89 27495 A Reinforce thigh 16.54 NA NA 13.67 13.09 27496 A Decompression of thigh/knee 6.78 NA NA 7.76 6.98 27497 A Decompression of thigh/knee 7.79 NA NA 7.78 6.95 27498 A Decompression of thigh/knee 8.66 NA NA 8.86 7.68 27499 A Decompression of thigh/knee 9.43 NA NA 9.31 8.32 27500 A Treatment of thigh fracture 6.30 7.56 7.19 6.53 6.15 27501 A Treatment of thigh fracture 6.45 7.02 6.71 6.91 6.55 27502 A Treatment of thigh fracture 11.36 NA NA 9.44 9.09 27503 A Treatment of thigh fracture 11.27 NA NA 10.26 9.76 27506 A Treatment of thigh fracture 19.65 NA NA 16.25 15.41 27507 A Treatment of thigh fracture 14.48 NA NA 11.60 11.13 27508 A Treatment of thigh fracture 6.20 7.81 7.47 6.99 6.64 27509 A Treatment of thigh fracture 8.14 NA NA 9.17 8.82 27510 A Treatment of thigh fracture 9.80 NA NA 8.62 8.35 27511 A Treatment of thigh fracture 15.11 NA NA 11.65 11.36 27513 A Treatment of thigh fracture 19.25 NA NA 14.06 13.77 27514 A Treatment of thigh fracture 14.60 NA NA 11.34 11.42 27516 A Treat thigh fx growth plate 5.59 8.00 7.52 7.16 6.71 27517 A Treat thigh fx growth plate 9.12 NA NA 9.23 8.77 
CMS-1503-P 869

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

27519 A Treat thigh fx growth plate 13.25 NA NA 10.64 10.57 27520 A Treat kneecap fracture 3.04 5.57 5.33 4.83 4.53 27524 A Treat kneecap fracture 10.37 NA NA 9.78 9.37 27530 A Treat knee fracture 4.09 6.57 6.28 5.85 5.53 27532 A Treat knee fracture 7.55 8.96 8.54 7.95 7.56 27535 A Treat knee fracture 13.41 NA NA 10.66 10.37 27536 A Treat knee fracture 17.39 NA NA 14.57 13.84 27538 A Treat knee fracture(s) 5.09 7.56 7.22 6.76 6.40 27540 A Treat knee fracture 11.30 NA NA 10.49 10.16 27550 A Treat knee dislocation 5.98 7.29 6.97 6.33 6.00 27552 A Treat knee dislocation 8.18 NA NA 8.61 8.18 27556 A Treat knee dislocation 13.00 NA NA 10.49 10.43 27557 A Treat knee dislocation 15.90 NA NA 12.19 12.08 27558 A Treat knee dislocation 18.39 NA NA 13.64 13.31 27560 A Treat kneecap dislocation 3.99 6.19 5.83 5.49 5.00 27562 A Treat kneecap dislocation 5.98 NA NA 6.94 6.40 27566 A Treat kneecap dislocation 12.71 NA NA 11.11 10.65 27570 A Fixation of knee joint 1.79 NA NA 2.25 2.14 27580 A Fusion of knee 21.10 NA NA 17.45 16.72 27590 A Amputate leg at thigh 13.47 NA NA 8.36 7.99 27591 A Amputate leg at thigh 13.94 NA NA 9.99 9.76 27592 A Amputate leg at thigh 10.98 NA NA 7.71 7.38 27594 A Amputation follow-up surgery 7.29 NA NA 6.34 6.14 27596 A Amputation follow-up surgery 11.29 NA NA 8.26 7.94 27598 A Amputate lower leg at knee 11.22 NA NA 8.70 8.35 27599 C Leg surgery procedure 0.00 0.00 0.00 0.00 0.00 
CMS-1503-P 870

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

27600 A Decompression of lower leg 6.03 NA NA 5.07 5.01 27601 A Decompression of lower leg 6.05 NA NA 5.91 5.68 27602 A Decompression of lower leg 7.82 NA NA 5.64 5.57 27603 A Drain lower leg lesion 5.23 9.43 9.01 5.42 5.12 27604 A Drain lower leg bursa 4.59 8.46 7.98 4.61 4.42 27605 A Incision of achilles tendon 2.92 6.43 6.68 2.17 2.23 27606 A Incision of achilles tendon 4.18 NA NA 3.59 3.51 27607 A Treat lower leg bone lesion 8.62 NA NA 7.96 7.59 27610 A Explore/treat ankle joint 9.13 NA NA 8.54 8.16 27612 A Exploration of ankle joint 8.15 NA NA 7.21 6.95 27613 A Biopsy lower leg soft tissue 2.22 4.80 4.66 2.33 2.26 27614 A Biopsy lower leg soft tissue 5.80 9.92 9.46 5.20 5.03 27615 A Resect leg/ankle tum < 5 cm 15.72 NA NA 12.02 10.80 27616 A Resect leg/ankle tum > 5 cm 19.63 NA NA 14.38 14.38 27618 A Exc leg/ankle tum < 3 cm 3.96 8.18 7.90 4.30 4.50 27619 A Exc leg/ankle tum deep <5 cm 6.91 NA NA 6.21 6.39 27620 A Explore/treat ankle joint 6.15 NA NA 6.29 6.07 27625 A Remove ankle joint lining 8.49 NA NA 7.16 7.02 27626 A Remove ankle joint lining 9.10 NA NA 7.96 7.69 27630 A Removal of tendon lesion 4.94 10.38 9.86 5.06 4.90 27632 A Exc leg/ankle les sc > 3 cm 5.91 NA NA 5.25 5.25 27634 A Exc leg/ankle tum deep >5 cm 10.13 NA NA 8.00 8.00 27635 A Remove lower leg bone lesion 8.03 NA NA 7.97 7.64 27637 A Remove/graft leg bone lesion 10.31 NA NA 10.15 9.63 27638 A Remove/graft leg bone lesion 10.99 NA NA 9.69 9.38 27640 A Partial removal of tibia 12.24 NA NA 10.50 10.30 
CMS-1503-P 871

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

27641 A Partial removal of fibula 9.84 NA NA 8.32 8.21 27645 A Resect tibia tumor 27.21 NA NA 20.59 16.35 27646 A Resect fibula tumor 23.21 NA NA 18.25 14.43 27647 A Resect talus/calcaneus tum 20.26 NA NA 10.73 9.36 27648 A Injection for ankle x-ray 0.96 3.54 3.57 0.48 0.45 27650 A Repair achilles tendon 9.21 NA NA 8.97 8.64 27652 A Repair/graft achilles tendon 10.78 NA NA 8.43 8.36 27654 A Repair of achilles tendon 10.53 NA NA 8.99 8.63 27656 A Repair leg fascia defect 4.71 12.33 11.05 5.90 5.18 27658 A Repair of leg tendon, each 5.12 NA NA 5.18 5.04 27659 A Repair of leg tendon, each 7.10 NA NA 6.31 6.12 27664 A Repair of leg tendon, each 4.73 NA NA 5.27 5.06 27665 A Repair of leg tendon, each 5.57 NA NA 5.59 5.48 27675 A Repair lower leg tendons 7.35 NA NA 6.07 5.98 27676 A Repair lower leg tendons 8.73 NA NA 7.95 7.66 27680 A Release of lower leg tendon 5.88 NA NA 5.92 5.67 27681 A Release of lower leg tendons 7.05 NA NA 7.57 6.97 27685 A Revision of lower leg tendon 6.69 11.58 10.80 6.11 5.95 27686 A Revise lower leg tendons 7.75 NA NA 7.30 7.09 27687 A Revision of calf tendon 6.41 NA NA 6.08 5.87 27690 A Revise lower leg tendon 9.17 NA NA 8.38 7.94 27691 A Revise lower leg tendon 10.49 NA NA 9.94 9.48 27692 A Revise additional leg tendon 1.87 NA NA 1.03 0.99 27695 A Repair of ankle ligament 6.70 NA NA 6.37 6.28 27696 A Repair of ankle ligaments 8.58 NA NA 6.89 6.77 27698 A Repair of ankle ligament 9.61 NA NA 7.94 7.70 
CMS-1503-P 872

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

27700 A Revision of ankle joint 9.66 NA NA 6.69 6.57 27702 A Reconstruct ankle joint 14.42 NA NA 11.88 11.55 27703 A Reconstruction, ankle joint 16.94 NA NA 13.44 13.05 27704 A Removal of ankle implant 7.81 NA NA 7.82 7.36 27705 A Incision of tibia 10.86 NA NA 9.73 9.31 27707 A Incision of fibula 4.78 NA NA 6.19 5.89 27709 A Incision of tibia & fibula 17.48 NA NA 14.29 13.01 27712 A Realignment of lower leg 15.87 NA NA 13.76 13.04 27715 A Revision of lower leg 15.50 NA NA 12.71 12.30 27720 A Repair of tibia 12.36 NA NA 11.14 10.71 27722 A Repair/graft of tibia 12.45 NA NA 11.40 10.75 27724 A Repair/graft of tibia 19.31 NA NA 14.74 14.12 27725 A Repair of lower leg 17.41 NA NA 15.30 14.44 27726 A Repair fibula nonunion 14.34 NA NA 11.83 10.67 27727 A Repair of lower leg 14.84 NA NA 12.93 11.43 27730 A Repair of tibia epiphysis 7.70 NA NA 7.98 7.59 27732 A Repair of fibula epiphysis 5.46 NA NA 6.51 5.74 27734 A Repair lower leg epiphyses 8.83 NA NA 8.72 7.60 27740 A Repair of leg epiphyses 9.61 NA NA 6.63 6.97 27742 A Repair of leg epiphyses 10.63 NA NA 8.77 7.91 27745 A Reinforce tibia 10.49 NA NA 9.68 9.31 27750 A Treatment of tibia fracture 3.37 5.87 5.61 5.11 4.83 27752 A Treatment of tibia fracture 6.27 8.16 7.80 7.06 6.73 27756 A Treatment of tibia fracture 7.45 NA NA 7.94 7.58 27758 A Treatment of tibia fracture 12.54 NA NA 11.37 10.82 27759 A Treatment of tibia fracture 14.45 NA NA 12.34 11.80 
CMS-1503-P 873

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

27760 A Cltx medial ankle fx 3.21 5.74 5.49 4.96 4.68 27762 A Cltx med ankle fx w/mnpj 5.47 7.40 7.15 6.30 6.08 27766 A Optx medial ankle fx 7.89 NA NA 8.55 8.19 27767 A Cltx post ankle fx 2.64 4.94 4.56 4.98 4.60 27768 A Cltx post ankle fx w/mnpj 5.14 NA NA 6.63 5.98 27769 A Optx post ankle fx 10.14 NA NA 9.60 8.63 27780 A Treatment of fibula fracture 2.83 5.33 5.05 4.60 4.29 27781 A Treatment of fibula fracture 4.59 6.81 6.49 5.99 5.67 27784 A Treatment of fibula fracture 9.67 NA NA 9.63 8.97 27786 A Treatment of ankle fracture 3.02 5.47 5.23 4.66 4.39 27788 A Treatment of ankle fracture 4.64 6.70 6.45 5.74 5.50 27792 A Treatment of ankle fracture 9.71 NA NA 9.54 8.98 27808 A Treatment of ankle fracture 3.03 5.90 5.65 5.00 4.73 27810 A Treatment of ankle fracture 5.32 7.24 7.01 6.12 5.92 27814 A Treatment of ankle fracture 10.62 NA NA 10.17 9.75 27816 A Treatment of ankle fracture 3.07 5.47 5.17 4.60 4.30 27818 A Treatment of ankle fracture 5.69 7.14 6.95 5.86 5.70 27822 A Treatment of ankle fracture 11.21 NA NA 11.46 11.14 27823 A Treatment of ankle fracture 13.16 NA NA 12.59 12.18 27824 A Treat lower leg fracture 3.31 5.06 4.83 4.82 4.55 27825 A Treat lower leg fracture 6.69 7.95 7.64 6.59 6.32 27826 A Treat lower leg fracture 11.10 NA NA 11.46 10.87 27827 A Treat lower leg fracture 14.79 NA NA 14.37 13.84 27828 A Treat lower leg fracture 18.43 NA NA 16.45 15.76 27829 A Treat lower leg joint 8.80 NA NA 9.63 9.06 27830 A Treat lower leg dislocation 3.96 6.23 5.71 5.53 5.04 
CMS-1503-P 874

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

27831 A Treat lower leg dislocation 4.73 NA NA 5.97 5.51 27832 A Treat lower leg dislocation 10.17 NA NA 10.09 9.18 27840 A Treat ankle dislocation 4.77 NA NA 4.82 4.59 27842 A Treat ankle dislocation 6.46 NA NA 6.90 6.46 27846 A Treat ankle dislocation 10.28 NA NA 9.47 9.11 27848 A Treat ankle dislocation 11.68 NA NA 10.30 10.06 27860 A Fixation of ankle joint 2.39 NA NA 2.32 2.28 27870 A Fusion of ankle joint, open 15.41 NA NA 12.66 12.17 27871 A Fusion of tibiofibular joint 9.54 NA NA 9.07 8.70 27880 A Amputation of lower leg 15.37 NA NA 9.43 8.92 27881 A Amputation of lower leg 13.47 NA NA 10.11 9.83 27882 A Amputation of lower leg 9.79 NA NA 6.66 6.56 27884 A Amputation follow-up surgery 8.76 NA NA 6.93 6.68 27886 A Amputation follow-up surgery 10.02 NA NA 7.82 7.56 27888 A Amputation of foot at ankle 10.37 NA NA 8.07 8.01 27889 A Amputation of foot at ankle 10.86 NA NA 7.07 6.98 27892 A Decompression of leg 7.94 NA NA 6.94 6.56 27893 A Decompression of leg 7.90 NA NA 8.41 7.43 27894 A Decompression of leg 12.67 NA NA 10.30 9.82 27899 C Leg/ankle surgery procedure 0.00 0.00 0.00 0.00 0.00 28001 A Drainage of bursa of foot 2.78 4.91 4.66 1.95 1.99 28002 A Treatment of foot infection 5.93 8.40 7.92 4.52 4.44 28003 A Treatment of foot infection 9.06 9.65 9.24 5.68 5.70 28005 A Treat foot bone lesion 9.44 NA NA 7.03 6.93 28008 A Incision of foot fascia 4.59 7.52 7.13 3.63 3.61 28010 A Incision of toe tendon 2.97 3.58 3.41 2.93 2.86 
CMS-1503-P 875

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

28011 A Incision of toe tendons 4.28 4.97 4.69 3.97 3.85 28020 A Exploration of foot joint 5.15 9.70 9.01 4.77 4.62 28022 A Exploration of foot joint 4.81 8.58 8.11 4.11 4.11 28024 A Exploration of toe joint 4.52 8.13 7.74 3.86 3.91 28035 A Decompression of tibia nerve 5.23 9.30 8.81 4.56 4.52 28039 A Exc foot/toe tum sc > 1.5 cm 5.42 8.21 8.21 3.98 3.98 28041 A Exc foot/toe tum deep >1.5cm 7.13 NA NA 5.20 5.20 28043 A Exc foot/toe tum sc < 1.5 cm 3.96 7.38 6.38 3.47 3.43 28045 A Exc foot/toe tum deep <1.5cm 5.45 8.72 8.28 4.47 4.24 28046 A Resect foot/toe tumor < 3 cm 12.38 NA NA 8.42 7.79 28047 A Resect foot/toe tumor > 3 cm 17.45 NA NA 8.45 8.45 28050 A Biopsy of foot joint lining 4.39 7.59 7.58 3.51 3.76 28052 A Biopsy of foot joint lining 4.06 7.91 7.46 3.61 3.60 28054 A Biopsy of toe joint lining 3.57 7.01 6.95 3.07 3.26 28055 A Neurectomy, foot 6.29 NA NA 4.35 4.30 28060 A Partial removal, foot fascia 5.40 9.03 8.48 4.52 4.43 28062 A Removal of foot fascia 6.69 9.78 9.34 4.75 4.69 28070 A Removal of foot joint lining 5.24 9.70 8.83 4.69 4.47 28072 A Removal of foot joint lining 4.72 9.60 9.00 4.59 4.58 28080 A Removal of foot lesion 4.86 9.68 8.98 5.30 5.06 28086 A Excise foot tendon sheath 4.92 10.04 9.60 4.92 4.83 28088 A Excise foot tendon sheath 3.98 9.60 8.82 4.47 4.29 28090 A Removal of foot lesion 4.55 8.56 8.04 4.02 3.95 28092 A Removal of toe lesions 3.78 8.18 7.70 3.79 3.75 28100 A Removal of ankle/heel lesion 5.83 10.59 10.14 5.31 5.20 28102 A Remove/graft foot lesion 7.92 NA NA 8.32 7.63 
CMS-1503-P 876

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

28103 A Remove/graft foot lesion 6.67 NA NA 4.39 4.84 28104 A Removal of foot lesion 5.26 9.04 8.52 4.33 4.30 28106 A Remove/graft foot lesion 7.35 NA NA 4.76 4.99 28107 A Remove/graft foot lesion 5.73 8.85 8.94 4.11 4.40 28108 A Removal of toe lesions 4.30 7.97 7.46 3.73 3.68 28110 A Part removal of metatarsal 4.22 8.69 8.17 3.83 3.76 28111 A Part removal of metatarsal 5.15 9.06 8.65 4.13 4.07 28112 A Part removal of metatarsal 4.63 9.12 8.62 4.13 4.06 28113 A Part removal of metatarsal 6.11 10.59 9.92 5.85 5.64 28114 A Removal of metatarsal heads 12.00 17.65 16.56 11.06 10.55 28116 A Revision of foot 9.14 11.97 11.12 6.76 6.51 28118 A Removal of heel bone 6.13 10.26 9.64 5.26 5.13 28119 A Removal of heel spur 5.56 9.11 8.54 4.50 4.40 28120 A Part removal of ankle/heel 8.27 11.86 10.61 6.83 5.87 28122 A Partial removal of foot bone 7.72 10.51 10.05 6.05 5.97 28124 A Partial removal of toe 5.00 8.41 7.94 4.27 4.23 28126 A Partial removal of toe 3.64 7.43 6.98 3.30 3.29 28130 A Removal of ankle bone 9.50 NA NA 10.03 8.73 28140 A Removal of metatarsal 7.14 9.71 9.42 5.16 5.16 28150 A Removal of toe 4.23 7.98 7.51 3.74 3.69 28153 A Partial removal of toe 3.80 7.83 7.30 3.64 3.51 28160 A Partial removal of toe 3.88 7.98 7.47 3.69 3.66 28171 A Resect tarsal tumor 16.41 NA NA 7.61 6.96 28173 A Resect metatarsal tumor 14.16 NA NA 7.36 6.55 28175 A Resect phalanx of toe tumor 8.29 NA NA 5.49 4.93 28190 A Removal of foot foreign body 2.01 5.11 4.84 1.72 1.68 
CMS-1503-P 877

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

28192 A Removal of foot foreign body 4.78 8.45 7.99 4.02 3.98 28193 A Removal of foot foreign body 5.90 9.05 8.59 4.47 4.44 28200 A Repair of foot tendon 4.74 8.62 8.11 4.03 3.99 28202 A Repair/graft of foot tendon 7.07 9.36 9.21 4.68 4.79 28208 A Repair of foot tendon 4.51 8.58 7.98 4.09 3.97 28210 A Repair/graft of foot tendon 6.52 9.44 9.01 4.84 4.78 28220 A Release of foot tendon 4.67 7.93 7.48 3.77 3.77 28222 A Release of foot tendons 5.76 8.61 8.13 4.12 4.16 28225 A Release of foot tendon 3.78 7.42 6.95 3.33 3.28 28226 A Release of foot tendons 4.67 7.78 7.68 3.59 3.84 28230 A Incision of foot tendon(s) 4.36 7.74 7.32 3.52 3.59 28232 A Incision of toe tendon 3.51 7.48 7.04 3.36 3.37 28234 A Incision of foot tendon 3.54 8.03 7.52 3.90 3.83 28238 A Revision of foot tendon 7.96 10.91 10.27 5.70 5.57 28240 A Release of big toe 4.48 7.83 7.46 3.60 3.67 28250 A Revision of foot fascia 6.06 9.88 9.20 5.04 4.90 28260 A Release of midfoot joint 8.19 11.31 10.33 6.24 5.94 28261 A Revision of foot tendon 13.11 13.88 13.02 8.26 8.11 28262 A Revision of foot and ankle 17.21 20.54 19.24 13.19 12.68 28264 A Release of midfoot joint 10.65 16.54 14.29 9.95 8.94 28270 A Release of foot contracture 4.93 8.90 8.25 4.43 4.32 28272 A Release of toe joint, each 3.92 7.17 6.77 3.23 3.22 28280 A Fusion of toes 5.33 9.16 8.76 4.44 4.49 28285 A Repair of hammertoe 4.76 8.51 7.95 4.24 4.13 28286 A Repair of hammertoe 4.70 8.17 7.66 3.80 3.75 28288 A Partial removal of foot bone 6.02 11.10 10.23 6.09 5.87 
CMS-1503-P 878

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

28289 A Repair hallux rigidus 8.31 12.20 11.47 6.95 6.73 28290 A Correction of bunion 5.83 10.57 9.83 5.14 5.05 28292 A Correction of bunion 9.05 13.15 12.29 7.83 7.51 28293 A Correction of bunion 11.48 17.93 16.94 8.52 8.26 28294 A Correction of bunion 8.75 11.46 11.04 5.72 5.72 28296 A Correction of bunion 8.35 11.70 11.20 6.27 6.20 28297 A Correction of bunion 9.43 13.36 12.67 6.83 6.77 28298 A Correction of bunion 8.13 12.02 11.24 5.95 5.81 28299 A Correction of bunion 11.57 13.50 12.79 7.32 7.19 28300 A Incision of heel bone 9.73 NA NA 8.25 7.97 28302 A Incision of ankle bone 9.74 NA NA 9.42 8.51 28304 A Incision of midfoot bones 9.41 12.98 12.03 7.01 6.73 28305 A Incise/graft midfoot bones 10.77 NA NA 7.50 7.56 28306 A Incision of metatarsal 6.00 11.15 10.40 5.22 5.03 28307 A Incision of metatarsal 6.50 12.25 12.19 5.81 5.82 28308 A Incision of metatarsal 5.48 10.22 9.50 4.95 4.76 28309 A Incision of metatarsals 14.16 NA NA 10.42 9.81 28310 A Revision of big toe 5.57 9.63 9.01 4.36 4.25 28312 A Revision of toe 4.69 9.41 8.81 4.13 4.08 28313 A Repair deformity of toe 5.15 9.60 8.95 4.81 4.83 28315 A Removal of sesamoid bone 5.00 8.35 7.84 4.01 3.94 28320 A Repair of foot bones 9.37 NA NA 7.35 7.23 28322 A Repair of metatarsals 8.53 13.11 12.29 7.28 7.01 28340 A Resect enlarged toe tissue 7.15 9.22 9.04 4.53 4.66 28341 A Resect enlarged toe 8.72 10.28 9.93 5.19 5.26 28344 A Repair extra toe(s) 4.40 7.71 7.96 3.58 3.88 
CMS-1503-P 879

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

28345 A Repair webbed toe(s) 6.09 8.68 8.76 4.22 4.58 28360 A Reconstruct cleft foot 14.92 NA NA 14.15 12.26 28400 A Treatment of heel fracture 2.31 4.44 4.26 3.86 3.69 28405 A Treatment of heel fracture 4.74 6.10 5.72 5.10 4.86 28406 A Treatment of heel fracture 6.56 NA NA 7.65 7.40 28415 A Treat heel fracture 16.19 NA NA 14.09 13.73 28420 A Treat/graft heel fracture 17.52 NA NA 16.11 14.81 28430 A Treatment of ankle fracture 2.22 4.16 3.96 3.45 3.25 28435 A Treatment of ankle fracture 3.54 6.13 5.42 5.09 4.57 28436 A Treatment of ankle fracture 4.90 NA NA 7.14 6.70 28445 A Treat ankle fracture 15.76 NA NA 12.81 12.39 28446 A Osteochondral talus autogrft 17.71 NA NA 15.13 13.99 28450 A Treat midfoot fracture, each 2.03 3.85 3.68 3.20 3.05 28455 A Treat midfoot fracture, each 3.24 4.82 4.57 4.01 3.89 28456 A Treat midfoot fracture 2.86 NA NA 5.94 5.21 28465 A Treat midfoot fracture, each 8.80 NA NA 7.93 7.64 28470 A Treat metatarsal fracture 2.03 3.72 3.59 3.15 3.01 28475 A Treat metatarsal fracture 3.01 4.04 3.92 3.25 3.23 28476 A Treat metatarsal fracture 3.60 NA NA 5.92 5.69 28485 A Treat metatarsal fracture 7.44 NA NA 7.27 6.96 28490 A Treat big toe fracture 1.17 2.76 2.61 2.22 2.10 28495 A Treat big toe fracture 1.68 3.25 3.05 2.47 2.38 28496 A Treat big toe fracture 2.48 9.63 9.25 3.93 3.76 28505 A Treat big toe fracture 7.44 11.18 10.58 6.43 5.99 28510 A Treatment of toe fracture 1.17 2.20 2.07 2.11 2.00 28515 A Treatment of toe fracture 1.56 2.87 2.70 2.35 2.27 
CMS-1503-P 880

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

28525 A Treat toe fracture 5.62 10.26 9.73 5.48 5.13 28530 A Treat sesamoid bone fracture 1.11 2.13 2.00 1.76 1.69 28531 A Treat sesamoid bone fracture 2.57 7.10 7.22 2.57 2.55 28540 A Treat foot dislocation 2.19 3.47 3.28 2.91 2.81 28545 A Treat foot dislocation 2.60 5.35 4.61 4.43 3.87 28546 A Treat foot dislocation 3.40 12.24 10.71 5.72 5.14 28555 A Repair foot dislocation 9.65 14.27 13.56 8.46 8.02 28570 A Treat foot dislocation 1.76 2.81 2.80 2.16 2.23 28575 A Treat foot dislocation 3.49 6.31 5.72 5.36 4.93 28576 A Treat foot dislocation 4.60 NA NA 6.01 5.32 28585 A Repair foot dislocation 11.13 14.17 13.40 8.56 8.36 28600 A Treat foot dislocation 2.02 4.02 3.77 3.17 3.04 28605 A Treat foot dislocation 2.89 5.90 5.05 5.01 4.35 28606 A Treat foot dislocation 5.09 NA NA 5.63 5.35 28615 A Repair foot dislocation 10.70 NA NA 10.81 10.31 28630 A Treat toe dislocation 1.75 2.48 2.29 1.23 1.18 28635 A Treat toe dislocation 1.96 3.04 2.84 1.79 1.73 28636 A Treat toe dislocation 2.77 4.36 4.60 1.96 2.25 28645 A Repair toe dislocation 7.44 10.63 9.79 5.89 5.54 28660 A Treat toe dislocation 1.28 1.79 1.67 1.08 1.02 28665 A Treat toe dislocation 1.97 2.35 2.20 1.71 1.67 28666 A Treat toe dislocation 2.66 NA NA 3.02 2.72 28675 A Repair of toe dislocation 5.62 10.45 10.03 5.67 5.38 28705 A Fusion of foot bones 20.33 NA NA 14.60 14.13 28715 A Fusion of foot bones 14.60 NA NA 11.73 11.27 28725 A Fusion of foot bones 12.18 NA NA 9.40 9.04 
CMS-1503-P 881

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

28730 A Fusion of foot bones 12.42 NA NA 10.66 10.17 28735 A Fusion of foot bones 12.23 NA NA 9.52 9.15 28737 A Revision of foot bones 11.03 NA NA 7.63 7.62 28740 A Fusion of foot bones 9.29 14.33 13.64 8.01 7.70 28750 A Fusion of big toe joint 8.57 14.23 13.73 7.89 7.64 28755 A Fusion of big toe joint 4.88 9.21 8.76 4.25 4.20 28760 A Fusion of big toe joint 9.14 13.12 12.21 7.06 6.78 28800 A Amputation of midfoot 8.79 NA NA 6.49 6.39 28805 A Amputation thru metatarsal 12.71 NA NA 7.75 7.44 28810 A Amputation toe & metatarsal 6.64 NA NA 5.32 5.18 28820 A Amputation of toe 5.00 9.51 9.28 4.51 4.42 28825 A Partial amputation of toe 6.01 10.16 9.72 5.27 5.02 28890 A High energy eswt, plantar f 3.45 6.12 5.95 2.98 2.79 28899 C Foot/toes surgery procedure 0.00 0.00 0.00 0.00 0.00 29000 A Application of body cast 2.25 6.82 5.82 2.70 2.41 29010 A Application of body cast 2.06 6.72 5.52 2.60 2.26 29015 A Application of body cast 2.41 4.02 3.91 1.87 1.81 29020 A Application of body cast 2.11 3.81 3.84 1.49 1.55 29025 A Application of body cast 2.40 4.15 4.22 1.93 2.01 29035 A Application of body cast 1.77 5.10 4.86 2.10 1.99 29040 A Application of body cast 2.22 4.34 4.06 1.95 1.85 29044 A Application of body cast 2.12 5.59 5.16 2.40 2.24 29046 A Application of body cast 2.41 4.43 4.72 2.00 2.20 29049 A Application of figure eight 0.89 1.76 1.55 0.99 0.83 29055 A Application of shoulder cast 1.78 4.19 3.90 1.94 1.81 29058 A Application of shoulder cast 1.31 1.20 1.36 0.77 0.78 
CMS-1503-P 882

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

29065 A Application of long arm cast 0.87 1.70 1.63 0.97 0.92 29075 A Application of forearm cast 0.77 1.65 1.57 0.91 0.86 29085 A Apply hand/wrist cast 0.87 1.70 1.61 0.96 0.89 29086 A Apply finger cast 0.62 1.51 1.38 0.79 0.72 29105 A Apply long arm splint 0.87 1.45 1.40 0.73 0.69 29125 A Apply forearm splint 0.59 1.29 1.23 0.59 0.55 29126 A Apply forearm splint 0.77 1.38 1.31 0.68 0.63 29130 A Application of finger splint 0.50 0.60 0.56 0.28 0.25 29131 A Application of finger splint 0.55 0.86 0.82 0.36 0.33 29200 A Strapping of chest 0.65 0.85 0.80 0.49 0.45 29240 A Strapping of shoulder 0.71 0.86 0.85 0.51 0.48 29260 A Strapping of elbow or wrist 0.55 0.88 0.84 0.50 0.46 29280 A Strapping of hand or finger 0.51 0.89 0.86 0.51 0.46 29305 A Application of hip cast 2.03 4.61 4.32 2.25 2.13 29325 A Application of hip casts 2.32 5.02 4.72 2.48 2.36 29345 A Application of long leg cast 1.40 2.24 2.14 1.31 1.25 29355 A Application of long leg cast 1.53 2.28 2.14 1.36 1.29 29358 A Apply long leg cast brace 1.43 2.87 2.68 1.36 1.28 29365 A Application of long leg cast 1.18 2.12 2.02 1.18 1.14 29405 A Apply short leg cast 0.86 1.57 1.50 0.88 0.84 29425 A Apply short leg cast 1.01 1.59 1.52 0.86 0.84 29435 A Apply short leg cast 1.18 1.99 1.92 1.09 1.06 29440 A Addition of walker to cast 0.57 0.65 0.72 0.24 0.28 29445 A Apply rigid leg cast 1.78 2.03 1.99 1.17 1.13 29450 A Application of leg cast 2.08 1.88 1.85 1.05 1.08 29505 A Application, long leg splint 0.69 1.42 1.36 0.62 0.58 
CMS-1503-P 883

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

29515 A Application lower leg splint 0.73 1.26 1.19 0.62 0.59 29520 A Strapping of hip 0.54 0.84 0.82 0.47 0.46 29530 A Strapping of knee 0.57 0.88 0.84 0.49 0.46 29540 A Strapping of ankle and/or ft 0.51 0.67 0.64 0.37 0.37 29550 A Strapping of toes 0.47 0.69 0.65 0.36 0.36 29580 A Application of paste boot 0.55 0.90 0.87 0.44 0.42 29581 A Apply multlay comprs lwr leg 0.60 2.00 2.00 0.27 0.27 29590 A Application of foot splint 0.76 0.73 0.70 0.31 0.32 29700 A Removal/revision of cast 0.57 1.22 1.17 0.35 0.34 29705 A Removal/revision of cast 0.76 1.05 1.00 0.52 0.49 29710 A Removal/revision of cast 1.34 1.97 1.82 0.91 0.83 29715 A Removal/revision of cast 0.94 1.28 1.35 0.52 0.52 29720 A Repair of body cast 0.68 1.57 1.48 0.50 0.47 29730 A Windowing of cast 0.75 1.01 0.96 0.48 0.45 29740 A Wedging of cast 1.12 1.27 1.26 0.58 0.58 29750 A Wedging of clubfoot cast 1.26 1.43 1.37 0.76 0.73 29799 C Casting/strapping procedure 0.00 0.00 0.00 0.00 0.00 29800 A Jaw arthroscopy/surgery 6.84 NA NA 7.33 6.98 29804 A Jaw arthroscopy/surgery 8.87 NA NA 9.01 8.34 29805 A Shoulder arthroscopy, dx 6.03 NA NA 6.62 6.35 29806 A Shoulder arthroscopy/surgery 15.14 NA NA 13.30 12.73 29807 A Shoulder arthroscopy/surgery 14.67 NA NA 13.13 12.55 29819 A Shoulder arthroscopy/surgery 7.79 NA NA 7.96 7.63 29820 A Shoulder arthroscopy/surgery 7.21 NA NA 7.26 6.98 29821 A Shoulder arthroscopy/surgery 7.89 NA NA 7.94 7.63 29822 A Shoulder arthroscopy/surgery 7.60 NA NA 7.79 7.49 
CMS-1503-P 884

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

29823 A Shoulder arthroscopy/surgery 8.36 NA NA 8.44 8.12 29824 A Shoulder arthroscopy/surgery 8.98 NA NA 9.11 8.73 29825 A Shoulder arthroscopy/surgery 7.79 NA NA 7.90 7.59 29826 A Shoulder arthroscopy/surgery 9.16 NA NA 8.68 8.36 29827 A Arthroscop rotator cuff repr 15.59 NA NA 13.22 12.73 29828 A Arthroscopy biceps tenodesis 13.16 NA NA 11.56 10.88 29830 A Elbow arthroscopy 5.88 NA NA 6.31 6.04 29834 A Elbow arthroscopy/surgery 6.42 NA NA 6.85 6.57 29835 A Elbow arthroscopy/surgery 6.62 NA NA 6.98 6.69 29836 A Elbow arthroscopy/surgery 7.72 NA NA 7.92 7.60 29837 A Elbow arthroscopy/surgery 7.01 NA NA 7.20 6.91 29838 A Elbow arthroscopy/surgery 7.88 NA NA 8.05 7.71 29840 A Wrist arthroscopy 5.68 NA NA 6.43 6.16 29843 A Wrist arthroscopy/surgery 6.15 NA NA 6.82 6.53 29844 A Wrist arthroscopy/surgery 6.51 NA NA 7.02 6.65 29845 A Wrist arthroscopy/surgery 7.69 NA NA 7.97 7.50 29846 A Wrist arthroscopy/surgery 6.89 NA NA 7.29 6.92 29847 A Wrist arthroscopy/surgery 7.22 NA NA 7.33 7.04 29848 A Wrist endoscopy/surgery 6.39 NA NA 7.49 7.02 29850 A Knee arthroscopy/surgery 8.27 NA NA 8.45 7.39 29851 A Knee arthroscopy/surgery 13.26 NA NA 11.74 11.20 29855 A Tibial arthroscopy/surgery 10.76 NA NA 10.32 9.89 29856 A Tibial arthroscopy/surgery 14.28 NA NA 12.44 11.92 29860 A Hip arthroscopy, dx 9.00 NA NA 8.88 8.33 29861 A Hip arthroscopy/surgery 10.10 NA NA 9.52 8.96 29862 A Hip arthroscopy/surgery 11.17 NA NA 10.80 10.24 
CMS-1503-P 885

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

29863 A Hip arthroscopy/surgery 11.17 NA NA 10.76 10.17 29866 A Autgrft implnt, knee w/scope 14.67 NA NA 13.47 12.82 29867 A Allgrft implnt, knee w/scope 18.39 NA NA 15.92 15.01 29868 A Meniscal trnspl, knee w/scpe 25.10 NA NA 19.84 18.76 29870 A Knee arthroscopy, dx 5.19 10.54 10.54 5.89 5.62 29871 A Knee arthroscopy/drainage 6.69 NA NA 7.11 6.79 29873 A Knee arthroscopy/surgery 6.24 NA NA 7.84 7.49 29874 A Knee arthroscopy/surgery 7.19 NA NA 7.29 6.96 29875 A Knee arthroscopy/surgery 6.45 NA NA 6.86 6.58 29876 A Knee arthroscopy/surgery 8.87 NA NA 8.78 8.33 29877 A Knee arthroscopy/surgery 8.30 NA NA 8.44 8.02 29879 A Knee arthroscopy/surgery 8.99 NA NA 8.83 8.40 29880 A Knee arthroscopy/surgery 9.45 NA NA 9.11 8.67 29881 A Knee arthroscopy/surgery 8.71 NA NA 8.68 8.25 29882 A Knee arthroscopy/surgery 9.60 NA NA 9.17 8.69 29883 A Knee arthroscopy/surgery 11.77 NA NA 10.74 10.30 29884 A Knee arthroscopy/surgery 8.28 NA NA 8.41 7.99 29885 A Knee arthroscopy/surgery 10.21 NA NA 9.98 9.47 29886 A Knee arthroscopy/surgery 8.49 NA NA 8.58 8.15 29887 A Knee arthroscopy/surgery 10.16 NA NA 9.90 9.40 29888 A Knee arthroscopy/surgery 14.30 NA NA 12.21 11.67 29889 A Knee arthroscopy/surgery 17.41 NA NA 15.41 14.64 29891 A Ankle arthroscopy/surgery 9.67 NA NA 9.06 8.72 29892 A Ankle arthroscopy/surgery 10.27 NA NA 6.09 7.09 29893 A Scope, plantar fasciotomy 6.32 10.85 10.24 5.70 5.51 29894 A Ankle arthroscopy/surgery 7.35 NA NA 6.68 6.36 
CMS-1503-P 886

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

29895 A Ankle arthroscopy/surgery 7.13 NA NA 6.26 6.03 29897 A Ankle arthroscopy/surgery 7.32 NA NA 6.59 6.42 29898 A Ankle arthroscopy/surgery 8.49 NA NA 7.11 6.88 29899 A Ankle arthroscopy/surgery 15.41 NA NA 12.66 12.19 29900 A Mcp joint arthroscopy, dx 5.88 NA NA 7.39 6.70 29901 A Mcp joint arthroscopy, surg 6.59 NA NA 7.70 7.03 29902 A Mcp joint arthroscopy, surg 7.16 NA NA 8.50 7.58 29904 A Subtalar arthro w/fb rmvl 8.65 NA NA 8.46 7.90 29905 A Subtalar arthro w/exc 9.18 NA NA 9.33 8.72 29906 A Subtalar arthro w/deb 9.65 NA NA 9.85 9.19 29907 A Subtalar arthro w/fusion 12.18 NA NA 11.33 10.58 29999 C Arthroscopy of joint 0.00 0.00 0.00 0.00 0.00 30000 A Drainage of nose lesion 1.48 5.02 4.94 1.86 1.76 30020 A Drainage of nose lesion 1.48 5.12 4.89 1.90 1.79 

3008F I Body mass index docd 0.00 0.00 0.00 0.00 0.00 

30100 A Intranasal biopsy 0.94 3.10 2.99 1.00 0.97 30110 A Removal of nose polyp(s) 1.68 4.86 4.67 2.02 1.91 30115 A Removal of nose polyp(s) 4.44 NA NA 7.79 7.47 30117 A Removal of intranasal lesion 3.26 21.57 20.83 6.32 6.07 30118 A Removal of intranasal lesion 9.92 NA NA 11.74 11.16 30120 A Revision of nose 5.39 9.09 8.81 6.85 6.72 30124 A Removal of nose lesion 3.20 NA NA 4.57 4.33 30125 A Removal of nose lesion 7.30 NA NA 9.95 9.56 30130 A Excise inferior turbinate 3.47 NA NA 7.31 7.04 30140 A Resect inferior turbinate 3.57 NA NA 8.92 8.58 30150 A Partial removal of nose 9.55 NA NA 12.06 11.76 
CMS-1503-P 887

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

3015F I Cerv cancer screen docd 0.00 0.00 0.00 0.00 0.00 

30160 A Removal of nose 9.99 NA NA 11.96 11.52 

3018F I Pre-prxd rsk et al docd 0.00 0.00 0.00 0.00 0.00 

30200 A Injection treatment of nose 0.78 2.46 2.37 0.92 0.88 30210 A Nasal sinus therapy 1.13 3.14 3.02 1.70 1.63 30220 A Insert nasal septal button 1.59 7.04 6.76 1.97 1.87 30300 A Remove nasal foreign body 1.09 5.42 5.32 2.47 2.36 30310 A Remove nasal foreign body 2.01 NA NA 3.81 3.68 30320 A Remove nasal foreign body 4.64 NA NA 8.17 7.88 

3038F I Pulm fx w/in 12 mon b/4 surg 0.00 0.00 0.00 0.00 0.00 

30400 R Reconstruction of nose 10.86 NA NA 17.73 17.49 30410 R Reconstruction of nose 14.00 NA NA 19.54 19.21 30420 R Reconstruction of nose 16.90 NA NA 21.71 20.80 30430 R Revision of nose 8.24 NA NA 16.23 16.49 30435 R Revision of nose 12.73 NA NA 21.85 20.74 30450 R Revision of nose 19.66 NA NA 22.79 22.57 30460 A Revision of nose 10.32 NA NA 10.36 10.04 30462 A Revision of nose 20.28 NA NA 23.08 21.43 30465 A Repair nasal stenosis 12.36 NA NA 15.35 14.55 30520 A Repair of nasal septum 7.01 NA NA 10.70 10.01 30540 A Repair nasal defect 7.92 NA NA 11.58 10.83 30545 A Repair nasal defect 11.62 NA NA 12.04 12.86 30560 A Release of nasal adhesions 1.31 6.39 6.27 2.61 2.54 30580 A Repair upper jaw fistula 6.88 11.21 10.52 7.43 6.79 30600 A Repair mouth/nose fistula 6.16 10.08 9.69 6.02 5.73 30620 A Intranasal reconstruction 6.16 NA NA 11.35 10.95 
CMS-1503-P 888

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

30630 A Repair nasal septum defect 7.29 NA NA 10.39 9.92 30801 A Ablate inf turbinate, superf 1.14 5.31 5.22 2.73 2.62 30802 A Ablate inf turbinate submuc 2.08 6.15 6.00 3.31 3.15 30901 A Control of nosebleed 1.21 1.69 1.62 0.50 0.44 30903 A Control of nosebleed 1.54 4.11 3.92 0.68 0.62 30905 A Control of nosebleed 1.97 5.01 4.79 0.82 0.77 30906 A Repeat control of nosebleed 2.45 5.42 5.23 1.27 1.19 30915 A Ligation, nasal sinus artery 7.44 NA NA 8.88 8.40 30920 A Ligation, upper jaw artery 11.14 NA NA 12.48 11.70 30930 A Ther fx, nasal inf turbinate 1.31 NA NA 2.19 2.09 30999 C Nasal surgery procedure 0.00 0.00 0.00 0.00 0.00 31000 A Irrigation, maxillary sinus 1.20 3.94 3.83 1.78 1.71 31002 A Irrigation, sphenoid sinus 1.96 NA NA 3.67 3.60 31020 A Exploration, maxillary sinus 3.07 10.53 10.40 7.01 6.79 31030 A Exploration, maxillary sinus 6.01 13.39 13.14 8.78 8.35 31032 A Explore sinus, remove polyps 6.69 NA NA 9.49 9.03 31040 A Exploration behind upper jaw 9.77 NA NA 11.31 10.69 31050 A Exploration, sphenoid sinus 5.37 NA NA 8.37 8.13 31051 A Sphenoid sinus surgery 7.25 NA NA 11.04 10.55 31070 A Exploration of frontal sinus 4.40 NA NA 8.03 7.71 31075 A Exploration of frontal sinus 9.51 NA NA 12.63 12.07 31080 A Removal of frontal sinus 12.74 NA NA 16.46 15.32 31081 A Removal of frontal sinus 14.19 NA NA 23.58 20.88 31084 A Removal of frontal sinus 14.95 NA NA 17.73 17.17 31085 A Removal of frontal sinus 15.64 NA NA 18.13 17.75 31086 A Removal of frontal sinus 14.36 NA NA 17.39 16.46 
CMS-1503-P 889

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

31087 A Removal of frontal sinus 14.57 NA NA 16.07 15.36 31090 A Exploration of sinuses 11.17 NA NA 17.81 16.87 31200 A Removal of ethmoid sinus 5.14 NA NA 10.54 10.06 31201 A Removal of ethmoid sinus 8.60 NA NA 12.28 11.62 31205 A Removal of ethmoid sinus 10.58 NA NA 14.49 13.48 31225 A Removal of upper jaw 26.70 NA NA 26.13 24.09 31230 A Removal of upper jaw 30.82 NA NA 28.11 25.86 31231 A Nasal endoscopy, dx 1.10 4.36 4.29 1.10 1.04 31233 A Nasal/sinus endoscopy, dx 2.18 5.35 5.23 1.72 1.61 31235 A Nasal/sinus endoscopy, dx 2.64 5.83 5.77 1.95 1.84 31237 A Nasal/sinus endoscopy, surg 2.98 6.23 6.10 2.18 2.03 31238 A Nasal/sinus endoscopy, surg 3.26 6.20 6.07 2.34 2.19 31239 A Nasal/sinus endoscopy, surg 9.33 NA NA 9.99 9.22 31240 A Nasal/sinus endoscopy, surg 2.61 NA NA 1.97 1.85 31254 A Revision of ethmoid sinus 4.64 NA NA 3.15 2.93 31255 A Removal of ethmoid sinus 6.95 NA NA 4.47 4.15 31256 A Exploration maxillary sinus 3.29 NA NA 2.36 2.20 31267 A Endoscopy, maxillary sinus 5.45 NA NA 3.60 3.35 31276 A Sinus endoscopy, surgical 8.84 NA NA 5.55 5.14 31287 A Nasal/sinus endoscopy, surg 3.91 NA NA 2.71 2.53 31288 A Nasal/sinus endoscopy, surg 4.57 NA NA 3.10 2.89 31290 A Nasal/sinus endoscopy, surg 18.61 NA NA 14.09 13.15 31291 A Nasal/sinus endoscopy, surg 19.56 NA NA 14.79 13.77 31292 A Nasal/sinus endoscopy, surg 15.90 NA NA 12.48 11.66 31293 A Nasal/sinus endoscopy, surg 17.47 NA NA 13.44 12.54 31294 A Nasal/sinus endoscopy, surg 20.31 NA NA 15.08 14.04 
CMS-1503-P 890

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

31299 C Sinus surgery procedure 0.00 0.00 0.00 0.00 0.00 31300 A Removal of larynx lesion 15.91 NA NA 20.03 18.99 31320 A Diagnostic incision, larynx 5.73 NA NA 12.91 12.52 31360 A Removal of larynx 29.91 NA NA 29.10 26.38 31365 A Removal of larynx 38.81 NA NA 34.18 30.92 31367 A Partial removal of larynx 30.57 NA NA 32.02 29.72 

31368 A Partial removal of larynx 34.19 NA NA 35.23 32.80 

31370 A Partial removal of larynx 27.57 NA NA 31.26 29.23 

31375 A Partial removal of larynx 26.07 NA NA 29.77 27.77 

31380 A Partial removal of larynx 25.57 NA NA 29.49 27.48 

31382 A Partial removal of larynx 28.57 NA NA 31.84 29.58 

31390 A Removal of larynx & pharynx 42.51 NA NA 37.97 34.79 31395 A Reconstruct larynx & pharynx 43.80 NA NA 41.62 38.31 31400 A Revision of larynx 11.60 NA NA 16.72 16.15 31420 A Removal of epiglottis 11.43 NA NA 12.30 11.61 31500 A Insert emergency airway 2.33 NA NA 0.62 0.59 31502 A Change of windpipe airway 0.65 NA NA 0.33 0.31 31505 A Diagnostic laryngoscopy 0.61 1.75 1.73 0.79 0.76 31510 A Laryngoscopy with biopsy 1.92 4.04 3.97 1.50 1.42 31511 A Remove foreign body, larynx 2.16 3.74 3.67 1.38 1.33 31512 A Removal of larynx lesion 2.07 3.85 3.74 1.66 1.54 31513 A Injection into vocal cord 2.10 NA NA 1.67 1.57 31515 A Laryngoscopy for aspiration 1.80 4.06 4.02 1.29 1.22 31520 A Dx laryngoscopy, newborn 2.56 NA NA 1.94 1.76 31525 A Dx laryngoscopy excl nb 2.63 4.50 4.36 1.91 1.79 31526 A Dx laryngoscopy w/oper scope 2.57 NA NA 1.94 1.82 
CMS-1503-P 891

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

31527 A Laryngoscopy for treatment 3.27 NA NA 2.35 2.13 31528 A Laryngoscopy and dilation 2.37 NA NA 1.77 1.65 31529 A Laryngoscopy and dilation 2.68 NA NA 1.95 1.83 31530 A Laryngoscopy w/fb removal 3.38 NA NA 2.27 2.11 31531 A Laryngoscopy w/fb & op scope 3.58 NA NA 2.50 2.34 31535 A Laryngoscopy w/biopsy 3.16 NA NA 2.27 2.12 31536 A Laryngoscopy w/bx & op scope 3.55 NA NA 2.51 2.34 31540 A Laryngoscopy w/exc of tumor 4.12 NA NA 2.83 2.64 31541 A Larynscop w/tumr exc + scope 4.52 NA NA 3.06 2.86 31545 A Remove vc lesion w/scope 6.30 NA NA 4.12 3.80 31546 A Remove vc lesion scope/graft 9.73 NA NA 6.11 5.53 31560 A Laryngoscop w/arytenoidectom 5.45 NA NA 3.56 3.29 31561 A Larynscop, remve cart + scop 5.99 NA NA 3.87 3.57 31570 A Laryngoscope w/vc inj 3.86 5.74 5.67 2.65 2.47 31571 A Laryngoscop w/vc inj + scope 4.26 NA NA 2.90 2.71 31575 A Diagnostic laryngoscopy 1.10 2.16 2.13 1.09 1.03 31576 A Laryngoscopy with biopsy 1.97 4.39 4.35 1.56 1.47 31577 A Remove foreign body, larynx 2.47 4.40 4.29 1.73 1.64 31578 A Removal of larynx lesion 2.84 5.16 5.03 2.10 1.91 31579 A Diagnostic laryngoscopy 2.26 3.74 3.74 1.76 1.65 31580 A Revision of larynx 14.66 NA NA 20.07 18.98 31582 A Revision of larynx 23.22 NA NA 30.63 29.54 31584 A Treat larynx fracture 20.47 NA NA 22.41 21.22 31587 A Revision of larynx 15.27 NA NA 13.26 12.13 31588 A Revision of larynx 14.99 NA NA 17.48 16.54 31590 A Reinnervate larynx 7.85 NA NA 17.45 17.12 
CMS-1503-P 892

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

31595 A Larynx nerve surgery 8.84 NA NA 12.87 12.41 31599 C Larynx surgery procedure 0.00 0.00 0.00 0.00 0.00 31600 A Incision of windpipe 7.17 NA NA 3.58 3.37 31601 A Incision of windpipe 4.44 NA NA 2.98 2.77 31603 A Incision of windpipe 4.14 NA NA 1.97 1.83 31605 A Incision of windpipe 3.57 NA NA 1.31 1.23 31610 A Incision of windpipe 9.38 NA NA 10.71 10.14 31611 A Surgery/speech prosthesis 6.00 NA NA 9.34 8.94 31612 A Puncture/clear windpipe 0.91 1.40 1.35 0.43 0.39 31613 A Repair windpipe opening 4.71 NA NA 7.95 7.66 31614 A Repair windpipe opening 8.63 NA NA 12.77 12.06 31615 A Visualization of windpipe 2.09 3.03 2.98 1.54 1.44 31620 A Endobronchial us add-on 1.40 6.07 6.52 0.48 0.48 31622 A Dx bronchoscope/wash 2.78 5.65 5.99 1.23 1.19 31623 A Dx bronchoscope/brush 2.88 6.07 6.62 1.20 1.17 31624 A Dx bronchoscope/lavage 2.88 5.56 5.99 1.22 1.18 31625 A Bronchoscopy w/biopsy(s) 3.36 5.71 6.14 1.38 1.34 31626 A Bronchoscopy w/markers 4.16 8.30 8.30 1.66 1.66 31627 A Navigational bronchoscopy 2.00 34.63 34.63 0.86 0.86 31628 A Bronchoscopy/lung bx, each 3.80 6.57 7.38 1.51 1.46 31629 A Bronchoscopy/needle bx, each 4.09 12.03 13.39 1.62 1.56 31630 A Bronchoscopy dilate/fx repr 3.81 NA NA 1.71 1.71 31631 A Bronchoscopy, dilate w/stent 4.36 NA NA 1.92 1.89 31632 A Bronchoscopy/lung bx, addl 1.03 0.95 0.98 0.36 0.34 31633 A Bronchoscopy/needle bx addl 1.32 1.10 1.13 0.45 0.43 31635 A Bronchoscopy w/fb removal 3.67 5.60 6.02 1.54 1.51 
CMS-1503-P 893

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

31636 A Bronchoscopy, bronch stents 4.30 NA NA 1.77 1.78 31637 A Bronchoscopy, stent add-on 1.58 NA NA 0.59 0.57 31638 A Bronchoscopy, revise stent 4.88 NA NA 2.09 2.07 31640 A Bronchoscopy w/tumor excise 4.93 NA NA 2.10 2.09 31641 A Bronchoscopy, treat blockage 5.02 NA NA 2.10 2.03 31643 A Diag bronchoscope/catheter 3.49 NA NA 1.39 1.36 31645 A Bronchoscopy, clear airways 3.16 4.99 5.35 1.31 1.27 31646 A Bronchoscopy, reclear airway 2.72 4.70 5.04 1.15 1.12 31656 A Bronchoscopy, inj for x-ray 2.17 5.86 6.56 0.89 0.89 31715 A Injection for bronchus x-ray 1.11 NA NA 0.35 0.37 31717 A Bronchial brush biopsy 2.12 5.26 6.00 1.00 0.94 31720 A Clearance of airways 1.06 NA NA 0.39 0.37 31725 A Clearance of airways 1.96 NA NA 0.71 0.63 31730 A Intro, windpipe wire/tube 2.85 28.92 26.09 1.16 1.10 31750 A Repair of windpipe 15.39 NA NA 23.15 22.16 31755 A Repair of windpipe 17.54 NA NA 31.53 30.45 31760 A Repair of windpipe 23.48 NA NA 12.10 12.53 31766 A Reconstruction of windpipe 31.67 NA NA 14.36 14.70 31770 A Repair/graft of bronchus 23.54 NA NA 10.96 11.21 31775 A Reconstruct bronchus 24.59 NA NA 10.05 10.77 31780 A Reconstruct windpipe 19.84 NA NA 13.20 12.46 31781 A Reconstruct windpipe 24.85 NA NA 10.97 11.93 31785 A Remove windpipe lesion 18.35 NA NA 11.86 11.11 31786 A Remove windpipe lesion 25.42 NA NA 11.93 12.78 31800 A Repair of windpipe injury 8.18 NA NA 11.79 11.26 31805 A Repair of windpipe injury 13.42 NA NA 7.77 8.02 
CMS-1503-P 894

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

31820 A Closure of windpipe lesion 4.64 7.68 7.35 4.64 4.38 31825 A Repair of windpipe defect 7.07 10.00 9.57 6.55 6.18 31830 A Revise windpipe scar 4.62 7.79 7.45 5.00 4.74 31899 C Airways surgical procedure 0.00 0.00 0.00 0.00 0.00 32035 A Exploration of chest 11.29 NA NA 7.84 7.65 32036 A Exploration of chest 12.30 NA NA 8.10 8.04 32095 A Biopsy through chest wall 10.14 NA NA 6.47 6.46 32100 A Exploration/biopsy of chest 16.16 NA NA 8.78 8.91 32110 A Explore/repair chest 25.28 NA NA 13.03 12.84 32120 A Re-exploration of chest 14.39 NA NA 8.47 8.53 32124 A Explore chest free adhesions 15.45 NA NA 8.84 8.82 32140 A Removal of lung lesion(s) 16.66 NA NA 9.22 9.26 32141 A Remove/treat lung lesions 27.18 NA NA 12.77 12.51 32150 A Removal of lung lesion(s) 16.82 NA NA 9.40 9.35 32151 A Remove lung foreign body 16.94 NA NA 9.23 9.54 32160 A Open chest heart massage 13.10 NA NA 7.38 7.24 32200 A Drain, open, lung lesion 18.68 NA NA 11.20 11.04 32201 A Drain, percut, lung lesion 3.99 20.33 22.22 1.39 1.60 32215 A Treat chest lining 13.05 NA NA 7.90 7.99 32220 A Release of lung 26.65 NA NA 14.91 15.10 32225 A Partial release of lung 16.75 NA NA 9.33 9.35 32310 A Removal of chest lining 15.28 NA NA 8.65 8.73 32320 A Free/remove chest lining 27.25 NA NA 14.66 14.66 32400 A Needle biopsy chest lining 1.76 2.20 2.40 0.61 0.67 32402 A Open biopsy chest lining 8.97 NA NA 5.93 5.99 32405 A Biopsy, lung or mediastinum 1.93 0.66 0.78 0.66 0.77 
CMS-1503-P 895

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

32420 A Puncture/clear lung 2.18 NA NA 0.78 0.85 32421 A Thoracentesis for aspiration 1.54 2.54 2.82 0.56 0.58 32422 A Thoracentesis w/tube insert 2.19 3.00 3.29 1.14 1.23 32440 A Removal of lung 27.28 NA NA 13.62 13.99 32442 A Sleeve pneumonectomy 56.47 NA NA 22.74 22.33 32445 A Removal of lung 63.84 NA NA 27.64 26.82 32480 A Partial removal of lung 25.82 NA NA 12.91 13.18 32482 A Bilobectomy 27.44 NA NA 14.04 14.31 32484 A Segmentectomy 25.38 NA NA 12.15 12.39 32486 A Sleeve lobectomy 42.88 NA NA 18.31 18.28 32488 A Completion pneumonectomy 42.99 NA NA 19.47 19.21 32491 R Lung volume reduction 25.24 NA NA 13.28 13.78 32500 A Partial removal of lung 24.64 NA NA 12.91 13.23 32501 A Repair bronchus add-on 4.68 NA NA 1.67 1.74 32503 A Resect apical lung tumor 31.74 NA NA 15.37 15.71 32504 A Resect apical lung tum/chest 36.54 NA NA 16.52 17.39 32540 A Removal of lung lesion 30.35 NA NA 14.59 14.45 32550 A Insert pleural cath 4.17 16.95 18.19 1.80 1.89 32551 A Insertion of chest tube 3.29 NA NA 1.25 1.31 32552 A Remove lung catheter 2.53 2.34 2.34 1.69 1.69 32553 A Ins mark thor for rt perq 3.80 13.17 13.17 1.48 1.48 32560 A Treat pleurodesis w/agent 1.54 5.06 5.75 0.55 0.67 32561 A Lyse chest fibrin init day 1.39 1.18 1.18 0.50 0.50 32562 A Lyse chest fibrin subq day 1.24 1.05 1.05 0.45 0.45 32601 A Thoracoscopy, diagnostic 5.45 NA NA 2.59 2.65 32602 A Thoracoscopy, diagnostic 5.95 NA NA 2.78 2.83 
CMS-1503-P 896

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

32603 A Thoracoscopy, diagnostic 7.80 NA NA 3.36 3.49 32604 A Thoracoscopy, diagnostic 8.77 NA NA 3.70 3.89 32605 A Thoracoscopy, diagnostic 6.92 NA NA 3.05 3.13 32606 A Thoracoscopy, diagnostic 8.39 NA NA 3.65 3.76 32650 A Thoracoscopy, surgical 10.83 NA NA 6.67 6.83 32651 A Thoracoscopy, surgical 18.78 NA NA 9.92 9.70 32652 A Thoracoscopy, surgical 29.13 NA NA 14.15 13.95 32653 A Thoracoscopy, surgical 18.17 NA NA 9.43 9.30 32654 A Thoracoscopy, surgical 20.52 NA NA 10.26 10.11 32655 A Thoracoscopy, surgical 16.17 NA NA 8.86 8.80 32656 A Thoracoscopy, surgical 13.26 NA NA 7.67 7.85 32657 A Thoracoscopy, surgical 12.93 NA NA 7.65 7.82 32658 A Thoracoscopy, surgical 11.71 NA NA 6.87 7.19 32659 A Thoracoscopy, surgical 11.94 NA NA 7.22 7.46 32660 A Thoracoscopy, surgical 17.77 NA NA 9.15 9.51 32661 A Thoracoscopy, surgical 13.33 NA NA 7.43 7.75 32662 A Thoracoscopy, surgical 14.99 NA NA 8.35 8.65 32663 A Thoracoscopy, surgical 24.64 NA NA 11.79 12.05 32664 A Thoracoscopy, surgical 14.28 NA NA 7.76 7.99 32665 A Thoracoscopy, surgical 21.53 NA NA 10.45 10.53 32800 A Repair lung hernia 15.71 NA NA 8.82 8.86 32810 A Close chest after drainage 14.95 NA NA 8.50 8.70 32815 A Close bronchial fistula 50.03 NA NA 22.77 21.95 32820 A Reconstruct injured chest 22.51 NA NA 12.06 12.66 32850 X Donor pneumonectomy 0.00 0.00 0.00 0.00 0.00 32851 A Lung transplant, single 41.61 NA NA 25.75 26.79 
CMS-1503-P 897

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

32852 A Lung transplant with bypass 45.48 NA NA 28.96 30.35 32853 A Lung transplant, double 50.78 NA NA 28.96 30.22 32854 A Lung transplant with bypass 54.74 NA NA 32.74 34.13 32855 C Prepare donor lung, single 0.00 0.00 0.00 0.00 0.00 32856 C Prepare donor lung, double 0.00 0.00 0.00 0.00 0.00 32900 A Removal of rib(s) 23.81 NA NA 12.93 12.53 32905 A Revise & repair chest wall 23.29 NA NA 11.39 11.69 32906 A Revise & repair chest wall 29.30 NA NA 13.47 13.91 

3293F I Abo rh blood typing docd 0.00 0.00 0.00 0.00 0.00 

32940 A Revision of lung 21.34 NA NA 10.80 10.91 

3294F I Grp b strep screening docd 0.00 0.00 0.00 0.00 0.00 

32960 A Therapeutic pneumothorax 1.84 1.66 1.85 0.77 0.82 32997 A Total lung lavage 7.31 NA NA 2.32 2.28 

32998 A Perq rf ablate tx, pul tumor 5.68 71.17 76.62 2.09 2.45 32999 C Chest surgery procedure 0.00 0.00 0.00 0.00 0.00 33010 A Drainage of heart sac 2.24 NA NA 0.84 1.02 33011 A Repeat drainage of heart sac 2.24 NA NA 0.87 0.99 33015 A Incision of heart sac 8.52 NA NA 4.72 5.54 33020 A Incision of heart sac 14.95 NA NA 8.06 8.12 33025 A Incision of heart sac 13.70 NA NA 7.21 7.37 33030 A Partial removal of heart sac 22.39 NA NA 11.38 11.48 33031 A Partial removal of heart sac 25.38 NA NA 11.85 12.13 33050 A Removal of heart sac lesion 16.97 NA NA 9.46 9.45 33120 A Removal of heart lesion 27.45 NA NA 13.05 13.41 33130 A Removal of heart lesion 24.17 NA NA 11.69 12.02 33140 A Heart revascularize (tmr) 28.34 NA NA 12.77 13.17 
CMS-1503-P 898

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

33141 A Heart tmr w/other procedure 2.54 NA NA 0.91 1.07 33202 A Insert epicard eltrd, open 13.20 NA NA 6.97 7.28 33203 A Insert epicard eltrd, endo 13.97 NA NA 6.90 7.58 33206 A Insertion of heart pacemaker 7.39 NA NA 4.33 5.15 33207 A Insertion of heart pacemaker 8.05 NA NA 4.39 5.27 33208 A Insertion of heart pacemaker 8.77 NA NA 4.66 5.61 33210 A Insertion of heart electrode 3.30 NA NA 1.28 1.59 33211 A Insertion of heart electrode 3.39 NA NA 1.29 1.54 33212 A Insertion of pulse generator 5.52 NA NA 3.15 3.76 33213 A Insertion of pulse generator 6.37 NA NA 3.47 4.20 33214 A Upgrade of pacemaker system 7.84 NA NA 4.57 5.40 33215 A Reposition pacing-defib lead 4.92 NA NA 2.87 3.48 33216 A Insert 1 electrode pm-defib 5.87 NA NA 3.73 4.55 33217 A Insert 2 electrode pm-defib 5.84 NA NA 3.74 4.51 33218 A Repair lead pace-defib, one 6.07 NA NA 4.01 4.81 

3321F I AJCC cncr 0/IA melan docd 0.00 0.00 0.00 0.00 0.00 

33220 A Repair lead pace-defib, dual 6.15 NA NA 4.01 4.82 33222 A Revise pocket, pacemaker 5.10 NA NA 3.81 4.48 33223 A Revise pocket for defib 6.55 NA NA 3.99 4.88 33224 A Insert pacing lead & connect 9.04 NA NA 3.87 4.78 33225 A L ventric pacing lead add-on 8.33 NA NA 3.27 4.10 33226 A Reposition l ventric lead 8.68 NA NA 3.75 4.63 

3322F I Melan >AJCC stage 0 or IA 0.00 0.00 0.00 0.00 0.00 

33233 A Removal of pacemaker system 3.39 NA NA 2.70 3.29 33234 A Removal of pacemaker system 7.91 NA NA 4.52 5.47 33235 A Removal pacemaker electrode 10.15 NA NA 6.10 7.33 
CMS-1503-P 899

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

33236 A Remove electrode/thoracotomy 12.73 NA NA 7.72 8.02 33237 A Remove electrode/thoracotomy 13.84 NA NA 7.60 8.63 33238 A Remove electrode/thoracotomy 15.40 NA NA 9.16 9.40 33240 A Insert pulse generator 7.64 NA NA 4.11 5.11 33241 A Remove pulse generator 3.29 NA NA 2.41 2.98 33243 A Remove eltrd/thoracotomy 23.57 NA NA 11.94 12.84 33244 A Remove eltrd, transven 13.99 NA NA 7.75 9.48 33249 A Eltrd/insert pace-defib 15.17 NA NA 7.91 9.77 

3324F I Mri ct scan ord rvwd rqstd 0.00 0.00 0.00 0.00 0.00 

33250 A Ablate heart dysrhythm focus 25.90 NA NA 12.29 12.70 33251 A Ablate heart dysrhythm focus 28.92 NA NA 13.82 14.01 33254 A Ablate atria, lmtd 23.71 NA NA 12.00 12.25 33255 A Ablate atria w/o bypass, ext 29.04 NA NA 13.81 14.57 33256 A Ablate atria w/bypass, exten 34.90 NA NA 15.83 16.78 33257 A Ablate atria, lmtd, add-on 9.63 NA NA 5.72 5.90 33258 A Ablate atria, x10sv, add-on 11.00 NA NA 6.23 6.44 33259 A Ablate atria w/bypass add-on 14.14 NA NA 8.07 8.36 33261 A Ablate heart dysrhythm focus 28.92 NA NA 13.20 13.62 33265 A Ablate atria, lmtd, endo 23.71 NA NA 11.68 12.04 33266 A Ablate atria, x10sv, endo 33.04 NA NA 15.01 15.60 33282 A Implant pat-active ht record 4.80 NA NA 3.42 4.20 33284 A Remove pat-active ht record 3.14 NA NA 2.78 3.41 

3328F I Prfrmnc docd 2 wks b/4 surg 0.00 0.00 0.00 0.00 0.00 

33300 A Repair of heart wound 44.97 NA NA 18.86 18.22 33305 A Repair of heart wound 76.93 NA NA 30.02 29.02 33310 A Exploratory heart surgery 20.34 NA NA 10.26 10.55 
CMS-1503-P 900

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

33315 A Exploratory heart surgery 26.17 NA NA 12.48 12.93 33320 A Repair major blood vessel(s) 18.54 NA NA 9.41 9.65 33321 A Repair major vessel 20.81 NA NA 10.37 10.60 33322 A Repair major blood vessel(s) 24.42 NA NA 12.07 12.37 33330 A Insert major vessel graft 25.29 NA NA 11.96 12.01 33332 A Insert major vessel graft 24.56 NA NA 11.55 12.13 33335 A Insert major vessel graft 33.91 NA NA 15.30 15.70 33400 A Repair of aortic valve 41.50 NA NA 18.22 18.82 33401 A Valvuloplasty, open 24.63 NA NA 12.37 14.05 33403 A Valvuloplasty, w/cp bypass 25.61 NA NA 13.00 13.90 33404 A Prepare heart-aorta conduit 31.37 NA NA 14.46 15.24 33405 A Replacement of aortic valve 41.32 NA NA 18.53 19.35 33406 A Replacement of aortic valve 52.68 NA NA 22.29 22.99 33410 A Replacement of aortic valve 46.41 NA NA 20.30 20.71 33411 A Replacement of aortic valve 62.07 NA NA 25.83 26.05 33412 A Replacement of aortic valve 43.94 NA NA 19.78 20.93 33413 A Replacement of aortic valve 59.87 NA NA 24.56 25.57 33414 A Repair of aortic valve 39.37 NA NA 16.73 17.56 33415 A Revision, subvalvular tissue 37.27 NA NA 16.02 16.10 33416 A Revise ventricle muscle 36.56 NA NA 16.80 16.93 33417 A Repair of aortic valve 29.33 NA NA 14.33 14.89 33420 A Revision of mitral valve 25.79 NA NA 15.33 13.35 33422 A Revision of mitral valve 29.73 NA NA 13.93 14.60 33425 A Repair of mitral valve 49.96 NA NA 21.58 21.29 33426 A Repair of mitral valve 43.28 NA NA 19.29 19.88 33427 A Repair of mitral valve 44.83 NA NA 19.19 20.14 
CMS-1503-P 901

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

33430 A Replacement of mitral valve 50.93 NA NA 22.69 22.97 33460 A Revision of tricuspid valve 44.70 NA NA 18.02 18.24 33463 A Valvuloplasty, tricuspid 57.08 NA NA 23.79 23.42 33464 A Valvuloplasty, tricuspid 44.62 NA NA 19.65 19.54 33465 A Replace tricuspid valve 50.72 NA NA 21.44 21.21 33468 A Revision of tricuspid valve 32.94 NA NA 14.77 16.12 33470 A Revision of pulmonary valve 21.54 NA NA 12.29 11.93 33471 A Valvotomy, pulmonary valve 22.96 NA NA 12.85 12.55 33472 A Revision of pulmonary valve 23.06 NA NA 10.85 11.65 33474 A Revision of pulmonary valve 39.40 NA NA 16.96 16.42 33475 A Replacement, pulmonary valve 42.40 NA NA 18.49 18.85 33476 A Revision of heart chamber 26.57 NA NA 13.04 13.10 33478 A Revision of heart chamber 27.54 NA NA 13.24 13.79 33496 A Repair, prosth valve clot 29.84 NA NA 13.95 14.40 33500 A Repair heart vessel fistula 27.94 NA NA 12.99 13.50 33501 A Repair heart vessel fistula 19.51 NA NA 9.70 9.95 33502 A Coronary artery correction 21.85 NA NA 11.29 11.68 33503 A Coronary artery graft 22.51 NA NA 11.56 13.40 33504 A Coronary artery graft 25.46 NA NA 12.57 12.88 33505 A Repair artery w/tunnel 38.40 NA NA 15.07 15.40 33506 A Repair artery, translocation 37.85 NA NA 22.35 19.60 33507 A Repair art, intramural 31.40 NA NA 13.20 14.03 33508 A Endoscopic vein harvest 0.31 NA NA 0.11 0.12 33510 A CABG, vein, single 34.98 NA NA 15.97 16.71 33511 A CABG, vein, two 38.45 NA NA 17.40 18.15 33512 A CABG, vein, three 43.98 NA NA 19.42 20.12 
CMS-1503-P 902

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

33513 A CABG, vein, four 45.37 NA NA 19.79 20.21 33514 A CABG, vein, five 48.08 NA NA 20.68 21.43 33516 A Cabg, vein, six or more 49.76 NA NA 21.35 22.27 33517 A CABG, artery-vein, single 3.61 NA NA 1.29 1.31 33518 A CABG, artery-vein, two 7.93 NA NA 2.84 2.83 33519 A CABG, artery-vein, three 10.49 NA NA 3.76 3.79 

3351F I Neg scrn dep symp by deptool 0.00 0.00 0.00 0.00 0.00 

33521 A CABG, artery-vein, four 12.59 NA NA 4.53 4.60 33522 A CABG, artery-vein, five 14.14 NA NA 5.09 5.22 33523 A Cabg, art-vein, six or more 16.08 NA NA 5.75 5.92 

3352F I No sig dep symp by dep tool 0.00 0.00 0.00 0.00 0.00 

33530 A Coronary artery, bypass/reop 10.13 NA NA 3.62 3.59 33533 A CABG, arterial, single 33.75 NA NA 15.36 16.26 33534 A CABG, arterial, two 39.88 NA NA 17.88 18.76 33535 A CABG, arterial, three 44.75 NA NA 19.62 20.48 33536 A Cabg, arterial, four or more 48.43 NA NA 20.99 21.61 

3353F I Mild-mod dep symp by deptool 0.00 0.00 0.00 0.00 0.00 

33542 A Removal of heart lesion 48.21 NA NA 20.71 20.49 33545 A Repair of heart damage 57.06 NA NA 23.76 23.69 33548 A Restore/remodel, ventricle 54.14 NA NA 23.60 24.39 

3354F I Clin sig dep sym by dep tool 0.00 0.00 0.00 0.00 0.00 

33572 A Open coronary endarterectomy 4.44 NA NA 1.59 1.66 33600 A Closure of valve 30.31 NA NA 14.38 14.72 33602 A Closure of valve 29.34 NA NA 14.05 14.07 33606 A Anastomosis/artery-aorta 31.53 NA NA 16.73 16.21 33608 A Repair anomaly w/conduit 31.88 NA NA 14.93 15.72 
CMS-1503-P 903

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

33610 A Repair by enlargement 31.40 NA NA 14.60 15.21 33611 A Repair double ventricle 35.57 NA NA 15.10 15.78 33612 A Repair double ventricle 36.57 NA NA 15.28 15.92 33615 A Repair, modified fontan 35.89 NA NA 16.28 17.16 33617 A Repair single ventricle 39.09 NA NA 17.09 17.44 33619 A Repair single ventricle 48.76 NA NA 25.36 23.27 33641 A Repair heart septum defect 29.58 NA NA 13.53 13.48 33645 A Revision of heart veins 28.10 NA NA 12.96 13.51 33647 A Repair heart septum defects 29.53 NA NA 14.11 15.06 33660 A Repair of heart defects 31.83 NA NA 19.60 17.20 33665 A Repair of heart defects 34.85 NA NA 14.85 15.50 33670 A Repair of heart chambers 36.63 NA NA 14.54 15.20 33675 A Close mult vsd 35.95 NA NA 15.11 15.74 33676 A Close mult vsd w/resection 36.95 NA NA 18.30 17.85 33677 A Cl mult vsd w/rem pul band 38.45 NA NA 13.77 15.86 33681 A Repair heart septum defect 32.34 NA NA 15.88 16.19 33684 A Repair heart septum defect 34.37 NA NA 14.68 15.32 33688 A Repair heart septum defect 34.75 NA NA 13.98 14.32 33690 A Reinforce pulmonary artery 20.36 NA NA 13.04 12.11 33692 A Repair of heart defects 31.54 NA NA 16.04 15.66 33694 A Repair of heart defects 35.57 NA NA 14.94 15.92 33697 A Repair of heart defects 37.57 NA NA 16.44 18.42 33702 A Repair of heart defects 27.24 NA NA 12.98 13.30 33710 A Repair of heart defects 30.41 NA NA 13.93 16.77 33720 A Repair of heart defect 27.26 NA NA 12.85 13.49 33722 A Repair of heart defect 29.21 NA NA 15.03 14.31 
CMS-1503-P 904

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

33724 A Repair venous anomaly 27.63 NA NA 12.59 13.41 33726 A Repair pul venous stenosis 37.12 NA NA 19.08 18.28 33730 A Repair heart-vein defect(s) 36.14 NA NA 15.77 15.67 33732 A Repair heart-vein defect 28.96 NA NA 13.92 14.45 33735 A Revision of heart chamber 22.20 NA NA 11.45 11.72 33736 A Revision of heart chamber 24.32 NA NA 12.18 12.65 33737 A Revision of heart chamber 22.47 NA NA 11.21 11.70 33750 A Major vessel shunt 22.22 NA NA 9.14 11.81 33755 A Major vessel shunt 22.60 NA NA 11.71 11.76 33762 A Major vessel shunt 22.60 NA NA 12.17 12.00 33764 A Major vessel shunt & graft 22.60 NA NA 12.97 12.15 33766 A Major vessel shunt 23.57 NA NA 10.96 12.35 33767 A Major vessel shunt 25.30 NA NA 11.68 11.85 33768 A Cavopulmonary shunting 8.00 NA NA 3.46 3.35 33770 A Repair great vessels defect 39.07 NA NA 15.68 16.51 33771 A Repair great vessels defect 40.63 NA NA 19.02 18.13 33774 A Repair great vessels defect 31.73 NA NA 14.92 15.63 33775 A Repair great vessels defect 32.99 NA NA 17.37 17.19 33776 A Repair great vessels defect 34.75 NA NA 18.46 18.25 33777 A Repair great vessels defect 34.17 NA NA 17.34 17.23 33778 A Repair great vessels defect 42.75 NA NA 21.31 20.82 33779 A Repair great vessels defect 43.23 NA NA 20.42 19.78 33780 A Repair great vessels defect 43.90 NA NA 20.89 20.76 33781 A Repair great vessels defect 43.21 NA NA 20.14 19.23 33782 A Nikaidoh proc 60.08 NA NA 23.63 23.63 33783 A Nikaidoh proc w/ostia implt 65.08 NA NA 25.37 25.37 
CMS-1503-P 905

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

33786 A Repair arterial trunk 41.87 NA NA 16.98 17.98 33788 A Revision of pulmonary artery 27.42 NA NA 12.28 13.05 33800 A Aortic suspension 17.28 NA NA 8.33 8.45 33802 A Repair vessel defect 18.37 NA NA 11.81 10.85 33803 A Repair vessel defect 20.31 NA NA 9.51 9.62 33813 A Repair septal defect 21.36 NA NA 12.15 12.83 33814 A Repair septal defect 26.57 NA NA 12.95 13.50 33820 A Revise major vessel 16.69 NA NA 8.56 9.01 33822 A Revise major vessel 17.71 NA NA 9.95 9.93 33824 A Revise major vessel 20.23 NA NA 11.63 11.38 33840 A Remove aorta constriction 21.34 NA NA 10.93 10.84 33845 A Remove aorta constriction 22.93 NA NA 11.70 12.81 33851 A Remove aorta constriction 21.98 NA NA 18.08 14.82 33852 A Repair septal defect 24.41 NA NA 11.81 12.33 33853 A Repair septal defect 32.51 NA NA 14.98 16.45 33860 A Ascending aortic graft 59.46 NA NA 24.60 24.67 33861 A Ascending aortic graft 44.07 NA NA 19.10 19.83 33863 A Ascending aortic graft 58.79 NA NA 23.56 24.15 33864 A Ascending aortic graft 60.08 NA NA 24.06 24.97 33870 A Transverse aortic arch graft 46.06 NA NA 19.72 20.56 33875 A Thoracic aortic graft 35.78 NA NA 16.84 16.81 33877 A Thoracoabdominal graft 69.03 NA NA 26.65 26.03 33880 A Endovasc taa repr incl subcl 34.58 NA NA 13.61 14.22 33881 A Endovasc taa repr w/o subcl 29.58 NA NA 11.98 12.44 33883 A Insert endovasc prosth, taa 21.09 NA NA 9.12 9.44 33884 A Endovasc prosth, taa, add-on 8.20 NA NA 2.78 2.82 
CMS-1503-P 906

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

33886 A Endovasc prosth, delayed 18.09 NA NA 7.98 8.21 33889 A Artery transpose/endovas taa 15.92 NA NA 5.52 5.48 33891 A Car-car bp grft/endovas taa 20.00 NA NA 6.15 6.41 33910 A Remove lung artery emboli 29.71 NA NA 14.03 14.36 33915 A Remove lung artery emboli 24.95 NA NA 10.36 10.94 33916 A Surgery of great vessel 28.42 NA NA 13.03 14.69 33917 A Repair pulmonary artery 25.30 NA NA 12.65 13.87 33920 A Repair pulmonary atresia 32.74 NA NA 14.25 14.91 33922 A Transect pulmonary artery 24.22 NA NA 11.81 12.22 33924 A Remove pulmonary shunt 5.49 NA NA 1.88 1.96 33925 A Rpr pul art unifocal w/o cpb 31.30 NA NA 13.31 14.37 33926 A Repr pul art, unifocal w/cpb 44.73 NA NA 26.15 21.44 33930 X Removal of donor heart/lung 0.00 0.00 0.00 0.00 0.00 33933 C Prepare donor heart/lung 0.00 0.00 0.00 0.00 0.00 33935 R Transplantation, heart/lung 62.01 NA NA 27.41 28.77 33940 X Removal of donor heart 0.00 0.00 0.00 0.00 0.00 33944 C Prepare donor heart 0.00 0.00 0.00 0.00 0.00 33945 R Transplantation of heart 89.50 NA NA 36.75 36.43 33960 A External circulation assist 19.33 NA NA 6.99 6.97 33961 A External circulation assist 10.91 NA NA 3.93 4.06 33967 A Insert ia percut device 4.84 NA NA 1.87 2.32 33968 A Remove aortic assist device 0.64 NA NA 0.25 0.28 33970 A Aortic circulation assist 6.74 NA NA 2.47 2.81 33971 A Aortic circulation assist 11.99 NA NA 6.62 7.11 33973 A Insert balloon device 9.75 NA NA 3.64 4.13 33974 A Remove intra-aortic balloon 15.03 NA NA 7.91 8.88 
CMS-1503-P 907

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

33975 A Implant ventricular device 20.97 NA NA 7.51 7.87 33976 A Implant ventricular device 22.97 NA NA 8.00 8.84 33977 A Remove ventricular device 20.28 NA NA 11.27 11.78 33978 A Remove ventricular device 22.72 NA NA 12.21 12.54 33979 A Insert intracorporeal device 45.93 NA NA 16.15 17.04 33980 A Remove intracorporeal device 65.20 NA NA 29.25 30.10 33981 C Replace vad pump ext 0.00 0.00 0.00 0.00 0.00 33982 C Replace vad intra w/o bp 0.00 0.00 0.00 0.00 0.00 33983 C Replace vad intra w/bp 0.00 0.00 0.00 0.00 0.00 33999 C Cardiac surgery procedure 0.00 0.00 0.00 0.00 0.00 34001 A Removal of artery clot 17.88 NA NA 8.76 8.50 34051 A Removal of artery clot 16.99 NA NA 8.91 9.01 34101 A Removal of artery clot 10.93 NA NA 5.67 5.66 34111 A Removal of arm artery clot 10.93 NA NA 5.69 5.66 34151 A Removal of artery clot 26.52 NA NA 11.81 11.52 34201 A Removal of artery clot 19.48 NA NA 8.81 8.32 34203 A Removal of leg artery clot 17.86 NA NA 8.48 8.48 34401 A Removal of vein clot 26.52 NA NA 14.36 13.71 34421 A Removal of vein clot 13.37 NA NA 6.81 6.80 34451 A Removal of vein clot 28.52 NA NA 10.62 11.43 34471 A Removal of vein clot 21.11 NA NA 12.03 10.26 34490 A Removal of vein clot 10.91 NA NA 6.00 5.89 34501 A Repair valve, femoral vein 16.85 NA NA 7.66 8.26 34502 A Reconstruct vena cava 28.07 NA NA 13.07 13.32 

3450F I Dyspnea scrnd, no-mild dysp 0.00 0.00 0.00 0.00 0.00 

34510 A Transposition of vein valve 19.91 NA NA 11.53 10.47 
CMS-1503-P 908

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

3451F I Dyspnea scrnd mod-high dysp 0.00 0.00 0.00 0.00 0.00 

34520 A Cross-over vein graft 19.18 NA NA 7.86 8.39 

3452F I Dyspnea not screened 0.00 0.00 0.00 0.00 0.00 

34530 A Leg vein fusion 17.93 NA NA 7.78 8.33 34800 A Endovas aaa repr w/sm tube 21.54 NA NA 9.06 9.47 34802 A Endovas aaa repr w/2-p part 23.79 NA NA 10.10 10.42 34803 A Endovas aaa repr w/3-p part 24.82 NA NA 10.25 10.48 34804 A Endovas aaa repr w/1-p part 23.79 NA NA 10.08 10.41 34805 A Endovas aaa repr w/long tube 22.67 NA NA 9.63 9.72 34806 A Aneurysm press sensor add-on 2.06 NA NA 0.70 0.74 34808 A Endovas iliac a device addon 4.12 NA NA 1.43 1.43 34812 A Xpose for endoprosth, femorl 6.74 NA NA 2.35 2.33 34813 A Femoral endovas graft add-on 4.79 NA NA 1.63 1.61 34820 A Xpose for endoprosth, iliac 9.74 NA NA 3.34 3.36 34825 A Endovasc extend prosth, init 12.80 NA NA 6.24 6.48 34826 A Endovasc exten prosth, addl 4.12 NA NA 1.44 1.47 34830 A Open aortic tube prosth repr 35.23 NA NA 12.77 13.53 34831 A Open aortoiliac prosth repr 37.98 NA NA 13.62 13.95 34832 A Open aortofemor prosth repr 37.98 NA NA 13.62 14.41 34833 A Xpose for endoprosth, iliac 11.98 NA NA 4.41 4.46 34834 A Xpose, endoprosth, brachial 5.34 NA NA 2.08 2.12 34900 A Endovasc iliac repr w/graft 16.85 NA NA 7.60 7.87 

3491F I HIV unsure baby of HIV+moms 0.00 0.00 0.00 0.00 0.00 3497F I CD4+ cell percentage <15% 0.00 0.00 0.00 0.00 0.00 3498F I CD4+ cell percentage >=15% 0.00 0.00 0.00 0.00 0.00 

35001 A Repair defect of artery 20.81 NA NA 9.73 9.95 
CMS-1503-P 909

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

35002 A Repair artery rupture, neck 22.23 NA NA 8.77 9.57 35005 A Repair defect of artery 19.29 NA NA 11.38 10.59 35011 A Repair defect of artery 18.58 NA NA 8.67 8.56 35013 A Repair artery rupture, arm 23.23 NA NA 11.05 10.70 35021 A Repair defect of artery 22.17 NA NA 8.97 9.97 35022 A Repair artery rupture, chest 25.70 NA NA 11.90 11.79 35045 A Repair defect of arm artery 18.01 NA NA 9.13 8.72 35081 A Repair defect of artery 33.53 NA NA 14.42 14.06 35082 A Repair artery rupture, aorta 42.09 NA NA 17.71 17.28 35091 A Repair defect of artery 35.35 NA NA 13.49 13.59 35092 A Repair artery rupture, aorta 50.97 NA NA 19.80 19.55 35102 A Repair defect of artery 36.53 NA NA 15.13 14.84 35103 A Repair artery rupture, groin 43.62 NA NA 17.45 17.27 

3510F I Doc tb scrng-rslts interpd 0.00 0.00 0.00 0.00 0.00 

35111 A Repair defect of artery 26.28 NA NA 14.26 12.83 35112 A Repair artery rupture,spleen 32.57 NA NA 17.11 15.37 35121 A Repair defect of artery 31.52 NA NA 13.64 13.29 35122 A Repair artery rupture, belly 37.89 NA NA 13.59 14.59 35131 A Repair defect of artery 26.40 NA NA 11.56 11.54 35132 A Repair artery rupture, groin 32.57 NA NA 11.96 12.65 

3513F I Hep B scrng docd as done 0.00 0.00 0.00 0.00 0.00 

35141 A Repair defect of artery 20.91 NA NA 9.31 9.29 35142 A Repair artery rupture, thigh 25.16 NA NA 11.02 11.03 

3514F I Hep C scrng docd as done 0.00 0.00 0.00 0.00 0.00 

35151 A Repair defect of artery 23.72 NA NA 10.42 10.37 35152 A Repair artery rupture, knee 27.66 NA NA 10.44 11.20 
CMS-1503-P 910

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

3515F I Pt has docd immun to hep C 0.00 0.00 0.00 0.00 0.00 

35180 A Repair blood vessel lesion 15.10 NA NA 11.10 9.88 35182 A Repair blood vessel lesion 31.71 NA NA 14.79 14.87 35184 A Repair blood vessel lesion 18.82 NA NA 9.25 8.98 35188 A Repair blood vessel lesion 15.16 NA NA 6.59 7.32 35189 A Repair blood vessel lesion 29.98 NA NA 16.00 14.48 35190 A Repair blood vessel lesion 13.42 NA NA 7.11 6.99 35201 A Repair blood vessel lesion 16.93 NA NA 8.72 8.57 35206 A Repair blood vessel lesion 13.84 NA NA 7.36 7.14 35207 A Repair blood vessel lesion 10.94 NA NA 9.66 9.03 35211 A Repair blood vessel lesion 24.58 NA NA 11.80 12.06 35216 A Repair blood vessel lesion 36.61 NA NA 17.67 16.69 35221 A Repair blood vessel lesion 26.62 NA NA 12.20 11.62 35226 A Repair blood vessel lesion 15.30 NA NA 7.36 7.50 35231 A Repair blood vessel lesion 21.16 NA NA 11.45 11.05 35236 A Repair blood vessel lesion 18.02 NA NA 8.71 8.56 35241 A Repair blood vessel lesion 25.58 NA NA 13.01 12.92 35246 A Repair blood vessel lesion 28.23 NA NA 10.74 12.06 35251 A Repair blood vessel lesion 31.91 NA NA 13.95 13.32 35256 A Repair blood vessel lesion 19.06 NA NA 8.66 8.65 35261 A Repair blood vessel lesion 18.96 NA NA 9.52 9.33 35266 A Repair blood vessel lesion 15.83 NA NA 7.71 7.61 35271 A Repair blood vessel lesion 24.58 NA NA 11.82 12.05 35276 A Repair blood vessel lesion 25.83 NA NA 12.33 12.54 35281 A Repair blood vessel lesion 30.06 NA NA 13.64 13.17 35286 A Repair blood vessel lesion 17.19 NA NA 8.41 8.41 
CMS-1503-P 911

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

35301 A Rechanneling of artery 19.61 NA NA 9.03 8.97 35302 A Rechanneling of artery 21.35 NA NA 9.42 9.10 35303 A Rechanneling of artery 23.60 NA NA 10.40 9.97 35304 A Rechanneling of artery 24.60 NA NA 10.55 10.19 35305 A Rechanneling of artery 23.60 NA NA 10.30 9.89 35306 A Rechanneling of artery 9.25 NA NA 3.98 3.45 35311 A Rechanneling of artery 28.60 NA NA 12.01 12.24 35321 A Rechanneling of artery 16.59 NA NA 7.84 7.78 35331 A Rechanneling of artery 27.72 NA NA 12.12 12.17 35341 A Rechanneling of artery 26.21 NA NA 11.02 11.12 35351 A Rechanneling of artery 24.61 NA NA 10.53 10.39 35355 A Rechanneling of artery 19.86 NA NA 8.62 8.57 35361 A Rechanneling of artery 30.24 NA NA 11.24 11.96 35363 A Rechanneling of artery 32.35 NA NA 14.02 14.34 35371 A Rechanneling of artery 15.31 NA NA 7.26 7.20 35372 A Rechanneling of artery 18.58 NA NA 8.31 8.28 35390 A Reoperation, carotid add-on 3.19 NA NA 1.12 1.12 35400 A Angioscopy 3.00 NA NA 1.02 1.05 35450 A Repair arterial blockage 10.05 NA NA 3.82 3.89 35452 A Repair arterial blockage 6.90 NA NA 2.78 2.78 35454 A Repair arterial blockage 6.03 NA NA 2.38 2.41 35456 A Repair arterial blockage 7.34 NA NA 2.89 2.90 35458 A Repair arterial blockage 9.48 NA NA 3.76 3.73 35459 A Repair arterial blockage 8.62 NA NA 3.31 3.39 35460 A Repair venous blockage 6.03 NA NA 2.53 2.45 35470 A Repair arterial blockage 8.62 59.94 70.16 3.35 3.80 
CMS-1503-P 912

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

35471 A Repair arterial blockage 10.05 60.21 73.93 3.96 4.73 35472 A Repair arterial blockage 6.90 46.98 53.91 2.78 3.07 35473 A Repair arterial blockage 6.03 45.52 52.16 2.44 2.75 35474 A Repair arterial blockage 7.35 59.13 69.24 2.91 3.29 35475 R Repair arterial blockage 9.48 52.40 56.10 3.63 3.98 35476 A Repair venous blockage 6.03 40.84 43.75 2.41 2.62 35480 A Atherectomy, open 11.06 NA NA 5.13 4.65 35481 A Atherectomy, open 7.60 NA NA 3.09 3.19 35482 A Atherectomy, open 6.64 NA NA 2.27 2.61 35483 A Atherectomy, open 8.09 NA NA 3.34 3.38 35484 A Atherectomy, open 10.42 NA NA 3.43 3.70 35485 A Atherectomy, open 9.48 NA NA 3.86 3.85 35490 A Atherectomy, percutaneous 11.06 NA NA 4.89 5.62 35491 A Atherectomy, percutaneous 7.60 NA NA 3.54 3.69 35492 A Atherectomy, percutaneous 6.64 NA NA 3.12 3.55 35493 A Atherectomy, percutaneous 8.09 NA NA 3.64 4.23 35494 A Atherectomy, percutaneous 10.42 NA NA 4.48 5.24 35495 A Atherectomy, percutaneous 9.48 NA NA 4.15 4.79 35500 A Harvest vein for bypass 6.44 NA NA 2.23 2.20 35501 A Artery bypass graft 29.09 NA NA 14.25 13.79 35506 A Artery bypass graft 25.33 NA NA 10.66 10.90 35508 A Artery bypass graft 26.09 NA NA 12.06 11.91 35509 A Artery bypass graft 28.09 NA NA 12.28 12.47 

3550F I Low rsk thromboembolism 0.00 0.00 0.00 0.00 0.00 

35510 A Artery bypass graft 24.39 NA NA 9.18 9.88 35511 A Artery bypass graft 22.20 NA NA 12.61 11.38 
CMS-1503-P 913

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

35512 A Artery bypass graft 23.89 NA NA 9.02 9.58 35515 A Artery bypass graft 26.09 NA NA 10.20 10.19 35516 A Artery bypass graft 24.21 NA NA 9.08 9.09 35518 A Artery bypass graft 22.65 NA NA 8.51 9.34 

3551F I Intrmed rsk thromboembolism 0.00 0.00 0.00 0.00 0.00 

35521 A Artery bypass graft 24.13 NA NA 13.48 11.98 35522 A Artery bypass graft 23.15 NA NA 10.18 10.14 35523 A Artery bypass graft 24.13 NA NA 10.91 11.10 35525 A Artery bypass graft 21.69 NA NA 9.81 9.63 35526 A Artery bypass graft 31.55 NA NA 11.67 12.82 

3552F I Hgh risk for thromboembolism 0.00 0.00 0.00 0.00 0.00 

35531 A Artery bypass graft 39.11 NA NA 16.25 15.99 35533 A Artery bypass graft 29.92 NA NA 15.97 14.39 35535 A Artery bypass graft 38.13 NA NA 13.71 15.02 35536 A Artery bypass graft 33.73 NA NA 12.31 12.87 35537 A Artery bypass graft 41.88 NA NA 21.25 18.94 35538 A Artery bypass graft 47.03 NA NA 23.51 21.13 35539 A Artery bypass graft 44.11 NA NA 15.58 16.07 35540 A Artery bypass graft 49.33 NA NA 20.81 19.73 35548 A Artery bypass graft 22.68 NA NA 8.91 9.51 35549 A Artery bypass graft 24.45 NA NA 15.70 13.47 35551 A Artery bypass graft 27.83 NA NA 15.06 13.93 35556 A Artery bypass graft 26.75 NA NA 11.68 11.40 35558 A Artery bypass graft 23.13 NA NA 10.81 10.58 

3555F I Pt inr measurement performed 0.00 0.00 0.00 0.00 0.00 

35560 A Artery bypass graft 34.03 NA NA 12.40 13.30 
CMS-1503-P 914

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

35563 A Artery bypass graft 26.12 NA NA 9.97 10.47 35565 A Artery bypass graft 25.13 NA NA 11.07 11.00 35566 A Artery bypass graft 32.35 NA NA 13.56 13.24 35570 A Artery bypass graft 29.15 NA NA 11.05 12.11 35571 A Artery bypass graft 25.52 NA NA 11.02 11.01 35572 A Harvest femoropopliteal vein 6.81 NA NA 2.45 2.51 35583 A Vein bypass graft 27.75 NA NA 12.07 11.71 35585 A Vein bypass graft 32.35 NA NA 13.87 13.53 35587 A Vein bypass graft 26.21 NA NA 11.73 11.61 35600 A Harvest art for cabg add-on 4.94 NA NA 1.81 1.89 35601 A Artery bypass graft 27.09 NA NA 13.32 12.73 35606 A Artery bypass graft 22.46 NA NA 9.63 9.65 35612 A Artery bypass graft 16.82 NA NA 7.10 7.82 35616 A Artery bypass graft 21.82 NA NA 11.85 10.51 35621 A Artery bypass graft 21.03 NA NA 9.12 9.08 35623 A Bypass graft, not vein 25.92 NA NA 14.25 12.69 35626 A Artery bypass graft 29.14 NA NA 12.75 13.04 35631 A Artery bypass graft 36.03 NA NA 14.29 14.28 35632 A Artery bypass graft 36.13 NA NA 13.10 14.35 35633 A Artery bypass graft 39.11 NA NA 15.24 15.97 35634 A Artery bypass graft 35.33 NA NA 13.72 14.52 35636 A Artery bypass graft 31.75 NA NA 16.76 15.01 35637 A Artery bypass graft 33.05 NA NA 14.02 13.64 35638 A Artery bypass graft 33.60 NA NA 14.41 14.09 35642 A Artery bypass graft 18.94 NA NA 11.74 10.72 35645 A Artery bypass graft 18.43 NA NA 10.73 9.54 
CMS-1503-P 915

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

35646 A Artery bypass graft 32.98 NA NA 13.93 13.90 35647 A Artery bypass graft 29.73 NA NA 12.92 12.82 35650 A Artery bypass graft 20.16 NA NA 9.28 9.10 35651 A Artery bypass graft 26.08 NA NA 9.95 10.82 35654 A Artery bypass graft 26.28 NA NA 11.38 11.28 35656 A Artery bypass graft 20.47 NA NA 9.24 9.16 35661 A Artery bypass graft 20.35 NA NA 9.51 9.45 35663 A Artery bypass graft 23.93 NA NA 10.34 10.41 35665 A Artery bypass graft 22.35 NA NA 9.89 9.87 35666 A Artery bypass graft 23.66 NA NA 11.30 11.26 35671 A Artery bypass graft 20.77 NA NA 10.02 10.01 35681 A Composite bypass graft 1.60 NA NA 0.57 0.56 35682 A Composite bypass graft 7.19 NA NA 2.41 2.41 35683 A Composite bypass graft 8.49 NA NA 2.61 2.72 35685 A Bypass graft patency/patch 4.04 NA NA 1.39 1.37 35686 A Bypass graft/av fist patency 3.34 NA NA 1.14 1.17 35691 A Arterial transposition 18.41 NA NA 7.42 7.97 35693 A Arterial transposition 15.73 NA NA 7.17 7.77 35694 A Arterial transposition 19.28 NA NA 8.62 8.56 35695 A Arterial transposition 20.06 NA NA 7.93 8.43 35697 A Reimplant artery each 3.00 NA NA 1.03 1.03 35700 A Reoperation, bypass graft 3.08 NA NA 1.07 1.07 35701 A Exploration, carotid artery 9.19 NA NA 6.46 6.07 35721 A Exploration, femoral artery 7.72 NA NA 4.71 4.77 

3572F I Pt consid poss risk fx 0.00 0.00 0.00 0.00 0.00 3573F I Pt not consid poss risk fx 0.00 0.00 0.00 0.00 0.00 
CMS-1503-P 916

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

35741 A Exploration popliteal artery 8.69 NA NA 5.29 5.16 35761 A Exploration of artery/vein 5.93 NA NA 4.77 4.60 35800 A Explore neck vessels 8.07 NA NA 5.51 5.31 35820 A Explore chest vessels 36.89 NA NA 15.72 15.21 35840 A Explore abdominal vessels 10.96 NA NA 6.70 6.39 35860 A Explore limb vessels 6.80 NA NA 4.42 4.40 35870 A Repair vessel graft defect 24.50 NA NA 9.47 9.99 35875 A Removal of clot in graft 10.72 NA NA 5.71 5.64 35876 A Removal of clot in graft 17.82 NA NA 8.15 8.04 35879 A Revise graft w/vein 17.41 NA NA 8.10 8.01 35881 A Revise graft w/vein 19.35 NA NA 8.74 8.76 35883 A Revise graft w/nonauto graft 23.15 NA NA 10.04 9.66 35884 A Revise graft w/vein 24.65 NA NA 9.19 9.32 35901 A Excision, graft, neck 8.38 NA NA 5.58 5.55 35903 A Excision, graft, extremity 9.53 NA NA 6.13 6.13 35905 A Excision, graft, thorax 33.52 NA NA 12.25 13.00 35907 A Excision, graft, abdomen 37.27 NA NA 15.31 15.01 36000 A Place needle in vein 0.18 0.47 0.53 0.08 0.08 36002 A Pseudoaneurysm injection trt 1.96 2.37 2.65 0.92 1.02 36005 A Injection ext venography 0.95 8.31 9.00 0.34 0.39 36010 A Place catheter in vein 2.43 11.63 13.65 0.85 0.93 36011 A Place catheter in vein 3.14 20.91 23.32 1.13 1.22 36012 A Place catheter in vein 3.51 20.65 22.10 1.26 1.41 36013 A Place catheter in artery 2.52 19.04 20.82 0.92 0.99 36014 A Place catheter in artery 3.02 19.80 21.48 1.07 1.24 36015 A Place catheter in artery 3.51 21.05 23.10 1.25 1.43 
CMS-1503-P 917

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

36100 A Establish access to artery 3.02 10.70 11.99 1.13 1.28 36120 A Establish access to artery 2.01 10.13 10.89 0.70 0.74 36140 A Establish access to artery 2.01 10.48 11.79 0.73 0.80 36147 A Access av dial grft for eval 3.72 19.47 19.47 1.37 1.37 36148 A Access av dial grft for proc 1.00 6.33 6.33 0.35 0.35 36160 A Establish access to aorta 2.52 10.84 12.41 0.88 1.04 36200 A Place catheter in aorta 3.02 14.04 15.57 1.06 1.17 36215 A Place catheter in artery 4.67 25.88 28.46 1.76 2.01 36216 A Place catheter in artery 5.27 28.59 31.15 2.04 2.29 36217 A Place catheter in artery 6.29 49.15 53.44 2.45 2.73 36218 A Place catheter in artery 1.01 4.04 4.47 0.39 0.43 36245 A Place catheter in artery 4.67 26.00 30.38 1.76 2.12 36246 A Place catheter in artery 5.27 26.81 30.05 1.91 2.18 36247 A Place catheter in artery 6.29 44.40 49.59 2.27 2.58 36248 A Place catheter in artery 1.01 3.13 3.58 0.35 0.41 36260 A Insertion of infusion pump 9.91 NA NA 7.08 6.43 36261 A Revision of infusion pump 5.63 NA NA 4.92 4.52 36262 A Removal of infusion pump 4.11 NA NA 3.99 3.67 36299 C Vessel injection procedure 0.00 0.00 0.00 0.00 0.00 36400 A Bl draw < 3 yrs fem/jugular 0.38 0.50 0.42 0.07 0.08 36405 A Bl draw < 3 yrs scalp vein 0.31 0.32 0.34 0.12 0.11 36406 A Bl draw < 3 yrs other vein 0.18 0.27 0.29 0.07 0.07 36410 A Non-routine bl draw > 3 yrs 0.18 0.40 0.39 0.08 0.07 36415 X Routine venipuncture 0.00 0.00 0.00 0.00 0.00 36416 B Capillary blood draw 0.00 0.00 0.00 0.00 0.00 36420 A Vein access cutdown < 1 yr 1.01 NA NA 0.22 0.26 
CMS-1503-P 918

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

36425 A Vein access cutdown > 1 yr 0.76 NA NA 0.33 0.31 36430 A Blood transfusion service 0.00 0.87 1.00 NA NA 36440 A Bl push transfuse, 2 yr or < 1.03 NA NA 0.49 0.41 36450 A Bl exchange/transfuse, nb 2.23 NA NA 1.06 1.01 36455 A Bl exchange/transfuse non-nb 2.43 NA NA 0.83 0.97 36460 A Transfusion service, fetal 6.58 NA NA 2.96 2.64 36468 R Injection(s), spider veins 0.00 0.00 0.00 0.00 0.00 36469 R Injection(s), spider veins 0.00 0.00 0.00 0.00 0.00 36470 A Injection therapy of vein 1.10 2.86 2.89 0.83 0.82 36471 A Injection therapy of veins 1.65 3.17 3.22 1.09 1.06 36475 A Endovenous rf, 1st vein 6.72 43.24 45.70 2.77 2.71 36476 A Endovenous rf, vein add-on 3.38 7.50 7.70 1.23 1.21 36478 A Endovenous laser, 1st vein 6.72 30.82 34.49 2.70 2.73 36479 A Endovenous laser vein addon 3.38 7.63 8.08 1.27 1.24 36481 A Insertion of catheter, vein 6.98 51.68 28.38 2.88 2.88 36500 A Insertion of catheter, vein 3.51 NA NA 1.31 1.45 

3650F I Eeg ordered rvwd reqstd 0.00 0.00 0.00 0.00 0.00 

36510 A Insertion of catheter, vein 1.09 1.48 1.78 0.52 0.49 36511 A Apheresis wbc 1.74 NA NA 0.85 0.80 36512 A Apheresis rbc 1.74 NA NA 0.84 0.82 36513 A Apheresis platelets 1.74 NA NA 0.95 0.89 36514 A Apheresis plasma 1.74 11.68 13.00 0.76 0.74 36515 A Apheresis, adsorp/reinfuse 1.74 48.65 54.00 0.85 0.76 36516 A Apheresis, selective 1.22 52.68 60.37 0.54 0.52 36522 A Photopheresis 1.67 33.80 37.55 1.16 1.16 36555 A Insert non-tunnel cv cath 2.68 4.50 4.95 0.63 0.72 
CMS-1503-P 919

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

36556 A Insert non-tunnel cv cath 2.50 3.80 4.04 0.82 0.78 36557 A Insert tunneled cv cath 5.14 22.24 21.23 3.54 3.31 36558 A Insert tunneled cv cath 4.84 16.33 18.00 2.71 2.87 36560 A Insert tunneled cv cath 6.29 31.33 30.09 4.05 3.76 36561 A Insert tunneled cv cath 6.04 26.10 27.41 3.51 3.45 36563 A Insert tunneled cv cath 6.24 29.87 29.29 3.82 3.59 36565 A Insert tunneled cv cath 6.04 21.21 22.16 3.30 3.27 36566 A Insert tunneled cv cath 6.54 137.55 122.33 3.63 3.52 36568 A Insert picc cath 1.92 5.58 6.54 0.69 0.73 36569 A Insert picc cath 1.82 4.75 5.51 0.69 0.76 36570 A Insert picvad cath 5.36 23.21 26.86 2.83 3.10 36571 A Insert picvad cath 5.34 29.61 30.79 3.27 3.19 36575 A Repair tunneled cv cath 0.67 3.72 3.94 0.28 0.29 36576 A Repair tunneled cv cath 3.24 6.95 7.18 2.01 2.02 36578 A Replace tunneled cv cath 3.54 10.17 10.88 2.29 2.41 36580 A Replace cvad cath 1.31 4.42 5.04 0.52 0.54 36581 A Replace tunneled cv cath 3.48 16.91 18.37 1.88 2.06 36582 A Replace tunneled cv cath 5.24 24.83 26.04 3.03 3.10 36583 A Replace tunneled cv cath 5.29 31.74 29.50 3.61 3.38 36584 A Replace picc cath 1.20 4.17 4.93 0.62 0.69 36585 A Replace picvad cath 4.84 24.90 26.77 2.76 2.92 36589 A Removal tunneled cv cath 2.28 2.21 2.30 1.50 1.54 36590 A Removal tunneled cv cath 3.35 4.55 4.43 2.17 2.10 36591 T Draw blood off venous device 0.00 0.59 0.66 NA NA 36592 T Collect blood from picc 0.00 0.67 0.73 NA NA 36593 A Declot vascular device 0.00 0.79 0.82 NA NA 
CMS-1503-P 920

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

36595 A Mech remov tunneled cv cath 3.59 11.42 13.19 1.45 1.63 36596 A Mech remov tunneled cv cath 0.75 2.80 3.11 0.47 0.51 36597 A Reposition venous catheter 1.21 2.11 2.35 0.46 0.52 36598 T Inj w/fluor, eval cv device 0.74 2.21 2.48 0.26 0.65 36600 A Withdrawal of arterial blood 0.32 0.51 0.55 0.11 0.10 36620 A Insertion catheter, artery 1.15 NA NA 0.28 0.24 36625 A Insertion catheter, artery 2.11 NA NA 0.70 0.69 36640 A Insertion catheter, artery 2.10 NA NA 1.38 1.27 36660 A Insertion catheter, artery 1.40 NA NA 0.67 0.52 36680 A Insert needle, bone cavity 1.20 NA NA 0.34 0.36 36800 A Insertion of cannula 2.43 NA NA 1.97 1.96 36810 A Insertion of cannula 3.96 NA NA 1.76 1.71 36815 A Insertion of cannula 2.62 NA NA 1.44 1.40 36818 A Av fuse, uppr arm, cephalic 11.89 NA NA 6.33 6.20 36819 A Av fuse, uppr arm, basilic 14.47 NA NA 7.21 7.00 36820 A Av fusion/forearm vein 14.47 NA NA 7.46 7.17 36821 A Av fusion direct any site 12.11 NA NA 6.76 6.37 36822 A Insertion of cannula(s) 5.57 NA NA 4.63 4.72 36823 A Insertion of cannula(s) 22.98 NA NA 12.27 11.75 36825 A Artery-vein autograft 15.13 NA NA 7.77 6.64 36830 A Artery-vein nonautograft 12.03 NA NA 5.79 5.64 36831 A Open thrombect av fistula 8.04 NA NA 4.42 4.30 36832 A Av fistula revision, open 10.53 NA NA 5.26 5.11 36833 A Av fistula revision 11.98 NA NA 5.82 5.65 36835 A Artery to vein shunt 7.51 NA NA 5.84 5.42 36838 A Dist revas ligation, hemo 21.69 NA NA 9.51 9.48 
CMS-1503-P 921

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

36860 A External cannula declotting 2.01 3.69 3.64 1.02 0.92 36861 A Cannula declotting 2.52 NA NA 1.57 1.59 36870 A Percut thrombect av fistula 5.20 44.72 48.60 2.98 3.26 37140 A Revision of circulation 25.23 NA NA 13.94 12.69 37145 A Revision of circulation 26.24 NA NA 14.28 13.48 37160 A Revision of circulation 23.24 NA NA 13.08 11.81 37180 A Revision of circulation 26.24 NA NA 14.37 12.88 37181 A Splice spleen/kidney veins 28.37 NA NA 15.29 13.88 37182 A Insert hepatic shunt (tips) 16.97 NA NA 5.96 7.07 37183 A Remove hepatic shunt (tips) 7.99 145.78 145.78 2.83 3.41 37184 A Prim art mech thrombectomy 8.66 53.20 59.90 3.47 3.83 37185 A Prim art m-thrombect add-on 3.28 17.07 19.28 1.18 1.30 37186 A Sec art m-thrombect add-on 4.92 33.73 39.87 1.80 2.07 37187 A Venous mech thrombectomy 8.03 50.66 57.41 3.08 3.49 37188 A Venous m-thrombectomy add-on 5.71 43.51 49.71 2.31 2.63 37195 C Thrombolytic therapy, stroke 0.00 0.00 0.00 0.00 0.00 37200 A Transcatheter biopsy 4.55 NA NA 1.54 1.83 37201 A Transcatheter therapy infuse 4.99 NA NA 2.41 2.70 37202 A Transcatheter therapy infuse 5.67 NA NA 2.94 3.45 37203 A Transcatheter retrieval 5.02 30.61 33.65 2.01 2.31 37204 A Transcatheter occlusion 18.11 NA NA 6.22 7.13 37205 A Transcath iv stent, percut 8.27 106.19 116.33 3.01 3.58 37206 A Transcath iv stent/perc addl 4.12 64.76 71.03 1.48 1.69 37207 A Transcath iv stent, open 8.27 NA NA 3.24 3.25 37208 A Transcath iv stent/open addl 4.12 NA NA 1.42 1.41 37209 A Change iv cath at thromb tx 2.27 NA NA 0.77 0.87 
CMS-1503-P 922

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

37210 A Embolization uterine fibroid 10.60 84.76 92.32 3.65 4.45 37215 R Transcath stent, cca w/eps 19.68 NA NA 8.88 10.37 37216 N Transcath stent, cca w/o eps 18.95 NA NA 9.92 9.85 37250 A Iv us first vessel add-on 2.10 NA NA 0.74 0.84 37251 A Iv us each add vessel add-on 1.60 NA NA 0.54 0.58 37500 A Endoscopy ligate perf veins 11.67 NA NA 7.08 7.07 37501 C Vascular endoscopy procedure 0.00 0.00 0.00 0.00 0.00 37565 A Ligation of neck vein 12.05 NA NA 7.65 7.11 37600 A Ligation of neck artery 12.42 NA NA 7.08 6.81 37605 A Ligation of neck artery 14.28 NA NA 7.47 7.28 37606 A Ligation of neck artery 8.81 NA NA 4.41 4.87 37607 A Ligation of a-v fistula 6.25 NA NA 4.08 3.98 37609 A Temporal artery procedure 3.05 5.54 5.34 2.64 2.46 37615 A Ligation of neck artery 7.80 NA NA 6.81 5.94 37616 A Ligation of chest artery 18.97 NA NA 10.21 10.10 37617 A Ligation of abdomen artery 23.79 NA NA 11.64 10.93 37618 A Ligation of extremity artery 6.03 NA NA 4.48 4.34 37620 A Revision of major vein 11.57 NA NA 5.81 6.38 37650 A Revision of major vein 8.49 NA NA 4.16 4.73 37660 A Revision of major vein 22.28 NA NA 12.06 10.94 37700 A Revise leg vein 3.82 NA NA 3.13 3.08 37718 A Ligate/strip short leg vein 7.13 NA NA 4.82 4.68 37722 A Ligate/strip long leg vein 8.16 NA NA 5.09 4.93 37735 A Removal of leg veins/lesion 10.90 NA NA 6.12 6.06 37760 A Ligate leg veins radical 10.78 NA NA 7.35 6.61 37761 A Ligate leg veins open 9.13 NA NA 6.14 6.14 
CMS-1503-P 923

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

37765 A Phleb veins - extrem - to 20 7.71 10.42 7.61 NA NA 37766 A Phleb veins - extrem 20+ 9.66 11.80 8.66 NA NA 37780 A Revision of leg vein 3.93 NA NA 3.23 3.19 37785 A Ligate/divide/excise vein 3.93 5.90 5.94 3.24 3.20 37788 A Revascularization, penis 23.33 NA NA 12.62 13.48 37790 A Penile venous occlusion 8.43 NA NA 5.00 5.22 37799 C Vascular surgery procedure 0.00 0.00 0.00 0.00 0.00 38100 A Removal of spleen, total 19.55 NA NA 10.62 9.49 38101 A Removal of spleen, partial 19.55 NA NA 10.89 9.67 38102 A Removal of spleen, total 4.79 NA NA 2.05 1.88 38115 A Repair of ruptured spleen 21.88 NA NA 11.65 10.41 38120 A Laparoscopy, splenectomy 17.07 NA NA 10.56 9.63 38129 C Laparoscope proc, spleen 0.00 0.00 0.00 0.00 0.00 38200 A Injection for spleen x-ray 2.64 NA NA 1.14 1.16 38204 B Bl donor search management 2.00 NA NA 0.86 0.84 38205 R Harvest allogenic stem cells 1.50 NA NA 0.78 0.75 38206 R Harvest auto stem cells 1.50 NA NA 0.78 0.75 38207 I Cryopreserve stem cells 0.89 NA NA 0.38 0.46 38208 I Thaw preserved stem cells 0.56 NA NA 0.24 0.29 38209 I Wash harvest stem cells 0.24 NA NA 0.10 0.12 38210 I T-cell depletion of harvest 1.57 NA NA 0.68 0.81 38211 I Tumor cell deplete of harvst 1.42 NA NA 0.61 0.73 38212 I Rbc depletion of harvest 0.94 NA NA 0.41 0.49 38213 I Platelet deplete of harvest 0.24 NA NA 0.10 0.12 38214 I Volume deplete of harvest 0.81 NA NA 0.35 0.42 38215 I Harvest stem cell concentrte 0.94 NA NA 0.41 0.49 
CMS-1503-P 924

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

38220 A Bone marrow aspiration 1.08 2.85 3.20 0.61 0.61 38221 A Bone marrow biopsy 1.37 2.87 3.29 0.77 0.76 38230 R Bone marrow collection 4.85 NA NA 4.34 4.07 38240 R Bone marrow/stem transplant 2.24 NA NA 1.31 1.27 38241 R Bone marrow/stem transplant 2.24 NA NA 1.30 1.27 38242 A Lymphocyte infuse transplant 1.71 NA NA 1.03 0.98 38300 A Drainage, lymph node lesion 2.36 5.20 5.16 2.66 2.57 38305 A Drainage, lymph node lesion 6.68 NA NA 5.61 5.38 38308 A Incision of lymph channels 6.81 NA NA 5.09 4.75 38380 A Thoracic duct procedure 8.46 NA NA 7.87 7.13 38381 A Thoracic duct procedure 13.38 NA NA 7.51 7.64 38382 A Thoracic duct procedure 10.65 NA NA 6.92 6.81 38500 A Biopsy/removal, lymph nodes 3.79 5.05 4.78 2.92 2.72 38505 A Needle biopsy, lymph nodes 1.14 2.23 2.38 0.80 0.86 38510 A Biopsy/removal, lymph nodes 6.74 7.45 7.03 4.70 4.33 38520 A Biopsy/removal, lymph nodes 7.03 NA NA 5.42 5.08 38525 A Biopsy/removal, lymph nodes 6.43 NA NA 5.03 4.62 38530 A Biopsy/removal, lymph nodes 8.34 NA NA 6.17 5.69 38542 A Explore deep node(s), neck 7.95 NA NA 6.37 5.89 38550 A Removal, neck/armpit lesion 7.11 NA NA 6.27 5.69 38555 A Removal, neck/armpit lesion 15.59 NA NA 10.89 10.24 38562 A Removal, pelvic lymph nodes 11.06 NA NA 7.51 7.32 38564 A Removal, abdomen lymph nodes 11.38 NA NA 7.23 6.82 38570 A Laparoscopy, lymph node biop 9.34 NA NA 5.08 5.09 38571 A Laparoscopy, lymphadenectomy 14.76 NA NA 7.03 7.71 38572 A Laparoscopy, lymphadenectomy 16.94 NA NA 8.70 8.26 
CMS-1503-P 925

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

38589 C Laparoscope proc, lymphatic 0.00 0.00 0.00 0.00 0.00 38700 A Removal of lymph nodes, neck 12.81 NA NA 9.92 8.97 38720 A Removal of lymph nodes, neck 21.95 NA NA 15.57 14.02 38724 A Removal of lymph nodes, neck 23.95 NA NA 17.22 15.28 38740 A Remove armpit lymph nodes 10.70 NA NA 7.42 6.80 38745 A Remove armpit lymph nodes 13.87 NA NA 9.09 8.29 38746 A Remove thoracic lymph nodes 4.88 NA NA 1.77 1.83 38747 A Remove abdominal lymph nodes 4.88 NA NA 2.07 1.90 38760 A Remove groin lymph nodes 13.62 NA NA 8.58 8.01 38765 A Remove groin lymph nodes 21.91 NA NA 12.14 11.42 38770 A Remove pelvis lymph nodes 14.06 NA NA 7.77 7.97 38780 A Remove abdomen lymph nodes 17.70 NA NA 10.09 10.17 38790 A Inject for lymphatic x-ray 1.29 NA NA 0.94 0.93 38792 A Identify sentinel node 0.52 NA NA 0.57 0.58 38794 A Access thoracic lymph duct 4.62 NA NA 3.22 3.65 38999 C Blood/lymph system procedure 0.00 0.00 0.00 0.00 0.00 39000 A Exploration of chest 7.57 NA NA 5.67 5.58 39010 A Exploration of chest 13.19 NA NA 7.47 7.73 39200 A Removal chest lesion 15.09 NA NA 7.80 7.98 39220 A Removal chest lesion 19.55 NA NA 10.27 10.39 39400 A Visualization of chest 8.05 NA NA 5.23 5.30 39499 C Chest procedure 0.00 0.00 0.00 0.00 0.00 39501 A Repair diaphragm laceration 13.98 NA NA 8.32 7.88 39502 A Repair paraesophageal hernia 17.18 NA NA 9.98 9.17 39503 A Repair of diaphragm hernia 108.91 NA NA 51.39 45.17 39520 A Repair of diaphragm hernia 16.74 NA NA 9.50 9.17 
CMS-1503-P 926

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

39530 A Repair of diaphragm hernia 16.30 NA NA 9.03 8.58 39531 A Repair of diaphragm hernia 17.31 NA NA 10.09 9.11 39540 A Repair of diaphragm hernia 14.57 NA NA 8.64 7.93 39541 A Repair of diaphragm hernia 15.75 NA NA 9.08 8.43 39545 A Revision of diaphragm 14.67 NA NA 8.61 8.68 39560 A Resect diaphragm, simple 13.06 NA NA 7.72 7.41 39561 A Resect diaphragm, complex 19.99 NA NA 12.81 12.20 39599 C Diaphragm surgery procedure 0.00 0.00 0.00 0.00 0.00 

4004F I Pt tobacco use done rcvd tlk 0.00 0.00 0.00 0.00 0.00 

40490 A Biopsy of lip 1.22 2.34 2.35 0.87 0.81 40500 A Partial excision of lip 4.47 9.80 9.47 5.85 5.55 40510 A Partial excision of lip 4.82 8.81 8.46 5.28 4.93 40520 A Partial excision of lip 4.79 9.01 8.77 5.37 5.04 40525 A Reconstruct lip with flap 7.72 NA NA 7.81 7.38 40527 A Reconstruct lip with flap 9.32 NA NA 8.43 8.19 40530 A Partial removal of lip 5.54 9.66 9.39 5.89 5.57 

4063F I Antidepres rxthxpy not rxd 0.00 0.00 0.00 0.00 0.00 

40650 A Repair lip 3.78 7.80 7.60 4.20 4.03 40652 A Repair lip 4.43 9.07 8.87 5.40 5.14 40654 A Repair lip 5.48 10.39 10.14 6.41 6.10 40700 A Repair cleft lip/nasal 14.17 NA NA 14.13 12.32 40701 A Repair cleft lip/nasal 17.23 NA NA 13.54 13.27 40702 A Repair cleft lip/nasal 14.27 NA NA 8.96 9.01 40720 A Repair cleft lip/nasal 14.72 NA NA 11.81 11.33 40761 A Repair cleft lip/nasal 15.84 NA NA 14.67 13.27 40799 C Lip surgery procedure 0.00 0.00 0.00 0.00 0.00 
CMS-1503-P 927

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

40800 A Drainage of mouth lesion 1.23 4.68 4.51 2.48 2.36 40801 A Drainage of mouth lesion 2.63 6.25 5.96 3.68 3.45 40804 A Removal, foreign body, mouth 1.30 4.89 4.64 2.53 2.37 40805 A Removal, foreign body, mouth 2.79 6.38 6.14 3.63 3.44 40806 A Incision of lip fold 0.31 2.66 2.68 0.51 0.56 40808 A Biopsy of mouth lesion 1.01 4.30 4.16 2.09 2.01 40810 A Excision of mouth lesion 1.36 4.52 4.34 2.30 2.18 40812 A Excise/repair mouth lesion 2.37 5.78 5.51 3.27 3.05 40814 A Excise/repair mouth lesion 3.52 7.42 7.02 5.20 4.88 40816 A Excision of mouth lesion 3.77 7.69 7.31 5.30 4.99 40818 A Excise oral mucosa for graft 2.83 7.15 7.00 4.81 4.73 40819 A Excise lip or cheek fold 2.51 6.18 5.92 4.19 3.97 40820 A Treatment of mouth lesion 1.34 6.16 6.09 3.56 3.50 40830 A Repair mouth laceration 1.82 5.16 4.96 2.65 2.54 40831 A Repair mouth laceration 2.57 6.78 6.45 3.69 3.55 40840 R Reconstruction of mouth 9.15 15.44 13.84 9.74 8.57 40842 R Reconstruction of mouth 9.15 13.83 12.84 9.27 8.14 40843 R Reconstruction of mouth 12.79 16.79 15.62 9.80 8.90 40844 R Reconstruction of mouth 16.80 21.94 20.60 15.76 14.12 40845 R Reconstruction of mouth 19.36 22.03 20.88 15.51 14.48 40899 C Mouth surgery procedure 0.00 0.00 0.00 0.00 0.00 41000 A Drainage of mouth lesion 1.35 3.24 3.11 1.84 1.74 41005 A Drainage of mouth lesion 1.31 4.99 4.96 2.36 2.26 41006 A Drainage of mouth lesion 3.34 6.94 6.62 4.25 3.89 41007 A Drainage of mouth lesion 3.20 6.94 6.74 3.87 3.69 41008 A Drainage of mouth lesion 3.46 7.23 6.83 4.23 3.93 
CMS-1503-P 928

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

41009 A Drainage of mouth lesion 3.71 7.67 7.24 4.64 4.32 41010 A Incision of tongue fold 1.11 4.77 4.66 2.04 1.97 41015 A Drainage of mouth lesion 4.08 8.63 7.94 5.82 5.34 41016 A Drainage of mouth lesion 4.19 8.25 7.81 5.82 5.43 41017 A Drainage of mouth lesion 4.19 8.38 7.93 5.86 5.48 41018 A Drainage of mouth lesion 5.22 8.79 8.39 6.18 5.84 41019 A Place needles h&n for rt 8.84 NA NA 4.78 4.52 41100 A Biopsy of tongue 1.42 3.37 3.26 1.67 1.59 41105 A Biopsy of tongue 1.47 3.40 3.25 1.73 1.62 41108 A Biopsy of floor of mouth 1.10 3.13 3.01 1.50 1.41 41110 A Excision of tongue lesion 1.56 4.53 4.35 2.23 2.11 41112 A Excision of tongue lesion 2.83 6.70 6.40 4.43 4.18 41113 A Excision of tongue lesion 3.29 7.10 6.76 4.74 4.44 41114 A Excision of tongue lesion 8.82 NA NA 9.43 8.74 41115 A Excision of tongue fold 1.79 5.17 5.01 2.56 2.37 41116 A Excision of mouth lesion 2.52 6.93 6.61 3.80 3.59 41120 A Partial removal of tongue 11.14 NA NA 18.83 18.25 41130 A Partial removal of tongue 15.74 NA NA 21.48 20.42 41135 A Tongue and neck surgery 30.14 NA NA 31.21 29.21 

41140 A Removal of tongue 29.15 NA NA 33.27 31.63 41145 A Tongue removal, neck surgery 37.93 NA NA 41.01 38.48 

41150 A Tongue, mouth, jaw surgery 29.86 NA NA 32.33 30.53 

41153 A Tongue, mouth, neck surgery 33.59 NA NA 34.21 31.96 

41155 A Tongue, jaw, & neck surgery 44.30 NA NA 40.59 37.26 

41250 A Repair tongue laceration 1.96 5.08 4.63 2.20 1.99 41251 A Repair tongue laceration 2.32 5.28 4.62 2.45 2.23 
CMS-1503-P 929

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

41252 A Repair tongue laceration 3.02 5.84 5.51 2.93 2.75 41500 A Fixation of tongue 3.80 NA NA 9.19 8.89 41510 A Tongue to lip surgery 3.51 NA NA 6.44 7.17 

41512 A Tongue suspension 6.86 NA NA 11.44 10.82 

41520 A Reconstruction, tongue fold 2.83 7.12 6.83 4.50 4.26 41530 A Tongue base vol reduction 4.51 88.45 88.27 7.42 7.07 

41599 C Tongue and mouth surgery 0.00 0.00 0.00 0.00 0.00 41800 A Drainage of gum lesion 1.27 6.03 5.55 2.73 2.51 41805 A Removal foreign body, gum 1.34 5.60 5.39 3.50 3.36 41806 A Removal foreign body,jawbone 2.79 7.54 6.97 4.71 4.36 41820 R Excision, gum, each quadrant 0.00 0.00 0.00 0.00 0.00 41821 R Excision of gum flap 0.00 0.00 0.00 0.00 0.00 41822 R Excision of gum lesion 2.41 5.80 5.55 2.83 2.51 41823 R Excision of gum lesion 3.77 8.33 8.02 5.48 5.12 41825 A Excision of gum lesion 1.41 4.54 4.39 2.07 2.05 41826 A Excision of gum lesion 2.41 6.44 5.90 3.65 3.33 41827 A Excision of gum lesion 3.83 8.59 8.15 4.97 4.61 41828 R Excision of gum lesion 3.14 5.54 5.18 2.98 2.71 41830 R Removal of gum tissue 3.45 7.65 7.25 4.66 4.29 41850 R Treatment of gum lesion 0.00 0.00 0.00 0.00 0.00 41870 R Gum graft 0.00 0.00 0.00 0.00 0.00 41872 R Repair gum 3.01 7.24 7.04 4.43 4.23 41874 R Repair tooth socket 3.19 7.35 6.98 4.11 3.80 41899 C Dental surgery procedure 0.00 0.00 0.00 0.00 0.00 42000 A Drainage mouth roof lesion 1.28 3.17 3.09 1.71 1.60 42100 A Biopsy roof of mouth 1.36 2.92 2.80 1.78 1.67 
CMS-1503-P 930

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

42104 A Excision lesion, mouth roof 1.69 4.48 4.23 2.32 2.15 42106 A Excision lesion, mouth roof 2.15 5.60 5.30 2.95 2.80 42107 A Excision lesion, mouth roof 4.56 8.56 8.13 5.35 4.99 42120 A Remove palate/lesion 11.86 NA NA 16.62 15.67 42140 A Excision of uvula 1.70 5.62 5.42 2.79 2.67 42145 A Repair palate, pharynx/uvula 9.78 NA NA 10.51 9.81 42160 A Treatment mouth roof lesion 1.85 4.81 4.77 2.38 2.32 42180 A Repair palate 2.55 3.90 3.93 2.33 2.35 42182 A Repair palate 3.87 5.36 5.11 3.52 3.34 42200 A Reconstruct cleft palate 12.53 NA NA 11.95 11.44 42205 A Reconstruct cleft palate 13.66 NA NA 14.21 12.64 42210 A Reconstruct cleft palate 15.03 NA NA 13.41 13.03 42215 A Reconstruct cleft palate 8.99 NA NA 11.31 10.41 42220 A Reconstruct cleft palate 7.16 NA NA 8.15 7.78 42225 A Reconstruct cleft palate 9.77 NA NA 15.53 15.80 42226 A Lengthening of palate 10.35 NA NA 15.38 15.22 42227 A Lengthening of palate 9.90 NA NA 14.23 14.52 42235 A Repair palate 8.01 NA NA 13.14 12.71 42260 A Repair nose to lip fistula 10.22 13.14 12.46 8.77 8.18 42280 A Preparation, palate mold 1.59 3.02 2.81 1.55 1.34 42281 A Insertion, palate prosthesis 1.98 3.92 3.71 2.37 2.24 42299 C Palate/uvula surgery 0.00 0.00 0.00 0.00 0.00 42300 A Drainage of salivary gland 1.98 4.03 3.84 2.41 2.27 42305 A Drainage of salivary gland 6.31 NA NA 5.94 5.57 42310 A Drainage of salivary gland 1.61 3.05 2.91 1.98 1.87 42320 A Drainage of salivary gland 2.40 4.81 4.58 2.67 2.52 
CMS-1503-P 931

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

42330 A Removal of salivary stone 2.26 4.40 4.21 2.48 2.32 42335 A Removal of salivary stone 3.41 7.36 7.02 4.02 3.80 42340 A Removal of salivary stone 4.72 8.58 8.20 4.95 4.67 42400 A Biopsy of salivary gland 0.78 2.26 2.26 0.80 0.80 42405 A Biopsy of salivary gland 3.34 5.13 4.98 3.09 2.92 42408 A Excision of salivary cyst 4.66 8.46 8.02 4.81 4.46 42409 A Drainage of salivary cyst 2.91 6.72 6.41 3.51 3.32 42410 A Excise parotid gland/lesion 9.57 NA NA 8.01 7.45 42415 A Excise parotid gland/lesion 18.12 NA NA 13.51 12.49 42420 A Excise parotid gland/lesion 21.00 NA NA 15.19 14.01 42425 A Excise parotid gland/lesion 13.42 NA NA 10.40 9.70 42426 A Excise parotid gland/lesion 22.66 NA NA 15.78 14.61 42440 A Excise submaxillary gland 7.13 NA NA 6.21 5.77 42450 A Excise sublingual gland 4.74 8.22 7.86 5.56 5.25 42500 A Repair salivary duct 4.42 7.99 7.63 5.40 5.11 42505 A Repair salivary duct 6.32 9.59 9.14 6.70 6.31 42507 A Parotid duct diversion 6.25 NA NA 8.55 8.17 42508 A Parotid duct diversion 9.33 NA NA 10.54 10.39 42509 A Parotid duct diversion 11.76 NA NA 9.97 10.28 42510 A Parotid duct diversion 8.35 NA NA 9.76 9.24 42550 A Injection for salivary x-ray 1.25 2.30 2.67 0.44 0.50 42600 A Closure of salivary fistula 4.94 8.88 8.55 5.10 4.85 

4260F I Wound srfc culturetech used 0.00 0.00 0.00 0.00 0.00 4261F I Tech other than surfc cultr 0.00 0.00 0.00 0.00 0.00 

42650 A Dilation of salivary duct 0.77 1.64 1.56 0.92 0.87 

4265F I Wet-dry dressings Rx-recmd 0.00 0.00 0.00 0.00 0.00 
CMS-1503-P 932

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

42660 A Dilation of salivary duct 1.13 1.92 1.83 1.11 1.04 42665 A Ligation of salivary duct 2.63 6.44 6.14 3.35 3.18 

4266F I No wet-dry drssings Rx-recmd 0.00 0.00 0.00 0.00 0.00 4268F I Pt ed re comp thxpy rcvd 0.00 0.00 0.00 0.00 0.00 

42699 C Salivary surgery procedure 0.00 0.00 0.00 0.00 0.00 

4269F I Appropos mthd offloading Rxd 0.00 0.00 0.00 0.00 0.00 

42700 A Drainage of tonsil abscess 1.67 3.75 3.61 2.22 2.12 42720 A Drainage of throat abscess 6.31 6.70 6.28 4.94 4.56 42725 A Drainage of throat abscess 12.41 NA NA 10.80 10.03 

4275F I Hep b vac inj admin/ rcvd 0.00 0.00 0.00 0.00 0.00 4279F I PCP prophylaxis Rxd 0.00 0.00 0.00 0.00 0.00 

42800 A Biopsy of throat 1.44 3.13 3.00 1.79 1.70 42802 A Biopsy of throat 1.59 5.08 5.11 2.24 2.19 42804 A Biopsy of upper nose/throat 1.29 4.40 4.37 1.99 1.94 42806 A Biopsy of upper nose/throat 1.63 4.74 4.70 2.18 2.12 42808 A Excise pharynx lesion 2.35 4.20 4.02 2.32 2.20 42809 A Remove pharynx foreign body 1.86 2.97 2.85 1.86 1.73 42810 A Excision of neck cyst 3.38 7.84 7.54 4.99 4.70 42815 A Excision of neck cyst 7.31 NA NA 8.64 8.16 42820 A Remove tonsils and adenoids 4.22 NA NA 4.14 3.88 42821 A Remove tonsils and adenoids 4.36 NA NA 4.33 4.08 42825 A Removal of tonsils 3.51 NA NA 4.04 3.83 42826 A Removal of tonsils 3.45 NA NA 3.79 3.59 42830 A Removal of adenoids 2.65 NA NA 3.33 3.16 42831 A Removal of adenoids 2.81 NA NA 3.64 3.47 42835 A Removal of adenoids 2.38 NA NA 2.54 2.61 
CMS-1503-P 933

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

42836 A Removal of adenoids 3.26 NA NA 3.68 3.50 42842 A Extensive surgery of throat 12.23 NA NA 16.39 15.35 42844 A Extensive surgery of throat 17.78 NA NA 21.50 20.33 42845 A Extensive surgery of throat 32.56 NA NA 31.09 28.97 42860 A Excision of tonsil tags 2.30 NA NA 3.13 2.98 42870 A Excision of lingual tonsil 5.52 NA NA 11.16 10.80 42890 A Partial removal of pharynx 19.13 NA NA 21.40 19.86 42892 A Revision of pharyngeal walls 26.03 NA NA 27.69 25.32 42894 A Revision of pharyngeal walls 33.92 NA NA 33.77 31.13 42900 A Repair throat wound 5.29 NA NA 4.46 4.16 42950 A Reconstruction of throat 8.27 NA NA 14.41 14.01 42953 A Repair throat, esophagus 9.45 NA NA 17.80 17.69 42955 A Surgical opening of throat 8.01 NA NA 13.64 13.03 42960 A Control throat bleeding 2.38 NA NA 2.48 2.33 42961 A Control throat bleeding 5.77 NA NA 6.33 5.97 42962 A Control throat bleeding 7.40 NA NA 7.48 7.05 42970 A Control nose/throat bleeding 5.82 NA NA 5.43 5.02 42971 A Control nose/throat bleeding 6.60 NA NA 6.58 6.14 42972 A Control nose/throat bleeding 7.59 NA NA 7.15 6.65 42999 C Throat surgery procedure 0.00 0.00 0.00 0.00 0.00 

4300F I Pt rcvng warf thxpy 0.00 0.00 0.00 0.00 0.00 4301F I Pt not rcvng warf thxpy 0.00 0.00 0.00 0.00 0.00 

43020 A Incision of esophagus 8.23 NA NA 7.29 6.47 43030 A Throat muscle surgery 7.99 NA NA 6.73 6.32 43045 A Incision of esophagus 21.88 NA NA 11.98 12.15 

4305F I Pt ed re ft care inspct rcvd 0.00 0.00 0.00 0.00 0.00 
CMS-1503-P 934

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

4306F I Pt tlk psych & Rx opd addic 0.00 0.00 0.00 0.00 0.00 

43100 A Excision of esophagus lesion 9.66 NA NA 8.37 7.63 43101 A Excision of esophagus lesion 17.07 NA NA 9.09 9.22 43107 A Removal of esophagus 44.18 NA NA 22.36 21.75 43108 A Removal of esophagus 82.87 NA NA 39.73 34.35 43112 A Removal of esophagus 47.48 NA NA 22.24 22.16 43113 A Removal of esophagus 80.06 NA NA 39.87 35.93 43116 A Partial removal of esophagus 92.99 NA NA 57.11 46.42 43117 A Partial removal of esophagus 43.65 NA NA 20.54 20.25 43118 A Partial removal of esophagus 67.07 NA NA 32.93 28.81 43121 A Partial removal of esophagus 51.43 NA NA 22.70 22.03 43122 A Partial removal of esophagus 44.18 NA NA 22.33 21.22 43123 A Partial removal of esophagus 83.12 NA NA 41.19 35.25 43124 A Removal of esophagus 69.09 NA NA 36.00 31.69 43130 A Removal of esophagus pouch 12.53 NA NA 9.43 8.89 43135 A Removal of esophagus pouch 26.17 NA NA 12.98 12.44 43200 A Esophagus endoscopy 1.59 4.43 4.49 1.35 1.29 43201 A Esoph scope w/submucous inj 2.09 6.06 6.22 1.46 1.45 43202 A Esophagus endoscopy, biopsy 1.89 5.91 6.07 1.30 1.25 43204 A Esoph scope w/sclerosis inj 3.76 NA NA 2.23 2.28 43205 A Esophagus endoscopy/ligation 3.78 NA NA 2.35 2.35 

4320F I Pt talk psychsoc+rx oh dpnd 0.00 0.00 0.00 0.00 0.00 

43215 A Esophagus endoscopy 2.60 NA NA 1.64 1.60 43216 A Esophagus endoscopy/lesion 2.40 3.57 3.31 1.56 1.52 43217 A Esophagus endoscopy 2.90 7.48 7.66 1.77 1.71 43219 A Esophagus endoscopy 2.80 NA NA 1.83 1.84 
CMS-1503-P 935

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

43220 A Esoph endoscopy, dilation 2.10 NA NA 1.42 1.38 43226 A Esoph endoscopy, dilation 2.34 NA NA 1.52 1.51 43227 A Esoph endoscopy, repair 3.59 NA NA 2.18 2.14 43228 A Esoph endoscopy, ablation 3.76 NA NA 2.33 2.31 43231 A Esoph endoscopy w/us exam 3.19 NA NA 2.02 2.02 43232 A Esoph endoscopy w/us fn bx 4.47 NA NA 2.68 2.67 43234 A Upper GI endoscopy, exam 2.01 5.65 5.83 1.30 1.25 43235 A Uppr gi endoscopy, diagnosis 2.39 5.59 5.90 1.58 1.57 43236 A Uppr gi scope w/submuc inj 2.92 6.96 7.39 1.88 1.89 43237 A Endoscopic us exam, esoph 3.98 NA NA 2.44 2.46 43238 A Uppr gi endoscopy w/us fn bx 5.02 NA NA 2.98 3.01 43239 A Upper GI endoscopy, biopsy 2.87 6.43 6.75 1.84 1.82 43240 A Esoph endoscope w/drain cyst 6.85 NA NA 3.99 3.97 43241 A Upper GI endoscopy with tube 2.59 NA NA 1.68 1.66 43242 A Uppr gi endoscopy w/us fn bx 7.30 NA NA 4.28 4.28 43243 A Upper gi endoscopy & inject 4.56 NA NA 2.75 2.75 43244 A Upper GI endoscopy/ligation 5.04 NA NA 3.05 3.05 43245 A Uppr gi scope dilate strictr 3.18 NA NA 1.96 1.93 43246 A Place gastrostomy tube 4.32 NA NA 2.53 2.51 43247 A Operative upper GI endoscopy 3.38 NA NA 2.10 2.09 43248 A Uppr gi endoscopy/guide wire 3.15 NA NA 2.02 2.03 43249 A Esoph endoscopy, dilation 2.90 NA NA 1.87 1.87 43250 A Upper GI endoscopy/tumor 3.20 NA NA 1.96 1.92 43251 A Operative upper GI endoscopy 3.69 NA NA 2.28 2.26 43255 A Operative upper GI endoscopy 4.81 NA NA 2.92 2.92 43256 A Uppr gi endoscopy w/stent 4.34 NA NA 2.59 2.59 
CMS-1503-P 936

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

43257 A Uppr gi scope w/thrml txmnt 5.50 NA NA 3.39 3.20 43258 A Operative upper GI endoscopy 4.54 NA NA 2.75 2.75 43259 A Endoscopic ultrasound exam 5.19 NA NA 3.13 3.13 43260 A Endo cholangiopancreatograph 5.95 NA NA 3.53 3.54 43261 A Endo cholangiopancreatograph 6.26 NA NA 3.71 3.72 43262 A Endo cholangiopancreatograph 7.38 NA NA 4.32 4.33 43263 A Endo cholangiopancreatograph 7.28 NA NA 4.19 4.25 43264 A Endo cholangiopancreatograph 8.89 NA NA 5.14 5.15 43265 A Endo cholangiopancreatograph 10.00 NA NA 5.74 5.75 43267 A Endo cholangiopancreatograph 7.38 NA NA 4.27 4.27 43268 A Endo cholangiopancreatograph 7.38 NA NA 4.48 4.49 43269 A Endo cholangiopancreatograph 8.20 NA NA 4.76 4.77 43271 A Endo cholangiopancreatograph 7.38 NA NA 4.31 4.32 43272 A Endo cholangiopancreatograph 7.38 NA NA 4.35 4.33 43273 A Endoscopic pancreatoscopy 2.24 NA NA 1.22 1.26 43279 A Lap myotomy, heller 22.10 NA NA 11.86 10.80 43280 A Laparoscopy, fundoplasty 18.10 NA NA 10.27 9.38 43281 A Lap paraesophag hern repair 26.60 NA NA 13.93 13.93 43282 A Lap paraesoph her rpr w/mesh 30.10 NA NA 15.42 15.42 43289 C Laparoscope proc, esoph 0.00 0.00 0.00 0.00 0.00 43300 A Repair of esophagus 9.33 NA NA 8.37 7.69 43305 A Repair esophagus and fistula 18.10 NA NA 13.27 12.19 

4330F I Cnslng epi spec sfty issues 0.00 0.00 0.00 0.00 0.00 

43310 A Repair of esophagus 26.26 NA NA 12.22 12.57 43312 A Repair esophagus and fistula 29.25 NA NA 12.09 12.96 43313 A Esophagoplasty congenital 48.45 NA NA 25.63 23.21 
CMS-1503-P 937

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

43314 A Tracheo-esophagoplasty cong 53.43 NA NA 22.75 24.38 43320 A Fuse esophagus & stomach 23.31 NA NA 13.19 12.35 43324 A Revise esophagus & stomach 22.99 NA NA 12.40 11.50 43325 A Revise esophagus & stomach 22.60 NA NA 12.19 11.37 43326 A Revise esophagus & stomach 22.28 NA NA 12.32 11.92 43330 A Repair of esophagus 22.19 NA NA 12.25 11.26 43331 A Repair of esophagus 23.06 NA NA 12.06 12.16 43340 A Fuse esophagus & intestine 22.99 NA NA 13.06 12.00 43341 A Fuse esophagus & intestine 24.23 NA NA 14.62 13.91 43350 A Surgical opening, esophagus 19.49 NA NA 14.14 12.15 43351 A Surgical opening, esophagus 22.05 NA NA 11.70 11.96 43352 A Surgical opening, esophagus 17.81 NA NA 9.97 10.09 43360 A Gastrointestinal repair 40.11 NA NA 18.39 18.64 43361 A Gastrointestinal repair 45.68 NA NA 20.18 20.49 43400 A Ligate esophagus veins 25.60 NA NA 14.18 15.40 43401 A Esophagus surgery for veins 26.49 NA NA 14.56 13.27 43405 A Ligate/staple esophagus 24.73 NA NA 15.68 14.31 

4340F I Cnslng chldbrng+ women epi 0.00 0.00 0.00 0.00 0.00 

43410 A Repair esophagus wound 16.41 NA NA 11.16 10.42 43415 A Repair esophagus wound 28.91 NA NA 16.04 15.41 43420 A Repair esophagus opening 16.78 NA NA 12.48 10.98 43425 A Repair esophagus opening 25.04 NA NA 14.97 14.20 43450 A Dilate esophagus 1.38 2.82 2.99 1.05 1.06 43453 A Dilate esophagus 1.51 6.41 6.86 1.12 1.13 43456 A Dilate esophagus 2.57 13.49 14.45 1.69 1.67 43458 A Dilate esophagus 3.06 7.49 7.80 1.94 1.90 
CMS-1503-P 938

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

43460 A Pressure treatment esophagus 3.79 NA NA 2.38 2.27 43496 C Free jejunum flap, microvasc 0.00 0.00 0.00 0.00 0.00 43499 C Esophagus surgery procedure 0.00 0.00 0.00 0.00 0.00 43500 A Surgical opening of stomach 12.79 NA NA 7.80 7.11 43501 A Surgical repair of stomach 22.60 NA NA 12.61 11.39 43502 A Surgical repair of stomach 25.69 NA NA 14.17 12.73 43510 A Surgical opening of stomach 15.14 NA NA 11.13 10.10 43520 A Incision of pyloric muscle 11.29 NA NA 6.72 6.42 43600 A Biopsy of stomach 1.91 NA NA 0.97 0.97 43605 A Biopsy of stomach 13.72 NA NA 8.18 7.39 43610 A Excision of stomach lesion 16.34 NA NA 9.36 8.46 43611 A Excision of stomach lesion 20.38 NA NA 11.60 10.51 43620 A Removal of stomach 34.04 NA NA 17.33 15.74 43621 A Removal of stomach 39.53 NA NA 19.65 17.58 43622 A Removal of stomach 40.03 NA NA 20.04 17.86 43631 A Removal of stomach, partial 24.51 NA NA 13.45 12.18 43632 A Removal of stomach, partial 35.14 NA NA 17.94 15.73 43633 A Removal of stomach, partial 33.14 NA NA 17.11 15.09 43634 A Removal of stomach, partial 36.64 NA NA 18.88 16.65 43635 A Removal of stomach, partial 2.06 NA NA 0.88 0.79 43640 A Vagotomy & pylorus repair 19.56 NA NA 11.38 10.24 43641 A Vagotomy & pylorus repair 19.81 NA NA 11.64 10.37 43644 A Lap gastric bypass/roux-en-y 29.40 NA NA 15.93 14.48 43645 A Lap gastr bypass incl smll i 31.53 NA NA 16.82 15.26 43647 C Lap impl electrode, antrum 0.00 0.00 0.00 0.00 0.00 43648 C Lap revise/remv eltrd antrum 0.00 0.00 0.00 0.00 0.00 
CMS-1503-P 939

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

43651 A Laparoscopy, vagus nerve 10.13 NA NA 7.05 6.43 43652 A Laparoscopy, vagus nerve 12.13 NA NA 7.91 7.20 43653 A Laparoscopy, gastrostomy 8.48 NA NA 6.54 5.97 43659 C Laparoscope proc, stom 0.00 0.00 0.00 0.00 0.00 43752 A Nasal/orogastric w/stent 0.81 NA NA 0.30 0.32 43760 A Change gastrostomy tube 0.90 11.99 10.63 0.41 0.43 43761 A Reposition gastrostomy tube 2.01 1.16 1.26 0.79 0.85 

43770 A Lap place gastr adj device 18.00 NA NA 11.35 10.34 43771 A Lap revise gastr adj device 20.79 NA NA 12.58 11.41 43772 A Lap rmvl gastr adj device 15.70 NA NA 9.35 8.54 43773 A Lap replace gastr adj device 20.79 NA NA 12.56 11.41 43774 A Lap rmvl gastr adj all parts 15.76 NA NA 9.35 8.56 43775 A Lap sleeve gastrectomy 21.56 NA NA 12.74 12.74 43800 A Reconstruction of pylorus 15.43 NA NA 8.87 8.08 43810 A Fusion of stomach and bowel 16.88 NA NA 9.71 8.72 43820 A Fusion of stomach and bowel 22.53 NA NA 12.59 11.10 43825 A Fusion of stomach and bowel 21.76 NA NA 12.51 11.20 43830 A Place gastrostomy tube 10.85 NA NA 7.58 6.93 43831 A Place gastrostomy tube 8.49 NA NA 7.19 6.60 43832 A Place gastrostomy tube 17.34 NA NA 10.23 9.49 43840 A Repair of stomach lesion 22.83 NA NA 12.74 11.26 43842 N V-band gastroplasty 21.03 NA NA 11.46 11.04 43843 A Gastroplasty w/o v-band 21.21 NA NA 12.29 10.98 43845 A Gastroplasty duodenal switch 33.30 NA NA 18.07 16.12 43846 A Gastric bypass for obesity 27.41 NA NA 15.34 13.86 43847 A Gastric bypass incl small i 30.28 NA NA 16.84 14.95 
CMS-1503-P 940

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

43848 A Revision gastroplasty 32.75 NA NA 17.82 16.04 43850 A Revise stomach-bowel fusion 27.58 NA NA 14.98 13.34 43855 A Revise stomach-bowel fusion 28.69 NA NA 15.46 13.91 43860 A Revise stomach-bowel fusion 27.89 NA NA 14.84 13.44 43865 A Revise stomach-bowel fusion 29.05 NA NA 15.61 14.01 43870 A Repair stomach opening 11.44 NA NA 7.31 6.62 43880 A Repair stomach-bowel fistula 27.18 NA NA 14.61 13.22 43881 C Impl/redo electrd, antrum 0.00 0.00 0.00 0.00 0.00 43882 C Revise/remove electrd antrum 0.00 0.00 0.00 0.00 0.00 43886 A Revise gastric port, open 4.64 NA NA 4.96 4.53 43887 A Remove gastric port, open 4.32 NA NA 4.33 3.99 43888 A Change gastric port, open 6.44 NA NA 5.70 5.22 43999 C Stomach surgery procedure 0.00 0.00 0.00 0.00 0.00 44005 A Freeing of bowel adhesion 18.46 NA NA 10.24 9.25 44010 A Incision of small bowel 14.26 NA NA 8.48 7.68 44015 A Insert needle cath bowel 2.62 NA NA 1.09 1.01 44020 A Explore small intestine 16.22 NA NA 9.32 8.40 44021 A Decompress small bowel 16.31 NA NA 9.42 8.56 44025 A Incision of large bowel 16.51 NA NA 9.44 8.52 44050 A Reduce bowel obstruction 15.52 NA NA 9.02 8.16 44055 A Correct malrotation of bowel 25.63 NA NA 13.49 12.12 44100 A Biopsy of bowel 2.01 NA NA 1.06 1.07 44110 A Excise intestine lesion(s) 14.04 NA NA 8.27 7.50 44111 A Excision of bowel lesion(s) 16.52 NA NA 9.31 8.43 44120 A Removal of small intestine 20.82 NA NA 11.26 10.10 44121 A Removal of small intestine 4.44 NA NA 1.90 1.72 
CMS-1503-P 941

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

44125 A Removal of small intestine 20.03 NA NA 11.07 9.97 44126 A Enterectomy w/o taper, cong 42.23 NA NA 22.20 19.72 44127 A Enterectomy w/taper, cong 49.30 NA NA 25.15 22.38 44128 A Enterectomy cong, add-on 4.44 NA NA 1.91 1.73 44130 A Bowel to bowel fusion 22.11 NA NA 12.41 10.92 44132 R Enterectomy, cadaver donor 0.00 0.00 0.00 0.00 0.00 44133 R Enterectomy, live donor 0.00 0.00 0.00 0.00 0.00 44135 R Intestine transplnt, cadaver 0.00 0.00 0.00 0.00 0.00 44136 R Intestine transplant, live 0.00 0.00 0.00 0.00 0.00 44137 C Remove intestinal allograft 0.00 0.00 0.00 0.00 0.00 44139 A Mobilization of colon 2.23 NA NA 0.96 0.86 44140 A Partial removal of colon 22.59 NA NA 12.68 11.47 44141 A Partial removal of colon 29.91 NA NA 18.17 16.16 44143 A Partial removal of colon 27.79 NA NA 16.03 14.49 44144 A Partial removal of colon 29.91 NA NA 16.66 14.82 44145 A Partial removal of colon 28.58 NA NA 15.25 13.77 44146 A Partial removal of colon 35.30 NA NA 20.87 18.68 44147 A Partial removal of colon 33.69 NA NA 17.49 15.22 44150 A Removal of colon 30.18 NA NA 19.31 17.37 44151 A Removal of colon/ileostomy 34.92 NA NA 21.34 19.21 44155 A Removal of colon/ileostomy 34.42 NA NA 21.07 18.84 44156 A Removal of colon/ileostomy 37.42 NA NA 23.24 20.85 44157 A Colectomy w/ileoanal anast 35.70 NA NA 21.40 19.31 44158 A Colectomy w/neo-rectum pouch 36.70 NA NA 21.69 19.59 44160 A Removal of colon 20.89 NA NA 11.84 10.65 44180 A Lap, enterolysis 15.27 NA NA 8.90 8.12 
CMS-1503-P 942

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

44186 A Lap, jejunostomy 10.38 NA NA 6.73 6.23 44187 A Lap, ileo/jejuno-stomy 17.40 NA NA 12.06 10.99 44188 A Lap, colostomy 19.35 NA NA 13.18 11.99 44202 A Lap, enterectomy 23.39 NA NA 13.07 11.82 44203 A Lap resect s/intestine, addl 4.44 NA NA 1.89 1.71 44204 A Laparo partial colectomy 26.42 NA NA 14.31 12.88 44205 A Lap colectomy part w/ileum 22.95 NA NA 12.56 11.33 44206 A Lap part colectomy w/stoma 29.79 NA NA 16.58 14.95 44207 A L colectomy/coloproctostomy 31.92 NA NA 16.58 14.86 44208 A L colectomy/coloproctostomy 33.99 NA NA 19.02 17.13 44210 A Laparo total proctocolectomy 30.09 NA NA 17.64 15.89 44211 A Lap colectomy w/proctectomy 37.08 NA NA 22.09 19.62 44212 A Laparo total proctocolectomy 34.58 NA NA 20.41 18.43 44213 A Lap, mobil splenic fl add-on 3.50 NA NA 1.50 1.35 44227 A Lap, close enterostomy 28.62 NA NA 15.39 13.88 44238 C Laparoscope proc, intestine 0.00 0.00 0.00 0.00 0.00 44300 A Open bowel to skin 13.75 NA NA 8.37 7.63 44310 A Ileostomy/jejunostomy 17.59 NA NA 10.03 9.06 44312 A Revision of ileostomy 9.43 NA NA 6.37 5.95 44314 A Revision of ileostomy 16.74 NA NA 10.06 9.22 44316 A Devise bowel pouch 23.59 NA NA 13.39 11.99 44320 A Colostomy 19.91 NA NA 11.76 10.62 44322 A Colostomy with biopsies 13.32 NA NA 13.18 12.04 44340 A Revision of colostomy 9.28 NA NA 7.25 6.55 44345 A Revision of colostomy 17.22 NA NA 10.66 9.62 44346 A Revision of colostomy 19.63 NA NA 11.71 10.51 
CMS-1503-P 943

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

44360 A Small bowel endoscopy 2.59 NA NA 1.72 1.73 44361 A Small bowel endoscopy/biopsy 2.87 NA NA 1.87 1.88 44363 A Small bowel endoscopy 3.49 NA NA 2.19 2.15 44364 A Small bowel endoscopy 3.73 NA NA 2.33 2.33 44365 A Small bowel endoscopy 3.31 NA NA 2.10 2.09 44366 A Small bowel endoscopy 4.40 NA NA 2.71 2.72 44369 A Small bowel endoscopy 4.51 NA NA 2.77 2.77 44370 A Small bowel endoscopy/stent 4.79 NA NA 3.11 3.09 44372 A Small bowel endoscopy 4.40 NA NA 2.58 2.53 44373 A Small bowel endoscopy 3.49 NA NA 2.11 2.11 44376 A Small bowel endoscopy 5.25 NA NA 3.04 3.01 44377 A Small bowel endoscopy/biopsy 5.52 NA NA 3.26 3.26 44378 A Small bowel endoscopy 7.12 NA NA 4.18 4.16 44379 A S bowel endoscope w/stent 7.46 NA NA 4.58 4.51 44380 A Small bowel endoscopy 1.05 NA NA 0.82 0.84 44382 A Small bowel endoscopy 1.27 NA NA 0.99 0.99 44383 A Ileoscopy w/stent 2.94 NA NA 1.61 1.76 44385 A Endoscopy of bowel pouch 1.82 5.27 5.28 1.09 1.06 44386 A Endoscopy, bowel pouch/biop 2.12 7.48 7.68 1.36 1.29 44388 A Colonoscopy 2.82 6.81 6.87 1.72 1.67 44389 A Colonoscopy with biopsy 3.13 7.73 8.00 1.93 1.89 44390 A Colonoscopy for foreign body 3.82 8.96 9.12 2.40 2.27 44391 A Colonoscopy for bleeding 4.31 9.30 9.84 2.56 2.53 44392 A Colonoscopy & polypectomy 3.81 8.20 8.31 2.17 2.09 44393 A Colonoscopy, lesion removal 4.83 9.10 9.18 2.79 2.70 44394 A Colonoscopy w/snare 4.42 9.30 9.60 2.58 2.53 
CMS-1503-P 944

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

44397 A Colonoscopy w/stent 4.70 NA NA 2.88 2.83 44500 A Intro, gastrointestinal tube 0.49 NA NA 0.18 0.20 44602 A Suture, small intestine 24.72 NA NA 12.25 10.70 44603 A Suture, small intestine 28.16 NA NA 14.35 12.55 44604 A Suture, large intestine 18.16 NA NA 9.60 8.66 44605 A Repair of bowel lesion 22.08 NA NA 12.33 11.13 44615 A Intestinal stricturoplasty 18.16 NA NA 10.19 9.21 44620 A Repair bowel opening 14.43 NA NA 8.57 7.68 44625 A Repair bowel opening 17.28 NA NA 9.78 8.76 44626 A Repair bowel opening 27.90 NA NA 14.34 12.91 44640 A Repair bowel-skin fistula 24.20 NA NA 12.76 11.51 44650 A Repair bowel fistula 25.12 NA NA 13.02 11.85 44660 A Repair bowel-bladder fistula 23.91 NA NA 12.02 11.75 44661 A Repair bowel-bladder fistula 27.35 NA NA 13.80 12.83 44680 A Surgical revision, intestine 17.96 NA NA 10.10 9.12 44700 A Suspend bowel w/prosthesis 17.48 NA NA 9.80 8.82 44701 A Intraop colon lavage add-on 3.10 NA NA 1.32 1.19 44715 C Prepare donor intestine 0.00 0.00 0.00 0.00 0.00 44720 A Prep donor intestine/venous 5.00 NA NA 2.15 2.09 44721 A Prep donor intestine/artery 7.00 NA NA 3.03 2.77 44799 C Unlisted procedure intestine 0.00 0.00 0.00 0.00 0.00 44800 A Excision of bowel pouch 12.05 NA NA 8.10 7.42 44820 A Excision of mesentery lesion 13.73 NA NA 8.32 7.62 44850 A Repair of mesentery 12.11 NA NA 7.63 6.87 44899 C Bowel surgery procedure 0.00 0.00 0.00 0.00 0.00 44900 A Drain app abscess, open 12.57 NA NA 7.76 6.98 
CMS-1503-P 945

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

44901 A Drain app abscess, percut 3.37 20.57 23.42 1.18 1.34 44950 A Appendectomy 10.60 NA NA 6.24 5.68 44955 A Appendectomy add-on 1.53 NA NA 0.66 0.61 44960 A Appendectomy 14.50 NA NA 8.41 7.57 44970 A Laparoscopy, appendectomy 9.45 NA NA 6.33 5.74 44979 C Laparoscope proc, app 0.00 0.00 0.00 0.00 0.00 45000 A Drainage of pelvic abscess 6.30 NA NA 5.03 4.63 45005 A Drainage of rectal abscess 2.02 5.20 4.97 2.21 2.06 45020 A Drainage of rectal abscess 8.56 NA NA 6.56 5.89 45100 A Biopsy of rectum 4.04 NA NA 4.00 3.65 45108 A Removal of anorectal lesion 5.12 NA NA 4.62 4.16 45110 A Removal of rectum 30.76 NA NA 18.57 16.74 45111 A Partial removal of rectum 18.01 NA NA 10.91 9.83 45112 A Removal of rectum 33.18 NA NA 17.13 15.31 45113 A Partial proctectomy 33.22 NA NA 18.65 16.75 45114 A Partial removal of rectum 30.79 NA NA 16.71 14.81 45116 A Partial removal of rectum 27.72 NA NA 15.37 13.52 45119 A Remove rectum w/reservoir 33.48 NA NA 18.97 16.85 45120 A Removal of rectum 26.40 NA NA 15.22 13.65 45121 A Removal of rectum and colon 29.08 NA NA 16.37 14.64 45123 A Partial proctectomy 18.86 NA NA 11.29 9.96 45126 A Pelvic exenteration 49.10 NA NA 26.25 24.48 45130 A Excision of rectal prolapse 18.50 NA NA 10.88 9.61 45135 A Excision of rectal prolapse 22.36 NA NA 13.71 12.12 45136 A Excise ileoanal reservior 30.82 NA NA 18.70 16.84 45150 A Excision of rectal stricture 5.85 NA NA 5.06 4.64 
CMS-1503-P 946

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

45160 A Excision of rectal lesion 16.33 NA NA 10.12 9.18 45171 A Exc rect tum transanal part 8.13 NA NA 7.91 7.91 45172 A Exc rect tum transanal full 12.13 NA NA 9.62 9.62 45190 A Destruction, rectal tumor 10.42 NA NA 8.11 7.30 45300 A Proctosigmoidoscopy dx 0.80 2.53 2.38 0.67 0.59 45303 A Proctosigmoidoscopy dilate 1.50 24.29 23.73 0.98 0.85 45305 A Proctosigmoidoscopy w/bx 1.25 3.99 3.81 0.88 0.80 45307 A Proctosigmoidoscopy fb 1.70 4.15 3.92 1.05 0.91 45308 A Proctosigmoidoscopy removal 1.40 4.27 3.93 0.96 0.83 45309 A Proctosigmoidoscopy removal 1.50 4.35 4.19 1.01 0.95 45315 A Proctosigmoidoscopy removal 1.80 4.76 4.47 1.12 1.05 45317 A Proctosigmoidoscopy bleed 2.00 4.35 4.04 1.21 1.06 45320 A Proctosigmoidoscopy ablate 1.78 4.38 4.20 1.12 1.06 45321 A Proctosigmoidoscopy volvul 1.75 NA NA 1.14 1.05 45327 A Proctosigmoidoscopy w/stent 2.00 NA NA 1.42 1.29 45330 A Diagnostic sigmoidoscopy 0.96 2.86 2.89 0.78 0.75 45331 A Sigmoidoscopy and biopsy 1.15 3.48 3.65 0.92 0.91 45332 A Sigmoidoscopy w/fb removal 1.79 6.09 6.24 1.24 1.20 45333 A Sigmoidoscopy & polypectomy 1.79 6.21 6.33 1.22 1.19 45334 A Sigmoidoscopy for bleeding 2.73 NA NA 1.76 1.76 45335 A Sigmoidoscopy w/submuc inj 1.46 5.67 5.64 1.06 1.04 45337 A Sigmoidoscopy & decompress 2.36 NA NA 1.53 1.49 45338 A Sigmoidoscopy w/tumr remove 2.34 6.31 6.53 1.53 1.51 45339 A Sigmoidoscopy w/ablate tumr 3.14 6.13 6.11 1.95 1.93 45340 A Sig w/balloon dilation 1.89 11.05 10.98 1.28 1.25 45341 A Sigmoidoscopy w/ultrasound 2.60 NA NA 1.70 1.70 
CMS-1503-P 947

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

45342 A Sigmoidoscopy w/us guide bx 4.05 NA NA 2.51 2.50 45345 A Sigmoidoscopy w/stent 2.92 NA NA 1.86 1.84 45355 A Surgical colonoscopy 3.51 NA NA 2.05 1.94 45378 A Diagnostic colonoscopy 3.69 6.98 7.24 2.23 2.19 45378 53 A Diagnostic colonoscopy 0.96 2.86 2.89 0.78 0.75 45379 A Colonoscopy w/fb removal 4.68 9.04 9.29 2.77 2.68 45380 A Colonoscopy and biopsy 4.43 8.30 8.67 2.67 2.64 45381 A Colonoscopy, submucous inj 4.19 8.18 8.57 2.54 2.52 45382 A Colonoscopy/control bleeding 5.68 10.88 11.50 3.37 3.36 45383 A Lesion removal colonoscopy 5.86 9.55 9.77 3.31 3.22 45384 A Lesion remove colonoscopy 4.69 7.99 8.21 2.71 2.65 45385 A Lesion removal colonoscopy 5.30 9.04 9.42 3.12 3.08 45386 A Colonoscopy dilate stricture 4.57 13.27 13.92 2.69 2.63 45387 A Colonoscopy w/stent 5.90 NA NA 3.56 3.51 45391 A Colonoscopy w/endoscope us 5.09 NA NA 3.03 3.01 45392 A Colonoscopy w/endoscopic fnb 6.54 NA NA 3.81 3.78 45395 A Lap, removal of rectum 33.00 NA NA 20.31 18.37 45397 A Lap, remove rectum w/pouch 36.50 NA NA 21.65 19.36 45400 A Laparoscopic proc 19.44 NA NA 11.34 10.20 45402 A Lap proctopexy w/sig resect 26.51 NA NA 14.38 12.87 45499 C Laparoscope proc, rectum 0.00 0.00 0.00 0.00 0.00 45500 A Repair of rectum 7.73 NA NA 6.50 5.83 45505 A Repair of rectum 8.36 NA NA 7.49 6.67 45520 A Treatment of rectal prolapse 0.55 3.67 3.36 0.56 0.51 45540 A Correct rectal prolapse 18.12 NA NA 10.24 9.19 45541 A Correct rectal prolapse 14.85 NA NA 10.12 9.04 
CMS-1503-P 948

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

45550 A Repair rectum/remove sigmoid 24.80 NA NA 14.42 12.84 45560 A Repair of rectocele 11.50 NA NA 7.36 7.01 45562 A Exploration/repair of rectum 17.98 NA NA 11.69 10.71 45563 A Exploration/repair of rectum 26.38 NA NA 16.77 15.01 45800 A Repair rect/bladder fistula 20.31 NA NA 11.81 11.35 45805 A Repair fistula w/colostomy 23.32 NA NA 14.96 13.43 45820 A Repair rectourethral fistula 20.37 NA NA 12.25 11.52 45825 A Repair fistula w/colostomy 24.17 NA NA 15.26 14.17 45900 A Reduction of rectal prolapse 2.99 NA NA 2.39 2.19 45905 A Dilation of anal sphincter 2.35 NA NA 2.19 2.05 45910 A Dilation of rectal narrowing 2.85 NA NA 2.40 2.29 45915 A Remove rectal obstruction 3.19 5.60 5.33 2.87 2.67 45990 A Surg dx exam, anorectal 1.80 NA NA 1.08 1.00 45999 C Rectum surgery procedure 0.00 0.00 0.00 0.00 0.00 46020 A Placement of seton 3.00 4.43 4.00 3.31 2.98 46030 A Removal of rectal marker 1.26 2.50 2.30 1.17 1.06 46040 A Incision of rectal abscess 5.37 8.82 8.18 5.62 5.17 46045 A Incision of rectal abscess 5.87 NA NA 5.62 5.05 46050 A Incision of anal abscess 1.24 4.15 3.87 1.37 1.25 46060 A Incision of rectal abscess 6.37 NA NA 6.34 5.69 46070 A Incision of anal septum 2.79 NA NA 3.75 3.43 46080 A Incision of anal sphincter 2.52 4.14 3.81 1.71 1.55 46083 A Incise external hemorrhoid 1.45 3.24 3.25 1.41 1.35 46200 A Removal of anal fissure 3.59 8.32 7.56 5.14 4.69 46220 A Excise anal ext tag/papilla 1.61 3.96 3.68 1.58 1.44 

46221 A Ligation of hemorrhoid(s) 2.36 4.89 4.52 2.78 2.56 
CMS-1503-P 949

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

46230 A Removal of anal tags 2.62 4.73 4.41 2.00 1.82 46250 A Remove ext hem groups = 2 4.25 8.08 7.54 4.11 3.76 46255 A Remove int/ext hem 1 group 4.96 8.46 7.98 4.41 4.05 46257 A Remove in/ex hem grp & fiss 5.76 NA NA 5.51 4.94 46258 A Remove in/ex hem grp w/fistu 6.41 NA NA 5.98 5.35 46260 A Remove in/ex hem groups = 2 6.73 NA NA 5.91 5.30 46261 A Remove in/ex hem grps & fiss 7.76 NA NA 6.39 5.72 46262 A Remove in/ex hem grps w/fist 7.91 NA NA 6.87 6.18 46270 A Remove anal fist subq 4.92 8.60 7.92 5.50 4.96 46275 A Remove anal fist inter 5.42 8.95 8.16 5.66 5.09 46280 A Remove anal fist complex 6.39 NA NA 6.17 5.53 46285 A Remove anal fist 2 stage 5.42 8.90 7.97 5.69 5.07 46288 A Repair anal fistula 7.81 NA NA 6.90 6.18 46320 A Removal of hemorrhoid clot 1.64 3.28 3.04 1.33 1.20 46500 A Injection into hemorrhoid(s) 1.69 4.71 4.29 1.80 1.65 46505 A Chemodenervation anal musc 3.18 4.51 4.20 3.26 2.98 46600 A Diagnostic anoscopy 0.55 1.82 1.76 0.56 0.50 46604 A Anoscopy and dilation 1.03 15.57 14.62 0.76 0.71 46606 A Anoscopy and biopsy 1.20 4.83 4.73 0.85 0.76 46608 A Anoscopy, remove for body 1.30 4.99 4.82 0.84 0.78 46610 A Anoscopy, remove lesion 1.28 4.86 4.74 0.89 0.81 46611 A Anoscopy 1.30 3.48 3.36 0.91 0.84 46612 A Anoscopy, remove lesions 1.50 5.65 5.57 0.99 0.95 46614 A Anoscopy, control bleeding 1.00 2.44 2.44 0.76 0.75 46615 A Anoscopy 1.50 2.34 2.32 0.99 0.95 46700 A Repair of anal stricture 9.81 NA NA 7.82 6.94 
CMS-1503-P 950

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

46705 A Repair of anal stricture 7.43 NA NA 6.10 5.90 46706 A Repr of anal fistula w/glue 2.44 NA NA 2.04 1.90 46707 A Repair anorectal fist w/plug 6.39 NA NA 6.40 6.40 46710 A Repr per/vag pouch sngl proc 17.14 NA NA 11.37 10.60 46712 A Repr per/vag pouch dbl proc 36.45 NA NA 21.84 19.62 46715 A Rep perf anoper fistu 7.62 NA NA 6.25 5.75 46716 A Rep perf anoper/vestib fistu 17.54 NA NA 13.54 14.23 46730 A Construction of absent anus 30.65 NA NA 18.88 18.14 46735 A Construction of absent anus 36.14 NA NA 21.26 20.39 46740 A Construction of absent anus 33.90 NA NA 22.21 19.90 46742 A Repair of imperforated anus 40.14 NA NA 24.80 22.55 46744 A Repair of cloacal anomaly 58.94 NA NA 34.40 29.80 46746 A Repair of cloacal anomaly 65.44 NA NA 34.06 33.03 46748 A Repair of cloacal anomaly 71.42 NA NA 33.50 33.42 46750 A Repair of anal sphincter 12.15 NA NA 8.44 7.70 46751 A Repair of anal sphincter 9.30 NA NA 6.84 6.78 46753 A Reconstruction of anus 8.89 NA NA 6.88 6.19 46754 A Removal of suture from anus 3.01 5.07 4.76 3.31 2.95 46760 A Repair of anal sphincter 17.45 NA NA 12.31 10.94 46761 A Repair of anal sphincter 15.29 NA NA 9.99 8.94 46762 A Implant artificial sphincter 14.82 NA NA 10.29 9.27 46900 A Destruction, anal lesion(s) 1.91 4.65 4.37 1.86 1.73 46910 A Destruction, anal lesion(s) 1.91 4.79 4.60 1.67 1.56 46916 A Cryosurgery, anal lesion(s) 1.91 4.44 4.42 2.10 2.00 46917 A Laser surgery, anal lesions 1.91 10.67 10.63 1.70 1.58 46922 A Excision of anal lesion(s) 1.91 5.28 4.97 1.72 1.57 
CMS-1503-P 951

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

46924 A Destruction, anal lesion(s) 2.81 11.75 11.47 2.20 2.02 46930 A Destroy internal hemorrhoids 1.61 3.84 4.05 2.35 2.43 46940 A Treatment of anal fissure 2.35 3.86 3.51 1.62 1.46 46942 A Treatment of anal fissure 2.07 3.76 3.42 1.50 1.35 46945 A Remove by ligat int hem grp 2.21 6.03 5.63 3.85 3.62 46946 A Remove by ligat int hem grps 2.63 5.74 5.50 3.41 3.26 46947 A Hemorrhoidopexy by stapling 5.57 NA NA 4.60 4.15 46999 C Anus surgery procedure 0.00 0.00 0.00 0.00 0.00 47000 A Needle biopsy of liver 1.90 7.84 7.82 0.69 0.79 47001 A Needle biopsy, liver add-on 1.90 NA NA 0.81 0.74 47010 A Open drainage, liver lesion 19.40 NA NA 11.95 11.13 47011 A Percut drain, liver lesion 3.69 NA NA 1.27 1.48 47015 A Inject/aspirate liver cyst 18.50 NA NA 11.97 10.77 47100 A Wedge biopsy of liver 12.91 NA NA 9.31 8.51 47120 A Partial removal of liver 39.01 NA NA 21.81 19.85 47122 A Extensive removal of liver 59.48 NA NA 29.82 27.14 47125 A Partial removal of liver 53.04 NA NA 27.07 24.64 47130 A Partial removal of liver 57.19 NA NA 28.70 26.18 47133 X Removal of donor liver 0.00 0.00 0.00 0.00 0.00 47135 R Transplantation of liver 83.64 NA NA 44.17 40.04 47136 R Transplantation of liver 70.74 NA NA 36.91 34.18 47140 A Partial removal, donor liver 59.40 NA NA 33.89 30.54 47141 A Partial removal, donor liver 71.50 NA NA 37.78 34.96 47142 A Partial removal, donor liver 79.44 NA NA 43.36 39.13 47143 C Prep donor liver, whole 0.00 0.00 0.00 0.00 0.00 47144 C Prep donor liver, 3-segment 0.00 0.00 0.00 0.00 0.00 
CMS-1503-P 952

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

47145 C Prep donor liver, lobe split 0.00 0.00 0.00 0.00 0.00 47146 A Prep donor liver/venous 6.00 NA NA 2.58 2.34 47147 A Prep donor liver/arterial 7.00 NA NA 3.01 2.73 47300 A Surgery for liver lesion 18.14 NA NA 11.67 10.51 47350 A Repair liver wound 22.49 NA NA 13.48 12.27 47360 A Repair liver wound 31.31 NA NA 17.76 15.99 47361 A Repair liver wound 52.60 NA NA 26.27 23.95 47362 A Repair liver wound 23.54 NA NA 14.42 12.89 47370 A Laparo ablate liver tumor rf 20.80 NA NA 11.72 10.70 47371 A Laparo ablate liver cryosurg 20.80 NA NA 12.05 11.18 47379 C Laparoscope procedure, liver 0.00 0.00 0.00 0.00 0.00 47380 A Open ablate liver tumor rf 24.56 NA NA 13.12 12.10 47381 A Open ablate liver tumor cryo 24.88 NA NA 10.56 11.06 47382 A Percut ablate liver rf 15.22 114.73 114.73 5.83 6.90 47399 C Liver surgery procedure 0.00 0.00 0.00 0.00 0.00 47400 A Incision of liver duct 36.36 NA NA 19.93 17.99 47420 A Incision of bile duct 22.03 NA NA 13.12 11.91 47425 A Incision of bile duct 22.31 NA NA 13.46 12.12 47460 A Incise bile duct sphincter 20.52 NA NA 12.69 11.87 47480 A Incision of gallbladder 13.25 NA NA 9.72 8.85 47490 A Incision of gallbladder 8.13 NA NA 5.24 5.98 47500 A Injection for liver x-rays 1.96 NA NA 0.67 0.79 47505 A Injection for liver x-rays 0.76 NA NA 0.26 0.30 47510 A Insert catheter, bile duct 8.03 NA NA 4.61 5.27 47511 A Insert bile duct drain 10.77 NA NA 4.86 5.68 47525 A Change bile duct catheter 1.54 11.84 13.12 0.77 1.19 
CMS-1503-P 953

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

47530 A Revise/reinsert bile tube 6.05 32.33 35.08 3.48 3.96 47550 A Bile duct endoscopy add-on 3.02 NA NA 1.30 1.19 47552 A Biliary endoscopy thru skin 6.03 NA NA 2.46 2.84 47553 A Biliary endoscopy thru skin 6.34 NA NA 2.19 2.53 47554 A Biliary endoscopy thru skin 9.05 NA NA 3.93 4.05 47555 A Biliary endoscopy thru skin 7.55 NA NA 2.55 3.03 47556 A Biliary endoscopy thru skin 8.55 NA NA 2.91 3.44 47560 A Laparoscopy w/cholangio 4.88 NA NA 2.10 1.93 47561 A Laparo w/cholangio/biopsy 5.17 NA NA 2.51 2.30 47562 A Laparoscopic cholecystectomy 11.76 NA NA 7.94 7.18 47563 A Laparo cholecystectomy/graph 12.11 NA NA 7.73 7.04 47564 A Laparo cholecystectomy/explr 14.24 NA NA 8.35 7.63 47570 A Laparo cholecystoenterostomy 12.56 NA NA 7.73 7.04 47579 C Laparoscope proc, biliary 0.00 0.00 0.00 0.00 0.00 47600 A Removal of gallbladder 17.48 NA NA 10.97 9.80 47605 A Removal of gallbladder 15.98 NA NA 9.76 8.85 47610 A Removal of gallbladder 20.92 NA NA 11.89 10.76 47612 A Removal of gallbladder 21.21 NA NA 11.96 10.81 47620 A Removal of gallbladder 23.07 NA NA 12.96 11.68 47630 A Remove bile duct stone 9.65 NA NA 5.03 5.53 47700 A Exploration of bile ducts 16.50 NA NA 11.09 10.15 47701 A Bile duct revision 28.73 NA NA 16.64 15.91 47711 A Excision of bile duct tumor 25.90 NA NA 14.92 13.52 47712 A Excision of bile duct tumor 33.72 NA NA 18.52 16.65 47715 A Excision of bile duct cyst 21.55 NA NA 13.28 11.91 47720 A Fuse gallbladder & bowel 18.34 NA NA 11.71 10.61 
CMS-1503-P 954

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

47721 A Fuse upper gi structures 21.99 NA NA 13.47 12.10 47740 A Fuse gallbladder & bowel 21.23 NA NA 13.14 11.78 47741 A Fuse gallbladder & bowel 24.21 NA NA 14.42 12.97 47760 A Fuse bile ducts and bowel 38.32 NA NA 20.66 18.18 47765 A Fuse liver ducts & bowel 52.19 NA NA 27.17 23.41 47780 A Fuse bile ducts and bowel 42.32 NA NA 22.27 19.55 47785 A Fuse bile ducts and bowel 56.19 NA NA 28.46 24.73 47800 A Reconstruction of bile ducts 26.17 NA NA 15.21 13.71 47801 A Placement, bile duct support 17.60 NA NA 9.59 10.09 47802 A Fuse liver duct & intestine 24.93 NA NA 15.02 13.53 47900 A Suture bile duct injury 22.44 NA NA 13.28 12.07 47999 C Bile tract surgery procedure 0.00 0.00 0.00 0.00 0.00 48000 A Drainage of abdomen 31.95 NA NA 16.64 15.37 48001 A Placement of drain, pancreas 39.69 NA NA 20.60 18.53 48020 A Removal of pancreatic stone 19.09 NA NA 11.73 10.63 48100 A Biopsy of pancreas, open 14.46 NA NA 8.84 8.04 48102 A Needle biopsy, pancreas 4.70 9.76 10.47 1.85 2.16 48105 A Resect/debride pancreas 49.26 NA NA 25.44 22.78 48120 A Removal of pancreas lesion 18.41 NA NA 10.56 9.55 48140 A Partial removal of pancreas 26.32 NA NA 14.53 13.14 48145 A Partial removal of pancreas 27.39 NA NA 15.31 13.70 48146 A Pancreatectomy 30.60 NA NA 18.60 16.68 48148 A Removal of pancreatic duct 20.39 NA NA 12.29 11.02 48150 A Partial removal of pancreas 52.84 NA NA 28.07 25.54 48152 A Pancreatectomy 48.65 NA NA 26.79 24.17 48153 A Pancreatectomy 52.79 NA NA 28.05 25.49 
CMS-1503-P 955

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

48154 A Pancreatectomy 48.88 NA NA 26.89 24.18 48155 A Removal of pancreas 29.45 NA NA 18.02 16.36 48160 N Pancreas removal/transplant 0.00 0.00 0.00 0.00 0.00 48400 A Injection, intraop add-on 1.95 NA NA 0.84 0.85 48500 A Surgery of pancreatic cyst 18.16 NA NA 12.02 10.82 48510 A Drain pancreatic pseudocyst 17.19 NA NA 11.36 10.32 48511 A Drain pancreatic pseudocyst 3.99 20.88 22.73 1.39 1.61 48520 A Fuse pancreas cyst and bowel 18.15 NA NA 10.47 9.49 48540 A Fuse pancreas cyst and bowel 21.94 NA NA 12.33 11.03 48545 A Pancreatorrhaphy 22.23 NA NA 12.96 11.54 48547 A Duodenal exclusion 30.38 NA NA 16.47 14.70 48548 A Fuse pancreas and bowel 28.09 NA NA 15.40 13.95 48550 X Donor pancreatectomy 0.00 0.00 0.00 0.00 0.00 48551 C Prep donor pancreas 0.00 0.00 0.00 0.00 0.00 48552 A Prep donor pancreas/venous 4.30 NA NA 1.85 1.70 48554 R Transpl allograft pancreas 37.80 NA NA 29.62 27.12 48556 A Removal, allograft pancreas 19.47 NA NA 14.00 12.66 48999 C Pancreas surgery procedure 0.00 0.00 0.00 0.00 0.00 49000 A Exploration of abdomen 12.54 NA NA 7.71 7.12 49002 A Reopening of abdomen 17.63 NA NA 9.80 8.68 49010 A Exploration behind abdomen 16.06 NA NA 8.77 8.23 49020 A Drain abdominal abscess 26.67 NA NA 15.14 13.79 49021 A Drain abdominal abscess 3.37 20.15 22.09 1.16 1.35 49040 A Drain, open, abdom abscess 16.52 NA NA 9.80 8.94 49041 A Drain, percut, abdom abscess 3.99 20.58 22.22 1.37 1.60 49060 A Drain, open, retrop abscess 18.53 NA NA 10.41 9.75 
CMS-1503-P 956

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

49061 A Drain, percut, retroper absc 3.69 20.21 21.97 1.27 1.48 49062 A Drain to peritoneal cavity 12.22 NA NA 7.41 6.96 49080 A Puncture, peritoneal cavity 1.35 2.84 3.25 0.50 0.56 49081 A Removal of abdominal fluid 1.26 3.21 3.31 0.55 0.56 49180 A Biopsy, abdominal mass 1.73 2.51 2.86 0.60 0.70 49203 A Exc abd tum 5 cm or less 20.13 NA NA 11.36 10.52 49204 A Exc abd tum over 5 cm 26.13 NA NA 13.92 12.85 49205 A Exc abd tum over 10 cm 30.13 NA NA 15.66 14.42 49215 A Excise sacral spine tumor 37.81 NA NA 20.39 18.39 49220 A Multiple surgery, abdomen 15.79 NA NA 9.61 8.80 49250 A Excision of umbilicus 9.01 NA NA 6.41 5.88 49255 A Removal of omentum 12.56 NA NA 8.23 7.59 49320 A Diag laparo separate proc 5.14 NA NA 3.49 3.28 49321 A Laparoscopy, biopsy 5.44 NA NA 3.70 3.44 49322 A Laparoscopy, aspiration 6.01 NA NA 3.79 3.59 49323 A Laparo drain lymphocele 10.23 NA NA 6.79 6.26 49324 A Lap insertion perm ip cath 6.32 NA NA 4.07 3.75 49325 A Lap revision perm ip cath 6.82 NA NA 4.26 3.92 49326 A Lap w/omentopexy add-on 3.50 NA NA 1.45 1.30 49329 C Laparo proc, abdm/per/oment 0.00 0.00 0.00 0.00 0.00 49400 A Air injection into abdomen 1.88 2.65 2.93 0.67 0.74 49402 A Remove foreign body, adbomen 14.09 NA NA 8.42 7.66 49411 A Ins mark abd/pel for rt perq 3.82 10.89 10.89 1.62 1.62 49419 A Insrt abdom cath for chemotx 7.08 NA NA 4.68 4.50 49420 A Insert abdom drain, temp 2.22 NA NA 1.34 1.38 49421 A Insert abdom drain, perm 5.90 NA NA 4.13 3.99 
CMS-1503-P 957

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

49422 A Remove perm cannula/catheter 6.29 NA NA 3.78 3.56 49423 A Exchange drainage catheter 1.46 13.58 14.82 0.53 0.63 49424 A Assess cyst, contrast inject 0.76 3.19 3.55 0.29 0.34 49425 A Insert abdomen-venous drain 12.22 NA NA 7.43 7.07 49426 A Revise abdomen-venous shunt 10.41 NA NA 6.36 6.05 49427 A Injection, abdominal shunt 0.89 NA NA 0.33 0.37 49428 A Ligation of shunt 6.87 NA NA 4.45 4.28 49429 A Removal of shunt 7.44 NA NA 4.58 4.24 49435 A Insert subq exten to ip cath 2.25 NA NA 0.88 0.80 49436 A Embedded ip cath exit-site 2.72 NA NA 2.19 2.07 49440 A Place gastrostomy tube perc 4.18 24.11 26.74 1.91 2.10 49441 A Place duod/jej tube perc 4.77 27.19 29.50 2.19 2.37 49442 A Place cecostomy tube perc 4.00 20.70 24.76 1.88 1.96 49446 A Change g-tube to g-j perc 3.31 23.20 25.35 1.15 1.34 49450 A Replace g/c tube perc 1.36 16.44 19.20 0.49 0.53 49451 A Replace duod/jej tube perc 1.84 17.53 18.88 0.65 0.75 49452 A Replace g-j tube perc 2.86 20.99 22.89 1.00 1.17 49460 A Fix g/colon tube w/device 0.96 18.77 21.76 0.36 0.39 49465 A Fluoro exam of g/colon tube 0.62 3.94 4.30 0.21 0.25 49491 A Rpr hern preemie reduc 12.53 NA NA 8.25 7.42 49492 A Rpr ing hern premie, blocked 15.43 NA NA 9.59 8.69 49495 A Rpr ing hernia baby, reduc 6.20 NA NA 4.56 4.05 49496 A Rpr ing hernia baby, blocked 9.42 NA NA 6.68 6.05 49500 A Rpr ing hernia, init, reduce 5.84 NA NA 3.82 3.90 49501 A Rpr ing hernia, init blocked 9.36 NA NA 6.50 5.90 49505 A Prp i/hern init reduc >5 yr 7.96 NA NA 5.72 5.23 
CMS-1503-P 958

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

49507 A Prp i/hern init block >5 yr 10.05 NA NA 6.68 6.09 49520 A Rerepair ing hernia, reduce 9.99 NA NA 6.59 6.01 49521 A Rerepair ing hernia, blocked 12.44 NA NA 7.61 6.94 49525 A Repair ing hernia, sliding 8.93 NA NA 6.12 5.60 49540 A Repair lumbar hernia 10.74 NA NA 7.05 6.39 49550 A Rpr rem hernia, init, reduce 8.99 NA NA 6.14 5.61 49553 A Rpr fem hernia, init blocked 9.92 NA NA 6.65 6.05 49555 A Rerepair fem hernia, reduce 9.39 NA NA 6.30 5.76 49557 A Rerepair fem hernia, blocked 11.62 NA NA 7.37 6.71 49560 A Rpr ventral hern init, reduc 11.92 NA NA 7.43 6.78 49561 A Rpr ventral hern init, block 15.38 NA NA 8.98 8.14 49565 A Rerepair ventrl hern, reduce 12.37 NA NA 7.80 7.09 49566 A Rerepair ventrl hern, block 15.53 NA NA 9.09 8.23 49568 A Hernia repair w/mesh 4.88 NA NA 2.10 1.91 49570 A Rpr epigastric hern, reduce 6.05 NA NA 4.89 4.48 49572 A Rpr epigastric hern, blocked 7.87 NA NA 5.68 5.14 49580 A Rpr umbil hern, reduc < 5 yr 4.47 NA NA 4.30 3.92 49582 A Rpr umbil hern, block < 5 yr 7.13 NA NA 5.54 5.03 49585 A Rpr umbil hern, reduc > 5 yr 6.59 NA NA 5.11 4.68 49587 A Rpr umbil hern, block > 5 yr 8.04 NA NA 5.73 5.23 49590 A Repair spigelian hernia 8.90 NA NA 6.13 5.59 49600 A Repair umbilical lesion 11.55 NA NA 7.58 7.05 49605 A Repair umbilical lesion 87.09 NA NA 41.56 38.48 49606 A Repair umbilical lesion 19.00 NA NA 10.57 9.62 49610 A Repair umbilical lesion 10.91 NA NA 7.09 6.54 49611 A Repair umbilical lesion 9.34 NA NA 5.92 6.03 
CMS-1503-P 959

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

49650 A Lap ing hernia repair init 6.36 NA NA 4.91 4.49 49651 A Lap ing hernia repair recur 8.38 NA NA 6.27 5.70 49652 A Lap vent/abd hernia repair 12.88 NA NA 8.01 7.28 49653 A Lap vent/abd hern proc comp 16.21 NA NA 9.96 9.03 49654 A Lap inc hernia repair 15.03 NA NA 8.96 8.12 49655 A Lap inc hern repair comp 18.11 NA NA 10.75 9.74 49656 A Lap inc hernia repair recur 15.08 NA NA 9.00 8.14 49657 A Lap inc hern recur comp 22.11 NA NA 12.50 11.27 49659 C Laparo proc, hernia repair 0.00 0.00 0.00 0.00 0.00 49900 A Repair of abdominal wall 12.41 NA NA 9.14 8.44 49904 A Omental flap, extra-abdom 22.35 NA NA 15.50 15.50 49905 A Omental flap, intra-abdom 6.54 NA NA 2.77 2.56 49906 C Free omental flap, microvasc 0.00 0.00 0.00 0.00 0.00 49999 C Abdomen surgery procedure 0.00 0.00 0.00 0.00 0.00 50010 A Exploration of kidney 12.28 NA NA 7.71 7.82 50020 A Renal abscess, open drain 18.08 NA NA 10.66 10.63 50021 A Renal abscess, percut drain 3.37 21.56 23.54 1.15 1.35 50040 A Drainage of kidney 16.68 NA NA 8.67 9.65 50045 A Exploration of kidney 16.82 NA NA 8.90 9.71 50060 A Removal of kidney stone 20.95 NA NA 10.52 11.64 50065 A Incision of kidney 22.32 NA NA 11.06 11.98 50070 A Incision of kidney 21.85 NA NA 10.88 12.12 50075 A Removal of kidney stone 27.09 NA NA 13.16 14.63 50080 A Removal of kidney stone 15.74 NA NA 8.23 9.16 50081 A Removal of kidney stone 23.50 NA NA 11.75 13.03 50100 A Revise kidney blood vessels 17.45 NA NA 7.41 8.35 
CMS-1503-P 960

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

50120 A Exploration of kidney 17.21 NA NA 8.98 9.84 50125 A Explore and drain kidney 17.82 NA NA 10.93 10.91 50130 A Removal of kidney stone 18.82 NA NA 9.73 10.76 50135 A Exploration of kidney 20.59 NA NA 10.38 11.43 50200 A Renal biopsy perq 2.63 13.53 13.53 1.22 1.37 50205 A Renal biopsy open 12.29 NA NA 7.53 7.11 

5020F I Txmnts 2 main Dr by 1 mon 0.00 0.00 0.00 0.00 0.00 

50220 A Remove kidney, open 18.68 NA NA 9.83 10.56 50225 A Removal kidney open, complex 21.88 NA NA 11.02 11.91 50230 A Removal kidney open, radical 23.81 NA NA 11.48 12.65 50234 A Removal of kidney & ureter 24.05 NA NA 11.84 13.01 50236 A Removal of kidney & ureter 26.94 NA NA 13.50 14.98 50240 A Partial removal of kidney 24.21 NA NA 12.31 13.56 50250 A Cryoablate renal mass open 22.22 NA NA 11.33 12.69 50280 A Removal of kidney lesion 17.09 NA NA 9.19 9.96 50290 A Removal of kidney lesion 16.15 NA NA 10.21 9.70 50300 X Remove cadaver donor kidney 0.00 0.00 0.00 0.00 0.00 50320 A Remove kidney, living donor 22.43 NA NA 15.25 15.13 50323 C Prep cadaver renal allograft 0.00 0.00 0.00 0.00 0.00 50325 C Prep donor renal graft 0.00 0.00 0.00 0.00 0.00 50327 A Prep renal graft/venous 4.00 NA NA 1.68 1.58 50328 A Prep renal graft/arterial 3.50 NA NA 1.47 1.39 50329 A Prep renal graft/ureteral 3.34 NA NA 1.36 1.40 50340 A Removal of kidney 14.04 NA NA 10.86 9.91 50360 A Transplantation of kidney 40.90 NA NA 26.81 24.47 50365 A Transplantation of kidney 46.13 NA NA 29.30 27.00 
CMS-1503-P 961

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

50370 A Remove transplanted kidney 18.88 NA NA 12.81 11.77 50380 A Reimplantation of kidney 30.11 NA NA 22.45 21.61 50382 A Change ureter stent, percut 5.50 26.99 30.96 1.97 2.30 50384 A Remove ureter stent, percut 5.00 21.18 25.44 1.77 2.08 50385 A Change stent via transureth 4.44 27.38 31.38 1.92 2.25 50386 A Remove stent via transureth 3.30 17.77 20.09 1.54 1.78 50387 A Change ext/int ureter stent 2.00 12.94 14.90 0.68 0.82 50389 A Remove renal tube w/fluoro 1.10 6.79 8.32 0.38 0.45 50390 A Drainage of kidney lesion 1.96 NA NA 0.67 0.79 50391 A Instll rx agnt into rnal tub 1.96 1.42 1.63 0.79 0.87 50392 A Insert kidney drain 3.37 NA NA 1.46 1.71 50393 A Insert ureteral tube 4.15 NA NA 1.73 2.03 50394 A Injection for kidney x-ray 0.76 1.90 2.21 0.58 0.66 50395 A Create passage to kidney 3.37 NA NA 1.53 1.75 50396 A Measure kidney pressure 2.09 NA NA 1.02 1.21 50398 A Change kidney tube 1.46 12.21 13.88 0.54 0.63 50400 A Revision of kidney/ureter 21.27 NA NA 10.69 11.72 50405 A Revision of kidney/ureter 25.86 NA NA 12.68 13.98 50500 A Repair of kidney wound 21.22 NA NA 11.88 11.46 50520 A Close kidney-skin fistula 18.88 NA NA 9.71 10.59 50525 A Repair renal-abdomen fistula 24.39 NA NA 13.97 13.69 50526 A Repair renal-abdomen fistula 26.31 NA NA 13.98 13.51 50540 A Revision of horseshoe kidney 21.10 NA NA 10.58 11.37 50541 A Laparo ablate renal cyst 16.86 NA NA 8.52 9.40 50542 A Laparo ablate renal mass 21.36 NA NA 10.88 12.02 50543 A Laparo partial nephrectomy 27.41 NA NA 13.69 15.14 
CMS-1503-P 962

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

50544 A Laparoscopy, pyeloplasty 23.37 NA NA 11.07 12.28 50545 A Laparo radical nephrectomy 25.06 NA NA 11.97 13.25 50546 A Laparoscopic nephrectomy 21.87 NA NA 11.19 12.27 50547 A Laparo removal donor kidney 26.34 NA NA 16.19 15.65 50548 A Laparo remove w/ureter 25.36 NA NA 11.88 13.18 50549 C Laparoscope proc, renal 0.00 0.00 0.00 0.00 0.00 50551 A Kidney endoscopy 5.59 4.25 4.88 2.57 2.86 50553 A Kidney endoscopy 5.98 4.46 5.03 2.63 2.94 50555 A Kidney endoscopy & biopsy 6.52 4.75 5.42 2.94 3.26 50557 A Kidney endoscopy & treatment 6.61 4.85 5.56 2.97 3.31 50561 A Kidney endoscopy & treatment 7.58 5.43 6.21 3.35 3.74 50562 A Renal scope w/tumor resect 10.90 NA NA 5.17 5.81 50570 A Kidney endoscopy 9.53 NA NA 4.09 4.57 50572 A Kidney endoscopy 10.33 NA NA 4.40 4.94 50574 A Kidney endoscopy & biopsy 11.00 NA NA 4.67 5.22 50575 A Kidney endoscopy 13.96 NA NA 5.83 6.53 50576 A Kidney endoscopy & treatment 10.97 NA NA 4.65 5.21 50580 A Kidney endoscopy & treatment 11.84 NA NA 5.00 5.53 50590 A Fragmenting of kidney stone 9.77 15.23 17.22 5.81 6.42 50592 A Perc rf ablate renal tumor 6.80 73.39 91.82 2.99 3.44 50593 A Perc cryo ablate renal tum 9.13 111.59 126.81 4.04 4.18 50600 A Exploration of ureter 17.17 NA NA 8.75 9.57 50605 A Insert ureteral support 16.79 NA NA 9.31 9.38 50610 A Removal of ureter stone 17.25 NA NA 8.84 9.79 50620 A Removal of ureter stone 16.43 NA NA 8.52 9.43 50630 A Removal of ureter stone 16.21 NA NA 8.43 9.12 
CMS-1503-P 963

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

50650 A Removal of ureter 18.82 NA NA 9.74 10.70 50660 A Removal of ureter 21.02 NA NA 10.55 11.58 50684 A Injection for ureter x-ray 0.76 3.81 4.42 0.60 0.67 50686 A Measure ureter pressure 1.51 2.57 1.88 1.01 1.09 50688 A Change of ureter tube/stent 1.20 NA NA 0.94 1.08 50690 A Injection for ureter x-ray 1.16 1.42 1.66 0.73 0.83 50700 A Revision of ureter 16.69 NA NA 8.84 9.69 50715 A Release of ureter 20.64 NA NA 11.39 11.08 50722 A Release of ureter 17.95 NA NA 10.17 9.77 50725 A Release/revise ureter 20.20 NA NA 11.95 11.80 50727 A Revise ureter 8.28 NA NA 5.64 6.16 50728 A Revise ureter 12.18 NA NA 7.07 7.61 50740 A Fusion of ureter & kidney 20.07 NA NA 11.89 11.37 50750 A Fusion of ureter & kidney 21.22 NA NA 10.63 11.84 50760 A Fusion of ureters 20.07 NA NA 10.54 11.09 50770 A Splicing of ureters 21.22 NA NA 10.63 11.18 50780 A Reimplant ureter in bladder 19.95 NA NA 10.31 11.12 50782 A Reimplant ureter in bladder 19.66 NA NA 10.01 10.76 50783 A Reimplant ureter in bladder 20.70 NA NA 12.16 11.76 50785 A Reimplant ureter in bladder 22.23 NA NA 11.15 12.21 50800 A Implant ureter in bowel 16.41 NA NA 9.04 9.86 50810 A Fusion of ureter & bowel 22.61 NA NA 11.84 12.01 50815 A Urine shunt to intestine 22.26 NA NA 11.48 12.63 50820 A Construct bowel bladder 24.07 NA NA 12.18 13.08 50825 A Construct bowel bladder 30.68 NA NA 14.99 16.39 50830 A Revise urine flow 33.77 NA NA 16.01 17.32 
CMS-1503-P 964

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

50840 A Replace ureter by bowel 22.39 NA NA 11.53 12.73 50845 A Appendico-vesicostomy 22.46 NA NA 12.00 13.22 50860 A Transplant ureter to skin 17.08 NA NA 9.00 9.86 50900 A Repair of ureter 15.04 NA NA 8.45 8.95 50920 A Closure ureter/skin fistula 15.81 NA NA 8.50 9.37 50930 A Closure ureter/bowel fistula 20.19 NA NA 10.22 10.62 50940 A Release of ureter 15.93 NA NA 8.54 9.31 50945 A Laparoscopy ureterolithotomy 17.97 NA NA 8.91 9.84 50947 A Laparo new ureter/bladder 25.78 NA NA 12.42 13.57 50948 A Laparo new ureter/bladder 23.82 NA NA 11.40 12.72 50949 C Laparoscope proc, ureter 0.00 0.00 0.00 0.00 0.00 50951 A Endoscopy of ureter 5.83 4.45 5.11 2.67 2.98 50953 A Endoscopy of ureter 6.23 4.66 5.33 3.15 3.51 50955 A Ureter endoscopy & biopsy 6.74 4.90 5.86 3.36 3.76 50957 A Ureter endoscopy & treatment 6.78 4.96 5.66 3.04 3.38 50961 A Ureter endoscopy & treatment 6.04 4.53 5.19 2.74 3.07 50970 A Ureter endoscopy 7.13 NA NA 3.14 3.51 50972 A Ureter endoscopy & catheter 6.88 NA NA 3.04 3.38 50974 A Ureter endoscopy & biopsy 9.16 NA NA 3.94 4.41 50976 A Ureter endoscopy & treatment 9.03 NA NA 3.89 4.33 50980 A Ureter endoscopy & treatment 6.84 NA NA 3.03 3.39 

5100F I Rsk fx ref w/n 24 hrs x-ray 0.00 0.00 0.00 0.00 0.00 

51020 A Incise & treat bladder 7.69 NA NA 5.18 5.73 51030 A Incise & treat bladder 7.81 NA NA 5.14 5.52 51040 A Incise & drain bladder 4.49 NA NA 3.46 3.86 51045 A Incise bladder/drain ureter 7.81 NA NA 5.53 5.79 
CMS-1503-P 965

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

51050 A Removal of bladder stone 7.97 NA NA 5.04 5.58 51060 A Removal of ureter stone 9.95 NA NA 6.05 6.71 51065 A Remove ureter calculus 9.95 NA NA 5.97 6.60 51080 A Drainage of bladder abscess 6.71 NA NA 4.53 4.97 51100 A Drain bladder by needle 0.78 0.93 1.00 0.31 0.32 51101 A Drain bladder by trocar/cath 1.02 2.40 2.65 0.44 0.45 51102 A Drain bl w/cath insertion 2.70 3.45 3.96 1.29 1.48 51500 A Removal of bladder cyst 11.05 NA NA 7.81 7.45 51520 A Removal of bladder lesion 10.21 NA NA 6.16 6.65 51525 A Removal of bladder lesion 15.42 NA NA 8.24 9.10 51530 A Removal of bladder lesion 13.71 NA NA 7.91 8.35 51535 A Repair of ureter lesion 13.90 NA NA 7.59 8.21 51550 A Partial removal of bladder 17.23 NA NA 9.16 9.79 51555 A Partial removal of bladder 23.18 NA NA 11.68 12.61 51565 A Revise bladder & ureter(s) 23.68 NA NA 12.05 13.02 51570 A Removal of bladder 27.46 NA NA 13.47 14.48 51575 A Removal of bladder & nodes 34.18 NA NA 16.13 17.83 51580 A Remove bladder/revise tract 35.37 NA NA 16.99 18.85 51585 A Removal of bladder & nodes 39.64 NA NA 18.67 20.72 51590 A Remove bladder/revise tract 36.33 NA NA 16.99 18.70 51595 A Remove bladder/revise tract 41.32 NA NA 19.16 21.16 51596 A Remove bladder/create pouch 44.26 NA NA 20.74 22.94 51597 A Removal of pelvic structures 42.86 NA NA 20.35 22.15 51600 A Injection for bladder x-ray 0.88 4.09 4.71 0.32 0.37 51605 A Preparation for bladder xray 0.64 NA NA 0.42 0.46 51610 A Injection for bladder x-ray 1.05 1.83 2.12 0.69 0.77 
CMS-1503-P 966

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

51700 A Irrigation of bladder 0.88 1.38 1.60 0.36 0.38 51701 A Insert bladder catheter 0.50 0.98 1.19 0.26 0.27 51702 A Insert temp bladder cath 0.50 1.41 1.70 0.33 0.36 51703 A Insert bladder cath, complex 1.47 2.06 2.47 0.78 0.86 51705 A Change of bladder tube 1.05 1.83 2.17 0.80 0.89 51710 A Change of bladder tube 1.52 2.45 2.96 1.10 1.22 51715 A Endoscopic injection/implant 3.73 4.12 4.66 1.78 1.92 51720 A Treatment of bladder lesion 1.50 1.48 1.75 0.72 0.82 51725 A Simple cystometrogram 1.51 3.56 4.50 NA NA 51725 TC A Simple cystometrogram 0.00 2.94 3.85 NA NA 51725 26 A Simple cystometrogram 1.51 0.62 0.65 0.62 0.65 51726 A Complex cystometrogram 1.71 5.61 7.09 NA NA 51726 TC A Complex cystometrogram 0.00 4.91 6.34 NA NA 51726 26 A Complex cystometrogram 1.71 0.70 0.75 0.70 0.75 51727 A Cystometrogram w/up 2.11 6.57 6.57 NA NA 51727 TC A Cystometrogram w/up 0.00 5.68 5.68 NA NA 51727 26 A Cystometrogram w/up 2.11 0.89 0.89 0.89 0.89 51728 A Cystometrogram w/vp 2.11 6.54 6.54 NA NA 51728 TC A Cystometrogram w/vp 0.00 5.68 5.68 NA NA 51728 26 A Cystometrogram w/vp 2.11 0.86 0.86 0.86 0.86 51729 A Cystometrogram w/vp&up 2.51 6.91 6.91 NA NA 51729 TC A Cystometrogram w/vp&up 0.00 5.86 5.86 NA NA 51729 26 A Cystometrogram w/vp&up 2.51 1.05 1.05 1.05 1.05 51736 A Urine flow measurement 0.61 0.85 0.94 NA NA 51736 TC A Urine flow measurement 0.00 0.60 0.67 NA NA 51736 26 A Urine flow measurement 0.61 0.25 0.27 0.25 0.27 
CMS-1503-P 967

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

51741 A Electro-uroflowmetry, first 1.14 1.16 1.28 NA NA 51741 TC A Electro-uroflowmetry, first 0.00 0.70 0.78 NA NA 51741 26 A Electro-uroflowmetry, first 1.14 0.46 0.50 0.46 0.50 51784 A Anal/urinary muscle study 1.53 3.85 4.34 NA NA 51784 TC A Anal/urinary muscle study 0.00 3.22 3.68 NA NA 51784 26 A Anal/urinary muscle study 1.53 0.63 0.66 0.63 0.66 51785 A Anal/urinary muscle study 1.53 4.43 4.92 NA NA 51785 TC A Anal/urinary muscle study 0.00 3.79 4.25 NA NA 51785 26 A Anal/urinary muscle study 1.53 0.64 0.67 0.64 0.67 51792 A Urinary reflex study 1.10 4.89 5.57 NA NA 51792 TC A Urinary reflex study 0.00 4.42 5.08 NA NA 51792 26 A Urinary reflex study 1.10 0.47 0.49 0.47 0.49 51797 A Intraabdominal pressure test 0.80 2.25 3.08 NA NA 51797 TC A Intraabdominal pressure test 0.00 1.92 2.69 NA NA 51797 26 A Intraabdominal pressure test 0.80 0.33 0.39 0.33 0.39 51798 A Us urine capacity measure 0.00 0.50 0.56 NA NA 51800 A Revision of bladder/urethra 18.89 NA NA 9.89 10.85 51820 A Revision of urinary tract 19.59 NA NA 10.30 10.81 51840 A Attach bladder/urethra 11.36 NA NA 6.69 6.92 51841 A Attach bladder/urethra 13.68 NA NA 7.78 8.00 51845 A Repair bladder neck 10.15 NA NA 6.00 6.46 51860 A Repair of bladder wound 12.60 NA NA 7.62 7.84 51865 A Repair of bladder wound 15.80 NA NA 8.69 9.29 51880 A Repair of bladder opening 7.87 NA NA 4.94 5.28 51900 A Repair bladder/vagina lesion 14.63 NA NA 8.29 8.75 51920 A Close bladder-uterus fistula 13.41 NA NA 7.63 8.12 
CMS-1503-P 968

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

51925 A Hysterectomy/bladder repair 17.53 NA NA 11.50 11.13 51940 A Correction of bladder defect 30.66 NA NA 14.68 15.38 51960 A Revision of bladder & bowel 25.40 NA NA 12.86 14.15 51980 A Construct bladder opening 12.57 NA NA 7.09 7.78 51990 A Laparo urethral suspension 13.36 NA NA 7.37 7.54 51992 A Laparo sling operation 14.87 NA NA 8.29 8.21 51999 C Laparoscope proc, bla 0.00 0.00 0.00 0.00 0.00 52000 A Cystoscopy 2.23 3.27 3.79 1.25 1.36 52001 A Cystoscopy, removal of clots 5.44 4.67 5.44 2.52 2.79 52005 A Cystoscopy & ureter catheter 2.37 5.05 5.94 1.30 1.44 52007 A Cystoscopy and biopsy 3.02 9.44 12.00 1.55 1.73 

5200F I Eval appros surg thxpy epi 0.00 0.00 0.00 0.00 0.00 

52010 A Cystoscopy & duct catheter 3.02 7.14 8.51 1.56 1.64 52204 A Cystoscopy w/biopsy(s) 2.59 7.29 9.54 1.32 1.45 52214 A Cystoscopy and treatment 3.70 13.73 14.44 1.76 2.29 52224 A Cystoscopy and treatment 3.14 13.03 18.64 1.54 1.71 52234 A Cystoscopy and treatment 4.62 NA NA 2.19 2.44 52235 A Cystoscopy and treatment 5.44 NA NA 2.54 2.83 52240 A Cystoscopy and treatment 9.71 NA NA 4.22 4.72 52250 A Cystoscopy and radiotracer 4.49 NA NA 2.24 2.47 52260 A Cystoscopy and treatment 3.91 NA NA 1.90 2.09 52265 A Cystoscopy and treatment 2.94 6.88 8.78 1.55 1.64 52270 A Cystoscopy & revise urethra 3.36 6.20 7.92 1.67 1.86 52275 A Cystoscopy & revise urethra 4.69 8.23 10.65 2.19 2.44 52276 A Cystoscopy and treatment 4.99 NA NA 2.35 2.63 52277 A Cystoscopy and treatment 6.16 NA NA 2.87 3.16 
CMS-1503-P 969

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

52281 A Cystoscopy and treatment 2.80 4.69 5.80 1.47 1.63 52282 A Cystoscopy, implant stent 6.39 NA NA 2.92 3.22 52283 A Cystoscopy and treatment 3.73 3.81 4.37 1.86 2.04 52285 A Cystoscopy and treatment 3.60 3.96 4.56 1.81 1.98 52290 A Cystoscopy and treatment 4.58 NA NA 2.18 2.43 52300 A Cystoscopy and treatment 5.30 NA NA 2.54 2.78 52301 A Cystoscopy and treatment 5.50 NA NA 2.60 2.90 52305 A Cystoscopy and treatment 5.30 NA NA 2.42 2.69 52310 A Cystoscopy and treatment 2.81 3.60 4.33 1.38 1.53 52315 A Cystoscopy and treatment 5.20 5.96 7.31 2.39 2.67 52317 A Remove bladder stone 6.71 15.00 19.51 2.91 3.25 52318 A Remove bladder stone 9.18 NA NA 3.94 4.40 52320 A Cystoscopy and treatment 4.69 NA NA 2.14 2.38 52325 A Cystoscopy, stone removal 6.15 NA NA 2.72 3.03 52327 A Cystoscopy, inject material 5.18 NA NA 2.06 2.30 52330 A Cystoscopy and treatment 5.03 8.28 14.16 2.27 2.53 52332 A Cystoscopy and treatment 2.83 10.83 11.82 1.48 1.64 52334 A Create passage to kidney 4.82 NA NA 2.26 2.53 52341 A Cysto w/ureter stricture tx 5.35 NA NA 2.63 2.97 52342 A Cysto w/up stricture tx 5.85 NA NA 2.83 3.19 52343 A Cysto w/renal stricture tx 6.55 NA NA 3.11 3.51 52344 A Cysto/uretero, stricture tx 7.05 NA NA 3.45 3.88 52345 A Cysto/uretero w/up stricture 7.55 NA NA 3.65 4.11 52346 A Cystouretero w/renal strict 8.58 NA NA 4.04 4.56 52351 A Cystouretero & or pyeloscope 5.85 NA NA 2.84 3.16 52352 A Cystouretero w/stone remove 6.87 NA NA 3.33 3.71 
CMS-1503-P 970

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

52353 A Cystouretero w/lithotripsy 7.96 NA NA 3.76 4.19 52354 A Cystouretero w/biopsy 7.33 NA NA 3.51 3.91 52355 A Cystouretero w/excise tumor 8.81 NA NA 4.09 4.57 52400 A Cystouretero w/congen repr 8.69 NA NA 4.51 5.07 52402 A Cystourethro cut ejacul duct 5.27 NA NA 2.12 2.38 52450 A Incision of prostate 7.78 NA NA 5.16 5.70 52500 A Revision of bladder neck 8.14 NA NA 5.30 5.88 52601 A Prostatectomy (TURP) 15.26 NA NA 8.06 8.62 52630 A Remove prostate regrowth 7.73 NA NA 4.54 4.99 52640 A Relieve bladder contracture 4.79 NA NA 3.31 3.77 52647 A Laser surgery of prostate 11.30 36.62 48.14 6.54 7.22 52648 A Laser surgery of prostate 12.15 37.19 48.67 6.88 7.59 52649 A Prostate laser enucleation 17.29 NA NA 8.93 10.40 52700 A Drainage of prostate abscess 7.49 NA NA 4.65 5.04 53000 A Incision of urethra 2.33 NA NA 1.74 1.94 53010 A Incision of urethra 4.45 NA NA 3.64 4.04 53020 A Incision of urethra 1.77 NA NA 0.91 1.01 53025 A Incision of urethra 1.13 NA NA 0.82 0.80 53040 A Drainage of urethra abscess 6.55 NA NA 4.26 4.69 53060 A Drainage of urethra abscess 2.68 2.32 2.38 1.83 1.80 53080 A Drainage of urinary leakage 6.92 NA NA 4.64 5.38 53085 A Drainage of urinary leakage 11.18 NA NA 6.70 6.76 53200 A Biopsy of urethra 2.59 1.67 1.83 1.31 1.42 53210 A Removal of urethra 13.72 NA NA 7.64 8.35 53215 A Removal of urethra 16.85 NA NA 8.76 9.75 53220 A Treatment of urethra lesion 7.63 NA NA 4.91 5.36 
CMS-1503-P 971

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

53230 A Removal of urethra lesion 10.44 NA NA 6.25 6.80 53235 A Removal of urethra lesion 10.99 NA NA 6.44 7.22 53240 A Surgery for urethra pouch 7.08 NA NA 4.61 5.17 53250 A Removal of urethra gland 6.52 NA NA 4.75 5.06 53260 A Treatment of urethra lesion 3.03 2.47 2.69 1.92 2.03 53265 A Treatment of urethra lesion 3.17 2.78 3.14 1.95 2.11 53270 A Removal of urethra gland 3.14 2.57 2.72 2.04 2.09 53275 A Repair of urethra defect 4.57 NA NA 2.65 2.97 53400 A Revise urethra, stage 1 14.13 NA NA 7.98 8.77 53405 A Revise urethra, stage 2 15.66 NA NA 8.43 9.40 53410 A Reconstruction of urethra 17.68 NA NA 9.36 10.36 53415 A Reconstruction of urethra 20.70 NA NA 10.47 11.57 53420 A Reconstruct urethra, stage 1 15.17 NA NA 8.03 8.26 53425 A Reconstruct urethra, stage 2 17.07 NA NA 8.78 9.82 53430 A Reconstruction of urethra 17.43 NA NA 9.14 9.74 53431 A Reconstruct urethra/bladder 21.18 NA NA 10.68 11.80 53440 A Male sling procedure 15.54 NA NA 8.83 9.70 53442 A Remove/revise male sling 13.49 NA NA 8.09 8.84 53444 A Insert tandem cuff 14.19 NA NA 7.69 8.56 53445 A Insert uro/ves nck sphincter 15.39 NA NA 8.78 9.81 53446 A Remove uro sphincter 11.02 NA NA 6.68 7.44 53447 A Remove/replace ur sphincter 14.28 NA NA 8.01 8.95 53448 A Remov/replc ur sphinctr comp 23.44 NA NA 11.90 13.21 53449 A Repair uro sphincter 10.56 NA NA 6.29 7.00 53450 A Revision of urethra 6.77 NA NA 4.47 4.97 53460 A Revision of urethra 7.75 NA NA 4.86 5.40 
CMS-1503-P 972

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

53500 A Urethrlys, transvag w/ scope 13.00 NA NA 7.54 8.16 53502 A Repair of urethra injury 8.26 NA NA 5.14 5.63 53505 A Repair of urethra injury 8.26 NA NA 5.13 5.70 53510 A Repair of urethra injury 10.96 NA NA 6.43 7.15 53515 A Repair of urethra injury 14.22 NA NA 7.72 8.51 53520 A Repair of urethra defect 9.48 NA NA 5.85 6.48 53600 A Dilate urethra stricture 1.21 1.06 1.23 0.56 0.62 53601 A Dilate urethra stricture 0.98 1.23 1.42 0.50 0.56 53605 A Dilate urethra stricture 1.28 NA NA 0.51 0.56 53620 A Dilate urethra stricture 1.62 1.54 1.85 0.79 0.88 53621 A Dilate urethra stricture 1.35 1.62 1.95 0.64 0.72 53660 A Dilation of urethra 0.71 1.20 1.39 0.44 0.48 53661 A Dilation of urethra 0.72 1.16 1.36 0.40 0.44 53665 A Dilation of urethra 0.76 NA NA 0.31 0.32 53850 A Prostatic microwave thermotx 10.08 42.86 57.47 5.59 6.18 53852 A Prostatic rf thermotx 10.83 40.42 54.21 6.32 6.97 53855 A Insert prost urethral stent 1.64 18.83 18.83 0.65 0.65 53899 C Urology surgery procedure 0.00 0.00 0.00 0.00 0.00 54000 A Slitting of prepuce 1.59 2.42 2.88 1.38 1.52 54001 A Slitting of prepuce 2.24 2.79 3.26 1.58 1.73 54015 A Drain penis lesion 5.36 NA NA 3.08 3.45 54050 A Destruction, penis lesion(s) 1.29 2.34 2.38 1.63 1.62 54055 A Destruction, penis lesion(s) 1.25 1.98 2.13 1.29 1.34 54056 A Cryosurgery, penis lesion(s) 1.29 2.65 2.63 1.82 1.77 54057 A Laser surg, penis lesion(s) 1.29 2.43 2.72 1.31 1.40 54060 A Excision of penis lesion(s) 1.98 2.90 3.33 1.61 1.72 
CMS-1503-P 973

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

54065 A Destruction, penis lesion(s) 2.47 3.57 3.66 2.33 2.27 54100 A Biopsy of penis 1.90 3.54 3.71 1.65 1.59 54105 A Biopsy of penis 3.54 3.66 4.31 2.33 2.61 54110 A Treatment of penis lesion 10.92 NA NA 6.28 6.95 54111 A Treat penis lesion, graft 14.42 NA NA 7.66 8.53 54112 A Treat penis lesion, graft 16.98 NA NA 8.89 9.93 54115 A Treatment of penis lesion 6.95 5.43 6.07 4.72 5.21 54120 A Partial removal of penis 11.01 NA NA 6.40 7.09 54125 A Removal of penis 14.56 NA NA 7.84 8.66 54130 A Remove penis & nodes 21.84 NA NA 11.09 12.33 54135 A Remove penis & nodes 28.17 NA NA 13.59 15.12 54150 A Circumcision w/regionl block 1.90 2.31 2.80 0.80 0.85 54160 A Circumcision, neonate 2.53 3.43 4.08 1.44 1.60 54161 A Circum 28 days or older 3.32 NA NA 2.09 2.32 54162 A Lysis penil circumic lesion 3.32 3.70 4.37 2.17 2.36 54163 A Repair of circumcision 3.32 NA NA 2.70 2.99 54164 A Frenulotomy of penis 2.82 NA NA 2.48 2.75 54200 A Treatment of penis lesion 1.11 1.81 2.09 1.19 1.34 54205 A Treatment of penis lesion 8.97 NA NA 5.69 6.40 54220 A Treatment of penis lesion 2.42 3.03 3.60 1.29 1.42 54230 A Prepare penis study 1.34 1.29 1.46 0.85 0.95 54231 A Dynamic cavernosometry 2.04 1.79 2.01 1.17 1.31 54235 A Penile injection 1.19 1.28 1.43 0.84 0.93 54240 A Penis study 1.31 1.42 1.58 NA NA 54240 TC A Penis study 0.00 0.91 1.01 NA NA 54240 26 A Penis study 1.31 0.51 0.57 0.51 0.57 
CMS-1503-P 974

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

54250 A Penis study 2.22 1.20 1.34 NA NA 54250 TC A Penis study 0.00 0.32 0.36 NA NA 54250 26 A Penis study 2.22 0.88 0.98 0.88 0.98 54300 A Revision of penis 11.20 NA NA 6.50 7.32 54304 A Revision of penis 13.28 NA NA 7.40 8.36 54308 A Reconstruction of urethra 12.62 NA NA 7.74 8.33 54312 A Reconstruction of urethra 14.51 NA NA 8.79 9.48 54316 A Reconstruction of urethra 18.05 NA NA 10.36 11.13 54318 A Reconstruction of urethra 12.43 NA NA 7.81 8.37 54322 A Reconstruction of urethra 13.98 NA NA 7.56 8.53 54324 A Reconstruction of urethra 17.55 NA NA 9.19 10.39 54326 A Reconstruction of urethra 17.02 NA NA 9.08 9.65 54328 A Revise penis/urethra 16.89 NA NA 9.03 9.99 54332 A Revise penis/urethra 18.37 NA NA 9.62 10.78 54336 A Revise penis/urethra 21.62 NA NA 12.24 12.10 54340 A Secondary urethral surgery 9.71 NA NA 5.99 6.56 54344 A Secondary urethral surgery 17.06 NA NA 9.92 10.68 54348 A Secondary urethral surgery 18.32 NA NA 16.54 14.40 54352 A Reconstruct urethra/penis 26.13 NA NA 22.46 19.46 54360 A Penis plastic surgery 12.78 NA NA 7.09 8.00 54380 A Repair penis 14.18 NA NA 7.86 8.86 54385 A Repair penis 16.56 NA NA 9.04 10.93 54390 A Repair penis and bladder 22.77 NA NA 12.55 12.22 54400 A Insert semi-rigid prosthesis 9.17 NA NA 5.43 6.07 54401 A Insert self-contd prosthesis 10.44 NA NA 7.58 8.45 54405 A Insert multi-comp penis pros 14.52 NA NA 7.80 8.67 
CMS-1503-P 975

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

54406 A Remove muti-comp penis pros 12.89 NA NA 7.25 8.05 54408 A Repair multi-comp penis pros 13.91 NA NA 7.89 8.73 54410 A Remove/replace penis prosth 15.18 NA NA 8.53 9.51 54411 A Remov/replc penis pros, comp 18.35 NA NA 9.98 11.02 54415 A Remove self-contd penis pros 8.88 NA NA 5.66 6.28 54416 A Remv/repl penis contain pros 12.08 NA NA 7.50 8.29 54417 A Remv/replc penis pros, compl 16.10 NA NA 8.69 9.62 54420 A Revision of penis 12.39 NA NA 7.04 7.88 54430 A Revision of penis 11.06 NA NA 6.58 7.36 54435 A Revision of penis 6.81 NA NA 4.66 5.20 54440 C Repair of penis 0.00 0.00 0.00 0.00 0.00 54450 A Preputial stretching 1.12 0.80 0.94 0.47 0.54 54500 A Biopsy of testis 1.31 NA NA 0.75 0.84 54505 A Biopsy of testis 3.50 NA NA 2.28 2.57 54512 A Excise lesion testis 9.33 NA NA 5.49 6.02 54520 A Removal of testis 5.30 NA NA 3.65 3.98 54522 A Orchiectomy, partial 10.25 NA NA 6.01 6.42 54530 A Removal of testis 8.46 NA NA 5.43 6.04 54535 A Extensive testis surgery 13.19 NA NA 7.33 7.91 54550 A Exploration for testis 8.41 NA NA 5.15 5.63 54560 A Exploration for testis 12.10 NA NA 6.83 7.16 54600 A Reduce testis torsion 7.64 NA NA 4.84 5.35 54620 A Suspension of testis 5.21 NA NA 3.06 3.43 54640 A Suspension of testis 7.73 NA NA 5.44 5.80 54650 A Orchiopexy (Fowler-Stephens) 12.39 NA NA 7.22 7.85 54660 A Revision of testis 5.74 NA NA 4.09 4.50 
CMS-1503-P 976

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

54670 A Repair testis injury 6.65 NA NA 4.50 4.97 54680 A Relocation of testis(es) 14.04 NA NA 7.67 8.32 54690 A Laparoscopy, orchiectomy 11.70 NA NA 6.43 6.58 54692 A Laparoscopy, orchiopexy 13.74 NA NA 7.21 8.04 54699 C Laparoscope proc, testis 0.00 0.00 0.00 0.00 0.00 54700 A Drainage of scrotum 3.47 NA NA 2.38 2.58 54800 A Biopsy of epididymis 2.33 NA NA 2.02 1.78 54830 A Remove epididymis lesion 6.01 NA NA 4.24 4.64 54840 A Remove epididymis lesion 5.27 NA NA 3.57 3.98 54860 A Removal of epididymis 6.95 NA NA 4.58 5.07 54861 A Removal of epididymis 9.70 NA NA 5.89 6.51 54865 A Explore epididymis 5.77 NA NA 4.10 4.51 54900 A Fusion of spermatic ducts 14.20 NA NA 7.87 7.93 54901 A Fusion of spermatic ducts 19.10 NA NA 10.96 11.64 55000 A Drainage of hydrocele 1.43 1.76 2.04 0.91 0.99 55040 A Removal of hydrocele 5.45 NA NA 3.83 4.20 55041 A Removal of hydroceles 8.54 NA NA 5.49 6.02 55060 A Repair of hydrocele 6.15 NA NA 4.30 4.70 55100 A Drainage of scrotum abscess 2.45 3.38 3.82 2.09 2.24 55110 A Explore scrotum 6.33 NA NA 4.36 4.74 55120 A Removal of scrotum lesion 5.72 NA NA 4.07 4.44 55150 A Removal of scrotum 8.14 NA NA 5.37 5.86 55175 A Revision of scrotum 5.87 NA NA 4.14 4.56 55180 A Revision of scrotum 11.78 NA NA 7.28 7.88 55200 A Incision of sperm duct 4.55 7.27 9.08 3.11 3.39 55250 A Removal of sperm duct(s) 3.37 7.23 8.84 2.93 3.20 
CMS-1503-P 977

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

55300 A Prepare, sperm duct x-ray 3.50 NA NA 1.68 1.71 55400 A Repair of sperm duct 8.61 NA NA 5.13 5.74 55450 A Ligation of sperm duct 4.43 5.33 6.38 2.66 2.90 55500 A Removal of hydrocele 6.22 NA NA 4.62 4.73 55520 A Removal of sperm cord lesion 6.66 NA NA 5.29 4.90 55530 A Revise spermatic cord veins 5.75 NA NA 3.95 4.35 55535 A Revise spermatic cord veins 7.19 NA NA 4.66 5.10 55540 A Revise hernia & sperm veins 8.30 NA NA 6.01 5.58 55550 A Laparo ligate spermatic vein 7.20 NA NA 4.60 4.95 55559 C Laparo proc, spermatic cord 0.00 0.00 0.00 0.00 0.00 55600 A Incise sperm duct pouch 7.01 NA NA 4.60 5.11 55605 A Incise sperm duct pouch 8.76 NA NA 6.08 6.11 55650 A Remove sperm duct pouch 12.65 NA NA 7.13 7.78 55680 A Remove sperm pouch lesion 5.67 NA NA 3.86 4.12 55700 A Biopsy of prostate 2.58 3.33 3.98 1.27 1.37 55705 A Biopsy of prostate 4.61 NA NA 2.74 3.07 55706 A Prostate saturation sampling 6.28 NA NA 4.00 4.64 55720 A Drainage of prostate abscess 7.73 NA NA 4.73 5.22 55725 A Drainage of prostate abscess 10.05 NA NA 6.29 6.88 55801 A Removal of prostate 19.80 NA NA 10.38 11.35 55810 A Extensive prostate surgery 24.29 NA NA 12.03 13.23 55812 A Extensive prostate surgery 29.89 NA NA 14.55 16.10 55815 A Extensive prostate surgery 32.95 NA NA 15.76 17.48 55821 A Removal of prostate 15.76 NA NA 8.36 9.26 55831 A Removal of prostate 17.19 NA NA 8.92 9.89 55840 A Extensive prostate surgery 24.63 NA NA 12.31 13.64 
CMS-1503-P 978

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

55842 A Extensive prostate surgery 26.49 NA NA 13.04 14.48 55845 A Extensive prostate surgery 30.67 NA NA 14.50 16.07 55860 A Surgical exposure, prostate 15.84 NA NA 8.29 9.22 55862 A Extensive prostate surgery 20.04 NA NA 10.24 11.43 55865 A Extensive prostate surgery 24.57 NA NA 12.27 13.67 55866 A Laparo radical prostatectomy 32.46 NA NA 15.60 17.28 55870 A Electroejaculation 2.58 2.22 2.48 1.35 1.52 55873 A Cryoablate prostate 13.60 169.57 169.57 7.47 10.45 55875 A Transperi needle place, pros 13.46 NA NA 7.66 8.43 55876 A Place rt device/marker, pros 1.73 1.99 2.25 1.06 1.19 55899 C Genital surgery procedure 0.00 0.00 0.00 0.00 0.00 55920 A Place needles pelvic for rt 8.31 NA NA 4.40 4.26 55970 N Sex transformation, M to F 0.00 0.00 0.00 0.00 0.00 55980 N Sex transformation, F to M 0.00 0.00 0.00 0.00 0.00 56405 A I & D of vulva/perineum 1.49 1.45 1.46 1.43 1.41 56420 A Drainage of gland abscess 1.44 1.82 1.94 1.02 1.02 56440 A Surgery for vulva lesion 2.89 NA NA 2.05 2.01 56441 A Lysis of labial lesion(s) 2.02 1.88 1.99 1.74 1.80 56442 A Hymenotomy 0.68 NA NA 0.61 0.63 56501 A Destroy, vulva lesions, sim 1.58 1.94 1.98 1.52 1.51 56515 A Destroy vulva lesion/s compl 3.08 3.00 2.98 2.35 2.26 56605 A Biopsy of vulva/perineum 1.10 1.11 1.14 0.54 0.50 56606 A Biopsy of vulva/perineum 0.55 0.46 0.47 0.25 0.23 56620 A Partial removal of vulva 7.53 NA NA 6.10 5.91 56625 A Complete removal of vulva 9.68 NA NA 6.66 6.36 56630 A Extensive vulva surgery 14.80 NA NA 9.20 8.61 
CMS-1503-P 979

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

56631 A Extensive vulva surgery 18.99 NA NA 11.45 10.71 56632 A Extensive vulva surgery 21.86 NA NA 13.70 12.68 56633 A Extensive vulva surgery 19.62 NA NA 11.62 10.82 56634 A Extensive vulva surgery 20.66 NA NA 12.46 11.55 56637 A Extensive vulva surgery 24.75 NA NA 14.09 13.08 56640 A Extensive vulva surgery 24.78 NA NA 13.21 12.42 56700 A Partial removal of hymen 2.84 NA NA 2.21 2.19 56740 A Remove vagina gland lesion 4.88 NA NA 3.17 3.05 56800 A Repair of vagina 3.93 NA NA 2.60 2.56 56805 A Repair clitoris 19.88 NA NA 11.13 10.62 56810 A Repair of perineum 4.29 NA NA 2.75 2.68 56820 A Exam of vulva w/scope 1.50 1.47 1.48 0.80 0.75 56821 A Exam/biopsy of vulva w/scope 2.05 1.89 1.91 1.05 0.99 57000 A Exploration of vagina 3.02 NA NA 2.09 2.08 57010 A Drainage of pelvic abscess 6.84 NA NA 4.90 4.76 57020 A Drainage of pelvic fluid 1.50 1.02 1.00 0.70 0.65 57022 A I & d vaginal hematoma, pp 2.73 NA NA 1.82 1.76 57023 A I & d vag hematoma, non-ob 5.18 NA NA 3.23 3.13 57061 A Destroy vag lesions, simple 1.30 1.75 1.81 1.34 1.35 57065 A Destroy vag lesions, complex 2.66 2.50 2.52 1.97 1.92 57100 A Biopsy of vagina 1.20 1.17 1.18 0.58 0.54 57105 A Biopsy of vagina 1.74 1.87 1.93 1.62 1.63 57106 A Remove vagina wall, partial 7.50 NA NA 5.58 5.41 57107 A Remove vagina tissue, part 24.56 NA NA 13.55 12.69 57109 A Vaginectomy partial w/nodes 28.40 NA NA 15.90 14.47 57110 A Remove vagina wall, complete 15.48 NA NA 8.80 8.42 
CMS-1503-P 980

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

57111 A Remove vagina tissue, compl 28.40 NA NA 15.05 14.32 57112 A Vaginectomy w/nodes, compl 30.52 NA NA 9.16 11.65 57120 A Closure of vagina 8.28 NA NA 5.53 5.42 57130 A Remove vagina lesion 2.46 2.31 2.38 1.84 1.84 57135 A Remove vagina lesion 2.70 2.45 2.50 1.96 1.94 57150 A Treat vagina infection 0.55 0.67 0.77 0.25 0.23 57155 A Insert uteri tandems/ovoids 6.87 NA NA 4.77 4.70 57160 A Insert pessary/other device 0.89 1.17 1.21 0.40 0.37 57170 A Fitting of diaphragm/cap 0.91 0.72 0.85 0.40 0.37 57180 A Treat vaginal bleeding 1.63 2.13 2.23 1.21 1.23 57200 A Repair of vagina 4.42 NA NA 3.66 3.63 57210 A Repair vagina/perineum 5.71 NA NA 4.19 4.15 57220 A Revision of urethra 4.85 NA NA 3.80 3.77 57230 A Repair of urethral lesion 6.30 NA NA 4.39 4.42 57240 A Repair bladder & vagina 11.50 NA NA 6.73 6.53 57250 A Repair rectum & vagina 11.50 NA NA 6.85 6.35 57260 A Repair of vagina 14.44 NA NA 8.15 7.58 57265 A Extensive repair of vagina 15.94 NA NA 8.81 8.33 57267 A Insert mesh/pelvic flr addon 4.88 NA NA 2.12 2.09 57268 A Repair of bowel bulge 7.57 NA NA 5.49 5.39 57270 A Repair of bowel pouch 13.67 NA NA 7.96 7.62 57280 A Suspension of vagina 16.72 NA NA 9.18 8.96 57282 A Colpopexy, extraperitoneal 7.97 NA NA 5.63 5.60 57283 A Colpopexy, intraperitoneal 11.66 NA NA 7.01 6.80 57284 A Repair paravag defect, open 14.33 NA NA 7.85 7.83 57285 A Repair paravag defect, vag 11.60 NA NA 6.75 6.61 
CMS-1503-P 981

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

57287 A Revise/remove sling repair 11.15 NA NA 7.38 7.70 57288 A Repair bladder defect 12.13 NA NA 7.05 7.38 57289 A Repair bladder & vagina 12.80 NA NA 7.29 7.63 57291 A Construction of vagina 8.64 NA NA 8.95 7.39 57292 A Construct vagina with graft 14.01 NA NA 8.11 7.93 57295 A Revise vag graft via vagina 7.82 NA NA 5.17 5.22 57296 A Revise vag graft, open abd 16.56 NA NA 9.14 8.72 57300 A Repair rectum-vagina fistula 8.71 NA NA 6.36 5.90 57305 A Repair rectum-vagina fistula 15.35 NA NA 9.45 8.61 57307 A Fistula repair & colostomy 17.17 NA NA 10.85 9.76 57308 A Fistula repair, transperine 10.59 NA NA 7.29 6.70 57310 A Repair urethrovaginal lesion 7.65 NA NA 5.02 5.43 57311 A Repair urethrovaginal lesion 8.91 NA NA 5.52 5.97 57320 A Repair bladder-vagina lesion 8.88 NA NA 5.67 6.01 57330 A Repair bladder-vagina lesion 13.21 NA NA 7.17 7.67 57335 A Repair vagina 20.02 NA NA 11.29 11.00 57400 A Dilation of vagina 2.27 NA NA 1.33 1.31 57410 A Pelvic examination 1.75 NA NA 1.15 1.11 57415 A Remove vaginal foreign body 2.49 NA NA 1.85 1.84 57420 A Exam of vagina w/scope 1.60 1.52 1.53 0.84 0.79 57421 A Exam/biopsy of vag w/scope 2.20 1.98 2.00 1.12 1.05 57423 A Repair paravag defect, lap 16.08 NA NA 8.66 8.44 57425 A Laparoscopy, surg, colpopexy 17.03 NA NA 9.38 8.98 57426 A Revise prosth vag graft lap 14.30 NA NA 8.93 8.93 57452 A Exam of cervix w/scope 1.50 1.42 1.44 0.99 0.95 57454 A Bx/curett of cervix w/scope 2.33 1.80 1.79 1.36 1.30 
CMS-1503-P 982

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

57455 A Biopsy of cervix w/scope 1.99 1.85 1.87 1.01 0.95 57456 A Endocerv curettage w/scope 1.85 1.77 1.80 0.95 0.90 57460 A Bx of cervix w/scope, leep 2.83 4.75 5.18 1.58 1.52 57461 A Conz of cervix w/scope, leep 3.43 5.13 5.55 1.65 1.56 57500 A Biopsy of cervix 1.20 2.22 2.40 0.85 0.82 57505 A Endocervical curettage 1.19 1.54 1.59 1.28 1.29 57510 A Cauterization of cervix 1.90 1.64 1.65 1.23 1.19 57511 A Cryocautery of cervix 1.95 1.96 1.99 1.62 1.60 57513 A Laser surgery of cervix 1.95 1.91 1.93 1.62 1.61 57520 A Conization of cervix 4.11 4.09 4.18 3.24 3.21 57522 A Conization of cervix 3.67 3.40 3.44 2.89 2.85 57530 A Removal of cervix 5.27 NA NA 4.04 3.98 57531 A Removal of cervix, radical 29.95 NA NA 16.83 15.51 57540 A Removal of residual cervix 13.29 NA NA 7.79 7.43 57545 A Remove cervix/repair pelvis 14.10 NA NA 8.16 7.78 57550 A Removal of residual cervix 6.34 NA NA 4.67 4.60 57555 A Remove cervix/repair vagina 9.94 NA NA 6.32 6.08 57556 A Remove cervix, repair bowel 9.36 NA NA 5.98 5.91 57558 A D&c of cervical stump 1.72 1.64 1.66 1.35 1.33 57700 A Revision of cervix 4.35 NA NA 4.04 4.05 57720 A Revision of cervix 4.61 NA NA 3.70 3.66 57800 A Dilation of cervical canal 0.77 0.85 0.87 0.55 0.53 58100 A Biopsy of uterus lining 1.53 1.41 1.43 0.84 0.80 58110 A Bx done w/colposcopy add-on 0.77 0.53 0.53 0.35 0.32 58120 A Dilation and curettage 3.59 3.33 3.25 2.29 2.20 58140 A Myomectomy abdom method 15.79 NA NA 8.98 8.47 
CMS-1503-P 983

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

58145 A Myomectomy vag method 8.91 NA NA 5.79 5.60 58146 A Myomectomy abdom complex 20.34 NA NA 10.89 10.35 58150 A Total hysterectomy 17.31 NA NA 9.64 9.05 58152 A Total hysterectomy 21.86 NA NA 11.83 11.19 58180 A Partial hysterectomy 16.60 NA NA 9.27 8.77 58200 A Extensive hysterectomy 23.10 NA NA 12.53 11.66 58210 A Extensive hysterectomy 30.91 NA NA 16.73 15.49 58240 A Removal of pelvis contents 49.33 NA NA 26.31 24.38 58260 A Vaginal hysterectomy 14.15 NA NA 8.23 7.85 58262 A Vag hyst including t/o 15.94 NA NA 9.01 8.58 58263 A Vag hyst w/t/o & vag repair 17.23 NA NA 9.59 9.14 58267 A Vag hyst w/urinary repair 18.36 NA NA 10.17 9.66 58270 A Vag hyst w/enterocele repair 15.30 NA NA 8.55 8.15 58275 A Hysterectomy/revise vagina 17.03 NA NA 9.54 9.09 58280 A Hysterectomy/revise vagina 18.33 NA NA 10.18 9.63 58285 A Extensive hysterectomy 23.38 NA NA 12.12 11.43 58290 A Vag hyst complex 20.27 NA NA 10.87 10.31 58291 A Vag hyst incl t/o, complex 22.06 NA NA 11.68 11.10 58292 A Vag hyst t/o & repair, compl 23.35 NA NA 12.24 11.59 58293 A Vag hyst w/uro repair, compl 24.33 NA NA 12.68 11.96 58294 A Vag hyst w/enterocele, compl 21.55 NA NA 11.43 10.79 58300 N Insert intrauterine device 1.01 0.92 1.03 0.44 0.43 58301 A Remove intrauterine device 1.27 1.28 1.32 0.57 0.53 58321 A Artificial insemination 0.92 1.15 1.21 0.41 0.39 58322 A Artificial insemination 1.10 1.21 1.25 0.49 0.46 58323 A Sperm washing 0.23 0.19 0.24 0.10 0.10 
CMS-1503-P 984

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

58340 A Catheter for hysterography 0.88 2.26 2.57 0.69 0.71 58345 A Reopen fallopian tube 4.70 NA NA 2.85 2.77 58346 A Insert heyman uteri capsule 7.56 NA NA 5.23 4.96 58350 A Reopen fallopian tube 1.06 1.52 1.59 1.06 1.07 58353 A Endometr ablate, thermal 3.60 23.15 27.05 2.32 2.27 58356 A Endometrial cryoablation 6.41 43.89 50.40 2.96 2.78 58400 A Suspension of uterus 7.14 NA NA 4.81 4.80 58410 A Suspension of uterus 13.80 NA NA 7.96 7.57 58520 A Repair of ruptured uterus 13.48 NA NA 7.82 7.39 58540 A Revision of uterus 15.71 NA NA 8.88 8.41 58541 A Lsh, uterus 250 g or less 14.70 NA NA 8.69 8.19 58542 A Lsh w/t/o ut 250 g or less 16.56 NA NA 9.54 8.95 58543 A Lsh uterus above 250 g 16.87 NA NA 9.69 9.07 58544 A Lsh w/t/o uterus above 250 g 18.37 NA NA 10.35 9.65 58545 A Laparoscopic myomectomy 15.55 NA NA 8.64 8.17 58546 A Laparo-myomectomy, complex 19.94 NA NA 10.53 9.97 58548 A Lap radical hyst 31.63 NA NA 17.37 15.75 58550 A Laparo-asst vag hysterectomy 15.10 NA NA 8.77 8.38 58552 A Laparo-vag hyst incl t/o 16.91 NA NA 9.58 9.11 58553 A Laparo-vag hyst, complex 20.06 NA NA 10.66 10.05 58554 A Laparo-vag hyst w/t/o, compl 23.11 NA NA 12.47 11.73 58555 A Hysteroscopy, dx, sep proc 3.33 4.81 4.00 1.81 1.72 58558 A Hysteroscopy, biopsy 4.74 5.89 4.93 2.47 2.35 58559 A Hysteroscopy, lysis 6.16 NA NA 3.11 2.95 58560 A Hysteroscopy, resect septum 6.99 NA NA 3.48 3.30 58561 A Hysteroscopy, remove myoma 9.99 NA NA 4.83 4.55 
CMS-1503-P 985

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

58562 A Hysteroscopy, remove fb 5.20 5.82 4.89 2.64 2.52 58563 A Hysteroscopy, ablation 6.16 37.97 43.95 3.11 2.95 58565 A Hysteroscopy, sterilization 7.12 42.54 47.36 4.60 4.47 58570 A Tlh, uterus 250 g or less 15.88 NA NA 9.27 8.69 58571 A Tlh w/t/o 250 g or less 17.69 NA NA 10.28 9.52 58572 A Tlh, uterus over 250 g 20.09 NA NA 11.20 10.39 58573 A Tlh w/t/o uterus over 250 g 23.11 NA NA 12.74 11.69 58578 C Laparo proc, uterus 0.00 0.00 0.00 0.00 0.00 58579 C Hysteroscope procedure 0.00 0.00 0.00 0.00 0.00 58600 A Division of fallopian tube 5.91 NA NA 3.94 3.80 58605 A Division of fallopian tube 5.28 NA NA 3.62 3.53 58611 A Ligate oviduct(s) add-on 1.45 NA NA 0.65 0.60 58615 A Occlude fallopian tube(s) 3.94 NA NA 2.65 2.65 58660 A Laparoscopy, lysis 11.59 NA NA 6.54 6.19 58661 A Laparoscopy, remove adnexa 11.35 NA NA 6.03 5.69 58662 A Laparoscopy, excise lesions 12.15 NA NA 6.89 6.56 58670 A Laparoscopy, tubal cautery 5.91 NA NA 3.96 3.85 58671 A Laparoscopy, tubal block 5.91 NA NA 3.96 3.84 58672 A Laparoscopy, fimbrioplasty 12.91 NA NA 7.00 6.64 58673 A Laparoscopy, salpingostomy 14.04 NA NA 7.60 7.24 58679 C Laparo proc, oviduct-ovary 0.00 0.00 0.00 0.00 0.00 58700 A Removal of fallopian tube 12.95 NA NA 7.90 7.42 58720 A Removal of ovary/tube(s) 12.16 NA NA 7.31 6.92 58740 A Adhesiolysis tube, ovary 14.90 NA NA 8.66 8.27 58750 A Repair oviduct 15.64 NA NA 8.75 8.35 58752 A Revise ovarian tube(s) 15.64 NA NA 8.69 8.44 
CMS-1503-P 986

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

58760 A Fimbrioplasty 13.93 NA NA 7.98 7.68 58770 A Create new tubal opening 14.77 NA NA 8.30 7.68 58800 A Drainage of ovarian cyst(s) 4.62 3.95 4.02 3.44 3.43 58805 A Drainage of ovarian cyst(s) 6.42 NA NA 4.36 4.35 58820 A Drain ovary abscess, open 4.70 NA NA 4.54 4.12 58822 A Drain ovary abscess, percut 11.81 NA NA 7.13 6.96 58823 A Drain pelvic abscess, percut 3.37 20.70 22.52 1.19 1.35 58825 A Transposition, ovary(s) 11.78 NA NA 7.39 6.91 58900 A Biopsy of ovary(s) 6.59 NA NA 5.35 4.87 58920 A Partial removal of ovary(s) 11.95 NA NA 6.99 6.64 58925 A Removal of ovarian cyst(s) 12.43 NA NA 7.51 7.09 58940 A Removal of ovary(s) 8.22 NA NA 5.72 5.36 58943 A Removal of ovary(s) 19.52 NA NA 10.92 10.18 58950 A Resect ovarian malignancy 18.37 NA NA 10.82 10.11 58951 A Resect ovarian malignancy 24.26 NA NA 13.30 12.34 58952 A Resect ovarian malignancy 27.29 NA NA 15.09 13.99 58953 A Tah, rad dissect for debulk 34.13 NA NA 18.30 16.94 58954 A Tah rad debulk/lymph remove 37.13 NA NA 19.69 18.23 58956 A Bso, omentectomy w/tah 22.80 NA NA 12.96 12.12 58957 A Resect recurrent gyn mal 26.22 NA NA 14.65 13.38 58958 A Resect recur gyn mal w/lym 29.22 NA NA 15.98 14.65 58960 A Exploration of abdomen 15.79 NA NA 9.28 8.74 58970 A Retrieval of oocyte 3.52 2.49 2.45 1.92 1.79 58974 C Transfer of embryo 0.00 0.00 0.00 0.00 0.00 58976 A Transfer of embryo 3.82 2.99 3.01 2.06 2.04 58999 C Genital surgery procedure 0.00 0.00 0.00 0.00 0.00 
CMS-1503-P 987

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

59000 A Amniocentesis, diagnostic 1.30 1.95 2.08 0.77 0.74 59001 A Amniocentesis, therapeutic 3.00 NA NA 1.58 1.59 59012 A Fetal cord puncture,prenatal 3.44 NA NA 1.73 1.64 59015 A Chorion biopsy 2.20 1.79 1.79 1.17 1.12 59020 A Fetal contract stress test 0.66 1.19 1.18 NA NA 59020 TC A Fetal contract stress test 0.00 0.89 0.91 NA NA 59020 26 A Fetal contract stress test 0.66 0.30 0.27 0.30 0.27 59025 A Fetal non-stress test 0.53 0.72 0.71 NA NA 59025 TC A Fetal non-stress test 0.00 0.48 0.49 NA NA 59025 26 A Fetal non-stress test 0.53 0.24 0.22 0.24 0.22 59030 A Fetal scalp blood sample 1.99 NA NA 0.86 0.81 59050 A Fetal monitor w/report 0.89 NA NA 0.40 0.37 59051 A Fetal monitor/interpret only 0.74 NA NA 0.33 0.31 59070 A Transabdom amnioinfus w/us 5.24 5.63 5.70 2.66 2.60 59072 A Umbilical cord occlud w/us 8.99 NA NA 4.28 4.14 59074 A Fetal fluid drainage w/us 5.24 5.75 5.44 2.93 2.70 59076 A Fetal shunt placement, w/us 8.99 NA NA 4.28 3.97 59100 A Remove uterus lesion 13.37 NA NA 7.92 7.51 59120 A Treat ectopic pregnancy 12.67 NA NA 7.60 7.29 59121 A Treat ectopic pregnancy 12.74 NA NA 7.55 7.25 59130 A Treat ectopic pregnancy 15.08 NA NA 8.60 8.16 59135 A Treat ectopic pregnancy 14.92 NA NA 8.49 8.41 59136 A Treat ectopic pregnancy 14.25 NA NA 8.16 7.77 59140 A Treat ectopic pregnancy 5.94 NA NA 4.32 4.16 59150 A Treat ectopic pregnancy 12.29 NA NA 7.35 7.03 59151 A Treat ectopic pregnancy 12.11 NA NA 6.99 6.70 
CMS-1503-P 988

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

59160 A D & c after delivery 2.76 2.48 2.65 1.67 1.72 59200 A Insert cervical dilator 0.79 1.07 1.14 0.36 0.33 59300 A Episiotomy or vaginal repair 2.41 2.56 2.58 1.39 1.29 59320 A Revision of cervix 2.48 NA NA 1.42 1.37 59325 A Revision of cervix 4.06 NA NA 2.13 2.03 59350 A Repair of uterus 4.94 NA NA 2.22 1.99 59400 A Obstetrical care 27.48 NA NA 19.18 18.46 59409 A Obstetrical care 13.48 NA NA 6.10 5.64 59410 A Obstetrical care 15.37 NA NA 7.66 7.14 59412 A Antepartum manipulation 1.71 NA NA 0.93 0.89 59414 A Deliver placenta 1.61 NA NA 0.72 0.67 59425 A Antepartum care only 6.50 5.56 5.36 2.92 2.56 59426 A Antepartum care only 11.57 10.13 9.77 5.19 4.54 59430 A Care after delivery 2.13 1.47 1.42 1.09 1.02 59510 A Cesarean delivery 31.07 NA NA 21.51 20.79 59514 A Cesarean delivery only 15.95 NA NA 7.23 6.69 59515 A Cesarean delivery 18.39 NA NA 9.40 8.83 59525 A Remove uterus after cesarean 8.53 NA NA 3.83 3.56 59610 A Vbac delivery 28.86 NA NA 19.78 19.20 59612 A Vbac delivery only 15.04 NA NA 6.82 6.35 59614 A Vbac care after delivery 16.64 NA NA 8.00 7.51 59618 A Attempted vbac delivery 32.51 NA NA 22.22 21.56 59620 A Attempted vbac delivery only 17.50 NA NA 7.92 7.35 59622 A Attempted vbac after care 19.83 NA NA 10.19 9.62 59812 A Treatment of miscarriage 4.44 3.73 3.67 3.14 3.05 59820 A Care of miscarriage 4.84 4.91 4.98 4.31 4.28 
CMS-1503-P 989

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

59821 A Treatment of miscarriage 5.09 4.71 4.76 4.06 4.01 59830 A Treat uterus infection 6.59 NA NA 4.57 4.48 59840 R Abortion 3.01 2.58 2.54 2.34 2.32 59841 R Abortion 5.65 4.13 4.03 3.56 3.42 59850 R Abortion 5.90 NA NA 3.89 3.87 59851 R Abortion 5.92 NA NA 4.28 4.22 59852 R Abortion 8.23 NA NA 5.90 5.91 59855 R Abortion 6.43 NA NA 4.18 4.06 59856 R Abortion 7.79 NA NA 4.65 4.50 59857 R Abortion 9.33 NA NA 5.25 5.25 59866 R Abortion (mpr) 3.99 NA NA 2.12 2.04 59870 A Evacuate mole of uterus 6.57 NA NA 5.54 5.56 59871 A Remove cerclage suture 2.13 NA NA 1.30 1.25 59897 C Fetal invas px w/us 0.00 0.00 0.00 0.00 0.00 59898 C Laparo proc, ob care/deliver 0.00 0.00 0.00 0.00 0.00 59899 C Maternity care procedure 0.00 0.00 0.00 0.00 0.00 60000 A Drain thyroid/tongue cyst 1.81 2.78 2.67 2.30 2.23 60100 A Biopsy of thyroid 1.56 1.41 1.53 0.58 0.62 60200 A Remove thyroid lesion 10.02 NA NA 8.06 7.50 60210 A Partial thyroid excision 11.23 NA NA 7.97 7.30 60212 A Partial thyroid excision 16.43 NA NA 11.17 10.08 60220 A Partial removal of thyroid 12.37 NA NA 8.71 7.96 60225 A Partial removal of thyroid 14.79 NA NA 10.50 9.62 60240 A Removal of thyroid 16.22 NA NA 10.11 9.24 60252 A Removal of thyroid 22.01 NA NA 13.85 12.64 60254 A Extensive thyroid surgery 28.42 NA NA 18.00 16.45 
CMS-1503-P 990

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

60260 A Repeat thyroid surgery 18.26 NA NA 11.67 10.66 60270 A Removal of thyroid 23.20 NA NA 13.73 12.88 60271 A Removal of thyroid 17.62 NA NA 11.18 10.32 60280 A Remove thyroid duct lesion 6.16 NA NA 6.36 5.95 60281 A Remove thyroid duct lesion 8.82 NA NA 8.00 7.31 60300 A Aspir/inj thyroid cyst 0.97 2.09 2.13 0.36 0.38 60500 A Explore parathyroid glands 16.78 NA NA 10.62 9.67 60502 A Re-explore parathyroids 21.15 NA NA 13.16 12.01 60505 A Explore parathyroid glands 23.06 NA NA 14.42 13.33 60512 A Autotransplant parathyroid 4.44 NA NA 2.06 1.86 60520 A Removal of thymus gland 17.16 NA NA 10.34 9.68 60521 A Removal of thymus gland 19.18 NA NA 10.21 10.46 60522 A Removal of thymus gland 23.48 NA NA 12.27 12.45 60540 A Explore adrenal gland 18.02 NA NA 10.09 10.09 60545 A Explore adrenal gland 20.93 NA NA 11.46 11.16 60600 A Remove carotid body lesion 25.09 NA NA 12.79 12.31 60605 A Remove carotid body lesion 31.96 NA NA 18.48 16.53 60650 A Laparoscopy adrenalectomy 20.73 NA NA 11.00 10.56 60659 C Laparo proc, endocrine 0.00 0.00 0.00 0.00 0.00 60699 C Endocrine surgery procedure 0.00 0.00 0.00 0.00 0.00 

6070F I Pt asked/cnsld aed effects 0.00 0.00 0.00 0.00 0.00 

61000 A Remove cranial cavity fluid 1.58 NA NA 1.29 1.32 61001 A Remove cranial cavity fluid 1.49 NA NA 1.30 1.34 61020 A Remove brain cavity fluid 1.51 NA NA 2.03 1.94 61026 A Injection into brain canal 1.69 NA NA 1.63 1.63 61050 A Remove brain canal fluid 1.51 NA NA 1.32 1.38 
CMS-1503-P 991

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

61055 A Injection into brain canal 2.10 NA NA 1.49 1.57 61070 A Brain canal shunt procedure 0.89 NA NA 1.36 1.33 61105 A Twist drill hole 5.45 NA NA 6.17 5.77 61107 A Drill skull for implantation 4.99 NA NA 2.71 2.62 61108 A Drill skull for drainage 11.64 NA NA 10.96 10.32 61120 A Burr hole for puncture 9.60 NA NA 8.99 8.44 61140 A Pierce skull for biopsy 17.23 NA NA 13.89 13.24 61150 A Pierce skull for drainage 18.90 NA NA 14.54 13.73 61151 A Pierce skull for drainage 13.49 NA NA 11.12 10.41 61154 A Pierce skull & remove clot 17.07 NA NA 14.31 13.55 61156 A Pierce skull for drainage 17.45 NA NA 13.18 12.65 61210 A Pierce skull, implant device 5.83 NA NA 3.16 3.05 61215 A Insert brain-fluid device 5.85 NA NA 6.85 6.48 61250 A Pierce skull & explore 11.49 NA NA 10.02 9.34 61253 A Pierce skull & explore 13.49 NA NA 9.91 9.38 61304 A Open skull for exploration 23.41 NA NA 17.19 16.33 61305 A Open skull for exploration 28.64 NA NA 20.86 19.80 61312 A Open skull for drainage 30.17 NA NA 20.88 19.84 61313 A Open skull for drainage 28.09 NA NA 20.74 19.69 61314 A Open skull for drainage 25.90 NA NA 19.09 18.10 61315 A Open skull for drainage 29.65 NA NA 21.17 20.21 61316 A Implt cran bone flap to abdo 1.39 NA NA 0.76 0.72 61320 A Open skull for drainage 27.42 NA NA 19.34 18.56 61321 A Open skull for drainage 30.53 NA NA 21.90 20.46 61322 A Decompressive craniotomy 34.26 NA NA 24.09 22.53 61323 A Decompressive lobectomy 35.06 NA NA 23.79 22.29 
CMS-1503-P 992

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

61330 A Decompress eye socket 25.30 NA NA 18.97 17.17 61332 A Explore/biopsy eye socket 28.60 NA NA 20.23 18.55 61333 A Explore orbit/remove lesion 29.27 NA NA 23.34 20.36 61334 A Explore orbit/remove object 19.60 NA NA 15.31 13.27 61340 A Subtemporal decompression 20.11 NA NA 15.59 14.66 61343 A Incise skull (press relief) 31.86 NA NA 22.10 21.09 61345 A Relieve cranial pressure 29.23 NA NA 20.99 19.96 61440 A Incise skull for surgery 28.66 NA NA 20.67 19.58 61450 A Incise skull for surgery 27.69 NA NA 19.62 18.52 61458 A Incise skull for brain wound 28.84 NA NA 20.55 19.65 61460 A Incise skull for surgery 30.24 NA NA 21.54 20.10 61470 A Incise skull for surgery 27.62 NA NA 19.58 18.58 61480 A Incise skull for surgery 28.05 NA NA 14.21 14.49 61490 A Incise skull for surgery 27.22 NA NA 19.36 18.47 61500 A Removal of skull lesion 19.18 NA NA 14.99 14.11 61501 A Remove infected skull bone 16.35 NA NA 13.41 12.56 61510 A Removal of brain lesion 30.83 NA NA 22.92 21.87 61512 A Remove brain lining lesion 37.14 NA NA 25.43 24.33 61514 A Removal of brain abscess 27.23 NA NA 19.45 18.64 61516 A Removal of brain lesion 26.58 NA NA 19.18 18.30 61517 A Implt brain chemotx add-on 1.38 NA NA 0.75 0.72 61518 A Removal of brain lesion 39.89 NA NA 27.81 26.52 61519 A Remove brain lining lesion 43.43 NA NA 28.94 27.63 61520 A Removal of brain lesion 57.09 NA NA 37.02 35.34 61521 A Removal of brain lesion 46.99 NA NA 31.16 29.53 61522 A Removal of brain abscess 31.54 NA NA 22.25 21.21 
CMS-1503-P 993

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

61524 A Removal of brain lesion 29.89 NA NA 21.35 20.15 61526 A Removal of brain lesion 54.08 NA NA 35.46 32.91 61530 A Removal of brain lesion 45.56 NA NA 29.93 28.01 61531 A Implant brain electrodes 16.41 NA NA 13.86 13.16 61533 A Implant brain electrodes 21.46 NA NA 16.12 15.30 61534 A Removal of brain lesion 23.01 NA NA 17.58 16.70 61535 A Remove brain electrodes 13.15 NA NA 11.66 11.05 61536 A Removal of brain lesion 37.72 NA NA 25.63 24.52 61537 A Removal of brain tissue 36.45 NA NA 24.07 22.39 61538 A Removal of brain tissue 39.45 NA NA 26.06 24.10 61539 A Removal of brain tissue 34.28 NA NA 23.75 22.41 61540 A Removal of brain tissue 31.43 NA NA 22.28 21.26 61541 A Incision of brain tissue 30.94 NA NA 21.92 20.77 61542 A Removal of brain tissue 33.16 NA NA 19.78 20.41 61543 A Removal of brain tissue 31.31 NA NA 22.12 20.68 61544 A Remove & treat brain lesion 27.36 NA NA 19.44 16.85 61545 A Excision of brain tumor 46.43 NA NA 31.82 30.11 61546 A Removal of pituitary gland 33.44 NA NA 23.29 22.07 61548 A Removal of pituitary gland 23.37 NA NA 16.50 15.63 61550 A Release of skull seams 15.59 NA NA 10.26 10.36 61552 A Release of skull seams 20.40 NA NA 11.23 12.57 61556 A Incise skull/sutures 24.09 NA NA 15.47 15.35 61557 A Incise skull/sutures 23.31 NA NA 18.19 17.46 61558 A Excision of skull/sutures 26.50 NA NA 14.01 15.94 61559 A Excision of skull/sutures 34.02 NA NA 24.88 23.90 61563 A Excision of skull tumor 28.44 NA NA 20.28 19.32 
CMS-1503-P 994

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

61564 A Excision of skull tumor 34.74 NA NA 24.45 23.34 61566 A Removal of brain tissue 32.45 NA NA 22.84 21.91 61567 A Incision of brain tissue 37.00 NA NA 26.04 25.04 61570 A Remove foreign body, brain 26.51 NA NA 19.50 18.29 61571 A Incise skull for brain wound 28.42 NA NA 20.54 19.60 61575 A Skull base/brainstem surgery 36.56 NA NA 25.00 23.08 61576 A Skull base/brainstem surgery 55.31 NA NA 42.57 41.30 61580 A Craniofacial approach, skull 34.51 NA NA 33.30 31.09 61581 A Craniofacial approach, skull 39.13 NA NA 37.56 34.73 61582 A Craniofacial approach, skull 35.14 NA NA 41.57 38.86 61583 A Craniofacial approach, skull 38.50 NA NA 34.13 32.69 61584 A Orbitocranial approach/skull 37.70 NA NA 33.83 32.33 61585 A Orbitocranial approach/skull 42.57 NA NA 37.91 34.39 61586 A Resect nasopharynx, skull 27.48 NA NA 34.26 30.56 61590 A Infratemporal approach/skull 47.04 NA NA 37.61 34.85 61591 A Infratemporal approach/skull 47.02 NA NA 37.26 34.86 61592 A Orbitocranial approach/skull 43.08 NA NA 36.12 34.66 61595 A Transtemporal approach/skull 33.74 NA NA 29.98 28.29 61596 A Transcochlear approach/skull 39.43 NA NA 30.77 28.94 61597 A Transcondylar approach/skull 40.82 NA NA 30.65 29.43 61598 A Transpetrosal approach/skull 36.53 NA NA 34.01 30.24 61600 A Resect/excise cranial lesion 30.01 NA NA 28.14 26.20 61601 A Resect/excise cranial lesion 31.14 NA NA 29.07 27.71 61605 A Resect/excise cranial lesion 32.57 NA NA 28.98 26.94 61606 A Resect/excise cranial lesion 42.05 NA NA 33.00 31.91 61607 A Resect/excise cranial lesion 40.93 NA NA 31.20 29.31 
CMS-1503-P 995

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

61608 A Resect/excise cranial lesion 45.54 NA NA 35.17 33.65 61609 A Transect artery, sinus 9.88 0.00 2.21 0.00 2.21 61610 A Transect artery, sinus 29.63 NA NA 13.96 14.27 61611 A Transect artery, sinus 7.41 NA NA 3.20 3.50 61612 A Transect artery, sinus 27.84 NA NA 12.04 12.60 61613 A Remove aneurysm, sinus 45.03 NA NA 36.15 34.05 61615 A Resect/excise lesion, skull 35.77 NA NA 28.81 27.78 61616 A Resect/excise lesion, skull 46.74 NA NA 37.41 35.54 61618 A Repair dura 18.69 NA NA 14.40 13.56 61619 A Repair dura 22.10 NA NA 16.25 15.24 61623 A Endovasc tempory vessel occl 9.95 NA NA 4.32 4.56 61624 A Transcath occlusion, cns 20.12 NA NA 8.43 8.87 61626 A Transcath occlusion, non-cns 16.60 NA NA 6.13 6.87 61630 R Intracranial angioplasty 22.07 NA NA 10.81 11.31 61635 R Intracran angioplsty w/stent 24.28 NA NA 11.73 12.26 61640 N Dilate ic vasospasm, init 12.32 NA NA 5.33 5.15 61641 N Dilate ic vasospasm add-on 4.33 NA NA 1.87 1.81 61642 N Dilate ic vasospasm add-on 8.66 NA NA 3.74 3.62 61680 A Intracranial vessel surgery 32.55 NA NA 22.98 22.00 61682 A Intracranial vessel surgery 63.41 NA NA 38.93 37.35 61684 A Intracranial vessel surgery 41.64 NA NA 28.23 26.53 61686 A Intracranial vessel surgery 67.50 NA NA 42.81 40.96 61690 A Intracranial vessel surgery 31.34 NA NA 22.46 21.27 61692 A Intracranial vessel surgery 54.59 NA NA 35.19 33.38 61697 A Brain aneurysm repr, complx 63.40 NA NA 40.27 37.93 61698 A Brain aneurysm repr, complx 69.63 NA NA 43.98 40.81 
CMS-1503-P 996

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

61700 A Brain aneurysm repr, simple 50.62 NA NA 33.28 32.04 61702 A Inner skull vessel surgery 60.04 NA NA 38.72 36.14 61703 A Clamp neck artery 18.80 NA NA 14.75 14.07 61705 A Revise circulation to head 38.10 NA NA 25.84 24.06 61708 A Revise circulation to head 37.20 NA NA 21.81 20.09 61710 A Revise circulation to head 31.29 NA NA 15.61 16.75 61711 A Fusion of skull arteries 38.23 NA NA 25.84 24.47 61720 A Incise skull/brain surgery 17.62 NA NA 13.74 12.30 61735 A Incise skull/brain surgery 22.35 NA NA 14.50 13.76 61750 A Incise skull/brain biopsy 19.83 NA NA 14.86 14.14 61751 A Brain biopsy w/ct/mr guide 18.79 NA NA 15.21 14.52 61760 A Implant brain electrodes 22.39 NA NA 16.55 15.24 61770 A Incise skull for treatment 23.19 NA NA 16.79 15.32 61790 A Treat trigeminal nerve 11.60 NA NA 10.20 9.45 61791 A Treat trigeminal tract 15.41 NA NA 12.38 11.67 61795 A Brain surgery using computer 4.03 NA NA 2.24 2.12 61796 A Srs, cranial lesion simple 13.93 NA NA 11.15 9.71 61797 A Srs, cran les simple, addl 3.48 NA NA 1.90 1.76 61798 A Srs, cranial lesion complex 19.85 NA NA 14.36 11.34 61799 A Srs, cran les complex, addl 4.81 NA NA 2.62 2.43 61800 A Apply srs headframe add-on 2.25 NA NA 1.55 1.44 61850 A Implant neuroelectrodes 13.34 NA NA 8.09 9.01 61860 A Implant neuroelectrodes 22.26 NA NA 16.28 15.52 61863 A Implant neuroelectrode 20.71 NA NA 16.30 15.63 61864 A Implant neuroelectrde, addl 4.49 NA NA 2.46 2.37 61867 A Implant neuroelectrode 33.03 NA NA 23.09 22.06 
CMS-1503-P 997

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

61868 A Implant neuroelectrde, addl 7.91 NA NA 4.32 4.17 61870 A Implant neuroelectrodes 16.34 NA NA 12.89 12.38 61875 A Implant neuroelectrodes 16.46 NA NA 12.95 12.27 61880 A Revise/remove neuroelectrode 6.95 NA NA 7.26 6.79 61885 A Insrt/redo neurostim 1 array 7.57 NA NA 9.59 8.94 61886 A Implant neurostim arrays 9.93 NA NA 11.31 10.63 61888 A Revise/remove neuroreceiver 5.23 NA NA 4.57 4.44 62000 A Treat skull fracture 13.93 NA NA 11.57 9.87 62005 A Treat skull fracture 17.63 NA NA 13.74 12.85 62010 A Treatment of head injury 21.43 NA NA 16.35 15.37 62100 A Repair brain fluid leakage 23.53 NA NA 16.82 15.89 62115 A Reduction of skull defect 22.91 NA NA 12.75 11.39 62116 A Reduction of skull defect 25.02 NA NA 18.69 17.80 62117 A Reduction of skull defect 28.35 NA NA 19.91 19.08 62120 A Repair skull cavity lesion 24.59 NA NA 23.11 22.29 62121 A Incise skull repair 23.03 NA NA 19.09 18.36 62140 A Repair of skull defect 14.55 NA NA 11.66 11.03 62141 A Repair of skull defect 16.07 NA NA 12.57 11.95 62142 A Remove skull plate/flap 11.83 NA NA 10.33 9.81 62143 A Replace skull plate/flap 14.15 NA NA 11.57 10.96 62145 A Repair of skull & brain 20.09 NA NA 14.67 14.03 62146 A Repair of skull with graft 17.28 NA NA 13.55 12.61 62147 A Repair of skull with graft 20.67 NA NA 15.41 14.52 62148 A Retr bone flap to fix skull 2.00 NA NA 1.10 1.03 62160 A Neuroendoscopy add-on 3.00 NA NA 1.63 1.58 62161 A Dissect brain w/scope 21.23 NA NA 16.17 15.39 
CMS-1503-P 998

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

62162 A Remove colloid cyst w/scope 26.80 NA NA 19.77 18.93 62163 A Neuroendoscopy w/fb removal 16.53 NA NA 13.78 13.20 62164 A Remove brain tumor w/scope 29.43 NA NA 22.08 20.55 62165 A Remove pituit tumor w/scope 23.23 NA NA 16.94 16.08 62180 A Establish brain cavity shunt 22.58 NA NA 16.87 16.07 62190 A Establish brain cavity shunt 12.17 NA NA 10.75 10.16 62192 A Establish brain cavity shunt 13.35 NA NA 10.97 10.34 62194 A Replace/irrigate catheter 5.78 NA NA 6.40 5.15 62200 A Establish brain cavity shunt 19.29 NA NA 14.65 13.93 62201 A Brain cavity shunt w/scope 16.04 NA NA 13.80 13.05 62220 A Establish brain cavity shunt 14.10 NA NA 11.23 10.60 62223 A Establish brain cavity shunt 14.05 NA NA 12.22 11.63 62225 A Replace/irrigate catheter 6.19 NA NA 6.86 6.43 62230 A Replace/revise brain shunt 11.43 NA NA 9.48 9.02 62252 A Csf shunt reprogram 0.74 2.03 2.01 NA NA 62252 TC A Csf shunt reprogram 0.00 1.63 1.62 NA NA 62252 26 A Csf shunt reprogram 0.74 0.40 0.39 0.40 0.39 62256 A Remove brain cavity shunt 7.38 NA NA 7.59 7.19 62258 A Replace brain cavity shunt 15.64 NA NA 12.15 11.62 62263 A Epidural lysis mult sessions 6.54 15.52 13.65 5.73 4.66 62264 A Epidural lysis on single day 4.42 7.97 7.27 2.52 2.04 62267 A Interdiscal perq aspir, dx 3.00 3.61 3.84 1.29 1.34 62268 A Drain spinal cord cyst 4.73 6.91 7.60 2.45 2.40 62269 A Needle biopsy, spinal cord 5.01 6.54 7.87 2.20 2.20 62270 A Spinal fluid tap, diagnostic 1.37 2.74 2.89 0.68 0.69 62272 A Drain cerebro spinal fluid 1.35 3.94 3.89 0.81 0.80 
CMS-1503-P 999

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

62273 A Inject epidural patch 2.15 2.69 2.52 1.05 0.91 62280 A Treat spinal cord lesion 2.63 6.65 6.30 1.91 1.62 62281 A Treat spinal cord lesion 2.66 6.16 5.74 1.72 1.47 62282 A Treat spinal canal lesion 2.33 5.77 5.91 1.67 1.47 62284 A Injection for myelogram 1.54 4.00 4.45 0.76 0.83 62287 A Percutaneous diskectomy 9.03 NA NA 6.78 6.22 62290 A Inject for spine disk x-ray 3.00 6.54 6.37 1.90 1.70 62291 A Inject for spine disk x-ray 2.91 6.22 5.94 1.86 1.63 62292 A Injection into disk lesion 9.24 NA NA 8.59 6.05 62294 A Injection into spinal artery 12.87 NA NA 4.41 6.16 62310 A Inject spine c/t 1.91 5.07 4.64 1.19 0.96 62311 A Inject spine l/s (cd) 1.54 4.28 4.09 0.97 0.82 62318 A Inject spine w/cath, c/t 2.04 4.82 4.66 0.81 0.70 62319 A Inject spine w/cath l/s (cd) 1.87 4.48 4.27 0.84 0.72 62350 A Implant spinal canal cath 6.05 NA NA 4.89 4.31 62351 A Implant spinal canal cath 11.66 NA NA 10.63 9.88 62355 A Remove spinal canal catheter 4.35 NA NA 3.97 3.53 62360 A Insert spine infusion device 4.33 NA NA 4.10 3.59 62361 A Implant spine infusion pump 5.65 NA NA 4.86 4.60 62362 A Implant spine infusion pump 6.10 NA NA 5.03 4.59 62365 A Remove spine infusion device 4.65 NA NA 4.37 3.96 62367 A Analyze spine infusion pump 0.48 0.71 0.65 0.23 0.19 62368 A Analyze spine infusion pump 0.75 1.00 0.87 0.37 0.30 63001 A Removal of spinal lamina 17.61 NA NA 13.39 12.68 63003 A Removal of spinal lamina 17.74 NA NA 13.46 12.76 63005 A Removal of spinal lamina 16.43 NA NA 13.39 12.78 
CMS-1503-P 1000

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

63011 A Removal of spinal lamina 15.91 NA NA 12.46 11.66 63012 A Removal of spinal lamina 16.85 NA NA 13.20 12.67 63015 A Removal of spinal lamina 20.85 NA NA 16.09 15.34 63016 A Removal of spinal lamina 22.03 NA NA 16.26 15.39 63017 A Removal of spinal lamina 17.33 NA NA 14.06 13.40 63020 A Neck spine disk surgery 16.20 NA NA 13.29 12.69 63030 A Low back disk surgery 13.18 NA NA 11.60 11.04 63035 A Spinal disk surgery add-on 3.15 NA NA 1.76 1.70 63040 A Laminotomy, single cervical 20.31 NA NA 15.13 14.42 63042 A Laminotomy, single lumbar 18.76 NA NA 14.61 13.95 63043 C Laminotomy, addl cervical 0.00 0.00 0.00 0.00 0.00 63044 C Laminotomy, addl lumbar 0.00 0.00 0.00 0.00 0.00 63045 A Removal of spinal lamina 17.95 NA NA 14.01 13.35 63046 A Removal of spinal lamina 17.25 NA NA 13.50 12.87 63047 A Removal of spinal lamina 15.37 NA NA 12.78 12.22 63048 A Remove spinal lamina add-on 3.47 NA NA 1.94 1.85 63050 A Cervical laminoplasty 22.01 NA NA 17.01 15.91 63051 A C-laminoplasty w/graft/plate 25.51 NA NA 18.33 17.36 63055 A Decompress spinal cord 23.55 NA NA 17.14 16.38 63056 A Decompress spinal cord 21.86 NA NA 15.96 15.18 63057 A Decompress spine cord add-on 5.25 NA NA 2.93 2.82 63064 A Decompress spinal cord 26.22 NA NA 18.48 17.52 63066 A Decompress spine cord add-on 3.26 NA NA 1.79 1.74 63075 A Neck spine disk surgery 19.60 NA NA 15.04 14.46 63076 A Neck spine disk surgery 4.04 NA NA 2.24 2.16 63077 A Spine disk surgery, thorax 22.88 NA NA 15.93 15.17 
CMS-1503-P 1001

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

63078 A Spine disk surgery, thorax 3.28 NA NA 1.82 1.74 63081 A Removal of vertebral body 26.10 NA NA 18.73 17.85 63082 A Remove vertebral body add-on 4.36 NA NA 2.42 2.34 63085 A Removal of vertebral body 29.47 NA NA 19.12 18.26 63086 A Remove vertebral body add-on 3.19 NA NA 1.68 1.64 63087 A Removal of vertebral body 37.53 NA NA 24.00 22.96 63088 A Remove vertebral body add-on 4.32 NA NA 2.42 2.33 63090 A Removal of vertebral body 30.93 NA NA 20.65 19.54 63091 A Remove vertebral body add-on 3.03 NA NA 1.66 1.60 63101 A Removal of vertebral body 34.10 NA NA 24.43 23.22 63102 A Removal of vertebral body 34.10 NA NA 24.11 22.92 63103 A Remove vertebral body add-on 4.82 NA NA 2.69 2.61 63170 A Incise spinal cord tract(s) 22.21 NA NA 17.09 15.89 63172 A Drainage of spinal cyst 19.76 NA NA 14.97 14.19 63173 A Drainage of spinal cyst 24.31 NA NA 18.24 17.35 63180 A Revise spinal cord ligaments 20.53 NA NA 16.17 14.66 63182 A Revise spinal cord ligaments 22.82 NA NA 17.43 14.81 63185 A Incise spinal column/nerves 16.49 NA NA 13.02 12.18 63190 A Incise spinal column/nerves 18.89 NA NA 14.54 13.80 63191 A Incise spinal column/nerves 18.92 NA NA 15.14 11.94 63194 A Incise spinal column & cord 22.10 NA NA 15.75 15.07 63195 A Incise spinal column & cord 21.64 NA NA 16.26 15.20 63196 A Incise spinal column & cord 25.27 NA NA 13.24 15.02 63197 A Incise spinal column & cord 24.08 NA NA 18.12 17.15 63198 A Incise spinal column & cord 29.90 NA NA 15.46 14.55 63199 A Incise spinal column & cord 31.47 NA NA 16.14 17.62 
CMS-1503-P 1002

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

63200 A Release of spinal cord 21.44 NA NA 16.21 15.35 63250 A Revise spinal cord vessels 43.86 NA NA 29.00 27.33 63251 A Revise spinal cord vessels 44.64 NA NA 29.87 28.36 63252 A Revise spinal cord vessels 44.63 NA NA 29.86 28.31 63265 A Excise intraspinal lesion 23.82 NA NA 17.63 16.80 63266 A Excise intraspinal lesion 24.68 NA NA 17.98 17.09 63267 A Excise intraspinal lesion 19.45 NA NA 15.06 14.38 63268 A Excise intraspinal lesion 20.02 NA NA 15.94 14.83 63270 A Excise intraspinal lesion 29.80 NA NA 21.30 20.11 63271 A Excise intraspinal lesion 29.92 NA NA 21.09 20.08 63272 A Excise intraspinal lesion 27.50 NA NA 19.57 18.68 63273 A Excise intraspinal lesion 26.47 NA NA 19.47 17.88 63275 A Biopsy/excise spinal tumor 25.86 NA NA 18.68 17.75 63276 A Biopsy/excise spinal tumor 25.69 NA NA 18.65 17.73 63277 A Biopsy/excise spinal tumor 22.39 NA NA 16.73 15.90 63278 A Biopsy/excise spinal tumor 22.12 NA NA 17.09 15.95 63280 A Biopsy/excise spinal tumor 30.29 NA NA 21.64 20.77 63281 A Biopsy/excise spinal tumor 29.99 NA NA 21.59 20.62 63282 A Biopsy/excise spinal tumor 28.15 NA NA 20.48 19.61 63283 A Biopsy/excise spinal tumor 26.76 NA NA 20.08 18.93 63285 A Biopsy/excise spinal tumor 38.05 NA NA 25.98 24.55 63286 A Biopsy/excise spinal tumor 37.62 NA NA 25.68 24.51 63287 A Biopsy/excise spinal tumor 40.08 NA NA 27.37 25.89 63290 A Biopsy/excise spinal tumor 40.82 NA NA 27.36 26.06 63295 A Repair of laminectomy defect 5.25 NA NA 2.87 2.68 63300 A Removal of vertebral body 26.80 NA NA 19.01 18.10 
CMS-1503-P 1003

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

63301 A Removal of vertebral body 31.57 NA NA 22.71 20.61 63302 A Removal of vertebral body 31.15 NA NA 22.48 20.50 63303 A Removal of vertebral body 33.55 NA NA 23.35 21.18 63304 A Removal of vertebral body 33.85 NA NA 23.96 22.57 63305 A Removal of vertebral body 36.24 NA NA 25.12 22.68 63306 A Removal of vertebral body 35.55 NA NA 15.92 19.10 63307 A Removal of vertebral body 34.96 NA NA 24.11 22.52 63308 A Remove vertebral body add-on 5.24 NA NA 2.84 2.76 63600 A Remove spinal cord lesion 15.12 NA NA 10.55 8.17 63610 A Stimulation of spinal cord 8.72 17.25 23.43 2.29 2.25 63615 A Remove lesion of spinal cord 17.32 NA NA 13.20 11.98 63620 A Srs, spinal lesion 15.60 NA NA 11.93 10.11 63621 A Srs, spinal lesion, addl 4.00 NA NA 2.19 2.02 63650 A Implant neuroelectrodes 7.20 NA NA 5.25 4.34 63655 A Implant neuroelectrodes 11.56 NA NA 10.49 9.82 63661 A Remove spine eltrd perq aray 5.08 11.66 11.66 3.90 3.90 63662 A Remove spine eltrd plate 11.00 NA NA 8.48 8.48 63663 A Revise spine eltrd perq aray 7.75 16.11 16.11 5.24 5.24 63664 A Revise spine eltrd plate 11.52 NA NA 8.75 8.75 63685 A Insrt/redo spine n generator 6.05 NA NA 5.04 4.47 63688 A Revise/remove neuroreceiver 5.30 NA NA 4.68 4.18 63700 A Repair of spinal herniation 17.47 NA NA 14.67 13.55 63702 A Repair of spinal herniation 19.41 NA NA 15.73 14.92 63704 A Repair of spinal herniation 22.43 NA NA 18.36 16.58 63706 A Repair of spinal herniation 25.35 NA NA 19.96 18.68 63707 A Repair spinal fluid leakage 12.65 NA NA 10.80 10.19 
CMS-1503-P 1004

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

63709 A Repair spinal fluid leakage 15.65 NA NA 12.43 11.83 63710 A Graft repair of spine defect 15.40 NA NA 12.48 11.86 63740 A Install spinal shunt 12.63 NA NA 10.80 10.43 63741 A Install spinal shunt 9.12 NA NA 7.40 6.53 63744 A Revision of spinal shunt 8.94 NA NA 7.92 7.24 63746 A Removal of spinal shunt 7.33 NA NA 7.65 7.04 64400 A N block inj, trigeminal 1.11 2.14 2.00 0.77 0.66 64402 A N block inj, facial 1.25 1.96 1.85 0.78 0.70 64405 A N block inj, occipital 1.32 1.91 1.70 0.88 0.74 64408 A N block inj, vagus 1.41 2.15 2.00 1.21 1.08 64410 A N block inj, phrenic 1.43 2.68 2.55 0.74 0.68 64412 A N block inj, spinal accessor 1.18 3.20 2.96 0.91 0.79 64413 A N block inj, cervical plexus 1.40 1.97 1.85 0.82 0.71 64415 A N block inj, brachial plexus 1.48 2.15 2.13 0.53 0.48 64416 A N block cont infuse, b plex 1.81 NA NA 0.41 0.42 64417 A N block inj, axillary 1.44 2.17 2.17 0.54 0.49 64418 A N block inj, suprascapular 1.32 2.64 2.54 0.82 0.71 64420 A N block inj, intercost, sng 1.18 1.97 2.67 0.75 0.65 64421 A N block inj, intercost, mlt 1.68 2.60 3.82 0.95 0.81 64425 A N block inj, ilio-ing/hypogi 1.75 2.04 1.87 0.95 0.81 64430 A N block inj, pudendal 1.46 2.22 2.57 0.78 0.84 64435 A N block inj, paracervical 1.45 2.28 2.41 0.77 0.75 64445 A N block inj, sciatic, sng 1.48 2.23 2.24 0.74 0.68 64446 A N blk inj, sciatic, cont inf 1.81 NA NA 0.42 0.47 64447 A N block inj fem, single 1.50 NA NA 0.34 0.32 64448 A N block inj fem, cont inf 1.63 NA NA 0.37 0.40 
CMS-1503-P 1005

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

64449 A N block inj, lumbar plexus 1.81 NA NA 0.49 0.51 64450 A N block, other peripheral 1.27 1.69 1.60 0.67 0.63 64455 A N block inj, plantar digit 0.75 0.58 0.60 0.23 0.26 64479 A Inj foramen epidural c/t 2.20 5.94 5.81 1.48 1.26 64480 A Inj foramen epidural add-on 1.54 2.66 2.48 0.81 0.67 64483 A Inj foramen epidural l/s 1.90 5.97 5.89 1.34 1.15 64484 A Inj foramen epidural add-on 1.33 2.71 2.60 0.69 0.56 64490 A Inj paravert f jnt c/t 1 lev 1.82 3.72 3.72 1.25 1.25 64491 A Inj paravert f jnt c/t 2 lev 1.16 1.57 1.57 0.58 0.58 64492 A Inj paravert f jnt c/t 3 lev 1.16 1.61 1.61 0.61 0.61 64493 A Inj paravert f jnt l/s 1 lev 1.52 3.45 3.45 1.09 1.09 64494 A Inj paravert f jnt l/s 2 lev 1.00 1.49 1.49 0.48 0.48 64495 A Inj paravert f jnt l/s 3 lev 1.00 1.53 1.53 0.51 0.51 64505 A N block, spenopalatine gangl 1.36 1.42 1.40 1.00 0.93 64508 A N block, carotid sinus s/p 1.12 3.54 3.23 0.98 0.86 64510 A N block, stellate ganglion 1.22 2.46 2.61 0.89 0.73 64517 A N block inj, hypogas plxs 2.20 2.95 2.69 1.34 1.13 64520 A N block, lumbar/thoracic 1.35 4.26 4.10 1.00 0.83 64530 A N block inj, celiac pelus 1.58 3.99 3.91 1.05 0.92 64550 A Apply neurostimulator 0.18 0.29 0.27 0.08 0.07 64553 A Implant neuroelectrodes 2.36 3.34 3.27 1.98 1.93 64555 A Implant neuroelectrodes 2.32 2.97 3.29 1.70 1.77 64560 A Implant neuroelectrodes 2.41 4.68 4.06 2.41 2.14 64561 A Implant neuroelectrodes 7.15 17.71 22.09 3.84 4.11 64565 A Implant neuroelectrodes 1.81 3.23 3.07 1.76 1.58 64573 A Implant neuroelectrodes 8.25 NA NA 7.48 6.94 
CMS-1503-P 1006

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

64575 A Implant neuroelectrodes 4.42 NA NA 4.17 3.53 64577 A Implant neuroelectrodes 4.69 NA NA 2.79 3.52 64580 A Implant neuroelectrodes 4.19 NA NA 3.85 3.75 64581 A Implant neuroelectrodes 14.23 NA NA 6.86 7.39 64585 A Revise/remove neuroelectrode 2.11 4.67 6.12 1.86 2.06 64590 A Insrt/redo pn/gastr stimul 2.45 4.68 5.61 1.94 2.19 64595 A Revise/rmv pn/gastr stimul 1.78 4.89 6.27 1.68 1.89 64600 A Injection treatment of nerve 3.49 8.04 7.90 2.75 2.41 64605 A Injection treatment of nerve 5.65 15.54 12.68 4.73 3.84 64610 A Injection treatment of nerve 7.20 12.76 11.87 5.16 4.90 64612 A Destroy nerve, face muscle 2.01 2.49 2.35 2.16 1.90 64613 A Destroy nerve, neck muscle 2.01 2.23 2.18 1.87 1.64 64614 A Destroy nerve, extrem musc 2.20 2.53 2.48 2.04 1.82 64620 A Injection treatment of nerve 2.89 3.02 3.80 2.10 1.79 64622 A Destr paravertebrl nerve l/s 3.05 6.90 6.48 2.50 2.05 64623 A Destr paravertebral n add-on 0.99 2.74 2.58 0.51 0.39 64626 A Destr paravertebrl nerve c/t 3.92 8.08 7.38 3.64 3.00 64627 A Destr paravertebral n add-on 1.16 3.92 3.73 0.60 0.47 64630 A Injection treatment of nerve 3.05 3.11 3.20 2.13 2.11 64632 A N block inj, common digit 1.23 1.16 1.15 0.71 0.73 64640 A Injection treatment of nerve 2.81 3.23 3.32 1.92 1.88 64650 A Chemodenerv eccrine glands 0.70 1.32 1.23 0.41 0.37 64653 A Chemodenerv eccrine glands 0.88 1.49 1.37 0.46 0.43 64680 A Injection treatment of nerve 2.67 6.33 6.16 1.99 1.80 64681 A Injection treatment of nerve 3.78 6.26 6.74 1.63 1.74 64702 A Revise finger/toe nerve 6.26 NA NA 7.35 6.64 
CMS-1503-P 1007

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

64704 A Revise hand/foot nerve 4.69 NA NA 4.25 4.16 64708 A Revise arm/leg nerve 6.36 NA NA 6.95 6.49 64712 A Revision of sciatic nerve 8.07 NA NA 7.08 6.56 64713 A Revision of arm nerve(s) 11.40 NA NA 8.88 8.39 64714 A Revise low back nerve(s) 10.55 NA NA 8.57 7.33 64716 A Revision of cranial nerve 6.99 NA NA 7.80 7.33 64718 A Revise ulnar nerve at elbow 7.26 NA NA 8.68 8.10 64719 A Revise ulnar nerve at wrist 4.97 NA NA 5.84 5.51 64721 A Carpal tunnel surgery 4.97 6.57 6.25 6.50 6.19 64722 A Relieve pressure on nerve(s) 4.82 NA NA 4.72 4.31 64726 A Release foot/toe nerve 4.27 NA NA 3.50 3.40 64727 A Internal nerve revision 3.10 NA NA 1.85 1.74 64732 A Incision of brow nerve 4.89 NA NA 6.17 5.52 64734 A Incision of cheek nerve 5.55 NA NA 6.98 6.03 64736 A Incision of chin nerve 5.23 NA NA 5.85 5.47 64738 A Incision of jaw nerve 6.36 NA NA 7.42 6.41 64740 A Incision of tongue nerve 6.22 NA NA 6.83 6.33 64742 A Incision of facial nerve 6.85 NA NA 7.10 6.23 64744 A Incise nerve, back of head 5.72 NA NA 6.62 5.64 64746 A Incise diaphragm nerve 6.56 NA NA 4.67 4.77 64752 A Incision of vagus nerve 7.69 NA NA 5.95 5.57 64755 A Incision of stomach nerves 15.05 NA NA 8.97 8.13 64760 A Incision of vagus nerve 7.59 NA NA 5.91 5.24 64761 A Incision of pelvis nerve 7.04 NA NA 5.33 5.01 64763 A Incise hip/thigh nerve 7.56 NA NA 5.80 6.19 64766 A Incise hip/thigh nerve 9.47 NA NA 6.96 6.83 
CMS-1503-P 1008

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

64771 A Sever cranial nerve 8.15 NA NA 7.35 7.18 64772 A Incision of spinal nerve 7.84 NA NA 7.49 7.02 64774 A Remove skin nerve lesion 5.80 NA NA 5.51 5.16 64776 A Remove digit nerve lesion 5.60 NA NA 5.19 4.86 64778 A Digit nerve surgery add-on 3.11 NA NA 2.21 1.90 64782 A Remove limb nerve lesion 6.86 NA NA 5.64 5.34 64783 A Limb nerve surgery add-on 3.71 NA NA 2.52 2.23 64784 A Remove nerve lesion 10.62 NA NA 9.29 8.57 64786 A Remove sciatic nerve lesion 16.25 NA NA 12.74 11.82 64787 A Implant nerve end 4.29 NA NA 2.24 2.21 64788 A Remove skin nerve lesion 5.24 NA NA 5.57 5.16 64790 A Removal of nerve lesion 12.10 NA NA 10.10 9.35 64792 A Removal of nerve lesion 15.86 NA NA 11.96 11.53 64795 A Biopsy of nerve 3.01 NA NA 2.10 1.96 64802 A Remove sympathetic nerves 10.37 NA NA 8.63 6.72 64804 A Remove sympathetic nerves 15.91 NA NA 6.76 6.83 64809 A Remove sympathetic nerves 14.71 NA NA 10.45 8.82 64818 A Remove sympathetic nerves 11.34 NA NA 6.73 6.14 64820 A Remove sympathetic nerves 10.74 NA NA 10.27 9.44 64821 A Remove sympathetic nerves 9.33 NA NA 9.21 8.79 64822 A Remove sympathetic nerves 9.33 NA NA 9.21 8.64 64823 A Remove sympathetic nerves 10.94 NA NA 10.16 9.40 64831 A Repair of digit nerve 9.16 NA NA 9.57 8.92 64832 A Repair nerve add-on 5.65 NA NA 3.63 3.37 64834 A Repair of hand or foot nerve 10.81 NA NA 9.60 8.92 64835 A Repair of hand or foot nerve 11.73 NA NA 10.10 9.50 
CMS-1503-P 1009

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

64836 A Repair of hand or foot nerve 11.73 NA NA 10.10 9.51 64837 A Repair nerve add-on 6.25 NA NA 3.65 3.55 64840 A Repair of leg nerve 14.02 NA NA 10.83 10.30 64856 A Repair/transpose nerve 15.07 NA NA 12.51 11.66 64857 A Repair arm/leg nerve 15.82 NA NA 12.87 12.04 64858 A Repair sciatic nerve 17.82 NA NA 15.65 14.23 64859 A Nerve surgery 4.25 NA NA 3.03 2.67 64861 A Repair of arm nerves 20.89 NA NA 12.26 12.71 64862 A Repair of low back nerves 21.09 NA NA 16.46 14.20 64864 A Repair of facial nerve 13.41 NA NA 10.87 10.13 64865 A Repair of facial nerve 16.09 NA NA 15.69 15.13 64866 A Fusion of facial/other nerve 16.83 NA NA 14.44 14.52 64868 A Fusion of facial/other nerve 14.90 NA NA 14.20 13.52 64870 A Fusion of facial/other nerve 17.08 NA NA 12.11 10.84 64872 A Subsequent repair of nerve 1.99 NA NA 1.16 1.14 64874 A Repair & revise nerve add-on 2.98 NA NA 2.03 1.80 64876 A Repair nerve/shorten bone 3.37 NA NA 1.85 1.70 64885 A Nerve graft, head or neck 17.60 NA NA 13.54 12.78 64886 A Nerve graft, head or neck 20.82 NA NA 15.44 14.82 64890 A Nerve graft, hand or foot 16.24 NA NA 12.74 12.17 64891 A Nerve graft, hand or foot 17.35 NA NA 15.32 13.59 64892 A Nerve graft, arm or leg 15.74 NA NA 12.44 11.81 64893 A Nerve graft, arm or leg 16.87 NA NA 13.85 12.62 64895 A Nerve graft, hand or foot 20.39 NA NA 17.48 15.24 64896 A Nerve graft, hand or foot 21.96 NA NA 15.55 15.13 64897 A Nerve graft, arm or leg 19.38 NA NA 15.22 14.09 
CMS-1503-P 1010

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

64898 A Nerve graft, arm or leg 20.97 NA NA 15.93 15.14 64901 A Nerve graft add-on 10.20 NA NA 7.26 6.29 64902 A Nerve graft add-on 11.81 NA NA 8.41 7.22 64905 A Nerve pedicle transfer 15.11 NA NA 12.74 11.82 64907 A Nerve pedicle transfer 20.03 NA NA 10.82 12.21 64910 A Nerve repair w/allograft 11.39 NA NA 11.23 10.47 64911 A Neurorraphy w/vein autograft 14.39 NA NA 14.06 12.54 64999 C Nervous system surgery 0.00 0.00 0.00 0.00 0.00 65091 A Revise eye 7.26 NA NA 10.40 9.58 65093 A Revise eye with implant 7.04 NA NA 10.39 9.67 65101 A Removal of eye 8.30 NA NA 12.22 11.24 65103 A Remove eye/insert implant 8.84 NA NA 12.59 11.54 65105 A Remove eye/attach implant 9.93 NA NA 13.72 12.54 65110 A Removal of eye 15.70 NA NA 18.28 16.56 65112 A Remove eye/revise socket 18.51 NA NA 21.22 19.20 65114 A Remove eye/revise socket 19.65 NA NA 22.03 19.82 65125 A Revise ocular implant 3.27 9.11 8.89 4.82 4.41 65130 A Insert ocular implant 8.42 NA NA 11.95 10.93 65135 A Insert ocular implant 8.60 NA NA 12.08 11.06 65140 A Attach ocular implant 9.46 NA NA 13.04 11.94 65150 A Revise ocular implant 6.43 NA NA 9.61 8.95 65155 A Reinsert ocular implant 10.10 NA NA 13.50 12.36 65175 A Removal of ocular implant 7.40 NA NA 10.90 10.02 65205 A Remove foreign body from eye 0.71 0.82 0.76 0.51 0.45 65210 A Remove foreign body from eye 0.84 1.08 0.99 0.67 0.58 65220 A Remove foreign body from eye 0.71 0.86 0.80 0.45 0.40 
CMS-1503-P 1011

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

65222 A Remove foreign body from eye 0.93 1.18 1.08 0.71 0.62 65235 A Remove foreign body from eye 9.01 NA NA 10.93 9.67 65260 A Remove foreign body from eye 12.54 NA NA 14.36 12.77 65265 A Remove foreign body from eye 14.34 NA NA 15.96 14.14 65270 A Repair of eye wound 1.95 5.28 5.16 1.99 1.77 65272 A Repair of eye wound 4.62 9.22 8.68 5.25 4.63 65273 A Repair of eye wound 5.16 NA NA 5.57 4.92 65275 A Repair of eye wound 6.29 9.78 8.76 6.74 5.81 65280 A Repair of eye wound 9.10 NA NA 9.64 8.54 65285 A Repair of eye wound 14.71 NA NA 14.50 12.67 65286 A Repair of eye wound 6.63 12.79 12.09 7.31 6.44 65290 A Repair of eye socket wound 6.53 NA NA 7.27 6.45 65400 A Removal of eye lesion 7.50 11.41 10.42 9.40 8.37 65410 A Biopsy of cornea 1.47 2.48 2.33 1.47 1.29 65420 A Removal of eye lesion 4.36 9.81 9.38 6.16 5.60 65426 A Removal of eye lesion 6.05 11.94 11.26 7.37 6.58 65430 A Corneal smear 1.47 1.73 1.57 1.44 1.28 65435 A Curette/treat cornea 0.92 1.31 1.20 1.04 0.93 65436 A Curette/treat cornea 4.82 6.03 5.40 5.61 4.98 65450 A Treatment of corneal lesion 3.47 5.57 5.10 5.48 5.00 65600 A Revision of cornea 4.20 6.77 6.20 5.45 4.83 65710 A Corneal transplant 14.45 NA NA 16.67 14.82 65730 A Corneal transplant 16.35 NA NA 18.20 16.11 65750 A Corneal transplant 16.90 NA NA 17.87 15.80 65755 A Corneal transplant 16.79 NA NA 17.80 15.73 65756 A Corneal trnspl, endothelial 16.84 NA NA 16.58 14.42 
CMS-1503-P 1012

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

65757 C Prep corneal endo allograft 0.00 0.00 0.00 0.00 0.00 65760 N Revision of cornea 0.00 0.00 0.00 0.00 0.00 65765 N Revision of cornea 0.00 0.00 0.00 0.00 0.00 65767 N Corneal tissue transplant 0.00 0.00 0.00 0.00 0.00 65770 A Revise cornea with implant 19.74 NA NA 19.87 17.50 65771 N Radial keratotomy 0.00 0.00 0.00 0.00 0.00 65772 A Correction of astigmatism 5.09 7.48 6.83 6.31 5.62 65775 A Correction of astigmatism 6.91 NA NA 8.57 7.68 65780 A Ocular reconst, transplant 10.73 NA NA 14.14 12.80 65781 A Ocular reconst, transplant 18.14 NA NA 19.42 17.29 65782 A Ocular reconst, transplant 15.43 NA NA 16.97 15.14 65800 A Drainage of eye 1.91 2.24 2.05 1.77 1.56 65805 A Drainage of eye 1.91 2.63 2.44 1.78 1.56 65810 A Drainage of eye 5.82 NA NA 7.44 6.63 65815 A Drainage of eye 6.00 11.59 10.95 7.39 6.57 65820 A Relieve inner eye pressure 8.91 NA NA 11.99 10.92 65850 A Incision of eye 11.39 NA NA 12.23 10.88 65855 A Laser surgery of eye 3.99 5.47 5.02 4.38 3.91 65860 A Incise inner eye adhesions 3.59 5.04 4.65 3.55 3.15 65865 A Incise inner eye adhesions 5.77 NA NA 7.45 6.78 65870 A Incise inner eye adhesions 7.39 NA NA 9.17 8.23 65875 A Incise inner eye adhesions 7.81 NA NA 9.84 8.83 65880 A Incise inner eye adhesions 8.36 NA NA 10.22 9.14 65900 A Remove eye lesion 12.51 NA NA 14.56 13.01 65920 A Remove implant of eye 9.99 NA NA 12.12 10.81 65930 A Remove blood clot from eye 8.39 NA NA 9.50 8.51 
CMS-1503-P 1013

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

66020 A Injection treatment of eye 1.64 3.49 3.32 2.04 1.84 66030 A Injection treatment of eye 1.30 3.25 3.12 1.80 1.63 66130 A Remove eye lesion 7.83 11.54 10.72 8.20 7.27 66150 A Glaucoma surgery 10.53 NA NA 13.99 12.55 66155 A Glaucoma surgery 10.52 NA NA 13.99 12.53 66160 A Glaucoma surgery 12.39 NA NA 15.31 13.66 66165 A Glaucoma surgery 10.24 NA NA 13.79 12.37 66170 A Glaucoma surgery 15.02 NA NA 18.64 16.60 66172 A Incision of eye 18.86 NA NA 23.61 20.99 66180 A Implant eye shunt 16.30 NA NA 16.54 14.53 66185 A Revise eye shunt 9.58 NA NA 11.46 10.17 66220 A Repair eye lesion 9.21 NA NA 11.63 10.25 66225 A Repair/graft eye lesion 12.63 NA NA 13.58 11.97 66250 A Follow-up surgery of eye 7.10 13.56 12.80 8.53 7.57 66500 A Incision of iris 3.83 NA NA 6.01 5.53 66505 A Incision of iris 4.22 NA NA 6.56 6.03 66600 A Remove iris and lesion 10.12 NA NA 13.16 11.71 66605 A Removal of iris 14.22 NA NA 15.52 13.65 66625 A Removal of iris 5.30 NA NA 6.72 6.05 66630 A Removal of iris 7.28 NA NA 8.70 7.73 66635 A Removal of iris 7.37 NA NA 8.77 7.79 66680 A Repair iris & ciliary body 6.39 NA NA 8.08 7.21 66682 A Repair iris & ciliary body 7.33 NA NA 10.44 9.35 66700 A Destruction, ciliary body 5.14 7.42 6.74 5.91 5.25 66710 A Ciliary transsleral therapy 5.14 7.17 6.51 5.90 5.24 66711 A Ciliary endoscopic ablation 7.93 NA NA 10.10 8.99 
CMS-1503-P 1014

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

66720 A Destruction, ciliary body 5.00 8.11 7.39 6.77 6.10 66740 A Destruction, ciliary body 5.14 7.07 6.42 5.91 5.26 66761 A Revision of iris 5.02 7.69 7.02 6.65 5.94 66762 A Revision of iris 5.38 7.88 7.17 6.58 5.85 66770 A Removal of inner eye lesion 6.13 8.60 7.80 7.42 6.60 66820 A Incision, secondary cataract 4.01 NA NA 6.88 6.46 66821 A After cataract laser surgery 3.42 5.75 5.26 5.24 4.76 66825 A Reposition intraocular lens 9.01 NA NA 12.20 11.10 66830 A Removal of lens lesion 9.47 NA NA 10.60 9.37 66840 A Removal of lens material 9.18 NA NA 10.40 9.19 66850 A Removal of lens material 10.55 NA NA 11.74 10.38 66852 A Removal of lens material 11.41 NA NA 12.36 10.92 66920 A Extraction of lens 10.13 NA NA 11.09 9.80 66930 A Extraction of lens 11.61 NA NA 12.51 11.04 66940 A Extraction of lens 10.37 NA NA 11.61 10.27 66982 A Cataract surgery, complex 15.02 NA NA 14.70 12.95 66983 A Cataract surg w/iol, 1 stage 10.43 NA NA 10.42 9.20 66984 A Cataract surg w/iol, 1 stage 10.52 NA NA 10.86 9.63 66985 A Insert lens prosthesis 9.98 NA NA 11.66 10.32 66986 A Exchange lens prosthesis 12.26 NA NA 13.31 11.87 66990 A Ophthalmic endoscope add-on 1.51 NA NA 1.07 0.91 66999 C Eye surgery procedure 0.00 0.00 0.00 0.00 0.00 67005 A Partial removal of eye fluid 5.89 NA NA 7.34 6.56 67010 A Partial removal of eye fluid 7.06 NA NA 8.16 7.26 67015 A Release of eye fluid 7.14 NA NA 9.09 8.19 67025 A Replace eye fluid 8.11 12.10 11.10 9.65 8.55 
CMS-1503-P 1015

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

67027 A Implant eye drug system 11.62 NA NA 12.30 10.86 67028 A Injection eye drug 2.52 3.36 3.10 2.21 1.93 67030 A Incise inner eye strands 6.11 NA NA 8.74 7.87 67031 A Laser surgery, eye strands 4.47 6.37 5.79 5.53 4.93 67036 A Removal of inner eye fluid 13.32 NA NA 13.71 12.08 67039 A Laser treatment of retina 16.74 NA NA 17.97 15.92 67040 A Laser treatment of retina 19.61 NA NA 20.39 17.99 67041 A Vit for macular pucker 19.25 NA NA 18.17 15.73 67042 A Vit for macular hole 22.38 NA NA 20.38 17.58 67043 A Vit for membrane dissect 23.24 NA NA 21.70 18.77 67101 A Repair detached retina 8.80 13.07 11.86 10.15 8.98 67105 A Repair detached retina 8.53 11.63 10.50 9.58 8.46 67107 A Repair detached retina 16.71 NA NA 17.53 15.41 67108 A Repair detached retina 22.89 NA NA 22.41 19.59 67110 A Repair detached retina 10.25 14.01 12.73 11.54 10.19 67112 A Rerepair detached retina 18.75 NA NA 18.65 16.31 67113 A Repair retinal detach, cplx 25.35 NA NA 23.93 20.72 67115 A Release encircling material 6.11 NA NA 7.87 7.02 67120 A Remove eye implant material 7.10 11.18 10.30 8.57 7.61 67121 A Remove eye implant material 12.25 NA NA 13.32 11.73 67141 A Treatment of retina 6.15 8.48 7.65 7.53 6.69 67145 A Treatment of retina 6.32 8.44 7.58 7.65 6.79 67208 A Treatment of retinal lesion 7.65 9.16 8.17 8.60 7.60 67210 A Treatment of retinal lesion 9.45 9.95 8.79 9.35 8.17 67218 A Treatment of retinal lesion 20.36 NA NA 18.74 16.33 67220 A Treatment of choroid lesion 14.39 15.43 13.68 14.10 12.33 
CMS-1503-P 1016

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

67221 R Ocular photodynamic ther 3.45 4.57 4.31 2.63 2.27 67225 A Eye photodynamic ther add-on 0.47 0.38 0.33 0.33 0.28 67227 A Treatment of retinal lesion 7.53 9.57 8.60 8.51 7.53 67228 A Treatment of retinal lesion 13.82 18.48 17.29 15.99 14.10 67229 A Tr retinal les preterm inf 16.30 NA NA 15.57 13.82 67250 A Reinforce eye wall 9.61 NA NA 12.22 11.10 67255 A Reinforce/graft eye wall 10.17 NA NA 13.33 12.11 67299 C Eye surgery procedure 0.00 0.00 0.00 0.00 0.00 67311 A Revise eye muscle 7.77 NA NA 9.02 8.03 67312 A Revise two eye muscles 9.66 NA NA 10.35 9.14 67314 A Revise eye muscle 8.79 NA NA 10.10 8.95 67316 A Revise two eye muscles 10.93 NA NA 11.58 10.18 67318 A Revise eye muscle(s) 9.12 NA NA 10.69 9.47 67320 A Revise eye muscle(s) add-on 5.40 NA NA 3.79 3.16 67331 A Eye surgery follow-up add-on 5.13 NA NA 3.57 2.97 67332 A Rerevise eye muscles add-on 5.56 NA NA 3.92 3.26 67334 A Revise eye muscle w/suture 5.05 NA NA 3.58 2.96 67335 A Eye suture during surgery 2.49 NA NA 1.75 1.49 67340 A Revise eye muscle add-on 6.00 NA NA 4.25 3.53 67343 A Release eye tissue 8.47 NA NA 9.85 8.76 67345 A Destroy nerve of eye muscle 3.01 3.54 3.18 2.92 2.57 67346 A Biopsy, eye muscle 2.87 NA NA 2.79 2.46 67399 C Eye muscle surgery procedure 0.00 0.00 0.00 0.00 0.00 67400 A Explore/biopsy eye socket 11.20 NA NA 14.76 13.48 67405 A Explore/drain eye socket 9.20 NA NA 12.85 11.84 67412 A Explore/treat eye socket 10.30 NA NA 13.45 12.38 
CMS-1503-P 1017

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

67413 A Explore/treat eye socket 10.24 NA NA 13.60 12.50 67414 A Explr/decompress eye socket 17.94 NA NA 19.30 17.01 67415 A Aspiration, orbital contents 1.76 NA NA 1.25 1.04 67420 A Explore/treat eye socket 21.87 NA NA 23.51 21.13 67430 A Explore/treat eye socket 15.29 NA NA 19.56 17.79 67440 A Explore/drain eye socket 14.84 NA NA 18.87 17.15 67445 A Explr/decompress eye socket 19.12 NA NA 20.26 18.03 67450 A Explore/biopsy eye socket 15.41 NA NA 19.65 17.84 67500 A Inject/treat eye socket 1.44 0.87 0.82 0.69 0.61 67505 A Inject/treat eye socket 1.27 1.24 1.08 1.04 0.85 67515 A Inject/treat eye socket 1.40 1.34 1.13 1.13 0.92 67550 A Insert eye socket implant 11.77 NA NA 15.17 13.84 67560 A Revise eye socket implant 12.18 NA NA 15.49 14.04 67570 A Decompress optic nerve 14.40 NA NA 17.43 16.01 67599 C Orbit surgery procedure 0.00 0.00 0.00 0.00 0.00 67700 A Drainage of eyelid abscess 1.40 5.81 5.76 1.84 1.66 67710 A Incision of eyelid 1.07 4.95 4.96 1.64 1.50 67715 A Incision of eyelid fold 1.27 5.11 5.08 1.77 1.61 67800 A Remove eyelid lesion 1.41 2.13 1.96 1.50 1.34 67801 A Remove eyelid lesions 1.91 2.61 2.39 1.86 1.64 67805 A Remove eyelid lesions 2.27 3.35 3.08 2.38 2.11 67808 A Remove eyelid lesion(s) 4.60 NA NA 5.72 5.11 67810 A Biopsy of eyelid 1.48 4.42 4.48 1.06 0.96 67820 A Revise eyelashes 0.71 0.70 0.65 0.79 0.71 67825 A Revise eyelashes 1.43 2.14 1.98 1.96 1.79 67830 A Revise eyelashes 1.75 5.49 5.39 2.12 1.91 
CMS-1503-P 1018

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

67835 A Revise eyelashes 5.70 NA NA 6.62 5.93 67840 A Remove eyelid lesion 2.09 5.43 5.32 2.36 2.12 67850 A Treat eyelid lesion 1.74 4.18 4.16 2.07 1.97 67875 A Closure of eyelid by suture 1.35 3.33 3.25 1.39 1.23 67880 A Revision of eyelid 4.60 8.08 7.54 5.72 5.12 67882 A Revision of eyelid 6.02 9.62 8.92 7.24 6.45 67900 A Repair brow defect 6.82 10.93 10.23 7.48 6.71 67901 A Repair eyelid defect 7.59 13.26 11.59 8.58 7.59 67902 A Repair eyelid defect 9.82 NA NA 10.55 9.13 67903 A Repair eyelid defect 6.51 9.98 9.49 7.10 6.43 67904 A Repair eyelid defect 7.97 12.35 11.41 8.83 7.75 67906 A Repair eyelid defect 6.93 NA NA 7.38 6.57 67908 A Repair eyelid defect 5.30 8.41 7.78 6.60 6.05 67909 A Revise eyelid defect 5.57 9.24 8.69 6.70 6.06 67911 A Revise eyelid defect 7.50 NA NA 8.30 7.26 67912 A Correction eyelid w/implant 6.36 17.83 17.71 7.41 6.76 67914 A Repair eyelid defect 3.75 6.94 6.61 4.34 3.90 67915 A Repair eyelid defect 3.26 6.24 6.00 3.84 3.48 67916 A Repair eyelid defect 5.48 9.42 8.86 6.63 5.98 67917 A Repair eyelid defect 6.19 10.05 9.41 7.14 6.42 67921 A Repair eyelid defect 3.47 6.73 6.42 4.13 3.71 67922 A Repair eyelid defect 3.14 6.04 5.82 3.69 3.35 67923 A Repair eyelid defect 6.05 9.70 9.05 7.04 6.31 67924 A Repair eyelid defect 5.93 10.27 9.68 6.67 5.97 67930 A Repair eyelid wound 3.65 6.43 6.10 3.15 2.77 67935 A Repair eyelid wound 6.36 10.11 9.47 6.12 5.44 
CMS-1503-P 1019

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

67938 A Remove eyelid foreign body 1.38 5.21 5.15 1.86 1.69 67950 A Revision of eyelid 5.99 9.88 9.31 7.01 6.35 67961 A Revision of eyelid 5.86 10.06 9.48 6.91 6.24 67966 A Revision of eyelid 8.97 12.45 11.35 9.54 8.34 67971 A Reconstruction of eyelid 10.01 NA NA 10.38 9.23 67973 A Reconstruction of eyelid 13.13 NA NA 13.14 11.68 67974 A Reconstruction of eyelid 13.10 NA NA 13.12 11.63 67975 A Reconstruction of eyelid 9.35 NA NA 9.93 8.85 67999 C Revision of eyelid 0.00 0.00 0.00 0.00 0.00 68020 A Incise/drain eyelid lining 1.42 1.92 1.75 1.68 1.52 68040 A Treatment of eyelid lesions 0.85 0.97 0.88 0.65 0.56 68100 A Biopsy of eyelid lining 1.35 3.27 3.20 1.41 1.25 68110 A Remove eyelid lining lesion 1.82 4.35 4.20 2.34 2.11 68115 A Remove eyelid lining lesion 2.41 6.09 5.91 2.76 2.46 68130 A Remove eyelid lining lesion 5.10 9.76 9.26 6.45 5.82 68135 A Remove eyelid lining lesion 1.89 2.48 2.25 2.34 2.11 68200 A Treat eyelid by injection 0.49 0.69 0.64 0.49 0.43 68320 A Revise/graft eyelid lining 6.64 13.34 12.59 8.47 7.57 68325 A Revise/graft eyelid lining 8.63 NA NA 9.89 8.79 68326 A Revise/graft eyelid lining 8.42 NA NA 9.73 8.63 68328 A Revise/graft eyelid lining 9.45 NA NA 10.52 9.36 68330 A Revise eyelid lining 5.78 10.89 10.28 7.15 6.38 68335 A Revise/graft eyelid lining 8.46 NA NA 9.72 8.63 68340 A Separate eyelid adhesions 4.97 10.02 9.50 6.22 5.54 68360 A Revise eyelid lining 5.17 9.44 8.90 6.33 5.66 68362 A Revise eyelid lining 8.61 NA NA 9.85 8.72 
CMS-1503-P 1020

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

68371 A Harvest eye tissue, alograft 5.09 NA NA 6.49 5.86 68399 C Eyelid lining surgery 0.00 0.00 0.00 0.00 0.00 68400 A Incise/drain tear gland 1.74 5.91 5.81 1.95 1.81 68420 A Incise/drain tear sac 2.35 6.38 6.21 2.39 2.19 68440 A Incise tear duct opening 0.99 1.84 1.81 1.76 1.62 68500 A Removal of tear gland 12.77 NA NA 14.64 12.99 68505 A Partial removal, tear gland 12.69 NA NA 14.58 13.09 68510 A Biopsy of tear gland 4.60 7.72 7.37 3.71 3.16 68520 A Removal of tear sac 8.78 NA NA 10.45 9.41 68525 A Biopsy of tear sac 4.42 NA NA 3.12 2.65 68530 A Clearance of tear duct 3.70 8.00 7.80 3.56 3.17 68540 A Remove tear gland lesion 12.18 NA NA 13.93 12.40 68550 A Remove tear gland lesion 15.16 NA NA 16.87 14.94 68700 A Repair tear ducts 7.87 NA NA 9.10 8.08 68705 A Revise tear duct opening 2.11 4.38 4.21 2.55 2.29 68720 A Create tear sac drain 9.96 NA NA 11.29 10.09 68745 A Create tear duct drain 9.90 NA NA 11.45 10.23 68750 A Create tear duct drain 10.10 NA NA 11.98 10.73 68760 A Close tear duct opening 1.78 3.73 3.58 2.30 2.08 68761 A Close tear duct opening 1.41 2.66 2.52 1.92 1.74 68770 A Close tear system fistula 8.29 NA NA 9.40 7.88 68801 A Dilate tear duct opening 1.00 2.44 2.32 1.99 1.86 68810 A Probe nasolacrimal duct 2.15 4.52 4.24 3.08 2.87 68811 A Probe nasolacrimal duct 2.45 NA NA 3.33 3.02 68815 A Probe nasolacrimal duct 3.30 8.94 8.64 3.92 3.53 68816 A Probe nl duct w/balloon 3.06 16.92 16.10 3.98 3.56 
CMS-1503-P 1021

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

68840 A Explore/irrigate tear ducts 1.30 2.25 2.06 1.95 1.74 68850 A Injection for tear sac x-ray 0.80 0.80 0.87 0.68 0.72 68899 C Tear duct system surgery 0.00 0.00 0.00 0.00 0.00 69000 A Drain external ear lesion 1.50 3.70 3.58 1.84 1.74 69005 A Drain external ear lesion 2.16 3.90 3.75 2.29 2.17 69020 A Drain outer ear canal lesion 1.53 5.10 5.00 2.54 2.45 69090 N Pierce earlobes 0.00 0.00 0.00 0.00 0.00 69100 A Biopsy of external ear 0.81 1.98 2.07 0.58 0.54 69105 A Biopsy of external ear canal 0.85 3.17 3.12 0.97 0.93 69110 A Remove external ear, partial 3.53 9.35 9.23 5.64 5.53 69120 A Removal of external ear 4.14 NA NA 7.33 7.04 69140 A Remove ear canal lesion(s) 8.14 NA NA 16.86 16.41 69145 A Remove ear canal lesion(s) 2.70 8.65 8.33 4.44 4.25 69150 A Extensive ear canal surgery 13.61 NA NA 15.83 15.24 69155 A Extensive ear/neck surgery 23.35 NA NA 24.32 23.08 69200 A Clear outer ear canal 0.77 2.72 2.68 0.86 0.79 69205 A Clear outer ear canal 1.21 NA NA 1.68 1.61 69210 A Remove impacted ear wax 0.61 0.83 0.77 0.31 0.27 69220 A Clean out mastoid cavity 0.83 3.12 3.06 0.94 0.89 69222 A Clean out mastoid cavity 1.45 4.85 4.78 2.48 2.41 69300 R Revise external ear 6.69 13.06 11.92 6.91 6.44 69310 A Rebuild outer ear canal 10.97 NA NA 20.03 19.45 69320 A Rebuild outer ear canal 17.18 NA NA 26.50 25.69 69399 C Outer ear surgery procedure 0.00 0.00 0.00 0.00 0.00 69400 A Inflate middle ear canal 0.83 3.40 3.28 0.94 0.89 69401 A Inflate middle ear canal 0.63 1.85 1.76 0.78 0.74 
CMS-1503-P 1022

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

69405 A Catheterize middle ear canal 2.68 4.79 4.58 2.82 2.67 69420 A Incision of eardrum 1.38 4.10 4.01 2.07 1.98 69421 A Incision of eardrum 1.78 NA NA 2.50 2.42 69424 A Remove ventilating tube 0.85 2.82 2.78 0.93 0.87 69433 A Create eardrum opening 1.57 4.14 4.02 2.15 2.05 69436 A Create eardrum opening 2.01 NA NA 2.59 2.51 69440 A Exploration of middle ear 7.71 NA NA 12.05 11.48 69450 A Eardrum revision 5.69 NA NA 9.93 9.48 69501 A Mastoidectomy 9.21 NA NA 11.76 11.13 69502 A Mastoidectomy 12.56 NA NA 15.18 14.38 69505 A Remove mastoid structures 13.17 NA NA 21.24 20.50 69511 A Extensive mastoid surgery 13.70 NA NA 21.54 20.83 69530 A Extensive mastoid surgery 20.38 NA NA 26.87 25.77 69535 A Remove part of temporal bone 37.42 NA NA 38.53 36.48 69540 A Remove ear lesion 1.25 4.75 4.67 2.40 2.33 69550 A Remove ear lesion 11.15 NA NA 18.61 18.00 69552 A Remove ear lesion 19.81 NA NA 25.06 23.97 69554 A Remove ear lesion 35.97 NA NA 36.15 33.35 69601 A Mastoid surgery revision 13.45 NA NA 16.54 15.66 69602 A Mastoid surgery revision 13.76 NA NA 17.43 16.53 69603 A Mastoid surgery revision 14.20 NA NA 21.83 21.18 69604 A Mastoid surgery revision 14.20 NA NA 17.68 16.90 69605 A Mastoid surgery revision 18.69 NA NA 25.90 24.90 69610 A Repair of eardrum 4.47 6.53 6.34 3.86 3.63 69620 A Repair of eardrum 6.03 13.75 13.45 7.92 7.57 69631 A Repair eardrum structures 10.05 NA NA 15.30 14.58 
CMS-1503-P 1023

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

69632 A Rebuild eardrum structures 12.96 NA NA 17.94 17.08 69633 A Rebuild eardrum structures 12.31 NA NA 17.52 16.69 69635 A Repair eardrum structures 13.51 NA NA 21.44 20.65 69636 A Rebuild eardrum structures 15.43 NA NA 24.03 23.18 69637 A Rebuild eardrum structures 15.32 NA NA 24.02 23.16 69641 A Revise middle ear & mastoid 12.89 NA NA 16.89 16.07 69642 A Revise middle ear & mastoid 17.06 NA NA 21.24 20.18 69643 A Revise middle ear & mastoid 15.59 NA NA 19.43 18.44 69644 A Revise middle ear & mastoid 17.23 NA NA 24.99 24.11 69645 A Revise middle ear & mastoid 16.71 NA NA 24.77 23.88 69646 A Revise middle ear & mastoid 18.37 NA NA 25.67 24.66 69650 A Release middle ear bone 9.80 NA NA 13.24 12.44 69660 A Revise middle ear bone 12.03 NA NA 14.52 13.77 69661 A Revise middle ear bone 15.92 NA NA 18.67 17.74 69662 A Revise middle ear bone 15.60 NA NA 17.48 16.57 69666 A Repair middle ear structures 9.89 NA NA 13.28 12.58 69667 A Repair middle ear structures 9.90 NA NA 13.26 12.61 69670 A Remove mastoid air cells 11.73 NA NA 15.32 14.51 69676 A Remove middle ear nerve 9.69 NA NA 14.14 13.52 69700 A Close mastoid fistula 8.37 NA NA 11.27 10.84 69710 N Implant/replace hearing aid 0.00 0.00 0.00 0.00 0.00 69711 A Remove/repair hearing aid 10.62 NA NA 14.10 13.48 69714 A Implant temple bone w/stimul 14.45 NA NA 16.32 15.45 69715 A Temple bne implnt w/stimulat 18.96 NA NA 19.11 17.99 69717 A Temple bone implant revision 15.43 NA NA 16.93 16.19 69718 A Revise temple bone implant 19.21 NA NA 19.25 18.15 
CMS-1503-P 1024

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

69720 A Release facial nerve 14.71 NA NA 18.94 17.99 69725 A Release facial nerve 27.64 NA NA 26.23 24.54 69740 A Repair facial nerve 16.27 NA NA 17.17 16.21 69745 A Repair facial nerve 17.02 NA NA 18.57 17.63 69799 C Middle ear surgery procedure 0.00 0.00 0.00 0.00 0.00 69801 A Incise inner ear 8.70 NA NA 12.82 12.21 69802 A Incise inner ear 13.50 NA NA 16.33 15.47 69805 A Explore inner ear 14.71 NA NA 15.50 14.55 69806 A Explore inner ear 12.63 NA NA 14.41 13.65 69820 A Establish inner ear window 10.52 NA NA 14.04 13.45 69840 A Revise inner ear window 10.44 NA NA 12.47 13.41 69905 A Remove inner ear 11.26 NA NA 15.05 14.35 69910 A Remove inner ear & mastoid 13.91 NA NA 15.23 14.43 69915 A Incise inner ear nerve 22.77 NA NA 21.30 19.87 69930 A Implant cochlear device 17.73 NA NA 17.27 16.41 69949 C Inner ear surgery procedure 0.00 0.00 0.00 0.00 0.00 69950 A Incise inner ear nerve 27.63 NA NA 28.17 24.54 69955 A Release facial nerve 29.42 NA NA 27.27 25.54 69960 A Release inner ear canal 29.42 NA NA 25.72 23.95 69970 A Remove inner ear lesion 32.41 NA NA 28.97 27.13 69979 C Temporal bone surgery 0.00 0.00 0.00 0.00 0.00 69990 R Microsurgery add-on 3.46 NA NA 1.89 1.83 70010 A Contrast x-ray of brain 1.19 2.75 3.34 NA NA 70010 TC A Contrast x-ray of brain 0.00 2.34 2.88 NA NA 70010 26 A Contrast x-ray of brain 1.19 0.41 0.46 0.41 0.46 70015 A Contrast x-ray of brain 1.19 2.87 2.99 NA NA 
CMS-1503-P 1025

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

70015 TC A Contrast x-ray of brain 0.00 2.45 2.51 NA NA 70015 26 A Contrast x-ray of brain 1.19 0.42 0.48 0.42 0.48 70030 A X-ray eye for foreign body 0.17 0.60 0.65 NA NA 70030 TC A X-ray eye for foreign body 0.00 0.54 0.58 NA NA 70030 26 A X-ray eye for foreign body 0.17 0.06 0.07 0.06 0.07 70100 A X-ray exam of jaw 0.18 0.78 0.77 NA NA 70100 TC A X-ray exam of jaw 0.00 0.70 0.69 NA NA 70100 26 A X-ray exam of jaw 0.18 0.08 0.08 0.08 0.08 70110 A X-ray exam of jaw 0.25 0.82 0.88 NA NA 70110 TC A X-ray exam of jaw 0.00 0.73 0.78 NA NA 70110 26 A X-ray exam of jaw 0.25 0.09 0.10 0.09 0.10 70120 A X-ray exam of mastoids 0.18 0.82 0.82 NA NA 70120 TC A X-ray exam of mastoids 0.00 0.74 0.74 NA NA 70120 26 A X-ray exam of mastoids 0.18 0.08 0.08 0.08 0.08 70130 A X-ray exam of mastoids 0.34 1.23 1.27 NA NA 70130 TC A X-ray exam of mastoids 0.00 1.10 1.13 NA NA 70130 26 A X-ray exam of mastoids 0.34 0.13 0.14 0.13 0.14 70134 A X-ray exam of middle ear 0.34 0.90 0.98 NA NA 70134 TC A X-ray exam of middle ear 0.00 0.78 0.85 NA NA 70134 26 A X-ray exam of middle ear 0.34 0.12 0.13 0.12 0.13 70140 A X-ray exam of facial bones 0.19 0.66 0.68 NA NA 70140 TC A X-ray exam of facial bones 0.00 0.56 0.59 NA NA 70140 26 A X-ray exam of facial bones 0.19 0.10 0.09 0.10 0.09 70150 A X-ray exam of facial bones 0.26 0.92 0.97 NA NA 70150 TC A X-ray exam of facial bones 0.00 0.81 0.86 NA NA 70150 26 A X-ray exam of facial bones 0.26 0.11 0.11 0.11 0.11 
CMS-1503-P 1026

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

70160 A X-ray exam of nasal bones 0.17 0.74 0.77 NA NA 70160 TC A X-ray exam of nasal bones 0.00 0.67 0.70 NA NA 70160 26 A X-ray exam of nasal bones 0.17 0.07 0.07 0.07 0.07 70170 C X-ray exam of tear duct 0.00 0.00 0.00 NA NA 70170 TC C X-ray exam of tear duct 0.00 0.00 0.00 NA NA 70170 26 A X-ray exam of tear duct 0.30 0.10 0.12 0.10 0.12 70190 A X-ray exam of eye sockets 0.21 0.78 0.82 NA NA 70190 TC A X-ray exam of eye sockets 0.00 0.69 0.73 NA NA 70190 26 A X-ray exam of eye sockets 0.21 0.09 0.09 0.09 0.09 70200 A X-ray exam of eye sockets 0.28 0.92 0.99 NA NA 70200 TC A X-ray exam of eye sockets 0.00 0.81 0.87 NA NA 70200 26 A X-ray exam of eye sockets 0.28 0.11 0.12 0.11 0.12 70210 A X-ray exam of sinuses 0.17 0.69 0.70 NA NA 70210 TC A X-ray exam of sinuses 0.00 0.61 0.63 NA NA 70210 26 A X-ray exam of sinuses 0.17 0.08 0.07 0.08 0.07 70220 A X-ray exam of sinuses 0.25 0.82 0.87 NA NA 70220 TC A X-ray exam of sinuses 0.00 0.72 0.77 NA NA 70220 26 A X-ray exam of sinuses 0.25 0.10 0.10 0.10 0.10 70240 A X-ray exam, pituitary saddle 0.19 0.62 0.66 NA NA 70240 TC A X-ray exam, pituitary saddle 0.00 0.54 0.58 NA NA 70240 26 A X-ray exam, pituitary saddle 0.19 0.08 0.08 0.08 0.08 70250 A X-ray exam of skull 0.24 0.81 0.83 NA NA 70250 TC A X-ray exam of skull 0.00 0.70 0.72 NA NA 70250 26 A X-ray exam of skull 0.24 0.11 0.11 0.11 0.11 70260 A X-ray exam of skull 0.34 0.98 1.03 NA NA 70260 TC A X-ray exam of skull 0.00 0.83 0.89 NA NA 
CMS-1503-P 1027

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

70260 26 A X-ray exam of skull 0.34 0.15 0.14 0.15 0.14 70300 A X-ray exam of teeth 0.10 0.30 0.31 NA NA 70300 TC A X-ray exam of teeth 0.00 0.23 0.25 NA NA 70300 26 A X-ray exam of teeth 0.10 0.07 0.06 0.07 0.06 70310 A X-ray exam of teeth 0.16 0.94 0.91 NA NA 70310 TC A X-ray exam of teeth 0.00 0.84 0.82 NA NA 70310 26 A X-ray exam of teeth 0.16 0.10 0.09 0.10 0.09 70320 A Full mouth x-ray of teeth 0.22 1.22 1.22 NA NA 70320 TC A Full mouth x-ray of teeth 0.00 1.09 1.11 NA NA 70320 26 A Full mouth x-ray of teeth 0.22 0.13 0.11 0.13 0.11 70328 A X-ray exam of jaw joint 0.18 0.67 0.69 NA NA 70328 TC A X-ray exam of jaw joint 0.00 0.60 0.62 NA NA 70328 26 A X-ray exam of jaw joint 0.18 0.07 0.07 0.07 0.07 70330 A X-ray exam of jaw joints 0.24 1.09 1.14 NA NA 70330 TC A X-ray exam of jaw joints 0.00 0.98 1.03 NA NA 70330 26 A X-ray exam of jaw joints 0.24 0.11 0.11 0.11 0.11 70332 A X-ray exam of jaw joint 0.54 1.82 1.90 NA NA 70332 TC A X-ray exam of jaw joint 0.00 1.52 1.64 NA NA 70332 26 A X-ray exam of jaw joint 0.54 0.30 0.26 0.30 0.26 70336 A Magnetic image, jaw joint 1.48 8.61 11.50 NA NA 70336 TC A Magnetic image, jaw joint 0.00 8.10 10.92 NA NA 70336 26 A Magnetic image, jaw joint 1.48 0.51 0.58 0.51 0.58 70350 A X-ray head for orthodontia 0.17 0.43 0.43 NA NA 70350 TC A X-ray head for orthodontia 0.00 0.31 0.34 NA NA 70350 26 A X-ray head for orthodontia 0.17 0.12 0.09 0.12 0.09 70355 A Panoramic x-ray of jaws 0.20 0.38 0.42 NA NA 
CMS-1503-P 1028

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

70355 TC A Panoramic x-ray of jaws 0.00 0.26 0.32 NA NA 70355 26 A Panoramic x-ray of jaws 0.20 0.12 0.10 0.12 0.10 70360 A X-ray exam of neck 0.17 0.57 0.61 NA NA 70360 TC A X-ray exam of neck 0.00 0.51 0.54 NA NA 70360 26 A X-ray exam of neck 0.17 0.06 0.07 0.06 0.07 70370 A Throat x-ray & fluoroscopy 0.32 2.07 2.01 NA NA 70370 TC A Throat x-ray & fluoroscopy 0.00 1.94 1.88 NA NA 70370 26 A Throat x-ray & fluoroscopy 0.32 0.13 0.13 0.13 0.13 70371 A Speech evaluation, complex 0.84 1.70 1.86 NA NA 70371 TC A Speech evaluation, complex 0.00 1.36 1.53 NA NA 70371 26 A Speech evaluation, complex 0.84 0.34 0.33 0.34 0.33 70373 A Contrast x-ray of larynx 0.44 1.88 1.92 NA NA 70373 TC A Contrast x-ray of larynx 0.00 1.70 1.76 NA NA 70373 26 A Contrast x-ray of larynx 0.44 0.18 0.16 0.18 0.16 70380 A X-ray exam of salivary gland 0.17 0.98 0.96 NA NA 70380 TC A X-ray exam of salivary gland 0.00 0.87 0.87 NA NA 70380 26 A X-ray exam of salivary gland 0.17 0.11 0.09 0.11 0.09 70390 A X-ray exam of salivary duct 0.38 2.37 2.51 NA NA 70390 TC A X-ray exam of salivary duct 0.00 2.23 2.36 NA NA 70390 26 A X-ray exam of salivary duct 0.38 0.14 0.15 0.14 0.15 70450 A Ct head/brain w/o dye 0.85 3.67 4.79 NA NA 70450 TC A Ct head/brain w/o dye 0.00 3.38 4.45 NA NA 70450 26 A Ct head/brain w/o dye 0.85 0.29 0.34 0.29 0.34 70460 A Ct head/brain w/dye 1.13 4.85 6.23 NA NA 70460 TC A Ct head/brain w/dye 0.00 4.45 5.78 NA NA 70460 26 A Ct head/brain w/dye 1.13 0.40 0.45 0.40 0.45 
CMS-1503-P 1029

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

70470 A Ct head/brain w/o & w/dye 1.27 5.92 7.63 NA NA 70470 TC A Ct head/brain w/o & w/dye 0.00 5.47 7.12 NA NA 70470 26 A Ct head/brain w/o & w/dye 1.27 0.45 0.51 0.45 0.51 70480 A Ct orbit/ear/fossa w/o dye 1.28 6.39 7.75 NA NA 70480 TC A Ct orbit/ear/fossa w/o dye 0.00 5.93 7.24 NA NA 70480 26 A Ct orbit/ear/fossa w/o dye 1.28 0.46 0.51 0.46 0.51 70481 A Ct orbit/ear/fossa w/dye 1.38 7.45 9.10 NA NA 70481 TC A Ct orbit/ear/fossa w/dye 0.00 6.97 8.55 NA NA 70481 26 A Ct orbit/ear/fossa w/dye 1.38 0.48 0.55 0.48 0.55 70482 A Ct orbit/ear/fossa w/o&w/dye 1.45 8.38 10.41 NA NA 70482 TC A Ct orbit/ear/fossa w/o&w/dye 0.00 7.87 9.84 NA NA 70482 26 A Ct orbit/ear/fossa w/o&w/dye 1.45 0.51 0.57 0.51 0.57 70486 A Ct maxillofacial w/o dye 1.14 5.18 6.39 NA NA 70486 TC A Ct maxillofacial w/o dye 0.00 4.76 5.93 NA NA 70486 26 A Ct maxillofacial w/o dye 1.14 0.42 0.46 0.42 0.46 70487 A Ct maxillofacial w/dye 1.30 6.23 7.77 NA NA 70487 TC A Ct maxillofacial w/dye 0.00 5.78 7.25 NA NA 70487 26 A Ct maxillofacial w/dye 1.30 0.45 0.52 0.45 0.52 70488 A Ct maxillofacial w/o & w/dye 1.42 7.71 9.62 NA NA 70488 TC A Ct maxillofacial w/o & w/dye 0.00 7.21 9.06 NA NA 70488 26 A Ct maxillofacial w/o & w/dye 1.42 0.50 0.56 0.50 0.56 70490 A Ct soft tissue neck w/o dye 1.28 4.84 6.09 NA NA 70490 TC A Ct soft tissue neck w/o dye 0.00 4.39 5.58 NA NA 70490 26 A Ct soft tissue neck w/o dye 1.28 0.45 0.51 0.45 0.51 70491 A Ct soft tissue neck w/dye 1.38 6.01 7.51 NA NA 70491 TC A Ct soft tissue neck w/dye 0.00 5.52 6.96 NA NA 
CMS-1503-P 1030

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

70491 26 A Ct soft tissue neck w/dye 1.38 0.49 0.55 0.49 0.55 70492 A Ct sft tsue nck w/o & w/dye 1.45 7.38 9.30 NA NA 70492 TC A Ct sft tsue nck w/o & w/dye 0.00 6.87 8.73 NA NA 70492 26 A Ct sft tsue nck w/o & w/dye 1.45 0.51 0.57 0.51 0.57 70496 A Ct angiography, head 1.75 12.06 15.32 NA NA 70496 TC A Ct angiography, head 0.00 11.45 14.62 NA NA 70496 26 A Ct angiography, head 1.75 0.61 0.70 0.61 0.70 70498 A Ct angiography, neck 1.75 12.56 15.63 NA NA 70498 TC A Ct angiography, neck 0.00 11.95 14.92 NA NA 70498 26 A Ct angiography, neck 1.75 0.61 0.71 0.61 0.71 70540 A Mri orbit/face/neck w/o dye 1.35 9.96 13.05 NA NA 70540 TC A Mri orbit/face/neck w/o dye 0.00 9.49 12.52 NA NA 70540 26 A Mri orbit/face/neck w/o dye 1.35 0.47 0.53 0.47 0.53 70542 A Mri orbit/face/neck w/dye 1.62 11.17 14.46 NA NA 70542 TC A Mri orbit/face/neck w/dye 0.00 10.60 13.82 NA NA 70542 26 A Mri orbit/face/neck w/dye 1.62 0.57 0.64 0.57 0.64 70543 A Mri orbt/fac/nck w/o & w/dye 2.15 13.42 18.89 NA NA 70543 TC A Mri orbt/fac/nck w/o & w/dye 0.00 12.67 18.05 NA NA 70543 26 A Mri orbt/fac/nck w/o & w/dye 2.15 0.75 0.84 0.75 0.84 70544 A Mr angiography head w/o dye 1.20 11.48 14.53 NA NA 70544 TC A Mr angiography head w/o dye 0.00 11.06 14.06 NA NA 70544 26 A Mr angiography head w/o dye 1.20 0.42 0.47 0.42 0.47 70545 A Mr angiography head w/dye 1.20 11.38 14.44 NA NA 70545 TC A Mr angiography head w/dye 0.00 10.96 13.97 NA NA 70545 26 A Mr angiography head w/dye 1.20 0.42 0.47 0.42 0.47 70546 A Mr angiograph head w/o&w/dye 1.80 17.39 22.84 NA NA 
CMS-1503-P 1031

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

70546 TC A Mr angiograph head w/o&w/dye 0.00 16.76 22.13 NA NA 70546 26 A Mr angiograph head w/o&w/dye 1.80 0.63 0.71 0.63 0.71 70547 A Mr angiography neck w/o dye 1.20 11.48 14.51 NA NA 70547 TC A Mr angiography neck w/o dye 0.00 11.06 14.03 NA NA 70547 26 A Mr angiography neck w/o dye 1.20 0.42 0.48 0.42 0.48 70548 A Mr angiography neck w/dye 1.20 12.24 15.28 NA NA 70548 TC A Mr angiography neck w/dye 0.00 11.82 14.80 NA NA 70548 26 A Mr angiography neck w/dye 1.20 0.42 0.48 0.42 0.48 70549 A Mr angiograph neck w/o&w/dye 1.80 17.40 22.85 NA NA 70549 TC A Mr angiograph neck w/o&w/dye 0.00 16.77 22.14 NA NA 70549 26 A Mr angiograph neck w/o&w/dye 1.80 0.63 0.71 0.63 0.71 70551 A Mri brain w/o dye 1.48 10.40 13.39 NA NA 70551 TC A Mri brain w/o dye 0.00 9.88 12.81 NA NA 70551 26 A Mri brain w/o dye 1.48 0.52 0.58 0.52 0.58 70552 A Mri brain w/dye 1.78 11.48 14.80 NA NA 70552 TC A Mri brain w/dye 0.00 10.85 14.09 NA NA 70552 26 A Mri brain w/dye 1.78 0.63 0.71 0.63 0.71 70553 A Mri brain w/o & w/dye 2.36 13.18 18.51 NA NA 70553 TC A Mri brain w/o & w/dye 0.00 12.35 17.57 NA NA 70553 26 A Mri brain w/o & w/dye 2.36 0.83 0.94 0.83 0.94 70554 A Fmri brain by tech 2.11 11.55 14.26 NA NA 70554 TC A Fmri brain by tech 0.00 10.79 13.40 NA NA 70554 26 A Fmri brain by tech 2.11 0.76 0.86 0.76 0.86 70555 C Fmri brain by phys/psych 0.00 0.00 0.00 NA NA 70555 TC C Fmri brain by phys/psych 0.00 0.00 0.00 NA NA 70555 26 A Fmri brain by phys/psych 2.54 0.86 1.02 0.86 1.02 
CMS-1503-P 1032

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

70557 C Mri brain w/o dye 0.00 0.00 0.00 NA NA 70557 TC C Mri brain w/o dye 0.00 0.00 0.00 NA NA 70557 26 A Mri brain w/o dye 2.90 1.59 1.48 1.59 1.48 70558 C Mri brain w/dye 0.00 0.00 0.00 NA NA 70558 TC C Mri brain w/dye 0.00 0.00 0.00 NA NA 70558 26 A Mri brain w/dye 3.20 1.12 1.28 1.12 1.28 70559 C Mri brain w/o & w/dye 0.00 0.00 0.00 NA NA 70559 TC C Mri brain w/o & w/dye 0.00 0.00 0.00 NA NA 70559 26 A Mri brain w/o & w/dye 3.20 1.16 1.33 1.16 1.33 71010 A Chest x-ray 0.18 0.45 0.49 NA NA 71010 TC A Chest x-ray 0.00 0.38 0.42 NA NA 71010 26 A Chest x-ray 0.18 0.07 0.07 0.07 0.07 71015 A Chest x-ray 0.21 0.60 0.64 NA NA 71015 TC A Chest x-ray 0.00 0.52 0.56 NA NA 71015 26 A Chest x-ray 0.21 0.08 0.08 0.08 0.08 71020 A Chest x-ray 0.22 0.59 0.66 NA NA 71020 TC A Chest x-ray 0.00 0.51 0.57 NA NA 71020 26 A Chest x-ray 0.22 0.08 0.09 0.08 0.09 71021 A Chest x-ray 0.27 0.78 0.83 NA NA 71021 TC A Chest x-ray 0.00 0.66 0.72 NA NA 71021 26 A Chest x-ray 0.27 0.12 0.11 0.12 0.11 71022 A Chest x-ray 0.31 0.96 1.03 NA NA 71022 TC A Chest x-ray 0.00 0.84 0.90 NA NA 71022 26 A Chest x-ray 0.31 0.12 0.13 0.12 0.13 71023 A Chest x-ray and fluoroscopy 0.38 1.56 1.61 NA NA 71023 TC A Chest x-ray and fluoroscopy 0.00 1.41 1.45 NA NA 
CMS-1503-P 1033

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

71023 26 A Chest x-ray and fluoroscopy 0.38 0.15 0.16 0.15 0.16 71030 A Chest x-ray 0.31 0.92 1.00 NA NA 71030 TC A Chest x-ray 0.00 0.81 0.88 NA NA 71030 26 A Chest x-ray 0.31 0.11 0.12 0.11 0.12 71034 A Chest x-ray and fluoroscopy 0.46 1.85 2.10 NA NA 71034 TC A Chest x-ray and fluoroscopy 0.00 1.68 1.89 NA NA 71034 26 A Chest x-ray and fluoroscopy 0.46 0.17 0.21 0.17 0.21 71035 A Chest x-ray 0.18 0.77 0.82 NA NA 71035 TC A Chest x-ray 0.00 0.71 0.75 NA NA 71035 26 A Chest x-ray 0.18 0.06 0.07 0.06 0.07 71040 A Contrast x-ray of bronchi 0.58 2.06 2.20 NA NA 71040 TC A Contrast x-ray of bronchi 0.00 1.86 1.97 NA NA 71040 26 A Contrast x-ray of bronchi 0.58 0.20 0.23 0.20 0.23 71060 A Contrast x-ray of bronchi 0.74 3.06 3.29 NA NA 71060 TC A Contrast x-ray of bronchi 0.00 2.80 3.00 NA NA 71060 26 A Contrast x-ray of bronchi 0.74 0.26 0.29 0.26 0.29 71090 C X-ray & pacemaker insertion 0.00 0.00 0.00 NA NA 71090 TC C X-ray & pacemaker insertion 0.00 0.00 0.00 NA NA 71090 26 A X-ray & pacemaker insertion 0.54 0.21 0.26 0.21 0.26 71100 A X-ray exam of ribs 0.22 0.67 0.71 NA NA 71100 TC A X-ray exam of ribs 0.00 0.58 0.62 NA NA 71100 26 A X-ray exam of ribs 0.22 0.09 0.09 0.09 0.09 71101 A X-ray exam of ribs/chest 0.27 0.80 0.86 NA NA 71101 TC A X-ray exam of ribs/chest 0.00 0.70 0.75 NA NA 71101 26 A X-ray exam of ribs/chest 0.27 0.10 0.11 0.10 0.11 71110 A X-ray exam of ribs 0.27 0.85 0.90 NA NA 
CMS-1503-P 1034

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

71110 TC A X-ray exam of ribs 0.00 0.74 0.79 NA NA 71110 26 A X-ray exam of ribs 0.27 0.11 0.11 0.11 0.11 71111 A X-ray exam of ribs/chest 0.32 1.15 1.20 NA NA 71111 TC A X-ray exam of ribs/chest 0.00 1.02 1.07 NA NA 71111 26 A X-ray exam of ribs/chest 0.32 0.13 0.13 0.13 0.13 71120 A X-ray exam of breastbone 0.20 0.64 0.71 NA NA 71120 TC A X-ray exam of breastbone 0.00 0.57 0.63 NA NA 71120 26 A X-ray exam of breastbone 0.20 0.07 0.08 0.07 0.08 71130 A X-ray exam of breastbone 0.22 0.79 0.85 NA NA 71130 TC A X-ray exam of breastbone 0.00 0.70 0.76 NA NA 71130 26 A X-ray exam of breastbone 0.22 0.09 0.09 0.09 0.09 71250 A Ct thorax w/o dye 1.16 4.81 6.23 NA NA 71250 TC A Ct thorax w/o dye 0.00 4.40 5.77 NA NA 71250 26 A Ct thorax w/o dye 1.16 0.41 0.46 0.41 0.46 71260 A Ct thorax w/dye 1.24 5.98 7.68 NA NA 71260 TC A Ct thorax w/dye 0.00 5.54 7.18 NA NA 71260 26 A Ct thorax w/dye 1.24 0.44 0.50 0.44 0.50 71270 A Ct thorax w/o & w/dye 1.38 7.41 9.60 NA NA 71270 TC A Ct thorax w/o & w/dye 0.00 6.93 9.05 NA NA 71270 26 A Ct thorax w/o & w/dye 1.38 0.48 0.55 0.48 0.55 71275 A Ct angiography, chest 1.92 9.04 11.72 NA NA 71275 TC A Ct angiography, chest 0.00 8.37 10.95 NA NA 71275 26 A Ct angiography, chest 1.92 0.67 0.77 0.67 0.77 71550 A Mri chest w/o dye 1.46 11.56 14.81 NA NA 71550 TC A Mri chest w/o dye 0.00 11.05 14.24 NA NA 71550 26 A Mri chest w/o dye 1.46 0.51 0.57 0.51 0.57 
CMS-1503-P 1035

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

71551 A Mri chest w/dye 1.73 13.10 16.62 NA NA 71551 TC A Mri chest w/dye 0.00 12.49 15.94 NA NA 71551 26 A Mri chest w/dye 1.73 0.61 0.68 0.61 0.68 71552 A Mri chest w/o & w/dye 2.26 16.05 21.90 NA NA 71552 TC A Mri chest w/o & w/dye 0.00 15.26 21.00 NA NA 71552 26 A Mri chest w/o & w/dye 2.26 0.79 0.90 0.79 0.90 71555 R Mri angio chest w or w/o dye 1.81 11.18 14.18 NA NA 71555 TC R Mri angio chest w or w/o dye 0.00 10.54 13.44 NA NA 71555 26 R Mri angio chest w or w/o dye 1.81 0.64 0.74 0.64 0.74 72010 A X-ray exam of spine 0.45 1.71 1.67 NA NA 72010 TC A X-ray exam of spine 0.00 1.51 1.49 NA NA 72010 26 A X-ray exam of spine 0.45 0.20 0.18 0.20 0.18 72020 A X-ray exam of spine 0.15 0.48 0.52 NA NA 72020 TC A X-ray exam of spine 0.00 0.42 0.46 NA NA 72020 26 A X-ray exam of spine 0.15 0.06 0.06 0.06 0.06 72040 A X-ray exam of neck spine 0.22 0.86 0.88 NA NA 72040 TC A X-ray exam of neck spine 0.00 0.76 0.78 NA NA 72040 26 A X-ray exam of neck spine 0.22 0.10 0.10 0.10 0.10 72050 A X-ray exam of neck spine 0.31 1.12 1.19 NA NA 72050 TC A X-ray exam of neck spine 0.00 1.00 1.06 NA NA 72050 26 A X-ray exam of neck spine 0.31 0.12 0.13 0.12 0.13 72052 A X-ray exam of neck spine 0.36 1.48 1.55 NA NA 72052 TC A X-ray exam of neck spine 0.00 1.34 1.40 NA NA 72052 26 A X-ray exam of neck spine 0.36 0.14 0.15 0.14 0.15 72069 A X-ray exam of trunk spine 0.22 0.81 0.82 NA NA 72069 TC A X-ray exam of trunk spine 0.00 0.72 0.73 NA NA 
CMS-1503-P 1036

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

72069 26 A X-ray exam of trunk spine 0.22 0.09 0.09 0.09 0.09 72070 A X-ray exam of thoracic spine 0.22 0.70 0.74 NA NA 72070 TC A X-ray exam of thoracic spine 0.00 0.61 0.65 NA NA 72070 26 A X-ray exam of thoracic spine 0.22 0.09 0.09 0.09 0.09 72072 A X-ray exam of thoracic spine 0.22 0.78 0.86 NA NA 72072 TC A X-ray exam of thoracic spine 0.00 0.70 0.77 NA NA 72072 26 A X-ray exam of thoracic spine 0.22 0.08 0.09 0.08 0.09 72074 A X-ray exam of thoracic spine 0.22 0.96 1.05 NA NA 72074 TC A X-ray exam of thoracic spine 0.00 0.88 0.96 NA NA 72074 26 A X-ray exam of thoracic spine 0.22 0.08 0.09 0.08 0.09 72080 A X-ray exam of trunk spine 0.22 0.78 0.81 NA NA 72080 TC A X-ray exam of trunk spine 0.00 0.68 0.71 NA NA 72080 26 A X-ray exam of trunk spine 0.22 0.10 0.10 0.10 0.10 72090 A X-ray exam of trunk spine 0.28 1.10 1.12 NA NA 72090 TC A X-ray exam of trunk spine 0.00 0.98 0.99 NA NA 72090 26 A X-ray exam of trunk spine 0.28 0.12 0.13 0.12 0.13 72100 A X-ray exam of lower spine 0.22 0.91 0.93 NA NA 72100 TC A X-ray exam of lower spine 0.00 0.81 0.83 NA NA 72100 26 A X-ray exam of lower spine 0.22 0.10 0.10 0.10 0.10 72110 A X-ray exam of lower spine 0.31 1.20 1.27 NA NA 72110 TC A X-ray exam of lower spine 0.00 1.08 1.14 NA NA 72110 26 A X-ray exam of lower spine 0.31 0.12 0.13 0.12 0.13 72114 A X-ray exam of lower spine 0.36 1.71 1.76 NA NA 72114 TC A X-ray exam of lower spine 0.00 1.56 1.60 NA NA 72114 26 A X-ray exam of lower spine 0.36 0.15 0.16 0.15 0.16 72120 A X-ray exam of lower spine 0.22 1.24 1.25 NA NA 
CMS-1503-P 1037

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

72120 TC A X-ray exam of lower spine 0.00 1.14 1.15 NA NA 72120 26 A X-ray exam of lower spine 0.22 0.10 0.10 0.10 0.10 72125 A Ct neck spine w/o dye 1.16 4.85 6.27 NA NA 72125 TC A Ct neck spine w/o dye 0.00 4.45 5.81 NA NA 72125 26 A Ct neck spine w/o dye 1.16 0.40 0.46 0.40 0.46 72126 A Ct neck spine w/dye 1.22 5.99 7.68 NA NA 72126 TC A Ct neck spine w/dye 0.00 5.56 7.20 NA NA 72126 26 A Ct neck spine w/dye 1.22 0.43 0.48 0.43 0.48 72127 A Ct neck spine w/o & w/dye 1.27 7.38 9.54 NA NA 72127 TC A Ct neck spine w/o & w/dye 0.00 6.94 9.04 NA NA 72127 26 A Ct neck spine w/o & w/dye 1.27 0.44 0.50 0.44 0.50 72128 A Ct chest spine w/o dye 1.16 4.85 6.25 NA NA 72128 TC A Ct chest spine w/o dye 0.00 4.44 5.79 NA NA 72128 26 A Ct chest spine w/o dye 1.16 0.41 0.46 0.41 0.46 72129 A Ct chest spine w/dye 1.22 6.01 7.70 NA NA 72129 TC A Ct chest spine w/dye 0.00 5.58 7.21 NA NA 72129 26 A Ct chest spine w/dye 1.22 0.43 0.49 0.43 0.49 72130 A Ct chest spine w/o & w/dye 1.27 7.39 9.55 NA NA 72130 TC A Ct chest spine w/o & w/dye 0.00 6.95 9.05 NA NA 72130 26 A Ct chest spine w/o & w/dye 1.27 0.44 0.50 0.44 0.50 72131 A Ct lumbar spine w/o dye 1.16 4.83 6.24 NA NA 72131 TC A Ct lumbar spine w/o dye 0.00 4.42 5.78 NA NA 72131 26 A Ct lumbar spine w/o dye 1.16 0.41 0.46 0.41 0.46 72132 A Ct lumbar spine w/dye 1.22 5.97 7.68 NA NA 72132 TC A Ct lumbar spine w/dye 0.00 5.55 7.19 NA NA 72132 26 A Ct lumbar spine w/dye 1.22 0.42 0.49 0.42 0.49 
CMS-1503-P 1038

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

72133 A Ct lumbar spine w/o & w/dye 1.27 7.38 9.54 NA NA 72133 TC A Ct lumbar spine w/o & w/dye 0.00 6.94 9.04 NA NA 72133 26 A Ct lumbar spine w/o & w/dye 1.27 0.44 0.50 0.44 0.50 72141 A Mri neck spine w/o dye 1.60 9.00 11.82 NA NA 72141 TC A Mri neck spine w/o dye 0.00 8.43 11.19 NA NA 72141 26 A Mri neck spine w/o dye 1.60 0.57 0.63 0.57 0.63 72142 A Mri neck spine w/dye 1.92 11.59 14.88 NA NA 72142 TC A Mri neck spine w/dye 0.00 10.90 14.11 NA NA 72142 26 A Mri neck spine w/dye 1.92 0.69 0.77 0.69 0.77 72146 A Mri chest spine w/o dye 1.60 9.01 12.02 NA NA 72146 TC A Mri chest spine w/o dye 0.00 8.44 11.38 NA NA 72146 26 A Mri chest spine w/o dye 1.60 0.57 0.64 0.57 0.64 72147 A Mri chest spine w/dye 1.92 10.08 13.22 NA NA 72147 TC A Mri chest spine w/dye 0.00 9.40 12.45 NA NA 72147 26 A Mri chest spine w/dye 1.92 0.68 0.77 0.68 0.77 72148 A Mri lumbar spine w/o dye 1.48 8.96 11.96 NA NA 72148 TC A Mri lumbar spine w/o dye 0.00 8.43 11.37 NA NA 72148 26 A Mri lumbar spine w/o dye 1.48 0.53 0.59 0.53 0.59 72149 A Mri lumbar spine w/dye 1.78 11.38 14.74 NA NA 72149 TC A Mri lumbar spine w/dye 0.00 10.74 14.02 NA NA 72149 26 A Mri lumbar spine w/dye 1.78 0.64 0.72 0.64 0.72 72156 A Mri neck spine w/o & w/dye 2.57 13.00 18.29 NA NA 72156 TC A Mri neck spine w/o & w/dye 0.00 12.09 17.27 NA NA 72156 26 A Mri neck spine w/o & w/dye 2.57 0.91 1.02 0.91 1.02 72157 A Mri chest spine w/o & w/dye 2.57 11.91 17.04 NA NA 72157 TC A Mri chest spine w/o & w/dye 0.00 11.01 16.02 NA NA 
CMS-1503-P 1039

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

72157 26 A Mri chest spine w/o & w/dye 2.57 0.90 1.02 0.90 1.02 72158 A Mri lumbar spine w/o & w/dye 2.36 12.89 18.18 NA NA 72158 TC A Mri lumbar spine w/o & w/dye 0.00 12.05 17.24 NA NA 72158 26 A Mri lumbar spine w/o & w/dye 2.36 0.84 0.94 0.84 0.94 72159 N Mr angio spine w/o&w/dye 1.80 13.41 15.99 NA NA 72159 TC N Mr angio spine w/o&w/dye 0.00 12.63 15.22 NA NA 72159 26 N Mr angio spine w/o&w/dye 1.80 0.78 0.77 0.78 0.77 72170 A X-ray exam of pelvis 0.17 0.55 0.58 NA NA 72170 TC A X-ray exam of pelvis 0.00 0.48 0.51 NA NA 72170 26 A X-ray exam of pelvis 0.17 0.07 0.07 0.07 0.07 72190 A X-ray exam of pelvis 0.21 0.95 0.97 NA NA 72190 TC A X-ray exam of pelvis 0.00 0.86 0.88 NA NA 72190 26 A X-ray exam of pelvis 0.21 0.09 0.09 0.09 0.09 72191 A Ct angiograph pelv w/o&w/dye 1.81 8.61 11.26 NA NA 72191 TC A Ct angiograph pelv w/o&w/dye 0.00 7.98 10.54 NA NA 72191 26 A Ct angiograph pelv w/o&w/dye 1.81 0.63 0.72 0.63 0.72 72192 A Ct pelvis w/o dye 1.09 4.49 5.89 NA NA 72192 TC A Ct pelvis w/o dye 0.00 4.11 5.45 NA NA 72192 26 A Ct pelvis w/o dye 1.09 0.38 0.44 0.38 0.44 72193 A Ct pelvis w/dye 1.16 5.63 7.27 NA NA 72193 TC A Ct pelvis w/dye 0.00 5.22 6.81 NA NA 72193 26 A Ct pelvis w/dye 1.16 0.41 0.46 0.41 0.46 72194 A Ct pelvis w/o & w/dye 1.22 7.47 9.60 NA NA 72194 TC A Ct pelvis w/o & w/dye 0.00 7.04 9.11 NA NA 72194 26 A Ct pelvis w/o & w/dye 1.22 0.43 0.49 0.43 0.49 72195 A Mri pelvis w/o dye 1.46 10.31 13.34 NA NA 
CMS-1503-P 1040

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

72195 TC A Mri pelvis w/o dye 0.00 9.79 12.76 NA NA 72195 26 A Mri pelvis w/o dye 1.46 0.52 0.58 0.52 0.58 72196 A Mri pelvis w/dye 1.73 11.32 14.64 NA NA 72196 TC A Mri pelvis w/dye 0.00 10.71 13.95 NA NA 72196 26 A Mri pelvis w/dye 1.73 0.61 0.69 0.61 0.69 72197 A Mri pelvis w/o & w/dye 2.26 13.64 19.11 NA NA 72197 TC A Mri pelvis w/o & w/dye 0.00 12.86 18.22 NA NA 72197 26 A Mri pelvis w/o & w/dye 2.26 0.78 0.89 0.78 0.89 72198 A Mr angio pelvis w/o & w/dye 1.80 11.12 14.08 NA NA 72198 TC A Mr angio pelvis w/o & w/dye 0.00 10.50 13.37 NA NA 72198 26 A Mr angio pelvis w/o & w/dye 1.80 0.62 0.71 0.62 0.71 72200 A X-ray exam sacroiliac joints 0.17 0.63 0.67 NA NA 72200 TC A X-ray exam sacroiliac joints 0.00 0.56 0.60 NA NA 72200 26 A X-ray exam sacroiliac joints 0.17 0.07 0.07 0.07 0.07 72202 A X-ray exam sacroiliac joints 0.19 0.74 0.80 NA NA 72202 TC A X-ray exam sacroiliac joints 0.00 0.67 0.72 NA NA 72202 26 A X-ray exam sacroiliac joints 0.19 0.07 0.08 0.07 0.08 72220 A X-ray exam of tailbone 0.17 0.62 0.66 NA NA 72220 TC A X-ray exam of tailbone 0.00 0.55 0.59 NA NA 72220 26 A X-ray exam of tailbone 0.17 0.07 0.07 0.07 0.07 72240 A Contrast x-ray of neck spine 0.91 2.62 3.22 NA NA 72240 TC A Contrast x-ray of neck spine 0.00 2.29 2.86 NA NA 72240 26 A Contrast x-ray of neck spine 0.91 0.33 0.36 0.33 0.36 72255 A Contrast x-ray, thorax spine 0.91 2.55 2.99 NA NA 72255 TC A Contrast x-ray, thorax spine 0.00 2.20 2.63 NA NA 72255 26 A Contrast x-ray, thorax spine 0.91 0.35 0.36 0.35 0.36 
CMS-1503-P 1041

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

72265 A Contrast x-ray, lower spine 0.83 2.63 3.11 NA NA 72265 TC A Contrast x-ray, lower spine 0.00 2.32 2.78 NA NA 72265 26 A Contrast x-ray, lower spine 0.83 0.31 0.33 0.31 0.33 72270 A Contrast x-ray, spine 1.33 4.06 4.81 NA NA 72270 TC A Contrast x-ray, spine 0.00 3.58 4.28 NA NA 72270 26 A Contrast x-ray, spine 1.33 0.48 0.53 0.48 0.53 72275 A Epidurography 0.76 2.65 2.46 NA NA 72275 TC A Epidurography 0.00 2.27 2.14 NA NA 72275 26 A Epidurography 0.76 0.38 0.32 0.38 0.32 72285 A X-ray c/t spine disk 1.16 2.23 3.09 NA NA 72285 TC A X-ray c/t spine disk 0.00 1.63 2.59 NA NA 72285 26 A X-ray c/t spine disk 1.16 0.60 0.50 0.60 0.50 72291 C Perq verte/sacroplsty, fluor 0.00 0.00 0.00 NA NA 72291 TC C Perq verte/sacroplsty, fluor 0.00 0.00 0.00 NA NA 72291 26 A Perq verte/sacroplsty, fluor 1.31 0.57 0.59 0.57 0.59 72292 C Perq verte/sacroplsty, ct 0.00 0.00 0.00 NA NA 72292 TC C Perq verte/sacroplsty, ct 0.00 0.00 0.00 NA NA 72292 26 A Perq verte/sacroplsty, ct 1.38 0.56 0.60 0.56 0.60 72295 A X-ray of lower spine disk 0.83 2.09 2.92 NA NA 72295 TC A X-ray of lower spine disk 0.00 1.67 2.55 NA NA 72295 26 A X-ray of lower spine disk 0.83 0.42 0.37 0.42 0.37 73000 A X-ray exam of collar bone 0.16 0.63 0.65 NA NA 73000 TC A X-ray exam of collar bone 0.00 0.56 0.58 NA NA 73000 26 A X-ray exam of collar bone 0.16 0.07 0.07 0.07 0.07 73010 A X-ray exam of shoulder blade 0.17 0.69 0.69 NA NA 73010 TC A X-ray exam of shoulder blade 0.00 0.61 0.61 NA NA 
CMS-1503-P 1042

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

73010 26 A X-ray exam of shoulder blade 0.17 0.08 0.08 0.08 0.08 73020 A X-ray exam of shoulder 0.15 0.50 0.52 NA NA 73020 TC A X-ray exam of shoulder 0.00 0.43 0.46 NA NA 73020 26 A X-ray exam of shoulder 0.15 0.07 0.06 0.07 0.06 73030 A X-ray exam of shoulder 0.18 0.65 0.68 NA NA 73030 TC A X-ray exam of shoulder 0.00 0.57 0.60 NA NA 73030 26 A X-ray exam of shoulder 0.18 0.08 0.08 0.08 0.08 73040 A Contrast x-ray of shoulder 0.54 2.37 2.55 NA NA 73040 TC A Contrast x-ray of shoulder 0.00 2.16 2.32 NA NA 73040 26 A Contrast x-ray of shoulder 0.54 0.21 0.23 0.21 0.23 73050 A X-ray exam of shoulders 0.20 0.89 0.89 NA NA 73050 TC A X-ray exam of shoulders 0.00 0.79 0.79 NA NA 73050 26 A X-ray exam of shoulders 0.20 0.10 0.10 0.10 0.10 73060 A X-ray exam of humerus 0.17 0.64 0.66 NA NA 73060 TC A X-ray exam of humerus 0.00 0.56 0.59 NA NA 73060 26 A X-ray exam of humerus 0.17 0.08 0.07 0.08 0.07 73070 A X-ray exam of elbow 0.15 0.64 0.66 NA NA 73070 TC A X-ray exam of elbow 0.00 0.57 0.59 NA NA 73070 26 A X-ray exam of elbow 0.15 0.07 0.07 0.07 0.07 73080 A X-ray exam of elbow 0.17 0.82 0.84 NA NA 73080 TC A X-ray exam of elbow 0.00 0.75 0.77 NA NA 73080 26 A X-ray exam of elbow 0.17 0.07 0.07 0.07 0.07 73085 A Contrast x-ray of elbow 0.54 2.14 2.26 NA NA 73085 TC A Contrast x-ray of elbow 0.00 1.90 2.02 NA NA 73085 26 A Contrast x-ray of elbow 0.54 0.24 0.24 0.24 0.24 73090 A X-ray exam of forearm 0.16 0.61 0.63 NA NA 
CMS-1503-P 1043

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

73090 TC A X-ray exam of forearm 0.00 0.54 0.57 NA NA 73090 26 A X-ray exam of forearm 0.16 0.07 0.06 0.07 0.06 73092 A X-ray exam of arm, infant 0.16 0.74 0.72 NA NA 73092 TC A X-ray exam of arm, infant 0.00 0.67 0.65 NA NA 73092 26 A X-ray exam of arm, infant 0.16 0.07 0.07 0.07 0.07 73100 A X-ray exam of wrist 0.16 0.71 0.71 NA NA 73100 TC A X-ray exam of wrist 0.00 0.63 0.63 NA NA 73100 26 A X-ray exam of wrist 0.16 0.08 0.08 0.08 0.08 73110 A X-ray exam of wrist 0.17 0.87 0.86 NA NA 73110 TC A X-ray exam of wrist 0.00 0.79 0.79 NA NA 73110 26 A X-ray exam of wrist 0.17 0.08 0.07 0.08 0.07 73115 A Contrast x-ray of wrist 0.54 2.57 2.57 NA NA 73115 TC A Contrast x-ray of wrist 0.00 2.33 2.33 NA NA 73115 26 A Contrast x-ray of wrist 0.54 0.24 0.24 0.24 0.24 73120 A X-ray exam of hand 0.16 0.61 0.63 NA NA 73120 TC A X-ray exam of hand 0.00 0.54 0.56 NA NA 73120 26 A X-ray exam of hand 0.16 0.07 0.07 0.07 0.07 73130 A X-ray exam of hand 0.17 0.72 0.74 NA NA 73130 TC A X-ray exam of hand 0.00 0.65 0.67 NA NA 73130 26 A X-ray exam of hand 0.17 0.07 0.07 0.07 0.07 73140 A X-ray exam of finger(s) 0.13 0.79 0.77 NA NA 73140 TC A X-ray exam of finger(s) 0.00 0.73 0.71 NA NA 73140 26 A X-ray exam of finger(s) 0.13 0.06 0.06 0.06 0.06 73200 A Ct upper extremity w/o dye 1.09 4.77 6.04 NA NA 73200 TC A Ct upper extremity w/o dye 0.00 4.39 5.61 NA NA 73200 26 A Ct upper extremity w/o dye 1.09 0.38 0.43 0.38 0.43 
CMS-1503-P 1044

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

73201 A Ct upper extremity w/dye 1.16 5.92 7.43 NA NA 73201 TC A Ct upper extremity w/dye 0.00 5.51 6.97 NA NA 73201 26 A Ct upper extremity w/dye 1.16 0.41 0.46 0.41 0.46 73202 A Ct uppr extremity w/o&w/dye 1.22 7.80 9.80 NA NA 73202 TC A Ct uppr extremity w/o&w/dye 0.00 7.37 9.32 NA NA 73202 26 A Ct uppr extremity w/o&w/dye 1.22 0.43 0.48 0.43 0.48 73206 A Ct angio upr extrm w/o&w/dye 1.81 8.19 10.70 NA NA 73206 TC A Ct angio upr extrm w/o&w/dye 0.00 7.55 9.96 NA NA 73206 26 A Ct angio upr extrm w/o&w/dye 1.81 0.64 0.74 0.64 0.74 73218 A Mri upper extremity w/o dye 1.35 10.66 13.60 NA NA 73218 TC A Mri upper extremity w/o dye 0.00 10.15 13.06 NA NA 73218 26 A Mri upper extremity w/o dye 1.35 0.51 0.54 0.51 0.54 73219 A Mri upper extremity w/dye 1.62 11.04 14.50 NA NA 73219 TC A Mri upper extremity w/dye 0.00 10.46 13.86 NA NA 73219 26 A Mri upper extremity w/dye 1.62 0.58 0.64 0.58 0.64 73220 A Mri uppr extremity w/o&w/dye 2.15 13.70 19.16 NA NA 73220 TC A Mri uppr extremity w/o&w/dye 0.00 12.94 18.31 NA NA 73220 26 A Mri uppr extremity w/o&w/dye 2.15 0.76 0.85 0.76 0.85 73221 A Mri joint upr extrem w/o dye 1.35 9.81 12.68 NA NA 73221 TC A Mri joint upr extrem w/o dye 0.00 9.30 12.13 NA NA 73221 26 A Mri joint upr extrem w/o dye 1.35 0.51 0.55 0.51 0.55 73222 A Mri joint upr extrem w/dye 1.62 10.39 13.67 NA NA 73222 TC A Mri joint upr extrem w/dye 0.00 9.81 13.03 NA NA 73222 26 A Mri joint upr extrem w/dye 1.62 0.58 0.64 0.58 0.64 73223 A Mri joint upr extr w/o&w/dye 2.15 12.79 18.09 NA NA 73223 TC A Mri joint upr extr w/o&w/dye 0.00 12.02 17.24 NA NA 
CMS-1503-P 1045

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

73223 26 A Mri joint upr extr w/o&w/dye 2.15 0.77 0.85 0.77 0.85 73225 N Mr angio upr extr w/o&w/dye 1.73 13.38 15.78 NA NA 73225 TC N Mr angio upr extr w/o&w/dye 0.00 12.63 15.04 NA NA 73225 26 N Mr angio upr extr w/o&w/dye 1.73 0.75 0.74 0.75 0.74 73500 A X-ray exam of hip 0.17 0.56 0.58 NA NA 73500 TC A X-ray exam of hip 0.00 0.48 0.50 NA NA 73500 26 A X-ray exam of hip 0.17 0.08 0.08 0.08 0.08 73510 A X-ray exam of hip 0.21 0.86 0.88 NA NA 73510 TC A X-ray exam of hip 0.00 0.77 0.78 NA NA 73510 26 A X-ray exam of hip 0.21 0.09 0.10 0.09 0.10 73520 A X-ray exam of hips 0.26 0.87 0.90 NA NA 73520 TC A X-ray exam of hips 0.00 0.75 0.79 NA NA 73520 26 A X-ray exam of hips 0.26 0.12 0.11 0.12 0.11 73525 A Contrast x-ray of hip 0.54 2.31 2.34 NA NA 73525 TC A Contrast x-ray of hip 0.00 2.05 2.09 NA NA 73525 26 A Contrast x-ray of hip 0.54 0.26 0.25 0.26 0.25 73530 C X-ray exam of hip 0.00 0.00 0.00 NA NA 73530 TC C X-ray exam of hip 0.00 0.00 0.00 NA NA 73530 26 A X-ray exam of hip 0.29 0.10 0.12 0.10 0.12 73540 A X-ray exam of pelvis & hips 0.20 1.01 0.95 NA NA 73540 TC A X-ray exam of pelvis & hips 0.00 0.91 0.86 NA NA 73540 26 A X-ray exam of pelvis & hips 0.20 0.10 0.09 0.10 0.09 73542 A X-ray exam, sacroiliac joint 0.59 1.83 1.78 NA NA 73542 TC A X-ray exam, sacroiliac joint 0.00 1.54 1.54 NA NA 73542 26 A X-ray exam, sacroiliac joint 0.59 0.29 0.24 0.29 0.24 73550 A X-ray exam of thigh 0.17 0.59 0.63 NA NA 
CMS-1503-P 1046

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

73550 TC A X-ray exam of thigh 0.00 0.52 0.56 NA NA 73550 26 A X-ray exam of thigh 0.17 0.07 0.07 0.07 0.07 73560 A X-ray exam of knee, 1 or 2 0.17 0.67 0.68 NA NA 73560 TC A X-ray exam of knee, 1 or 2 0.00 0.59 0.60 NA NA 73560 26 A X-ray exam of knee, 1 or 2 0.17 0.08 0.08 0.08 0.08 73562 A X-ray exam of knee, 3 0.18 0.85 0.85 NA NA 73562 TC A X-ray exam of knee, 3 0.00 0.76 0.76 NA NA 73562 26 A X-ray exam of knee, 3 0.18 0.09 0.09 0.09 0.09 73564 A X-ray exam, knee, 4 or more 0.22 0.97 0.97 NA NA 73564 TC A X-ray exam, knee, 4 or more 0.00 0.87 0.87 NA NA 73564 26 A X-ray exam, knee, 4 or more 0.22 0.10 0.10 0.10 0.10 73565 A X-ray exam of knees 0.17 0.81 0.78 NA NA 73565 TC A X-ray exam of knees 0.00 0.72 0.69 NA NA 73565 26 A X-ray exam of knees 0.17 0.09 0.09 0.09 0.09 73580 A Contrast x-ray of knee joint 0.54 3.36 3.25 NA NA 73580 TC A Contrast x-ray of knee joint 0.00 3.07 2.98 NA NA 73580 26 A Contrast x-ray of knee joint 0.54 0.29 0.27 0.29 0.27 73590 A X-ray exam of lower leg 0.17 0.59 0.62 NA NA 73590 TC A X-ray exam of lower leg 0.00 0.52 0.55 NA NA 73590 26 A X-ray exam of lower leg 0.17 0.07 0.07 0.07 0.07 73592 A X-ray exam of leg, infant 0.16 0.77 0.73 NA NA 73592 TC A X-ray exam of leg, infant 0.00 0.69 0.66 NA NA 73592 26 A X-ray exam of leg, infant 0.16 0.08 0.07 0.08 0.07 73600 A X-ray exam of ankle 0.16 0.64 0.65 NA NA 73600 TC A X-ray exam of ankle 0.00 0.57 0.58 NA NA 73600 26 A X-ray exam of ankle 0.16 0.07 0.07 0.07 0.07 
CMS-1503-P 1047

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

73610 A X-ray exam of ankle 0.17 0.75 0.76 NA NA 73610 TC A X-ray exam of ankle 0.00 0.68 0.69 NA NA 73610 26 A X-ray exam of ankle 0.17 0.07 0.07 0.07 0.07 73615 A Contrast x-ray of ankle 0.54 2.45 2.45 NA NA 73615 TC A Contrast x-ray of ankle 0.00 2.19 2.20 NA NA 73615 26 A Contrast x-ray of ankle 0.54 0.26 0.25 0.26 0.25 73620 A X-ray exam of foot 0.16 0.62 0.62 NA NA 73620 TC A X-ray exam of foot 0.00 0.56 0.56 NA NA 73620 26 A X-ray exam of foot 0.16 0.06 0.06 0.06 0.06 73630 A X-ray exam of foot 0.17 0.73 0.75 NA NA 73630 TC A X-ray exam of foot 0.00 0.67 0.68 NA NA 73630 26 A X-ray exam of foot 0.17 0.06 0.07 0.06 0.07 73650 A X-ray exam of heel 0.16 0.64 0.63 NA NA 73650 TC A X-ray exam of heel 0.00 0.57 0.57 NA NA 73650 26 A X-ray exam of heel 0.16 0.07 0.06 0.07 0.06 73660 A X-ray exam of toe(s) 0.13 0.71 0.70 NA NA 73660 TC A X-ray exam of toe(s) 0.00 0.66 0.65 NA NA 73660 26 A X-ray exam of toe(s) 0.13 0.05 0.05 0.05 0.05 73700 A Ct lower extremity w/o dye 1.09 4.78 6.05 NA NA 73700 TC A Ct lower extremity w/o dye 0.00 4.40 5.62 NA NA 73700 26 A Ct lower extremity w/o dye 1.09 0.38 0.43 0.38 0.43 73701 A Ct lower extremity w/dye 1.16 5.98 7.51 NA NA 73701 TC A Ct lower extremity w/dye 0.00 5.58 7.04 NA NA 73701 26 A Ct lower extremity w/dye 1.16 0.40 0.47 0.40 0.47 73702 A Ct lwr extremity w/o&w/dye 1.22 7.87 9.85 NA NA 73702 TC A Ct lwr extremity w/o&w/dye 0.00 7.44 9.36 NA NA 
CMS-1503-P 1048

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

73702 26 A Ct lwr extremity w/o&w/dye 1.22 0.43 0.49 0.43 0.49 73706 A Ct angio lwr extr w/o&w/dye 1.90 9.22 11.85 NA NA 73706 TC A Ct angio lwr extr w/o&w/dye 0.00 8.55 11.07 NA NA 73706 26 A Ct angio lwr extr w/o&w/dye 1.90 0.67 0.78 0.67 0.78 73718 A Mri lower extremity w/o dye 1.35 10.31 13.27 NA NA 73718 TC A Mri lower extremity w/o dye 0.00 9.83 12.73 NA NA 73718 26 A Mri lower extremity w/o dye 1.35 0.48 0.54 0.48 0.54 73719 A Mri lower extremity w/dye 1.62 11.13 14.44 NA NA 73719 TC A Mri lower extremity w/dye 0.00 10.56 13.80 NA NA 73719 26 A Mri lower extremity w/dye 1.62 0.57 0.64 0.57 0.64 73720 A Mri lwr extremity w/o&w/dye 2.15 13.74 19.17 NA NA 73720 TC A Mri lwr extremity w/o&w/dye 0.00 12.99 18.32 NA NA 73720 26 A Mri lwr extremity w/o&w/dye 2.15 0.75 0.85 0.75 0.85 73721 A Mri jnt of lwr extre w/o dye 1.35 10.05 12.96 NA NA 73721 TC A Mri jnt of lwr extre w/o dye 0.00 9.55 12.41 NA NA 73721 26 A Mri jnt of lwr extre w/o dye 1.35 0.50 0.55 0.50 0.55 73722 A Mri joint of lwr extr w/dye 1.62 10.70 13.90 NA NA 73722 TC A Mri joint of lwr extr w/dye 0.00 10.11 13.25 NA NA 73722 26 A Mri joint of lwr extr w/dye 1.62 0.59 0.65 0.59 0.65 73723 A Mri joint lwr extr w/o&w/dye 2.15 12.77 18.05 NA NA 73723 TC A Mri joint lwr extr w/o&w/dye 0.00 12.01 17.20 NA NA 73723 26 A Mri joint lwr extr w/o&w/dye 2.15 0.76 0.85 0.76 0.85 73725 R Mr ang lwr ext w or w/o dye 1.82 11.15 14.10 NA NA 73725 TC R Mr ang lwr ext w or w/o dye 0.00 10.52 13.38 NA NA 73725 26 R Mr ang lwr ext w or w/o dye 1.82 0.63 0.72 0.63 0.72 74000 A X-ray exam of abdomen 0.18 0.48 0.53 NA NA 
CMS-1503-P 1049

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

74000 TC A X-ray exam of abdomen 0.00 0.41 0.46 NA NA 74000 26 A X-ray exam of abdomen 0.18 0.07 0.07 0.07 0.07 74010 A X-ray exam of abdomen 0.23 0.82 0.86 NA NA 74010 TC A X-ray exam of abdomen 0.00 0.73 0.77 NA NA 74010 26 A X-ray exam of abdomen 0.23 0.09 0.09 0.09 0.09 74020 A X-ray exam of abdomen 0.27 0.81 0.88 NA NA 74020 TC A X-ray exam of abdomen 0.00 0.71 0.77 NA NA 74020 26 A X-ray exam of abdomen 0.27 0.10 0.11 0.10 0.11 74022 A X-ray exam series, abdomen 0.32 0.98 1.06 NA NA 74022 TC A X-ray exam series, abdomen 0.00 0.87 0.93 NA NA 74022 26 A X-ray exam series, abdomen 0.32 0.11 0.13 0.11 0.13 74150 A Ct abdomen w/o dye 1.19 4.53 5.89 NA NA 74150 TC A Ct abdomen w/o dye 0.00 4.11 5.42 NA NA 74150 26 A Ct abdomen w/o dye 1.19 0.42 0.47 0.42 0.47 74160 A Ct abdomen w/dye 1.27 6.57 8.32 NA NA 74160 TC A Ct abdomen w/dye 0.00 6.12 7.81 NA NA 74160 26 A Ct abdomen w/dye 1.27 0.45 0.51 0.45 0.51 74170 A Ct abdomen w/o & w/dye 1.40 9.02 11.29 NA NA 74170 TC A Ct abdomen w/o & w/dye 0.00 8.52 10.73 NA NA 74170 26 A Ct abdomen w/o & w/dye 1.40 0.50 0.56 0.50 0.56 74175 A Ct angio abdom w/o & w/dye 1.90 9.22 11.99 NA NA 74175 TC A Ct angio abdom w/o & w/dye 0.00 8.56 11.23 NA NA 74175 26 A Ct angio abdom w/o & w/dye 1.90 0.66 0.76 0.66 0.76 74181 A Mri abdomen w/o dye 1.46 8.95 11.78 NA NA 74181 TC A Mri abdomen w/o dye 0.00 8.44 11.20 NA NA 74181 26 A Mri abdomen w/o dye 1.46 0.51 0.58 0.51 0.58 
CMS-1503-P 1050

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

74182 A Mri abdomen w/dye 1.73 12.63 16.17 NA NA 74182 TC A Mri abdomen w/dye 0.00 12.03 15.49 NA NA 74182 26 A Mri abdomen w/dye 1.73 0.60 0.68 0.60 0.68 74183 A Mri abdomen w/o & w/dye 2.26 13.69 19.15 NA NA 74183 TC A Mri abdomen w/o & w/dye 0.00 12.91 18.26 NA NA 74183 26 A Mri abdomen w/o & w/dye 2.26 0.78 0.89 0.78 0.89 74185 R Mri angio, abdom w orw/o dye 1.80 11.10 14.05 NA NA 74185 TC R Mri angio, abdom w orw/o dye 0.00 10.48 13.34 NA NA 74185 26 R Mri angio, abdom w orw/o dye 1.80 0.62 0.71 0.62 0.71 74190 C X-ray exam of peritoneum 0.00 0.00 0.00 NA NA 74190 TC C X-ray exam of peritoneum 0.00 0.00 0.00 NA NA 74190 26 A X-ray exam of peritoneum 0.48 0.17 0.19 0.17 0.19 74210 A Contrst x-ray exam of throat 0.36 1.77 1.88 NA NA 74210 TC A Contrst x-ray exam of throat 0.00 1.64 1.73 NA NA 74210 26 A Contrst x-ray exam of throat 0.36 0.13 0.15 0.13 0.15 74220 A Contrast x-ray, esophagus 0.46 2.00 2.11 NA NA 74220 TC A Contrast x-ray, esophagus 0.00 1.84 1.93 NA NA 74220 26 A Contrast x-ray, esophagus 0.46 0.16 0.18 0.16 0.18 74230 A Cine/vid x-ray, throat/esoph 0.53 1.96 2.07 NA NA 74230 TC A Cine/vid x-ray, throat/esoph 0.00 1.77 1.86 NA NA 74230 26 A Cine/vid x-ray, throat/esoph 0.53 0.19 0.21 0.19 0.21 74235 C Remove esophagus obstruction 0.00 0.00 0.00 NA NA 74235 TC C Remove esophagus obstruction 0.00 0.00 0.00 NA NA 74235 26 A Remove esophagus obstruction 1.19 0.65 0.62 0.65 0.62 74240 A X-ray exam, upper gi tract 0.69 2.42 2.50 NA NA 74240 TC A X-ray exam, upper gi tract 0.00 2.17 2.22 NA NA 
CMS-1503-P 1051

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

74240 26 A X-ray exam, upper gi tract 0.69 0.25 0.28 0.25 0.28 74241 A X-ray exam, upper gi tract 0.69 2.58 2.70 NA NA 74241 TC A X-ray exam, upper gi tract 0.00 2.34 2.43 NA NA 74241 26 A X-ray exam, upper gi tract 0.69 0.24 0.27 0.24 0.27 74245 A X-ray exam, upper gi tract 0.91 3.92 4.14 NA NA 74245 TC A X-ray exam, upper gi tract 0.00 3.60 3.78 NA NA 74245 26 A X-ray exam, upper gi tract 0.91 0.32 0.36 0.32 0.36 74246 A Contrst x-ray uppr gi tract 0.69 2.78 2.93 NA NA 74246 TC A Contrst x-ray uppr gi tract 0.00 2.54 2.65 NA NA 74246 26 A Contrst x-ray uppr gi tract 0.69 0.24 0.28 0.24 0.28 74247 A Contrst x-ray uppr gi tract 0.69 3.20 3.34 NA NA 74247 TC A Contrst x-ray uppr gi tract 0.00 2.96 3.06 NA NA 74247 26 A Contrst x-ray uppr gi tract 0.69 0.24 0.28 0.24 0.28 74249 A Contrst x-ray uppr gi tract 0.91 4.32 4.54 NA NA 74249 TC A Contrst x-ray uppr gi tract 0.00 4.00 4.18 NA NA 74249 26 A Contrst x-ray uppr gi tract 0.91 0.32 0.36 0.32 0.36 74250 A X-ray exam of small bowel 0.47 2.46 2.56 NA NA 74250 TC A X-ray exam of small bowel 0.00 2.30 2.38 NA NA 74250 26 A X-ray exam of small bowel 0.47 0.16 0.18 0.16 0.18 74251 A X-ray exam of small bowel 0.69 10.09 9.76 NA NA 74251 TC A X-ray exam of small bowel 0.00 9.85 9.48 NA NA 74251 26 A X-ray exam of small bowel 0.69 0.24 0.28 0.24 0.28 74260 A X-ray exam of small bowel 0.50 8.33 8.14 NA NA 74260 TC A X-ray exam of small bowel 0.00 8.16 7.94 NA NA 74260 26 A X-ray exam of small bowel 0.50 0.17 0.20 0.17 0.20 74261 A Ct colonography, w/o dye 2.28 12.18 12.18 NA NA 
CMS-1503-P 1052

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

74261 TC A Ct colonography, w/o dye 0.00 11.38 11.38 NA NA 74261 26 A Ct colonography, w/o dye 2.28 0.80 0.80 0.80 0.80 74262 A Ct colonography, w/dye 2.50 13.73 13.73 NA NA 74262 TC A Ct colonography, w/dye 0.00 12.85 12.85 NA NA 74262 26 A Ct colonography, w/dye 2.50 0.88 0.88 0.88 0.88 74263 N Ct colonography, screen 2.28 19.72 19.72 NA NA 74263 TC N Ct colonography, screen 0.00 18.73 18.73 NA NA 74263 26 N Ct colonography, screen 2.28 0.99 0.99 0.99 0.99 74270 A Contrast x-ray exam of colon 0.69 3.56 3.68 NA NA 74270 TC A Contrast x-ray exam of colon 0.00 3.32 3.40 NA NA 74270 26 A Contrast x-ray exam of colon 0.69 0.24 0.28 0.24 0.28 74280 A Contrast x-ray exam of colon 0.99 4.92 5.07 NA NA 74280 TC A Contrast x-ray exam of colon 0.00 4.58 4.68 NA NA 74280 26 A Contrast x-ray exam of colon 0.99 0.34 0.39 0.34 0.39 74283 A Contrast x-ray exam of colon 2.02 3.59 3.87 NA NA 74283 TC A Contrast x-ray exam of colon 0.00 2.86 3.06 NA NA 74283 26 A Contrast x-ray exam of colon 2.02 0.73 0.81 0.73 0.81 74290 A Contrast x-ray, gallbladder 0.32 1.58 1.63 NA NA 74290 TC A Contrast x-ray, gallbladder 0.00 1.47 1.50 NA NA 74290 26 A Contrast x-ray, gallbladder 0.32 0.11 0.13 0.11 0.13 74291 A Contrast x-rays, gallbladder 0.20 1.71 1.63 NA NA 74291 TC A Contrast x-rays, gallbladder 0.00 1.63 1.55 NA NA 74291 26 A Contrast x-rays, gallbladder 0.20 0.08 0.08 0.08 0.08 74300 C X-ray bile ducts/pancreas 0.00 0.00 0.00 NA NA 74300 TC C X-ray bile ducts/pancreas 0.00 0.00 0.00 NA NA 74300 26 A X-ray bile ducts/pancreas 0.36 0.13 0.14 0.13 0.14 
CMS-1503-P 1053

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

74301 C X-rays at surgery add-on 0.00 0.00 0.00 NA NA 74301 TC C X-rays at surgery add-on 0.00 0.00 0.00 NA NA 74301 26 A X-rays at surgery add-on 0.21 0.08 0.09 0.08 0.09 74305 C X-ray bile ducts/pancreas 0.00 0.00 0.00 NA NA 74305 TC C X-ray bile ducts/pancreas 0.00 0.00 0.00 NA NA 74305 26 A X-ray bile ducts/pancreas 0.42 0.14 0.17 0.14 0.17 74320 A Contrast x-ray of bile ducts 0.54 2.15 2.55 NA NA 74320 TC A Contrast x-ray of bile ducts 0.00 1.97 2.33 NA NA 74320 26 A Contrast x-ray of bile ducts 0.54 0.18 0.22 0.18 0.22 74327 A X-ray bile stone removal 0.70 3.03 3.16 NA NA 74327 TC A X-ray bile stone removal 0.00 2.79 2.88 NA NA 74327 26 A X-ray bile stone removal 0.70 0.24 0.28 0.24 0.28 74328 C X-ray bile duct endoscopy 0.00 0.00 0.00 NA NA 74328 TC C X-ray bile duct endoscopy 0.00 0.00 0.00 NA NA 74328 26 A X-ray bile duct endoscopy 0.70 0.27 0.30 0.27 0.30 74329 C X-ray for pancreas endoscopy 0.00 0.00 0.00 NA NA 74329 TC C X-ray for pancreas endoscopy 0.00 0.00 0.00 NA NA 74329 26 A X-ray for pancreas endoscopy 0.70 0.28 0.30 0.28 0.30 74330 C X-ray bile/panc endoscopy 0.00 0.00 0.00 NA NA 74330 TC C X-ray bile/panc endoscopy 0.00 0.00 0.00 NA NA 74330 26 A X-ray bile/panc endoscopy 0.90 0.34 0.37 0.34 0.37 74340 C X-ray guide for GI tube 0.00 0.00 0.00 NA NA 74340 TC C X-ray guide for GI tube 0.00 0.00 0.00 NA NA 74340 26 A X-ray guide for GI tube 0.54 0.19 0.22 0.19 0.22 74355 C X-ray guide, intestinal tube 0.00 0.00 0.00 NA NA 74355 TC C X-ray guide, intestinal tube 0.00 0.00 0.00 NA NA 
CMS-1503-P 1054

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

74355 26 A X-ray guide, intestinal tube 0.76 0.30 0.32 0.30 0.32 74360 C X-ray guide, GI dilation 0.00 0.00 0.00 NA NA 74360 TC C X-ray guide, GI dilation 0.00 0.00 0.00 NA NA 74360 26 A X-ray guide, GI dilation 0.54 0.27 0.27 0.27 0.27 74363 C X-ray, bile duct dilation 0.00 0.00 0.00 NA NA 74363 TC C X-ray, bile duct dilation 0.00 0.00 0.00 NA NA 74363 26 A X-ray, bile duct dilation 0.88 0.30 0.35 0.30 0.35 74400 A Contrst x-ray, urinary tract 0.49 2.53 2.70 NA NA 74400 TC A Contrst x-ray, urinary tract 0.00 2.36 2.51 NA NA 74400 26 A Contrst x-ray, urinary tract 0.49 0.17 0.19 0.17 0.19 74410 A Contrst x-ray, urinary tract 0.49 2.57 2.81 NA NA 74410 TC A Contrst x-ray, urinary tract 0.00 2.39 2.61 NA NA 74410 26 A Contrst x-ray, urinary tract 0.49 0.18 0.20 0.18 0.20 74415 A Contrst x-ray, urinary tract 0.49 3.21 3.41 NA NA 74415 TC A Contrst x-ray, urinary tract 0.00 3.04 3.22 NA NA 74415 26 A Contrst x-ray, urinary tract 0.49 0.17 0.19 0.17 0.19 74420 C Contrst x-ray, urinary tract 0.00 0.00 0.00 NA NA 74420 TC C Contrst x-ray, urinary tract 0.00 0.00 0.00 NA NA 74420 26 A Contrst x-ray, urinary tract 0.36 0.13 0.15 0.13 0.15 74425 C Contrst x-ray, urinary tract 0.00 0.00 0.00 NA NA 74425 TC C Contrst x-ray, urinary tract 0.00 0.00 0.00 NA NA 74425 26 A Contrst x-ray, urinary tract 0.36 0.12 0.15 0.12 0.15 74430 A Contrast x-ray, bladder 0.32 1.91 2.01 NA NA 74430 TC A Contrast x-ray, bladder 0.00 1.79 1.88 NA NA 74430 26 A Contrast x-ray, bladder 0.32 0.12 0.13 0.12 0.13 74440 A X-ray, male genital tract 0.38 2.00 2.11 NA NA 
CMS-1503-P 1055

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

74440 TC A X-ray, male genital tract 0.00 1.85 1.95 NA NA 74440 26 A X-ray, male genital tract 0.38 0.15 0.16 0.15 0.16 74445 C X-ray exam of penis 0.00 0.00 0.00 NA NA 74445 TC C X-ray exam of penis 0.00 0.00 0.00 NA NA 74445 26 A X-ray exam of penis 1.14 0.45 0.50 0.45 0.50 74450 C X-ray, urethra/bladder 0.00 0.00 0.00 NA NA 74450 TC C X-ray, urethra/bladder 0.00 0.00 0.00 NA NA 74450 26 A X-ray, urethra/bladder 0.33 0.12 0.14 0.12 0.14 74455 A X-ray, urethra/bladder 0.33 2.05 2.26 NA NA 74455 TC A X-ray, urethra/bladder 0.00 1.93 2.12 NA NA 74455 26 A X-ray, urethra/bladder 0.33 0.12 0.14 0.12 0.14 74470 C X-ray exam of kidney lesion 0.00 0.00 0.00 NA NA 74470 TC C X-ray exam of kidney lesion 0.00 0.00 0.00 NA NA 74470 26 A X-ray exam of kidney lesion 0.54 0.19 0.22 0.19 0.22 74475 A X-ray control, cath insert 0.54 2.13 2.66 NA NA 74475 TC A X-ray control, cath insert 0.00 1.95 2.44 NA NA 74475 26 A X-ray control, cath insert 0.54 0.18 0.22 0.18 0.22 74480 A X-ray control, cath insert 0.54 2.14 2.67 NA NA 74480 TC A X-ray control, cath insert 0.00 1.95 2.45 NA NA 74480 26 A X-ray control, cath insert 0.54 0.19 0.22 0.19 0.22 74485 A X-ray guide, GU dilation 0.54 2.21 2.63 NA NA 74485 TC A X-ray guide, GU dilation 0.00 2.02 2.41 NA NA 74485 26 A X-ray guide, GU dilation 0.54 0.19 0.22 0.19 0.22 74710 A X-ray measurement of pelvis 0.34 0.64 0.80 NA NA 74710 TC A X-ray measurement of pelvis 0.00 0.52 0.66 NA NA 74710 26 A X-ray measurement of pelvis 0.34 0.12 0.14 0.12 0.14 
CMS-1503-P 1056

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

74740 A X-ray, female genital tract 0.38 1.77 1.89 NA NA 74740 TC A X-ray, female genital tract 0.00 1.63 1.74 NA NA 74740 26 A X-ray, female genital tract 0.38 0.14 0.15 0.14 0.15 74742 C X-ray, fallopian tube 0.00 0.00 0.00 NA NA 74742 TC C X-ray, fallopian tube 0.00 0.00 0.00 NA NA 74742 26 A X-ray, fallopian tube 0.61 0.27 0.27 0.27 0.27 74775 C X-ray exam of perineum 0.00 0.00 0.00 NA NA 74775 TC C X-ray exam of perineum 0.00 0.00 0.00 NA NA 74775 26 A X-ray exam of perineum 0.62 0.22 0.25 0.22 0.25 75557 A Cardiac mri for morph 2.35 7.92 10.58 NA NA 75557 TC A Cardiac mri for morph 0.00 7.06 9.55 NA NA 75557 26 A Cardiac mri for morph 2.35 0.86 1.03 0.86 1.03 75559 A Cardiac mri w/stress img 2.95 11.55 15.86 NA NA 75559 TC A Cardiac mri w/stress img 0.00 10.42 14.49 NA NA 75559 26 A Cardiac mri w/stress img 2.95 1.13 1.37 1.13 1.37 75561 A Cardiac mri for morph w/dye 2.60 11.11 14.93 NA NA 75561 TC A Cardiac mri for morph w/dye 0.00 10.15 13.79 NA NA 75561 26 A Cardiac mri for morph w/dye 2.60 0.96 1.14 0.96 1.14 75563 A Card mri w/stress img & dye 3.00 13.37 18.43 NA NA 75563 TC A Card mri w/stress img & dye 0.00 12.21 16.99 NA NA 75563 26 A Card mri w/stress img & dye 3.00 1.16 1.44 1.16 1.44 75565 A Card mri vel flw map add-on 0.25 1.89 1.89 NA NA 75565 TC A Card mri vel flw map add-on 0.00 1.78 1.78 NA NA 75565 26 A Card mri vel flw map add-on 0.25 0.11 0.11 0.11 0.11 75571 A Ct hrt w/o dye w/ca test 0.58 2.50 2.50 NA NA 75571 TC A Ct hrt w/o dye w/ca test 0.00 2.29 2.29 NA NA 
CMS-1503-P 1057

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

75571 26 A Ct hrt w/o dye w/ca test 0.58 0.21 0.21 0.21 0.21 75572 A Ct hrt w/3d image 1.75 6.71 6.71 NA NA 75572 TC A Ct hrt w/3d image 0.00 6.05 6.05 NA NA 75572 26 A Ct hrt w/3d image 1.75 0.66 0.66 0.66 0.66 75573 A Ct hrt w/3d image, congen 2.55 9.05 9.05 NA NA 75573 TC A Ct hrt w/3d image, congen 0.00 8.05 8.05 NA NA 75573 26 A Ct hrt w/3d image, congen 2.55 1.00 1.00 1.00 1.00 75574 A Ct angio hrt w/3d image 2.40 10.45 10.45 NA NA 75574 TC A Ct angio hrt w/3d image 0.00 9.55 9.55 NA NA 75574 26 A Ct angio hrt w/3d image 2.40 0.90 0.90 0.90 0.90 75600 A Contrast x-ray exam of aorta 0.49 5.38 7.36 NA NA 75600 TC A Contrast x-ray exam of aorta 0.00 5.19 7.13 NA NA 75600 26 A Contrast x-ray exam of aorta 0.49 0.19 0.23 0.19 0.23 75605 A Contrast x-ray exam of aorta 1.14 3.14 5.07 NA NA 75605 TC A Contrast x-ray exam of aorta 0.00 2.72 4.57 NA NA 75605 26 A Contrast x-ray exam of aorta 1.14 0.42 0.50 0.42 0.50 75625 A Contrast x-ray exam of aorta 1.14 3.22 5.04 NA NA 75625 TC A Contrast x-ray exam of aorta 0.00 2.81 4.58 NA NA 75625 26 A Contrast x-ray exam of aorta 1.14 0.41 0.46 0.41 0.46 75630 A X-ray aorta, leg arteries 1.79 3.47 5.46 NA NA 75630 TC A X-ray aorta, leg arteries 0.00 2.81 4.70 NA NA 75630 26 A X-ray aorta, leg arteries 1.79 0.66 0.76 0.66 0.76 75635 A Ct angio abdominal arteries 2.40 9.83 13.19 NA NA 75635 TC A Ct angio abdominal arteries 0.00 8.98 12.19 NA NA 75635 26 A Ct angio abdominal arteries 2.40 0.85 1.00 0.85 1.00 75650 A Artery x-rays, head & neck 1.49 3.37 5.23 NA NA 
CMS-1503-P 1058

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

75650 TC A Artery x-rays, head & neck 0.00 2.83 4.61 NA NA 75650 26 A Artery x-rays, head & neck 1.49 0.54 0.62 0.54 0.62 75658 A Artery x-rays, arm 1.31 3.96 5.58 NA NA 75658 TC A Artery x-rays, arm 0.00 3.51 5.08 NA NA 75658 26 A Artery x-rays, arm 1.31 0.45 0.50 0.45 0.50 75660 A Artery x-rays, head & neck 1.31 4.03 5.70 NA NA 75660 TC A Artery x-rays, head & neck 0.00 3.52 5.14 NA NA 75660 26 A Artery x-rays, head & neck 1.31 0.51 0.56 0.51 0.56 75662 A Artery x-rays, head & neck 1.66 4.94 6.65 NA NA 75662 TC A Artery x-rays, head & neck 0.00 4.28 5.91 NA NA 75662 26 A Artery x-rays, head & neck 1.66 0.66 0.74 0.66 0.74 75665 A Artery x-rays, head & neck 1.31 4.27 5.94 NA NA 75665 TC A Artery x-rays, head & neck 0.00 3.76 5.38 NA NA 75665 26 A Artery x-rays, head & neck 1.31 0.51 0.56 0.51 0.56 75671 A Artery x-rays, head & neck 1.66 5.10 6.81 NA NA 75671 TC A Artery x-rays, head & neck 0.00 4.47 6.10 NA NA 75671 26 A Artery x-rays, head & neck 1.66 0.63 0.71 0.63 0.71 75676 A Artery x-rays, neck 1.31 3.93 5.65 NA NA 75676 TC A Artery x-rays, neck 0.00 3.43 5.10 NA NA 75676 26 A Artery x-rays, neck 1.31 0.50 0.55 0.50 0.55 75680 A Artery x-rays, neck 1.66 4.46 6.26 NA NA 75680 TC A Artery x-rays, neck 0.00 3.83 5.55 NA NA 75680 26 A Artery x-rays, neck 1.66 0.63 0.71 0.63 0.71 75685 A Artery x-rays, spine 1.31 4.02 5.71 NA NA 75685 TC A Artery x-rays, spine 0.00 3.51 5.15 NA NA 75685 26 A Artery x-rays, spine 1.31 0.51 0.56 0.51 0.56 
CMS-1503-P 1059

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

75705 A Artery x-rays, spine 2.18 4.22 5.99 NA NA 75705 TC A Artery x-rays, spine 0.00 3.42 5.08 NA NA 75705 26 A Artery x-rays, spine 2.18 0.80 0.91 0.80 0.91 75710 A Artery x-rays, arm/leg 1.14 3.84 5.60 NA NA 75710 TC A Artery x-rays, arm/leg 0.00 3.43 5.14 NA NA 75710 26 A Artery x-rays, arm/leg 1.14 0.41 0.46 0.41 0.46 75716 A Artery x-rays, arms/legs 1.31 4.63 6.44 NA NA 75716 TC A Artery x-rays, arms/legs 0.00 4.16 5.90 NA NA 75716 26 A Artery x-rays, arms/legs 1.31 0.47 0.54 0.47 0.54 75722 A Artery x-rays, kidney 1.14 3.47 5.38 NA NA 75722 TC A Artery x-rays, kidney 0.00 3.06 4.89 NA NA 75722 26 A Artery x-rays, kidney 1.14 0.41 0.49 0.41 0.49 75724 A Artery x-rays, kidneys 1.49 4.17 6.27 NA NA 75724 TC A Artery x-rays, kidneys 0.00 3.60 5.56 NA NA 75724 26 A Artery x-rays, kidneys 1.49 0.57 0.71 0.57 0.71 75726 A Artery x-rays, abdomen 1.14 3.70 5.49 NA NA 75726 TC A Artery x-rays, abdomen 0.00 3.31 5.03 NA NA 75726 26 A Artery x-rays, abdomen 1.14 0.39 0.46 0.39 0.46 75731 A Artery x-rays, adrenal gland 1.14 3.63 5.61 NA NA 75731 TC A Artery x-rays, adrenal gland 0.00 3.23 5.10 NA NA 75731 26 A Artery x-rays, adrenal gland 1.14 0.40 0.51 0.40 0.51 75733 A Artery x-rays, adrenals 1.31 4.41 6.54 NA NA 75733 TC A Artery x-rays, adrenals 0.00 3.90 5.91 NA NA 75733 26 A Artery x-rays, adrenals 1.31 0.51 0.63 0.51 0.63 75736 A Artery x-rays, pelvis 1.14 3.69 5.52 NA NA 75736 TC A Artery x-rays, pelvis 0.00 3.28 5.05 NA NA 
CMS-1503-P 1060

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

75736 26 A Artery x-rays, pelvis 1.14 0.41 0.47 0.41 0.47 75741 A Artery x-rays, lung 1.31 3.14 4.96 NA NA 75741 TC A Artery x-rays, lung 0.00 2.69 4.43 NA NA 75741 26 A Artery x-rays, lung 1.31 0.45 0.53 0.45 0.53 75743 A Artery x-rays, lungs 1.66 3.52 5.36 NA NA 75743 TC A Artery x-rays, lungs 0.00 2.95 4.68 NA NA 75743 26 A Artery x-rays, lungs 1.66 0.57 0.68 0.57 0.68 75746 A Artery x-rays, lung 1.14 3.46 5.27 NA NA 75746 TC A Artery x-rays, lung 0.00 3.06 4.81 NA NA 75746 26 A Artery x-rays, lung 1.14 0.40 0.46 0.40 0.46 75756 A Artery x-rays, chest 1.14 3.75 5.69 NA NA 75756 TC A Artery x-rays, chest 0.00 3.34 5.16 NA NA 75756 26 A Artery x-rays, chest 1.14 0.41 0.53 0.41 0.53 75774 A Artery x-ray, each vessel 0.36 2.45 4.24 NA NA 75774 TC A Artery x-ray, each vessel 0.00 2.32 4.09 NA NA 75774 26 A Artery x-ray, each vessel 0.36 0.13 0.15 0.13 0.15 75791 A Av dialysis shunt imaging 1.71 7.59 7.59 NA NA 75791 TC A Av dialysis shunt imaging 0.00 6.99 6.99 NA NA 75791 26 A Av dialysis shunt imaging 1.71 0.60 0.60 0.60 0.60 75801 C Lymph vessel x-ray, arm/leg 0.00 0.00 0.00 NA NA 75801 TC C Lymph vessel x-ray, arm/leg 0.00 0.00 0.00 NA NA 75801 26 A Lymph vessel x-ray, arm/leg 0.81 0.35 0.33 0.35 0.33 75803 C Lymph vessel x-ray,arms/legs 0.00 0.00 0.00 NA NA 75803 TC C Lymph vessel x-ray,arms/legs 0.00 0.00 0.00 NA NA 75803 26 A Lymph vessel x-ray,arms/legs 1.17 0.41 0.47 0.41 0.47 75805 C Lymph vessel x-ray, trunk 0.00 0.00 0.00 NA NA 
CMS-1503-P 1061

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

75805 TC C Lymph vessel x-ray, trunk 0.00 0.00 0.00 NA NA 75805 26 A Lymph vessel x-ray, trunk 0.81 0.28 0.33 0.28 0.33 75807 C Lymph vessel x-ray, trunk 0.00 0.00 0.00 NA NA 75807 TC C Lymph vessel x-ray, trunk 0.00 0.00 0.00 NA NA 75807 26 A Lymph vessel x-ray, trunk 1.17 0.42 0.48 0.42 0.48 75809 A Nonvascular shunt, x-ray 0.47 2.41 2.33 NA NA 75809 TC A Nonvascular shunt, x-ray 0.00 2.22 2.13 NA NA 75809 26 A Nonvascular shunt, x-ray 0.47 0.19 0.20 0.19 0.20 75810 C Vein x-ray, spleen/liver 0.00 0.00 0.00 NA NA 75810 TC C Vein x-ray, spleen/liver 0.00 0.00 0.00 NA NA 75810 26 A Vein x-ray, spleen/liver 1.14 0.40 0.47 0.40 0.47 75820 A Vein x-ray, arm/leg 0.70 2.83 2.91 NA NA 75820 TC A Vein x-ray, arm/leg 0.00 2.57 2.61 NA NA 75820 26 A Vein x-ray, arm/leg 0.70 0.26 0.30 0.26 0.30 75822 A Vein x-ray, arms/legs 1.06 3.24 3.32 NA NA 75822 TC A Vein x-ray, arms/legs 0.00 2.87 2.90 NA NA 75822 26 A Vein x-ray, arms/legs 1.06 0.37 0.42 0.37 0.42 75825 A Vein x-ray, trunk 1.14 3.00 4.77 NA NA 75825 TC A Vein x-ray, trunk 0.00 2.61 4.33 NA NA 75825 26 A Vein x-ray, trunk 1.14 0.39 0.44 0.39 0.44 75827 A Vein x-ray, chest 1.14 3.17 4.86 NA NA 75827 TC A Vein x-ray, chest 0.00 2.78 4.43 NA NA 75827 26 A Vein x-ray, chest 1.14 0.39 0.43 0.39 0.43 75831 A Vein x-ray, kidney 1.14 3.10 4.88 NA NA 75831 TC A Vein x-ray, kidney 0.00 2.71 4.43 NA NA 75831 26 A Vein x-ray, kidney 1.14 0.39 0.45 0.39 0.45 
CMS-1503-P 1062

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

75833 A Vein x-ray, kidneys 1.49 3.75 5.47 NA NA 75833 TC A Vein x-ray, kidneys 0.00 3.25 4.91 NA NA 75833 26 A Vein x-ray, kidneys 1.49 0.50 0.56 0.50 0.56 75840 A Vein x-ray, adrenal gland 1.14 3.01 4.79 NA NA 75840 TC A Vein x-ray, adrenal gland 0.00 2.63 4.37 NA NA 75840 26 A Vein x-ray, adrenal gland 1.14 0.38 0.42 0.38 0.42 75842 A Vein x-ray, adrenal glands 1.49 3.61 5.45 NA NA 75842 TC A Vein x-ray, adrenal glands 0.00 3.09 4.85 NA NA 75842 26 A Vein x-ray, adrenal glands 1.49 0.52 0.60 0.52 0.60 75860 A Vein x-ray, neck 1.14 3.12 4.98 NA NA 75860 TC A Vein x-ray, neck 0.00 2.70 4.49 NA NA 75860 26 A Vein x-ray, neck 1.14 0.42 0.49 0.42 0.49 75870 A Vein x-ray, skull 1.14 3.00 4.87 NA NA 75870 TC A Vein x-ray, skull 0.00 2.60 4.42 NA NA 75870 26 A Vein x-ray, skull 1.14 0.40 0.45 0.40 0.45 75872 A Vein x-ray, skull 1.14 6.55 7.03 NA NA 75872 TC A Vein x-ray, skull 0.00 5.93 6.45 NA NA 75872 26 A Vein x-ray, skull 1.14 0.62 0.58 0.62 0.58 75880 A Vein x-ray, eye socket 0.70 5.35 4.21 NA NA 75880 TC A Vein x-ray, eye socket 0.00 5.02 3.90 NA NA 75880 26 A Vein x-ray, eye socket 0.70 0.33 0.31 0.33 0.31 75885 A Vein x-ray, liver 1.44 3.15 5.00 NA NA 75885 TC A Vein x-ray, liver 0.00 2.66 4.42 NA NA 75885 26 A Vein x-ray, liver 1.44 0.49 0.58 0.49 0.58 75887 A Vein x-ray, liver 1.44 3.24 5.08 NA NA 75887 TC A Vein x-ray, liver 0.00 2.74 4.49 NA NA 
CMS-1503-P 1063

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

75887 26 A Vein x-ray, liver 1.44 0.50 0.59 0.50 0.59 75889 A Vein x-ray, liver 1.14 3.08 4.88 NA NA 75889 TC A Vein x-ray, liver 0.00 2.69 4.42 NA NA 75889 26 A Vein x-ray, liver 1.14 0.39 0.46 0.39 0.46 75891 A Vein x-ray, liver 1.14 3.08 4.88 NA NA 75891 TC A Vein x-ray, liver 0.00 2.69 4.42 NA NA 75891 26 A Vein x-ray, liver 1.14 0.39 0.46 0.39 0.46 75893 A Venous sampling by catheter 0.54 2.82 4.59 NA NA 75893 TC A Venous sampling by catheter 0.00 2.63 4.38 NA NA 75893 26 A Venous sampling by catheter 0.54 0.19 0.21 0.19 0.21 75894 C X-rays, transcath therapy 0.00 0.00 0.00 NA NA 75894 TC C X-rays, transcath therapy 0.00 0.00 0.00 NA NA 75894 26 A X-rays, transcath therapy 1.31 0.46 0.52 0.46 0.52 75896 C X-rays, transcath therapy 0.00 0.00 0.00 NA NA 75896 TC C X-rays, transcath therapy 0.00 0.00 0.00 NA NA 75896 26 A X-rays, transcath therapy 1.31 0.47 0.55 0.47 0.55 75898 C Follow-up angiography 0.00 0.00 0.00 NA NA 75898 TC C Follow-up angiography 0.00 0.00 0.00 NA NA 75898 26 A Follow-up angiography 1.65 0.60 0.69 0.60 0.69 75900 C Intravascular cath exchange 0.00 0.00 0.00 NA NA 75900 TC C Intravascular cath exchange 0.00 0.00 0.00 NA NA 75900 26 A Intravascular cath exchange 0.49 0.17 0.19 0.17 0.19 75901 A Remove cva device obstruct 0.49 4.39 4.29 NA NA 75901 TC A Remove cva device obstruct 0.00 4.22 4.10 NA NA 75901 26 A Remove cva device obstruct 0.49 0.17 0.19 0.17 0.19 75902 A Remove cva lumen obstruct 0.39 1.70 1.80 NA NA 
CMS-1503-P 1064

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

75902 TC A Remove cva lumen obstruct 0.00 1.57 1.65 NA NA 75902 26 A Remove cva lumen obstruct 0.39 0.13 0.15 0.13 0.15 75940 C X-ray placement, vein filter 0.00 0.00 0.00 NA NA 75940 TC C X-ray placement, vein filter 0.00 0.00 0.00 NA NA 75940 26 A X-ray placement, vein filter 0.54 0.19 0.21 0.19 0.21 

75945 C Intravascular us 0.00 0.00 0.00 NA NA 75945 TC C Intravascular us 0.00 0.00 0.00 NA NA 75945 26 A Intravascular us 0.40 0.14 0.16 0.14 0.16 75946 C Intravascular us add-on 0.00 0.00 0.00 NA NA 75946 TC C Intravascular us add-on 0.00 0.00 0.00 NA NA 75946 26 A Intravascular us add-on 0.40 0.13 0.15 0.13 0.15 75952 C Endovasc repair abdom aorta 0.00 0.00 0.00 NA NA 75952 TC C Endovasc repair abdom aorta 0.00 0.00 0.00 NA NA 75952 26 A Endovasc repair abdom aorta 4.49 1.54 1.62 1.54 1.62 75953 C Abdom aneurysm endovas rpr 0.00 0.00 0.00 NA NA 75953 TC C Abdom aneurysm endovas rpr 0.00 0.00 0.00 NA NA 75953 26 A Abdom aneurysm endovas rpr 1.36 0.47 0.49 0.47 0.49 75954 C Iliac aneurysm endovas rpr 0.00 0.00 0.00 NA NA 75954 TC C Iliac aneurysm endovas rpr 0.00 0.00 0.00 NA NA 75954 26 A Iliac aneurysm endovas rpr 2.25 0.79 0.82 0.79 0.82 75956 C Xray, endovasc thor ao repr 0.00 0.00 0.00 NA NA 75956 TC C Xray, endovasc thor ao repr 0.00 0.00 0.00 NA NA 75956 26 A Xray, endovasc thor ao repr 7.00 2.33 2.52 2.33 2.52 75957 C Xray, endovasc thor ao repr 0.00 0.00 0.00 NA NA 75957 TC C Xray, endovasc thor ao repr 0.00 0.00 0.00 NA NA 75957 26 A Xray, endovasc thor ao repr 6.00 2.02 2.17 2.02 2.17 
CMS-1503-P 1065

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

75958 C Xray, place prox ext thor ao 0.00 0.00 0.00 NA NA 75958 TC C Xray, place prox ext thor ao 0.00 0.00 0.00 NA NA 75958 26 A Xray, place prox ext thor ao 4.00 1.34 1.41 1.34 1.41 75959 C Xray, place dist ext thor ao 0.00 0.00 0.00 NA NA 75959 TC C Xray, place dist ext thor ao 0.00 0.00 0.00 NA NA 75959 26 A Xray, place dist ext thor ao 3.50 1.08 1.20 1.08 1.20 75960 A Transcath iv stent rs&i 0.82 2.64 4.79 NA NA 75960 TC A Transcath iv stent rs&i 0.00 2.35 4.45 NA NA 75960 26 A Transcath iv stent rs&i 0.82 0.29 0.34 0.29 0.34 75961 A Retrieval, broken catheter 4.24 4.62 6.26 NA NA 75961 TC A Retrieval, broken catheter 0.00 3.16 4.57 NA NA 75961 26 A Retrieval, broken catheter 4.24 1.46 1.69 1.46 1.69 75962 A Repair arterial blockage 0.54 3.39 5.62 NA NA 75962 TC A Repair arterial blockage 0.00 3.20 5.40 NA NA 75962 26 A Repair arterial blockage 0.54 0.19 0.22 0.19 0.22 75964 A Repair artery blockage, each 0.36 2.31 3.46 NA NA 75964 TC A Repair artery blockage, each 0.00 2.18 3.32 NA NA 75964 26 A Repair artery blockage, each 0.36 0.13 0.14 0.13 0.14 75966 A Repair arterial blockage 1.31 3.66 6.07 NA NA 75966 TC A Repair arterial blockage 0.00 3.18 5.50 NA NA 75966 26 A Repair arterial blockage 1.31 0.48 0.57 0.48 0.57 75968 A Repair artery blockage, each 0.36 2.17 3.41 NA NA 75968 TC A Repair artery blockage, each 0.00 2.04 3.25 NA NA 75968 26 A Repair artery blockage, each 0.36 0.13 0.16 0.13 0.16 75970 C Vascular biopsy 0.00 0.00 0.00 NA NA 75970 TC C Vascular biopsy 0.00 0.00 0.00 NA NA 
CMS-1503-P 1066

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

75970 26 A Vascular biopsy 0.83 0.29 0.33 0.29 0.33 75978 A Repair venous blockage 0.54 3.50 5.60 NA NA 75978 TC A Repair venous blockage 0.00 3.31 5.39 NA NA 75978 26 A Repair venous blockage 0.54 0.19 0.21 0.19 0.21 75980 C Contrast xray exam bile duct 0.00 0.00 0.00 NA NA 75980 TC C Contrast xray exam bile duct 0.00 0.00 0.00 NA NA 75980 26 A Contrast xray exam bile duct 1.44 0.49 0.58 0.49 0.58 75982 C Contrast xray exam bile duct 0.00 0.00 0.00 NA NA 75982 TC C Contrast xray exam bile duct 0.00 0.00 0.00 NA NA 75982 26 A Contrast xray exam bile duct 1.44 0.49 0.58 0.49 0.58 75984 A Xray control catheter change 0.72 2.35 2.56 NA NA 75984 TC A Xray control catheter change 0.00 2.10 2.27 NA NA 75984 26 A Xray control catheter change 0.72 0.25 0.29 0.25 0.29 75989 A Abscess drainage under x-ray 1.19 2.26 2.69 NA NA 75989 TC A Abscess drainage under x-ray 0.00 1.85 2.21 NA NA 75989 26 A Abscess drainage under x-ray 1.19 0.41 0.48 0.41 0.48 75992 C Atherectomy, x-ray exam 0.00 0.00 0.00 NA NA 75992 TC C Atherectomy, x-ray exam 0.00 0.00 0.00 NA NA 75992 26 A Atherectomy, x-ray exam 0.54 0.20 0.23 0.20 0.23 75993 C Atherectomy, x-ray exam 0.00 0.00 0.00 NA NA 75993 TC C Atherectomy, x-ray exam 0.00 0.00 0.00 NA NA 75993 26 A Atherectomy, x-ray exam 0.36 0.13 0.15 0.13 0.15 75994 C Atherectomy, x-ray exam 0.00 0.00 0.00 NA NA 75994 TC C Atherectomy, x-ray exam 0.00 0.00 0.00 NA NA 75994 26 A Atherectomy, x-ray exam 1.31 0.40 0.42 0.40 0.42 75995 C Atherectomy, x-ray exam 0.00 0.00 0.00 NA NA 
CMS-1503-P 1067

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

75995 TC C Atherectomy, x-ray exam 0.00 0.00 0.00 NA NA 75995 26 A Atherectomy, x-ray exam 1.31 0.51 0.54 0.51 0.54 75996 C Atherectomy, x-ray exam 0.00 0.00 0.00 NA NA 75996 TC C Atherectomy, x-ray exam 0.00 0.00 0.00 NA NA 75996 26 A Atherectomy, x-ray exam 0.36 0.14 0.15 0.14 0.15 76000 A Fluoroscope examination 0.17 2.93 2.90 NA NA 76000 TC A Fluoroscope examination 0.00 2.86 2.83 NA NA 76000 26 A Fluoroscope examination 0.17 0.07 0.07 0.07 0.07 76001 C Fluoroscope exam, extensive 0.00 0.00 0.00 NA NA 76001 TC C Fluoroscope exam, extensive 0.00 0.00 0.00 NA NA 76001 26 A Fluoroscope exam, extensive 0.67 0.29 0.30 0.29 0.30 76010 A X-ray, nose to rectum 0.18 0.53 0.60 NA NA 76010 TC A X-ray, nose to rectum 0.00 0.47 0.53 NA NA 76010 26 A X-ray, nose to rectum 0.18 0.06 0.07 0.06 0.07 76080 A X-ray exam of fistula 0.54 1.10 1.23 NA NA 76080 TC A X-ray exam of fistula 0.00 0.91 1.01 NA NA 76080 26 A X-ray exam of fistula 0.54 0.19 0.22 0.19 0.22 76098 A X-ray exam, breast specimen 0.16 0.32 0.37 NA NA 76098 TC A X-ray exam, breast specimen 0.00 0.26 0.31 NA NA 76098 26 A X-ray exam, breast specimen 0.16 0.06 0.06 0.06 0.06 76100 A X-ray exam of body section 0.58 2.27 2.94 NA NA 76100 TC A X-ray exam of body section 0.00 1.97 2.66 NA NA 76100 26 A X-ray exam of body section 0.58 0.30 0.28 0.30 0.28 76101 A Complex body section x-ray 0.58 3.65 4.47 NA NA 76101 TC A Complex body section x-ray 0.00 3.24 4.15 NA NA 76101 26 A Complex body section x-ray 0.58 0.41 0.32 0.41 0.32 
CMS-1503-P 1068

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

76102 A Complex body section x-rays 0.58 5.09 6.22 NA NA 76102 TC A Complex body section x-rays 0.00 4.68 5.90 NA NA 76102 26 A Complex body section x-rays 0.58 0.41 0.32 0.41 0.32 76120 A Cine/video x-rays 0.38 1.69 1.82 NA NA 76120 TC A Cine/video x-rays 0.00 1.55 1.67 NA NA 76120 26 A Cine/video x-rays 0.38 0.14 0.15 0.14 0.15 76125 C Cine/video x-rays add-on 0.00 0.00 0.00 NA NA 76125 TC C Cine/video x-rays add-on 0.00 0.00 0.00 NA NA 76125 26 A Cine/video x-rays add-on 0.27 0.11 0.13 0.11 0.13 76140 I X-ray consultation 0.00 0.00 0.00 0.00 0.00 76150 A X-ray exam, dry process 0.00 0.64 0.61 NA NA 76350 C Special x-ray contrast study 0.00 0.00 0.00 0.00 0.00 76376 A 3d render w/o postprocess 0.20 1.39 1.84 NA NA 76376 TC A 3d render w/o postprocess 0.00 1.32 1.76 NA NA 76376 26 A 3d render w/o postprocess 0.20 0.07 0.08 0.07 0.08 76377 A 3d rendering w/postprocess 0.79 1.36 1.87 NA NA 76377 TC A 3d rendering w/postprocess 0.00 1.08 1.55 NA NA 76377 26 A 3d rendering w/postprocess 0.79 0.28 0.32 0.28 0.32 76380 A CAT scan follow-up study 0.98 3.58 4.48 NA NA 76380 TC A CAT scan follow-up study 0.00 3.22 4.08 NA NA 76380 26 A CAT scan follow-up study 0.98 0.36 0.40 0.36 0.40 76390 N Mr spectroscopy 1.40 11.68 12.30 NA NA 76390 TC N Mr spectroscopy 0.00 11.07 11.71 NA NA 76390 26 N Mr spectroscopy 1.40 0.61 0.59 0.61 0.59 76496 C Fluoroscopic procedure 0.00 0.00 0.00 NA NA 76496 TC C Fluoroscopic procedure 0.00 0.00 0.00 NA NA 
CMS-1503-P 1069

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

76496 26 C Fluoroscopic procedure 0.00 0.00 0.00 0.00 0.00 76497 C Ct procedure 0.00 0.00 0.00 NA NA 76497 TC C Ct procedure 0.00 0.00 0.00 NA NA 76497 26 C Ct procedure 0.00 0.00 0.00 0.00 0.00 76498 C Mri procedure 0.00 0.00 0.00 NA NA 76498 TC C Mri procedure 0.00 0.00 0.00 NA NA 76498 26 C Mri procedure 0.00 0.00 0.00 0.00 0.00 76499 C Radiographic procedure 0.00 0.00 0.00 NA NA 76499 TC C Radiographic procedure 0.00 0.00 0.00 NA NA 76499 26 C Radiographic procedure 0.00 0.00 0.00 0.00 0.00 76506 A Echo exam of head 0.63 2.73 2.82 NA NA 76506 TC A Echo exam of head 0.00 2.50 2.57 NA NA 76506 26 A Echo exam of head 0.63 0.23 0.25 0.23 0.25 76510 A Ophth us, b & quant a 1.55 3.24 3.08 NA NA 76510 TC A Ophth us, b & quant a 0.00 2.15 2.16 NA NA 76510 26 A Ophth us, b & quant a 1.55 1.09 0.92 1.09 0.92 76511 A Ophth us, quant a only 0.94 1.94 1.95 NA NA 76511 TC A Ophth us, quant a only 0.00 1.30 1.41 NA NA 76511 26 A Ophth us, quant a only 0.94 0.64 0.54 0.64 0.54 76512 A Ophth us, b w/non-quant a 0.94 1.69 1.72 NA NA 76512 TC A Ophth us, b w/non-quant a 0.00 1.05 1.17 NA NA 76512 26 A Ophth us, b w/non-quant a 0.94 0.64 0.55 0.64 0.55 76513 A Echo exam of eye, water bath 0.66 1.95 1.90 NA NA 76513 TC A Echo exam of eye, water bath 0.00 1.57 1.57 NA NA 76513 26 A Echo exam of eye, water bath 0.66 0.38 0.33 0.38 0.33 76514 A Echo exam of eye, thickness 0.17 0.24 0.22 NA NA 
CMS-1503-P 1070

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

76514 TC A Echo exam of eye, thickness 0.00 0.13 0.12 NA NA 76514 26 A Echo exam of eye, thickness 0.17 0.11 0.10 0.11 0.10 76516 A Echo exam of eye 0.54 1.62 1.55 NA NA 76516 TC A Echo exam of eye 0.00 1.25 1.24 NA NA 76516 26 A Echo exam of eye 0.54 0.37 0.31 0.37 0.31 76519 A Echo exam of eye 0.54 1.77 1.70 NA NA 76519 TC A Echo exam of eye 0.00 1.39 1.38 NA NA 76519 26 A Echo exam of eye 0.54 0.38 0.32 0.38 0.32 76529 A Echo exam of eye 0.57 1.62 1.54 NA NA 76529 TC A Echo exam of eye 0.00 1.22 1.21 NA NA 76529 26 A Echo exam of eye 0.57 0.40 0.33 0.40 0.33 76536 A Us exam of head and neck 0.56 2.78 2.82 NA NA 76536 TC A Us exam of head and neck 0.00 2.57 2.60 NA NA 76536 26 A Us exam of head and neck 0.56 0.21 0.22 0.21 0.22 76604 A Us exam, chest 0.55 1.82 1.96 NA NA 76604 TC A Us exam, chest 0.00 1.63 1.74 NA NA 76604 26 A Us exam, chest 0.55 0.19 0.22 0.19 0.22 76645 A Us exam, breast(s) 0.54 2.11 2.20 NA NA 76645 TC A Us exam, breast(s) 0.00 1.92 1.98 NA NA 76645 26 A Us exam, breast(s) 0.54 0.19 0.22 0.19 0.22 76700 A Us exam, abdom, complete 0.81 3.04 3.21 NA NA 76700 TC A Us exam, abdom, complete 0.00 2.75 2.89 NA NA 76700 26 A Us exam, abdom, complete 0.81 0.29 0.32 0.29 0.32 76705 A Echo exam of abdomen 0.59 2.33 2.47 NA NA 76705 TC A Echo exam of abdomen 0.00 2.12 2.23 NA NA 76705 26 A Echo exam of abdomen 0.59 0.21 0.24 0.21 0.24 
CMS-1503-P 1071

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

76770 A Us exam abdo back wall, comp 0.74 2.88 3.09 NA NA 76770 TC A Us exam abdo back wall, comp 0.00 2.61 2.79 NA NA 76770 26 A Us exam abdo back wall, comp 0.74 0.27 0.30 0.27 0.30 76775 A Us exam abdo back wall, lim 0.58 2.36 2.61 NA NA 76775 TC A Us exam abdo back wall, lim 0.00 2.15 2.37 NA NA 76775 26 A Us exam abdo back wall, lim 0.58 0.21 0.24 0.21 0.24 76776 A Us exam k transpl w/doppler 0.76 3.38 3.56 NA NA 76776 TC A Us exam k transpl w/doppler 0.00 3.12 3.26 NA NA 76776 26 A Us exam k transpl w/doppler 0.76 0.26 0.30 0.26 0.30 76800 A Us exam, spinal canal 1.13 2.84 2.71 NA NA 76800 TC A Us exam, spinal canal 0.00 2.35 2.27 NA NA 76800 26 A Us exam, spinal canal 1.13 0.49 0.44 0.49 0.44 76801 A Ob us < 14 wks, single fetus 0.99 2.52 2.74 NA NA 76801 TC A Ob us < 14 wks, single fetus 0.00 2.13 2.34 NA NA 76801 26 A Ob us < 14 wks, single fetus 0.99 0.39 0.40 0.39 0.40 76802 A Ob us < 14 wks, addl fetus 0.83 1.05 1.17 NA NA 76802 TC A Ob us < 14 wks, addl fetus 0.00 0.71 0.83 NA NA 76802 26 A Ob us < 14 wks, addl fetus 0.83 0.34 0.34 0.34 0.34 76805 A Ob us >/= 14 wks, sngl fetus 0.99 3.12 3.29 NA NA 76805 TC A Ob us >/= 14 wks, sngl fetus 0.00 2.72 2.89 NA NA 76805 26 A Ob us >/= 14 wks, sngl fetus 0.99 0.40 0.40 0.40 0.40 76810 A Ob us >/= 14 wks, addl fetus 0.98 1.74 1.82 NA NA 76810 TC A Ob us >/= 14 wks, addl fetus 0.00 1.34 1.42 NA NA 76810 26 A Ob us >/= 14 wks, addl fetus 0.98 0.40 0.40 0.40 0.40 76811 A Ob us, detailed, sngl fetus 1.90 3.32 3.66 NA NA 76811 TC A Ob us, detailed, sngl fetus 0.00 2.49 2.88 NA NA 
CMS-1503-P 1072

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

76811 26 A Ob us, detailed, sngl fetus 1.90 0.83 0.78 0.83 0.78 76812 A Ob us, detailed, addl fetus 1.78 4.19 4.12 NA NA 76812 TC A Ob us, detailed, addl fetus 0.00 3.41 3.39 NA NA 76812 26 A Ob us, detailed, addl fetus 1.78 0.78 0.73 0.78 0.73 76813 A Ob us nuchal meas, 1 gest 1.18 2.33 2.47 NA NA 76813 TC A Ob us nuchal meas, 1 gest 0.00 1.81 1.99 NA NA 76813 26 A Ob us nuchal meas, 1 gest 1.18 0.52 0.48 0.52 0.48 76814 A Ob us nuchal meas, add-on 0.99 1.30 1.33 NA NA 76814 TC A Ob us nuchal meas, add-on 0.00 0.86 0.93 NA NA 76814 26 A Ob us nuchal meas, add-on 0.99 0.44 0.40 0.44 0.40 76815 A Ob us, limited, fetus(s) 0.65 1.85 1.98 NA NA 76815 TC A Ob us, limited, fetus(s) 0.00 1.59 1.72 NA NA 76815 26 A Ob us, limited, fetus(s) 0.65 0.26 0.26 0.26 0.26 76816 A Ob us, follow-up, per fetus 0.85 2.48 2.51 NA NA 76816 TC A Ob us, follow-up, per fetus 0.00 2.11 2.16 NA NA 76816 26 A Ob us, follow-up, per fetus 0.85 0.37 0.35 0.37 0.35 76817 A Transvaginal us, obstetric 0.75 2.07 2.21 NA NA 76817 TC A Transvaginal us, obstetric 0.00 1.77 1.91 NA NA 76817 26 A Transvaginal us, obstetric 0.75 0.30 0.30 0.30 0.30 76818 A Fetal biophys profile w/nst 1.05 2.37 2.48 NA NA 76818 TC A Fetal biophys profile w/nst 0.00 1.91 2.04 NA NA 76818 26 A Fetal biophys profile w/nst 1.05 0.46 0.44 0.46 0.44 76819 A Fetal biophys profil w/o nst 0.77 1.70 1.87 NA NA 76819 TC A Fetal biophys profil w/o nst 0.00 1.38 1.55 NA NA 76819 26 A Fetal biophys profil w/o nst 0.77 0.32 0.32 0.32 0.32 76820 A Umbilical artery echo 0.50 0.64 0.85 NA NA 
CMS-1503-P 1073

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

76820 TC A Umbilical artery echo 0.00 0.42 0.64 NA NA 76820 26 A Umbilical artery echo 0.50 0.22 0.21 0.22 0.21 76821 A Middle cerebral artery echo 0.70 1.96 2.09 NA NA 76821 TC A Middle cerebral artery echo 0.00 1.65 1.80 NA NA 76821 26 A Middle cerebral artery echo 0.70 0.31 0.29 0.31 0.29 76825 A Echo exam of fetal heart 1.67 4.52 4.61 NA NA 76825 TC A Echo exam of fetal heart 0.00 3.81 3.92 NA NA 76825 26 A Echo exam of fetal heart 1.67 0.71 0.69 0.71 0.69 76826 A Echo exam of fetal heart 0.83 2.83 2.77 NA NA 76826 TC A Echo exam of fetal heart 0.00 2.48 2.44 NA NA 76826 26 A Echo exam of fetal heart 0.83 0.35 0.33 0.35 0.33 76827 A Echo exam of fetal heart 0.58 1.14 1.34 NA NA 76827 TC A Echo exam of fetal heart 0.00 0.89 1.10 NA NA 76827 26 A Echo exam of fetal heart 0.58 0.25 0.24 0.25 0.24 76828 A Echo exam of fetal heart 0.56 0.72 0.84 NA NA 76828 TC A Echo exam of fetal heart 0.00 0.47 0.61 NA NA 76828 26 A Echo exam of fetal heart 0.56 0.25 0.23 0.25 0.23 76830 A Transvaginal us, non-ob 0.69 2.78 2.89 NA NA 76830 TC A Transvaginal us, non-ob 0.00 2.51 2.61 NA NA 76830 26 A Transvaginal us, non-ob 0.69 0.27 0.28 0.27 0.28 76831 A Echo exam, uterus 0.72 2.81 2.88 NA NA 76831 TC A Echo exam, uterus 0.00 2.50 2.59 NA NA 76831 26 A Echo exam, uterus 0.72 0.31 0.29 0.31 0.29 76856 A Us exam, pelvic, complete 0.69 2.75 2.89 NA NA 76856 TC A Us exam, pelvic, complete 0.00 2.49 2.61 NA NA 76856 26 A Us exam, pelvic, complete 0.69 0.26 0.28 0.26 0.28 
CMS-1503-P 1074

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

76857 A Us exam, pelvic, limited 0.38 2.29 2.53 NA NA 76857 TC A Us exam, pelvic, limited 0.00 2.14 2.37 NA NA 76857 26 A Us exam, pelvic, limited 0.38 0.15 0.16 0.15 0.16 76870 A Us exam, scrotum 0.64 2.75 2.90 NA NA 76870 TC A Us exam, scrotum 0.00 2.52 2.64 NA NA 76870 26 A Us exam, scrotum 0.64 0.23 0.26 0.23 0.26 76872 A Us, transrectal 0.69 3.01 3.37 NA NA 76872 TC A Us, transrectal 0.00 2.74 3.07 NA NA 76872 26 A Us, transrectal 0.69 0.27 0.30 0.27 0.30 76873 A Echograp trans r, pros study 1.55 3.49 3.65 NA NA 76873 TC A Echograp trans r, pros study 0.00 2.79 2.96 NA NA 76873 26 A Echograp trans r, pros study 1.55 0.70 0.69 0.70 0.69 76880 A Us exam, extremity 0.59 3.44 3.38 NA NA 76880 TC A Us exam, extremity 0.00 3.23 3.16 NA NA 76880 26 A Us exam, extremity 0.59 0.21 0.22 0.21 0.22 76885 A Us exam infant hips, dynamic 0.74 3.36 3.42 NA NA 76885 TC A Us exam infant hips, dynamic 0.00 3.09 3.12 NA NA 76885 26 A Us exam infant hips, dynamic 0.74 0.27 0.30 0.27 0.30 76886 A Us exam infant hips, static 0.62 2.95 2.71 NA NA 76886 TC A Us exam infant hips, static 0.00 2.66 2.44 NA NA 76886 26 A Us exam infant hips, static 0.62 0.29 0.27 0.29 0.27 76930 A Echo guide, cardiocentesis 0.67 1.61 1.96 NA NA 76930 TC A Echo guide, cardiocentesis 0.00 1.35 1.64 NA NA 76930 26 A Echo guide, cardiocentesis 0.67 0.26 0.32 0.26 0.32 76932 C Echo guide for heart biopsy 0.00 0.00 0.00 NA NA 76932 TC C Echo guide for heart biopsy 0.00 0.00 0.00 NA NA 
CMS-1503-P 1075

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

76932 26 A Echo guide for heart biopsy 0.67 0.26 0.32 0.26 0.32 76936 A Echo guide for artery repair 1.99 6.13 6.83 NA NA 76936 TC A Echo guide for artery repair 0.00 5.43 6.04 NA NA 76936 26 A Echo guide for artery repair 1.99 0.70 0.79 0.70 0.79 76937 A Us guide, vascular access 0.30 0.65 0.68 NA NA 76937 TC A Us guide, vascular access 0.00 0.54 0.56 NA NA 76937 26 A Us guide, vascular access 0.30 0.11 0.12 0.11 0.12 76940 C Us guide, tissue ablation 0.00 0.00 0.00 NA NA 76940 TC C Us guide, tissue ablation 0.00 0.00 0.00 NA NA 76940 26 A Us guide, tissue ablation 2.00 0.77 0.80 0.77 0.80 76941 C Echo guide for transfusion 0.00 0.00 0.00 NA NA 76941 TC C Echo guide for transfusion 0.00 0.00 0.00 NA NA 76941 26 A Echo guide for transfusion 1.34 0.60 0.57 0.60 0.57 76942 A Echo guide for biopsy 0.67 4.81 5.00 NA NA 76942 TC A Echo guide for biopsy 0.00 4.56 4.72 NA NA 76942 26 A Echo guide for biopsy 0.67 0.25 0.28 0.25 0.28 76945 C Echo guide, villus sampling 0.00 0.00 0.00 NA NA 76945 TC C Echo guide, villus sampling 0.00 0.00 0.00 NA NA 76945 26 A Echo guide, villus sampling 0.67 0.30 0.28 0.30 0.28 76946 A Echo guide for amniocentesis 0.38 0.51 0.71 NA NA 76946 TC A Echo guide for amniocentesis 0.00 0.34 0.55 NA NA 76946 26 A Echo guide for amniocentesis 0.38 0.17 0.16 0.17 0.16 76948 A Echo guide, ova aspiration 0.38 0.52 0.71 NA NA 76948 TC A Echo guide, ova aspiration 0.00 0.35 0.55 NA NA 76948 26 A Echo guide, ova aspiration 0.38 0.17 0.16 0.17 0.16 76950 A Echo guidance radiotherapy 0.58 1.34 1.44 NA NA 
CMS-1503-P 1076

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

76950 TC A Echo guidance radiotherapy 0.00 1.06 1.18 NA NA 76950 26 A Echo guidance radiotherapy 0.58 0.28 0.26 0.28 0.26 76965 A Echo guidance radiotherapy 1.34 1.23 2.06 NA NA 76965 TC A Echo guidance radiotherapy 0.00 0.65 1.46 NA NA 76965 26 A Echo guidance radiotherapy 1.34 0.58 0.60 0.58 0.60 76970 A Ultrasound exam follow-up 0.40 2.52 2.35 NA NA 76970 TC A Ultrasound exam follow-up 0.00 2.35 2.19 NA NA 76970 26 A Ultrasound exam follow-up 0.40 0.17 0.16 0.17 0.16 76975 C GI endoscopic ultrasound 0.00 0.00 0.00 NA NA 76975 TC C GI endoscopic ultrasound 0.00 0.00 0.00 NA NA 76975 26 A GI endoscopic ultrasound 0.81 0.39 0.38 0.39 0.38 76977 A Us bone density measure 0.05 0.13 0.24 NA NA 76977 TC A Us bone density measure 0.00 0.11 0.22 NA NA 76977 26 A Us bone density measure 0.05 0.02 0.02 0.02 0.02 76998 C Us guide, intraop 0.00 0.00 0.00 NA NA 76998 TC C Us guide, intraop 0.00 0.00 0.00 NA NA 76998 26 A Us guide, intraop 1.20 0.46 0.47 0.46 0.47 76999 C Echo examination procedure 0.00 0.00 0.00 NA NA 76999 TC C Echo examination procedure 0.00 0.00 0.00 NA NA 76999 26 C Echo examination procedure 0.00 0.00 0.00 0.00 0.00 77001 A Fluoroguide for vein device 0.38 2.89 2.88 NA NA 77001 TC A Fluoroguide for vein device 0.00 2.75 2.73 NA NA 77001 26 A Fluoroguide for vein device 0.38 0.14 0.15 0.14 0.15 77002 A Needle localization by xray 0.54 1.62 1.61 NA NA 77002 TC A Needle localization by xray 0.00 1.37 1.38 NA NA 77002 26 A Needle localization by xray 0.54 0.25 0.23 0.25 0.23 
CMS-1503-P 1077

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

77003 A Fluoroguide for spine inject 0.60 1.23 1.19 NA NA 77003 TC A Fluoroguide for spine inject 0.00 0.94 0.95 NA NA 77003 26 A Fluoroguide for spine inject 0.60 0.29 0.24 0.29 0.24 77011 A Ct scan for localization 1.21 21.33 20.94 NA NA 77011 TC A Ct scan for localization 0.00 20.78 20.40 NA NA 77011 26 A Ct scan for localization 1.21 0.55 0.54 0.55 0.54 77012 A Ct scan for needle biopsy 1.16 2.34 3.53 NA NA 77012 TC A Ct scan for needle biopsy 0.00 1.94 3.06 NA NA 77012 26 A Ct scan for needle biopsy 1.16 0.40 0.47 0.40 0.47 77013 C Ct guide for tissue ablation 0.00 0.00 0.00 NA NA 77013 TC C Ct guide for tissue ablation 0.00 0.00 0.00 NA NA 77013 26 A Ct guide for tissue ablation 3.99 1.37 1.60 1.37 1.60 77014 A Ct scan for therapy guide 0.85 4.69 4.79 NA NA 77014 TC A Ct scan for therapy guide 0.00 4.27 4.41 NA NA 77014 26 A Ct scan for therapy guide 0.85 0.42 0.38 0.42 0.38 77021 A Mr guidance for needle place 1.50 9.40 10.88 NA NA 77021 TC A Mr guidance for needle place 0.00 8.87 10.28 NA NA 77021 26 A Mr guidance for needle place 1.50 0.53 0.60 0.53 0.60 77022 C Mri for tissue ablation 0.00 0.00 0.00 NA NA 77022 TC C Mri for tissue ablation 0.00 0.00 0.00 NA NA 77022 26 A Mri for tissue ablation 4.24 1.53 1.66 1.53 1.66 77031 A Stereotact guide for brst bx 1.59 1.92 2.97 NA NA 77031 TC A Stereotact guide for brst bx 0.00 1.35 2.34 NA NA 77031 26 A Stereotact guide for brst bx 1.59 0.57 0.63 0.57 0.63 77032 A Guidance for needle, breast 0.56 0.82 1.02 NA NA 77032 TC A Guidance for needle, breast 0.00 0.63 0.80 NA NA 
CMS-1503-P 1078

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

77032 26 A Guidance for needle, breast 0.56 0.19 0.22 0.19 0.22 77051 A Computer dx mammogram add-on 0.06 0.19 0.25 NA NA 77051 TC A Computer dx mammogram add-on 0.00 0.17 0.23 NA NA 77051 26 A Computer dx mammogram add-on 0.06 0.02 0.02 0.02 0.02 77052 A Comp screen mammogram add-on 0.06 0.19 0.25 NA NA 77052 TC A Comp screen mammogram add-on 0.00 0.17 0.23 NA NA 77052 26 A Comp screen mammogram add-on 0.06 0.02 0.02 0.02 0.02 77053 A X-ray of mammary duct 0.36 1.20 1.57 NA NA 77053 TC A X-ray of mammary duct 0.00 1.08 1.43 NA NA 77053 26 A X-ray of mammary duct 0.36 0.12 0.14 0.12 0.14 77054 A X-ray of mammary ducts 0.45 1.67 2.16 NA NA 77054 TC A X-ray of mammary ducts 0.00 1.51 1.98 NA NA 77054 26 A X-ray of mammary ducts 0.45 0.16 0.18 0.16 0.18 77055 A Mammogram, one breast 0.70 1.63 1.75 NA NA 77055 TC A Mammogram, one breast 0.00 1.38 1.47 NA NA 77055 26 A Mammogram, one breast 0.70 0.25 0.28 0.25 0.28 77056 A Mammogram, both breasts 0.87 2.11 2.26 NA NA 77056 TC A Mammogram, both breasts 0.00 1.81 1.92 NA NA 77056 26 A Mammogram, both breasts 0.87 0.30 0.34 0.30 0.34 77057 A Mammogram, screening 0.70 1.44 1.60 NA NA 77057 TC A Mammogram, screening 0.00 1.19 1.32 NA NA 77057 26 A Mammogram, screening 0.70 0.25 0.28 0.25 0.28 77058 A Mri, one breast 1.63 15.45 20.13 NA NA 77058 TC A Mri, one breast 0.00 14.89 19.49 NA NA 77058 26 A Mri, one breast 1.63 0.56 0.64 0.56 0.64 77059 A Mri, both breasts 1.63 15.36 20.97 NA NA 
CMS-1503-P 1079

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

77059 TC A Mri, both breasts 0.00 14.80 20.33 NA NA 77059 26 A Mri, both breasts 1.63 0.56 0.64 0.56 0.64 77071 A X-ray stress view 0.41 1.00 0.88 1.00 0.88 77072 A X-rays for bone age 0.19 0.44 0.48 NA NA 77072 TC A X-rays for bone age 0.00 0.37 0.40 NA NA 77072 26 A X-rays for bone age 0.19 0.07 0.08 0.07 0.08 77073 A X-rays, bone length studies 0.27 0.78 0.82 NA NA 77073 TC A X-rays, bone length studies 0.00 0.65 0.69 NA NA 77073 26 A X-rays, bone length studies 0.27 0.13 0.13 0.13 0.13 77074 A X-rays, bone survey, limited 0.45 1.42 1.53 NA NA 77074 TC A X-rays, bone survey, limited 0.00 1.26 1.35 NA NA 77074 26 A X-rays, bone survey, limited 0.45 0.16 0.18 0.16 0.18 77075 A X-rays, bone survey complete 0.54 2.25 2.40 NA NA 77075 TC A X-rays, bone survey complete 0.00 2.06 2.18 NA NA 77075 26 A X-rays, bone survey complete 0.54 0.19 0.22 0.19 0.22 77076 A X-rays, bone survey, infant 0.70 2.15 2.15 NA NA 77076 TC A X-rays, bone survey, infant 0.00 1.90 1.89 NA NA 77076 26 A X-rays, bone survey, infant 0.70 0.25 0.26 0.25 0.26 77077 A Joint survey, single view 0.31 0.80 0.88 NA NA 77077 TC A Joint survey, single view 0.00 0.65 0.74 NA NA 77077 26 A Joint survey, single view 0.31 0.15 0.14 0.15 0.14 77078 A Ct bone density, axial 0.25 3.42 4.29 NA NA 77078 TC A Ct bone density, axial 0.00 3.33 4.19 NA NA 77078 26 A Ct bone density, axial 0.25 0.09 0.10 0.09 0.10 77079 A Ct bone density, peripheral 0.22 0.91 1.24 NA NA 77079 TC A Ct bone density, peripheral 0.00 0.81 1.15 NA NA 
CMS-1503-P 1080

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

77079 26 A Ct bone density, peripheral 0.22 0.10 0.09 0.10 0.09 77080 A Dxa bone density, axial 0.32 3.46 3.46 NA NA 77080 TC A Dxa bone density, axial 0.00 3.35 3.35 NA NA 77080 26 A Dxa bone density, axial 0.32 0.11 0.11 0.11 0.11 77081 A Dxa bone density/peripheral 0.22 0.61 0.61 NA NA 77081 TC A Dxa bone density/peripheral 0.00 0.55 0.55 NA NA 77081 26 A Dxa bone density/peripheral 0.22 0.06 0.06 0.06 0.06 77082 A Dxa bone density, vert fx 0.18 0.87 0.87 NA NA 77082 TC A Dxa bone density, vert fx 0.00 0.81 0.81 NA NA 77082 26 A Dxa bone density, vert fx 0.18 0.06 0.06 0.06 0.06 77083 A Radiographic absorptiometry 0.20 0.46 0.52 NA NA 77083 TC A Radiographic absorptiometry 0.00 0.37 0.44 NA NA 77083 26 A Radiographic absorptiometry 0.20 0.09 0.08 0.09 0.08 77084 A Magnetic image, bone marrow 1.60 10.57 13.56 NA NA 77084 TC A Magnetic image, bone marrow 0.00 10.00 12.92 NA NA 77084 26 A Magnetic image, bone marrow 1.60 0.57 0.64 0.57 0.64 77261 A Radiation therapy planning 1.39 0.72 0.67 0.72 0.67 77262 A Radiation therapy planning 2.11 1.05 0.97 1.05 0.97 77263 A Radiation therapy planning 3.14 1.56 1.44 1.56 1.44 77280 A Set radiation therapy field 0.70 4.71 4.88 NA NA 77280 TC A Set radiation therapy field 0.00 4.36 4.56 NA NA 77280 26 A Set radiation therapy field 0.70 0.35 0.32 0.35 0.32 77285 A Set radiation therapy field 1.05 8.52 8.71 NA NA 77285 TC A Set radiation therapy field 0.00 8.00 8.24 NA NA 77285 26 A Set radiation therapy field 1.05 0.52 0.47 0.52 0.47 77290 A Set radiation therapy field 1.56 14.18 14.10 NA NA 
CMS-1503-P 1081

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

77290 TC A Set radiation therapy field 0.00 13.40 13.39 NA NA 77290 26 A Set radiation therapy field 1.56 0.78 0.71 0.78 0.71 77295 A Set radiation therapy field 4.56 8.42 11.95 NA NA 77295 TC A Set radiation therapy field 0.00 6.15 9.88 NA NA 77295 26 A Set radiation therapy field 4.56 2.27 2.07 2.27 2.07 77299 C Radiation therapy planning 0.00 0.00 0.00 NA NA 77299 TC C Radiation therapy planning 0.00 0.00 0.00 NA NA 77299 26 C Radiation therapy planning 0.00 0.00 0.00 0.00 0.00 77300 A Radiation therapy dose plan 0.62 1.33 1.42 NA NA 77300 TC A Radiation therapy dose plan 0.00 1.02 1.14 NA NA 77300 26 A Radiation therapy dose plan 0.62 0.31 0.28 0.31 0.28 77301 A Radiotherapy dose plan, imrt 7.99 60.71 60.43 NA NA 77301 TC A Radiotherapy dose plan, imrt 0.00 56.74 56.80 NA NA 77301 26 A Radiotherapy dose plan, imrt 7.99 3.97 3.63 3.97 3.63 77305 A Teletx isodose plan simple 0.70 1.04 1.24 NA NA 77305 TC A Teletx isodose plan simple 0.00 0.69 0.92 NA NA 77305 26 A Teletx isodose plan simple 0.70 0.35 0.32 0.35 0.32 77310 A Teletx isodose plan intermed 1.05 1.46 1.70 NA NA 77310 TC A Teletx isodose plan intermed 0.00 0.94 1.22 NA NA 77310 26 A Teletx isodose plan intermed 1.05 0.52 0.48 0.52 0.48 77315 A Teletx isodose plan complex 1.56 2.41 2.62 NA NA 77315 TC A Teletx isodose plan complex 0.00 1.63 1.91 NA NA 77315 26 A Teletx isodose plan complex 1.56 0.78 0.71 0.78 0.71 77321 A Special teletx port plan 0.95 1.71 2.19 NA NA 77321 TC A Special teletx port plan 0.00 1.24 1.76 NA NA 77321 26 A Special teletx port plan 0.95 0.47 0.43 0.47 0.43 
CMS-1503-P 1082

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

77326 A Brachytx isodose calc simp 0.93 3.25 3.34 NA NA 77326 TC A Brachytx isodose calc simp 0.00 2.78 2.92 NA NA 77326 26 A Brachytx isodose calc simp 0.93 0.47 0.42 0.47 0.42 77327 A Brachytx isodose calc interm 1.39 4.47 4.64 NA NA 77327 TC A Brachytx isodose calc interm 0.00 3.78 4.01 NA NA 77327 26 A Brachytx isodose calc interm 1.39 0.69 0.63 0.69 0.63 77328 A Brachytx isodose plan compl 2.09 5.75 6.05 NA NA 77328 TC A Brachytx isodose plan compl 0.00 4.71 5.10 NA NA 77328 26 A Brachytx isodose plan compl 2.09 1.04 0.95 1.04 0.95 77331 A Special radiation dosimetry 0.87 0.97 0.97 NA NA 77331 TC A Special radiation dosimetry 0.00 0.54 0.57 NA NA 77331 26 A Special radiation dosimetry 0.87 0.43 0.40 0.43 0.40 77332 A Radiation treatment aid(s) 0.54 1.69 1.76 NA NA 77332 TC A Radiation treatment aid(s) 0.00 1.42 1.52 NA NA 77332 26 A Radiation treatment aid(s) 0.54 0.27 0.24 0.27 0.24 77333 A Radiation treatment aid(s) 0.84 0.67 0.89 NA NA 77333 TC A Radiation treatment aid(s) 0.00 0.25 0.51 NA NA 77333 26 A Radiation treatment aid(s) 0.84 0.42 0.38 0.42 0.38 77334 A Radiation treatment aid(s) 1.24 3.02 3.27 NA NA 77334 TC A Radiation treatment aid(s) 0.00 2.40 2.71 NA NA 77334 26 A Radiation treatment aid(s) 1.24 0.62 0.56 0.62 0.56 77336 A Radiation physics consult 0.00 1.18 1.54 NA NA 77338 A Design mlc device for imrt 4.29 10.10 10.10 NA NA 77338 TC A Design mlc device for imrt 0.00 7.96 7.96 NA NA 77338 26 A Design mlc device for imrt 4.29 2.14 2.14 2.14 2.14 77370 A Radiation physics consult 0.00 3.16 3.44 NA NA 
CMS-1503-P 1083

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

77371 C Srs, multisource 0.00 0.00 0.00 0.00 0.00 77372 A Srs, linear based 0.00 23.63 25.23 NA NA 77373 A Sbrt delivery 0.00 44.40 47.10 NA NA 77399 C External radiation dosimetry 0.00 0.00 0.00 NA NA 77399 TC C External radiation dosimetry 0.00 0.00 0.00 NA NA 77399 26 C External radiation dosimetry 0.00 0.00 0.00 0.00 0.00 77401 A Radiation treatment delivery 0.00 0.54 0.74 NA NA 77402 A Radiation treatment delivery 0.00 5.74 5.08 NA NA 77403 A Radiation treatment delivery 0.00 3.89 3.88 NA NA 77404 A Radiation treatment delivery 0.00 4.37 4.31 NA NA 77406 A Radiation treatment delivery 0.00 4.39 4.34 NA NA 77407 A Radiation treatment delivery 0.00 7.82 7.38 NA NA 77408 A Radiation treatment delivery 0.00 5.37 5.28 NA NA 77409 A Radiation treatment delivery 0.00 6.01 5.87 NA NA 77411 A Radiation treatment delivery 0.00 5.99 5.85 NA NA 77412 A Radiation treatment delivery 0.00 7.09 6.90 NA NA 77413 A Radiation treatment delivery 0.00 7.11 6.94 NA NA 77414 A Radiation treatment delivery 0.00 8.01 7.77 NA NA 77416 A Radiation treatment delivery 0.00 8.05 7.80 NA NA 77417 A Radiology port film(s) 0.00 0.38 0.44 NA NA 77418 A Radiation tx delivery, imrt 0.00 13.68 15.38 NA NA 77421 A Stereoscopic x-ray guidance 0.39 2.54 2.86 NA NA 77421 TC A Stereoscopic x-ray guidance 0.00 2.35 2.68 NA NA 77421 26 A Stereoscopic x-ray guidance 0.39 0.19 0.18 0.19 0.18 77422 A Neutron beam tx, simple 0.00 5.50 5.90 NA NA 77423 A Neutron beam tx, complex 0.00 7.77 7.52 NA NA 
CMS-1503-P 1084

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

77427 A Radiation tx management, x5 3.70 2.02 1.83 2.02 1.83 77431 A Radiation therapy management 1.81 1.08 1.01 1.08 1.01 77432 A Stereotactic radiation trmt 7.92 3.97 3.66 3.97 3.66 77435 A Sbrt management 13.00 6.67 6.21 6.67 6.21 77470 A Special radiation treatment 2.09 2.33 3.81 NA NA 77470 TC A Special radiation treatment 0.00 1.29 2.86 NA NA 77470 26 A Special radiation treatment 2.09 1.04 0.95 1.04 0.95 77499 C Radiation therapy management 0.00 0.00 0.00 NA NA 77499 TC C Radiation therapy management 0.00 0.00 0.00 NA NA 77499 26 C Radiation therapy management 0.00 0.00 0.00 0.00 0.00 77520 C Proton trmt, simple w/o comp 0.00 0.00 0.00 0.00 0.00 77522 C Proton trmt, simple w/comp 0.00 0.00 0.00 0.00 0.00 77523 C Proton trmt, intermediate 0.00 0.00 0.00 0.00 0.00 77525 C Proton treatment, complex 0.00 0.00 0.00 0.00 0.00 77600 R Hyperthermia treatment 1.56 10.84 10.50 NA NA 77600 TC R Hyperthermia treatment 0.00 10.05 9.78 NA NA 77600 26 R Hyperthermia treatment 1.56 0.79 0.72 0.79 0.72 77605 R Hyperthermia treatment 2.09 29.52 24.33 NA NA 77605 TC R Hyperthermia treatment 0.00 28.62 23.52 NA NA 77605 26 R Hyperthermia treatment 2.09 0.90 0.81 0.90 0.81 77610 R Hyperthermia treatment 1.56 18.12 18.24 NA NA 77610 TC R Hyperthermia treatment 0.00 17.35 17.57 NA NA 77610 26 R Hyperthermia treatment 1.56 0.77 0.67 0.77 0.67 77615 R Hyperthermia treatment 2.09 27.27 26.70 NA NA 77615 TC R Hyperthermia treatment 0.00 26.22 25.75 NA NA 77615 26 R Hyperthermia treatment 2.09 1.05 0.95 1.05 0.95 
CMS-1503-P 1085

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

77620 R Hyperthermia treatment 1.56 13.94 12.29 NA NA 77620 TC R Hyperthermia treatment 0.00 13.27 11.68 NA NA 77620 26 R Hyperthermia treatment 1.56 0.67 0.61 0.67 0.61 77750 A Infuse radioactive materials 5.00 5.51 5.25 NA NA 77750 TC A Infuse radioactive materials 0.00 3.04 3.00 NA NA 77750 26 A Infuse radioactive materials 5.00 2.47 2.25 2.47 2.25 77761 A Apply intrcav radiat simple 3.85 7.05 6.90 NA NA 77761 TC A Apply intrcav radiat simple 0.00 5.17 5.20 NA NA 77761 26 A Apply intrcav radiat simple 3.85 1.88 1.70 1.88 1.70 77762 A Apply intrcav radiat interm 5.76 8.78 8.65 NA NA 77762 TC A Apply intrcav radiat interm 0.00 5.97 6.07 NA NA 77762 26 A Apply intrcav radiat interm 5.76 2.81 2.58 2.81 2.58 77763 A Apply intrcav radiat compl 8.66 11.99 11.74 NA NA 77763 TC A Apply intrcav radiat compl 0.00 7.76 7.86 NA NA 77763 26 A Apply intrcav radiat compl 8.66 4.23 3.88 4.23 3.88 77776 A Apply interstit radiat simpl 4.70 7.61 7.57 NA NA 77776 TC A Apply interstit radiat simpl 0.00 5.24 5.44 NA NA 77776 26 A Apply interstit radiat simpl 4.70 2.37 2.13 2.37 2.13 77777 A Apply interstit radiat inter 7.52 9.25 9.33 NA NA 77777 TC A Apply interstit radiat inter 0.00 5.62 5.91 NA NA 77777 26 A Apply interstit radiat inter 7.52 3.63 3.42 3.63 3.42 77778 A Apply interstit radiat compl 11.32 13.39 13.14 NA NA 77778 TC A Apply interstit radiat compl 0.00 7.87 8.06 NA NA 77778 26 A Apply interstit radiat compl 11.32 5.52 5.08 5.52 5.08 77785 A Hdr brachytx, 1 channel 1.42 5.81 5.05 NA NA 77785 TC A Hdr brachytx, 1 channel 0.00 5.11 4.40 NA NA 
CMS-1503-P 1086

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

77785 26 A Hdr brachytx, 1 channel 1.42 0.70 0.65 0.70 0.65 77786 A Hdr brachytx, 2-12 channel 3.25 12.94 13.55 NA NA 77786 TC A Hdr brachytx, 2-12 channel 0.00 11.32 12.11 NA NA 77786 26 A Hdr brachytx, 2-12 channel 3.25 1.62 1.44 1.62 1.44 77787 A Hdr brachytx over 12 chan 4.89 22.87 21.94 NA NA 77787 TC A Hdr brachytx over 12 chan 0.00 20.42 19.68 NA NA 77787 26 A Hdr brachytx over 12 chan 4.89 2.45 2.26 2.45 2.26 77789 A Apply surface radiation 1.14 2.23 2.12 NA NA 77789 TC A Apply surface radiation 0.00 1.64 1.59 NA NA 77789 26 A Apply surface radiation 1.14 0.59 0.53 0.59 0.53 77790 A Radiation handling 1.05 1.68 1.62 NA NA 77790 TC A Radiation handling 0.00 1.17 1.15 NA NA 77790 26 A Radiation handling 1.05 0.51 0.47 0.51 0.47 77799 C Radium/radioisotope therapy 0.00 0.00 0.00 NA NA 77799 TC C Radium/radioisotope therapy 0.00 0.00 0.00 NA NA 77799 26 C Radium/radioisotope therapy 0.00 0.00 0.00 0.00 0.00 78000 A Thyroid, single uptake 0.19 1.73 1.85 NA NA 78000 TC A Thyroid, single uptake 0.00 1.67 1.78 NA NA 78000 26 A Thyroid, single uptake 0.19 0.06 0.07 0.06 0.07 78001 A Thyroid, multiple uptakes 0.26 2.22 2.35 NA NA 78001 TC A Thyroid, multiple uptakes 0.00 2.13 2.25 NA NA 78001 26 A Thyroid, multiple uptakes 0.26 0.09 0.10 0.09 0.10 78003 A Thyroid suppress/stimul 0.33 1.85 1.95 NA NA 78003 TC A Thyroid suppress/stimul 0.00 1.73 1.82 NA NA 78003 26 A Thyroid suppress/stimul 0.33 0.12 0.13 0.12 0.13 78006 A Thyroid imaging with uptake 0.49 6.04 6.20 NA NA 
CMS-1503-P 1087

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

78006 TC A Thyroid imaging with uptake 0.00 5.88 6.01 NA NA 78006 26 A Thyroid imaging with uptake 0.49 0.16 0.19 0.16 0.19 78007 A Thyroid image, mult uptakes 0.50 6.41 5.01 NA NA 78007 TC A Thyroid image, mult uptakes 0.00 6.24 4.81 NA NA 78007 26 A Thyroid image, mult uptakes 0.50 0.17 0.20 0.17 0.20 78010 A Thyroid imaging 0.39 4.15 4.25 NA NA 78010 TC A Thyroid imaging 0.00 4.02 4.10 NA NA 78010 26 A Thyroid imaging 0.39 0.13 0.15 0.13 0.15 78011 A Thyroid imaging with flow 0.45 4.40 4.66 NA NA 78011 TC A Thyroid imaging with flow 0.00 4.24 4.48 NA NA 78011 26 A Thyroid imaging with flow 0.45 0.16 0.18 0.16 0.18 78015 A Thyroid met imaging 0.67 5.20 5.45 NA NA 78015 TC A Thyroid met imaging 0.00 4.99 5.20 NA NA 78015 26 A Thyroid met imaging 0.67 0.21 0.25 0.21 0.25 78016 A Thyroid met imaging/studies 0.82 6.95 7.94 NA NA 78016 TC A Thyroid met imaging/studies 0.00 6.81 7.69 NA NA 78016 26 A Thyroid met imaging/studies 0.82 0.14 0.25 0.14 0.25 78018 A Thyroid met imaging, body 0.86 7.57 8.22 NA NA 78018 TC A Thyroid met imaging, body 0.00 7.31 7.90 NA NA 78018 26 A Thyroid met imaging, body 0.86 0.26 0.32 0.26 0.32 78020 A Thyroid met uptake 0.60 1.60 1.86 NA NA 78020 TC A Thyroid met uptake 0.00 1.44 1.64 NA NA 78020 26 A Thyroid met uptake 0.60 0.16 0.22 0.16 0.22 78070 A Parathyroid nuclear imaging 0.82 3.24 3.88 NA NA 78070 TC A Parathyroid nuclear imaging 0.00 2.98 3.56 NA NA 78070 26 A Parathyroid nuclear imaging 0.82 0.26 0.32 0.26 0.32 
CMS-1503-P 1088

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

78075 A Adrenal nuclear imaging 0.74 10.74 11.42 NA NA 78075 TC A Adrenal nuclear imaging 0.00 10.53 11.14 NA NA 78075 26 A Adrenal nuclear imaging 0.74 0.21 0.28 0.21 0.28 78099 C Endocrine nuclear procedure 0.00 0.00 0.00 NA NA 78099 TC C Endocrine nuclear procedure 0.00 0.00 0.00 NA NA 78099 26 C Endocrine nuclear procedure 0.00 0.00 0.00 0.00 0.00 78102 A Bone marrow imaging, ltd 0.55 3.90 4.18 NA NA 78102 TC A Bone marrow imaging, ltd 0.00 3.74 3.97 NA NA 78102 26 A Bone marrow imaging, ltd 0.55 0.16 0.21 0.16 0.21 78103 A Bone marrow imaging, mult 0.75 5.03 5.49 NA NA 78103 TC A Bone marrow imaging, mult 0.00 4.82 5.22 NA NA 78103 26 A Bone marrow imaging, mult 0.75 0.21 0.27 0.21 0.27 78104 A Bone marrow imaging, body 0.80 5.73 6.30 NA NA 78104 TC A Bone marrow imaging, body 0.00 5.49 6.00 NA NA 78104 26 A Bone marrow imaging, body 0.80 0.24 0.30 0.24 0.30 78110 A Plasma volume, single 0.19 2.09 2.15 NA NA 78110 TC A Plasma volume, single 0.00 2.02 2.07 NA NA 78110 26 A Plasma volume, single 0.19 0.07 0.08 0.07 0.08 78111 A Plasma volume, multiple 0.22 1.77 2.29 NA NA 78111 TC A Plasma volume, multiple 0.00 1.73 2.21 NA NA 78111 26 A Plasma volume, multiple 0.22 0.04 0.08 0.04 0.08 78120 A Red cell mass, single 0.23 2.02 2.24 NA NA 78120 TC A Red cell mass, single 0.00 1.94 2.15 NA NA 78120 26 A Red cell mass, single 0.23 0.08 0.09 0.08 0.09 78121 A Red cell mass, multiple 0.32 2.13 2.53 NA NA 78121 TC A Red cell mass, multiple 0.00 2.02 2.40 NA NA 
CMS-1503-P 1089

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

78121 26 A Red cell mass, multiple 0.32 0.11 0.13 0.11 0.13 78122 A Blood volume 0.45 2.01 2.75 NA NA 78122 TC A Blood volume 0.00 1.88 2.59 NA NA 78122 26 A Blood volume 0.45 0.13 0.16 0.13 0.16 78130 A Red cell survival study 0.61 3.41 3.76 NA NA 78130 TC A Red cell survival study 0.00 3.19 3.51 NA NA 78130 26 A Red cell survival study 0.61 0.22 0.25 0.22 0.25 78135 A Red cell survival kinetics 0.64 8.87 9.15 NA NA 78135 TC A Red cell survival kinetics 0.00 8.64 8.89 NA NA 78135 26 A Red cell survival kinetics 0.64 0.23 0.26 0.23 0.26 78140 A Red cell sequestration 0.61 2.76 3.32 NA NA 78140 TC A Red cell sequestration 0.00 2.55 3.08 NA NA 78140 26 A Red cell sequestration 0.61 0.21 0.24 0.21 0.24 78185 A Spleen imaging 0.40 5.16 5.31 NA NA 78185 TC A Spleen imaging 0.00 5.02 5.15 NA NA 78185 26 A Spleen imaging 0.40 0.14 0.16 0.14 0.16 78190 A Platelet survival, kinetics 1.09 9.16 9.73 NA NA 78190 TC A Platelet survival, kinetics 0.00 8.75 9.30 NA NA 78190 26 A Platelet survival, kinetics 1.09 0.41 0.43 0.41 0.43 78191 A Platelet survival 0.61 3.43 4.41 NA NA 78191 TC A Platelet survival 0.00 3.21 4.17 NA NA 78191 26 A Platelet survival 0.61 0.22 0.24 0.22 0.24 78195 A Lymph system imaging 1.20 8.47 8.82 NA NA 78195 TC A Lymph system imaging 0.00 8.08 8.36 NA NA 78195 26 A Lymph system imaging 1.20 0.39 0.46 0.39 0.46 78199 C Blood/lymph nuclear exam 0.00 0.00 0.00 NA NA 
CMS-1503-P 1090

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

78199 TC C Blood/lymph nuclear exam 0.00 0.00 0.00 NA NA 78199 26 C Blood/lymph nuclear exam 0.00 0.00 0.00 0.00 0.00 78201 A Liver imaging 0.44 4.72 4.83 NA NA 78201 TC A Liver imaging 0.00 4.58 4.67 NA NA 78201 26 A Liver imaging 0.44 0.14 0.16 0.14 0.16 78202 A Liver imaging with flow 0.51 4.84 5.28 NA NA 78202 TC A Liver imaging with flow 0.00 4.71 5.10 NA NA 78202 26 A Liver imaging with flow 0.51 0.13 0.18 0.13 0.18 78205 A Liver imaging (3D) 0.71 4.94 5.77 NA NA 78205 TC A Liver imaging (3D) 0.00 4.73 5.50 NA NA 78205 26 A Liver imaging (3D) 0.71 0.21 0.27 0.21 0.27 78206 A Liver image (3d) with flow 0.96 8.34 8.97 NA NA 78206 TC A Liver image (3d) with flow 0.00 8.04 8.60 NA NA 78206 26 A Liver image (3d) with flow 0.96 0.30 0.37 0.30 0.37 78215 A Liver and spleen imaging 0.49 4.65 4.96 NA NA 78215 TC A Liver and spleen imaging 0.00 4.49 4.77 NA NA 78215 26 A Liver and spleen imaging 0.49 0.16 0.19 0.16 0.19 78216 A Liver & spleen image/flow 0.57 2.61 3.13 NA NA 78216 TC A Liver & spleen image/flow 0.00 2.43 2.92 NA NA 78216 26 A Liver & spleen image/flow 0.57 0.18 0.21 0.18 0.21 78220 A Liver function study 0.49 2.86 3.41 NA NA 78220 TC A Liver function study 0.00 2.71 3.22 NA NA 78220 26 A Liver function study 0.49 0.15 0.19 0.15 0.19 78223 A Hepatobiliary imaging 0.84 8.32 8.57 NA NA 78223 TC A Hepatobiliary imaging 0.00 8.04 8.24 NA NA 78223 26 A Hepatobiliary imaging 0.84 0.28 0.33 0.28 0.33 
CMS-1503-P 1091

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

78230 A Salivary gland imaging 0.45 4.07 4.24 NA NA 78230 TC A Salivary gland imaging 0.00 3.91 4.07 NA NA 78230 26 A Salivary gland imaging 0.45 0.16 0.17 0.16 0.17 78231 A Serial salivary imaging 0.52 2.71 3.13 NA NA 78231 TC A Serial salivary imaging 0.00 2.53 2.93 NA NA 78231 26 A Serial salivary imaging 0.52 0.18 0.20 0.18 0.20 78232 A Salivary gland function exam 0.47 2.08 2.88 NA NA 78232 TC A Salivary gland function exam 0.00 2.00 2.73 NA NA 78232 26 A Salivary gland function exam 0.47 0.08 0.15 0.08 0.15 78258 A Esophageal motility study 0.74 5.45 5.76 NA NA 78258 TC A Esophageal motility study 0.00 5.20 5.46 NA NA 78258 26 A Esophageal motility study 0.74 0.25 0.30 0.25 0.30 

78261 A Gastric mucosa imaging 0.69 5.99 6.40 NA NA 78261 TC A Gastric mucosa imaging 0.00 5.75 6.12 NA NA 78261 26 A Gastric mucosa imaging 0.69 0.24 0.28 0.24 0.28 78262 A Gastroesophageal reflux exam 0.68 5.92 6.32 NA NA 78262 TC A Gastroesophageal reflux exam 0.00 5.70 6.06 NA NA 78262 26 A Gastroesophageal reflux exam 0.68 0.22 0.26 0.22 0.26 78264 A Gastric emptying study 0.78 6.95 7.34 NA NA 78264 TC A Gastric emptying study 0.00 6.69 7.04 NA NA 78264 26 A Gastric emptying study 0.78 0.26 0.30 0.26 0.30 78267 X Breath tst attain/anal c-14 0.00 0.00 0.00 0.00 0.00 78268 X Breath test analysis, c-14 0.00 0.00 0.00 0.00 0.00 78270 A Vit B-12 absorption exam 0.20 1.98 2.12 NA NA 78270 TC A Vit B-12 absorption exam 0.00 1.91 2.04 NA NA 78270 26 A Vit B-12 absorption exam 0.20 0.07 0.08 0.07 0.08 
CMS-1503-P 1092

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

78271 A Vit b-12 absrp exam, int fac 0.20 2.25 2.26 NA NA 78271 TC A Vit b-12 absrp exam, int fac 0.00 2.16 2.18 NA NA 78271 26 A Vit b-12 absrp exam, int fac 0.20 0.09 0.08 0.09 0.08 78272 A Vit B-12 absorp, combined 0.27 2.10 2.31 NA NA 78272 TC A Vit B-12 absorp, combined 0.00 2.00 2.21 NA NA 78272 26 A Vit B-12 absorp, combined 0.27 0.10 0.10 0.10 0.10 78278 A Acute GI blood loss imaging 0.99 8.37 8.83 NA NA 78278 TC A Acute GI blood loss imaging 0.00 8.05 8.45 NA NA 78278 26 A Acute GI blood loss imaging 0.99 0.32 0.38 0.32 0.38 78282 C GI protein loss exam 0.00 0.00 0.00 NA NA 78282 TC C GI protein loss exam 0.00 0.00 0.00 NA NA 78282 26 A GI protein loss exam 0.38 0.13 0.15 0.13 0.15 78290 A Meckels divert exam 0.68 8.28 8.45 NA NA 78290 TC A Meckels divert exam 0.00 8.06 8.18 NA NA 78290 26 A Meckels divert exam 0.68 0.22 0.27 0.22 0.27 78291 A Leveen/shunt patency exam 0.88 6.01 6.30 NA NA 78291 TC A Leveen/shunt patency exam 0.00 5.73 5.96 NA NA 78291 26 A Leveen/shunt patency exam 0.88 0.28 0.34 0.28 0.34 78299 C GI nuclear procedure 0.00 0.00 0.00 NA NA 78299 TC C GI nuclear procedure 0.00 0.00 0.00 NA NA 78299 26 C GI nuclear procedure 0.00 0.00 0.00 0.00 0.00 78300 A Bone imaging, limited area 0.62 4.16 4.38 NA NA 78300 TC A Bone imaging, limited area 0.00 3.94 4.13 NA NA 78300 26 A Bone imaging, limited area 0.62 0.22 0.25 0.22 0.25 78305 A Bone imaging, multiple areas 0.83 5.47 5.78 NA NA 78305 TC A Bone imaging, multiple areas 0.00 5.19 5.46 NA NA 
CMS-1503-P 1093

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

78305 26 A Bone imaging, multiple areas 0.83 0.28 0.32 0.28 0.32 78306 A Bone imaging, whole body 0.86 5.86 6.34 NA NA 78306 TC A Bone imaging, whole body 0.00 5.58 6.01 NA NA 78306 26 A Bone imaging, whole body 0.86 0.28 0.33 0.28 0.33 78315 A Bone imaging, 3 phase 1.02 8.33 8.80 NA NA 78315 TC A Bone imaging, 3 phase 0.00 8.00 8.41 NA NA 78315 26 A Bone imaging, 3 phase 1.02 0.33 0.39 0.33 0.39 78320 A Bone imaging (3D) 1.04 5.09 5.91 NA NA 78320 TC A Bone imaging (3D) 0.00 4.77 5.52 NA NA 78320 26 A Bone imaging (3D) 1.04 0.32 0.39 0.32 0.39 78350 N Bone mineral, single photon 0.22 0.67 0.72 NA NA 78350 TC N Bone mineral, single photon 0.00 0.57 0.63 NA NA 78350 26 N Bone mineral, single photon 0.22 0.10 0.09 0.10 0.09 78351 N Bone mineral, dual photon 0.30 0.13 0.13 0.13 0.13 78399 C Musculoskeletal nuclear exam 0.00 0.00 0.00 NA NA 78399 TC C Musculoskeletal nuclear exam 0.00 0.00 0.00 NA NA 78399 26 C Musculoskeletal nuclear exam 0.00 0.00 0.00 0.00 0.00 78414 C Non-imaging heart function 0.00 0.00 0.00 NA NA 78414 TC C Non-imaging heart function 0.00 0.00 0.00 NA NA 78414 26 A Non-imaging heart function 0.45 0.20 0.18 0.20 0.18 78428 A Cardiac shunt imaging 0.78 4.28 4.79 NA NA 78428 TC A Cardiac shunt imaging 0.00 4.01 4.45 NA NA 78428 26 A Cardiac shunt imaging 0.78 0.27 0.34 0.27 0.34 78445 A Vascular flow imaging 0.49 4.14 4.39 NA NA 78445 TC A Vascular flow imaging 0.00 3.99 4.21 NA NA 78445 26 A Vascular flow imaging 0.49 0.15 0.18 0.15 0.18 
CMS-1503-P 1094

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

78451 A Ht muscle image spect, sing 1.38 8.42 8.42 NA NA 78451 TC A Ht muscle image spect, sing 0.00 7.91 7.91 NA NA 78451 26 A Ht muscle image spect, sing 1.38 0.51 0.51 0.51 0.51 78452 A Ht muscle image spect, mult 1.62 12.17 12.17 NA NA 78452 TC A Ht muscle image spect, mult 0.00 11.55 11.55 NA NA 78452 26 A Ht muscle image spect, mult 1.62 0.62 0.62 0.62 0.62 78453 A Ht muscle image,planar,sing 1.00 7.28 7.28 NA NA 78453 TC A Ht muscle image,planar,sing 0.00 6.93 6.93 NA NA 78453 26 A Ht muscle image,planar,sing 1.00 0.35 0.35 0.35 0.35 78454 A Ht musc image, planar, mult 1.34 10.57 10.57 NA NA 78454 TC A Ht musc image, planar, mult 0.00 10.10 10.10 NA NA 78454 26 A Ht musc image, planar, mult 1.34 0.47 0.47 0.47 0.47 78456 A Acute venous thrombus image 1.00 8.42 9.12 NA NA 78456 TC A Acute venous thrombus image 0.00 8.07 8.67 NA NA 78456 26 A Acute venous thrombus image 1.00 0.35 0.45 0.35 0.45 78457 A Venous thrombosis imaging 0.77 4.59 4.83 NA NA 78457 TC A Venous thrombosis imaging 0.00 4.32 4.53 NA NA 78457 26 A Venous thrombosis imaging 0.77 0.27 0.30 0.27 0.30 78458 A Ven thrombosis images, bilat 0.90 3.93 4.69 NA NA 78458 TC A Ven thrombosis images, bilat 0.00 3.73 4.39 NA NA 78458 26 A Ven thrombosis images, bilat 0.90 0.20 0.30 0.20 0.30 78459 C Heart muscle imaging (PET) 0.00 0.00 0.00 NA NA 78459 TC C Heart muscle imaging (PET) 0.00 0.00 0.00 NA NA 78459 26 A Heart muscle imaging (PET) 1.50 0.43 0.61 0.43 0.61 78466 A Heart infarct image 0.69 4.07 4.48 NA NA 78466 TC A Heart infarct image 0.00 3.82 4.18 NA NA 
CMS-1503-P 1095

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

78466 26 A Heart infarct image 0.69 0.25 0.30 0.25 0.30 78468 A Heart infarct image (ef) 0.80 4.80 5.52 NA NA 78468 TC A Heart infarct image (ef) 0.00 4.49 5.14 NA NA 78468 26 A Heart infarct image (ef) 0.80 0.31 0.38 0.31 0.38 78469 A Heart infarct image (3D) 0.92 5.92 6.48 NA NA 78469 TC A Heart infarct image (3D) 0.00 5.53 6.04 NA NA 78469 26 A Heart infarct image (3D) 0.92 0.39 0.44 0.39 0.44 78472 A Gated heart, planar, single 0.98 5.38 6.24 NA NA 78472 TC A Gated heart, planar, single 0.00 5.04 5.82 NA NA 78472 26 A Gated heart, planar, single 0.98 0.34 0.42 0.34 0.42 78473 A Gated heart, multiple 1.47 6.72 8.11 NA NA 78473 TC A Gated heart, multiple 0.00 6.18 7.45 NA NA 78473 26 A Gated heart, multiple 1.47 0.54 0.66 0.54 0.66 78481 A Heart first pass, single 0.98 4.15 5.10 NA NA 78481 TC A Heart first pass, single 0.00 3.77 4.63 NA NA 78481 26 A Heart first pass, single 0.98 0.38 0.47 0.38 0.47 78483 A Heart first pass, multiple 1.47 5.48 6.95 NA NA 78483 TC A Heart first pass, multiple 0.00 4.91 6.23 NA NA 78483 26 A Heart first pass, multiple 1.47 0.57 0.72 0.57 0.72 78491 C Heart image (pet), single 0.00 0.00 0.00 NA NA 78491 TC C Heart image (pet), single 0.00 0.00 0.00 NA NA 78491 26 A Heart image (pet), single 1.50 0.48 0.64 0.48 0.64 78492 C Heart image (pet), multiple 0.00 0.00 0.00 NA NA 78492 TC C Heart image (pet), multiple 0.00 0.00 0.00 NA NA 78492 26 A Heart image (pet), multiple 1.87 0.64 0.84 0.64 0.84 78494 A Heart image, spect 1.19 5.48 6.53 NA NA 
CMS-1503-P 1096

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

78494 TC A Heart image, spect 0.00 5.01 5.99 NA NA 78494 26 A Heart image, spect 1.19 0.47 0.54 0.47 0.54 78496 A Heart first pass add-on 0.50 0.73 1.84 NA NA 78496 TC A Heart first pass add-on 0.00 0.54 1.61 NA NA 78496 26 A Heart first pass add-on 0.50 0.19 0.23 0.19 0.23 78499 C Cardiovascular nuclear exam 0.00 0.00 0.00 NA NA 78499 TC C Cardiovascular nuclear exam 0.00 0.00 0.00 NA NA 78499 26 C Cardiovascular nuclear exam 0.00 0.00 0.00 0.00 0.00 78580 A Lung perfusion imaging 0.74 4.91 5.31 NA NA 78580 TC A Lung perfusion imaging 0.00 4.67 5.02 NA NA 78580 26 A Lung perfusion imaging 0.74 0.24 0.29 0.24 0.29 78584 A Lung V/Q image single breath 0.99 2.87 3.32 NA NA 78584 TC A Lung V/Q image single breath 0.00 2.53 2.93 NA NA 78584 26 A Lung V/Q image single breath 0.99 0.34 0.39 0.34 0.39 78585 A Lung V/Q imaging 1.09 8.36 8.96 NA NA 78585 TC A Lung V/Q imaging 0.00 8.01 8.54 NA NA 78585 26 A Lung V/Q imaging 1.09 0.35 0.42 0.35 0.42 78586 A Aerosol lung image, single 0.40 4.12 4.33 NA NA 78586 TC A Aerosol lung image, single 0.00 3.98 4.17 NA NA 78586 26 A Aerosol lung image, single 0.40 0.14 0.16 0.14 0.16 78587 A Aerosol lung image, multiple 0.49 5.12 5.45 NA NA 78587 TC A Aerosol lung image, multiple 0.00 4.97 5.26 NA NA 78587 26 A Aerosol lung image, multiple 0.49 0.15 0.19 0.15 0.19 

78588 A Perfusion lung image 1.09 8.44 8.66 NA NA 78588 TC A Perfusion lung image 0.00 8.08 8.23 NA NA 78588 26 A Perfusion lung image 1.09 0.36 0.43 0.36 0.43 
CMS-1503-P 1097

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

78591 A Vent image, 1 breath, 1 proj 0.40 4.15 4.39 NA NA 78591 TC A Vent image, 1 breath, 1 proj 0.00 4.01 4.23 NA NA 78591 26 A Vent image, 1 breath, 1 proj 0.40 0.14 0.16 0.14 0.16 78593 A Vent image, 1 proj, gas 0.49 4.73 5.07 NA NA 78593 TC A Vent image, 1 proj, gas 0.00 4.57 4.88 NA NA 78593 26 A Vent image, 1 proj, gas 0.49 0.16 0.19 0.16 0.19 78594 A Vent image, mult proj, gas 0.53 4.93 5.63 NA NA 78594 TC A Vent image, mult proj, gas 0.00 4.78 5.44 NA NA 78594 26 A Vent image, mult proj, gas 0.53 0.15 0.19 0.15 0.19 78596 A Lung differential function 1.27 8.66 9.39 NA NA 78596 TC A Lung differential function 0.00 8.25 8.92 NA NA 78596 26 A Lung differential function 1.27 0.41 0.47 0.41 0.47 78599 C Respiratory nuclear exam 0.00 0.00 0.00 NA NA 78599 TC C Respiratory nuclear exam 0.00 0.00 0.00 NA NA 78599 26 C Respiratory nuclear exam 0.00 0.00 0.00 0.00 0.00 78600 A Brain image < 4 views 0.44 4.35 4.66 NA NA 78600 TC A Brain image < 4 views 0.00 4.20 4.48 NA NA 78600 26 A Brain image < 4 views 0.44 0.15 0.18 0.15 0.18 78601 A Brain image w/flow < 4 views 0.51 5.18 5.55 NA NA 78601 TC A Brain image w/flow < 4 views 0.00 5.02 5.35 NA NA 78601 26 A Brain image w/flow < 4 views 0.51 0.16 0.20 0.16 0.20 78605 A Brain image 4+ views 0.53 4.66 5.06 NA NA 78605 TC A Brain image 4+ views 0.00 4.48 4.84 NA NA 78605 26 A Brain image 4+ views 0.53 0.18 0.22 0.18 0.22 78606 A Brain image w/flow 4 + views 0.64 8.35 8.59 NA NA 78606 TC A Brain image w/flow 4 + views 0.00 8.14 8.34 NA NA 
CMS-1503-P 1098

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

78606 26 A Brain image w/flow 4 + views 0.64 0.21 0.25 0.21 0.25 78607 A Brain imaging (3D) 1.23 8.34 9.14 NA NA 78607 TC A Brain imaging (3D) 0.00 7.97 8.68 NA NA 78607 26 A Brain imaging (3D) 1.23 0.37 0.46 0.37 0.46 78608 C Brain imaging (PET) 0.00 0.00 0.00 NA NA 78608 TC C Brain imaging (PET) 0.00 0.00 0.00 NA NA 78608 26 A Brain imaging (PET) 1.50 0.45 0.56 0.45 0.56 78609 N Brain imaging (PET) 1.50 0.65 0.62 NA NA 78609 TC N Brain imaging (PET) 0.00 0.00 0.00 NA NA 78609 26 N Brain imaging (PET) 1.50 0.65 0.62 0.65 0.62 78610 A Brain flow imaging only 0.30 4.28 4.75 NA NA 78610 TC A Brain flow imaging only 0.00 4.18 4.62 NA NA 78610 26 A Brain flow imaging only 0.30 0.10 0.13 0.10 0.13 78630 A Cerebrospinal fluid scan 0.68 8.45 8.90 NA NA 78630 TC A Cerebrospinal fluid scan 0.00 8.22 8.63 NA NA 78630 26 A Cerebrospinal fluid scan 0.68 0.23 0.27 0.23 0.27 78635 A CSF ventriculography 0.61 8.43 8.52 NA NA 78635 TC A CSF ventriculography 0.00 8.22 8.27 NA NA 78635 26 A CSF ventriculography 0.61 0.21 0.25 0.21 0.25 78645 A CSF shunt evaluation 0.57 8.15 8.44 NA NA 78645 TC A CSF shunt evaluation 0.00 7.97 8.22 NA NA 78645 26 A CSF shunt evaluation 0.57 0.18 0.22 0.18 0.22 78647 A Cerebrospinal fluid scan 0.90 8.43 9.01 NA NA 78647 TC A Cerebrospinal fluid scan 0.00 8.16 8.68 NA NA 78647 26 A Cerebrospinal fluid scan 0.90 0.27 0.33 0.27 0.33 78650 A CSF leakage imaging 0.61 8.34 8.77 NA NA 
CMS-1503-P 1099

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

78650 TC A CSF leakage imaging 0.00 8.15 8.54 NA NA 78650 26 A CSF leakage imaging 0.61 0.19 0.23 0.19 0.23 78660 A Nuclear exam of tear flow 0.53 4.49 4.52 NA NA 78660 TC A Nuclear exam of tear flow 0.00 4.28 4.29 NA NA 78660 26 A Nuclear exam of tear flow 0.53 0.21 0.23 0.21 0.23 78699 C Nervous system nuclear exam 0.00 0.00 0.00 NA NA 78699 TC C Nervous system nuclear exam 0.00 0.00 0.00 NA NA 78699 26 C Nervous system nuclear exam 0.00 0.00 0.00 0.00 0.00 78700 A Kidney imaging, morphol 0.45 4.24 4.56 NA NA 78700 TC A Kidney imaging, morphol 0.00 4.08 4.38 NA NA 78700 26 A Kidney imaging, morphol 0.45 0.16 0.18 0.16 0.18 78701 A Kidney imaging with flow 0.49 5.19 5.56 NA NA 78701 TC A Kidney imaging with flow 0.00 5.03 5.37 NA NA 78701 26 A Kidney imaging with flow 0.49 0.16 0.19 0.16 0.19 78707 A K flow/funct image w/o drug 0.96 5.22 5.81 NA NA 78707 TC A K flow/funct image w/o drug 0.00 4.92 5.44 NA NA 78707 26 A K flow/funct image w/o drug 0.96 0.30 0.37 0.30 0.37 78708 A K flow/funct image w/drug 1.21 3.20 3.91 NA NA 78708 TC A K flow/funct image w/drug 0.00 2.82 3.44 NA NA 78708 26 A K flow/funct image w/drug 1.21 0.38 0.47 0.38 0.47 78709 A K flow/funct image, multiple 1.41 8.55 9.03 NA NA 78709 TC A K flow/funct image, multiple 0.00 8.10 8.49 NA NA 78709 26 A K flow/funct image, multiple 1.41 0.45 0.54 0.45 0.54 

78710 A Kidney imaging (3D) 0.66 4.84 5.71 NA NA 78710 TC A Kidney imaging (3D) 0.00 4.65 5.47 NA NA 78710 26 A Kidney imaging (3D) 0.66 0.19 0.24 0.19 0.24 
CMS-1503-P 1100

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

78725 A Kidney function study 0.38 2.38 2.52 NA NA 78725 TC A Kidney function study 0.00 2.25 2.38 NA NA 78725 26 A Kidney function study 0.38 0.13 0.14 0.13 0.14 78730 A Urinary bladder retention 0.15 1.77 2.00 NA NA 78730 TC A Urinary bladder retention 0.00 1.71 1.92 NA NA 78730 26 A Urinary bladder retention 0.15 0.06 0.08 0.06 0.08 78740 A Ureteral reflux study 0.57 5.72 5.77 NA NA 78740 TC A Ureteral reflux study 0.00 5.50 5.53 NA NA 78740 26 A Ureteral reflux study 0.57 0.22 0.24 0.22 0.24 78761 A Testicular imaging w/flow 0.71 5.09 5.36 NA NA 78761 TC A Testicular imaging w/flow 0.00 4.83 5.07 NA NA 78761 26 A Testicular imaging w/flow 0.71 0.26 0.29 0.26 0.29 78799 C Genitourinary nuclear exam 0.00 0.00 0.00 NA NA 78799 TC C Genitourinary nuclear exam 0.00 0.00 0.00 NA NA 78799 26 C Genitourinary nuclear exam 0.00 0.00 0.00 0.00 0.00 78800 A Tumor imaging, limited area 0.66 4.34 4.65 NA NA 78800 TC A Tumor imaging, limited area 0.00 4.11 4.40 NA NA 78800 26 A Tumor imaging, limited area 0.66 0.23 0.25 0.23 0.25 78801 A Tumor imaging, mult areas 0.79 6.03 6.41 NA NA 78801 TC A Tumor imaging, mult areas 0.00 5.75 6.10 NA NA 78801 26 A Tumor imaging, mult areas 0.79 0.28 0.31 0.28 0.31 78802 A Tumor imaging, whole body 0.86 7.81 8.46 NA NA 78802 TC A Tumor imaging, whole body 0.00 7.54 8.13 NA NA 78802 26 A Tumor imaging, whole body 0.86 0.27 0.33 0.27 0.33 78803 A Tumor imaging (3D) 1.09 8.03 8.93 NA NA 78803 TC A Tumor imaging (3D) 0.00 7.72 8.53 NA NA 
CMS-1503-P 1101

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

78803 26 A Tumor imaging (3D) 1.09 0.31 0.40 0.31 0.40 78804 A Tumor imaging, whole body 1.07 14.18 15.50 NA NA 78804 TC A Tumor imaging, whole body 0.00 13.86 15.09 NA NA 78804 26 A Tumor imaging, whole body 1.07 0.32 0.41 0.32 0.41 78805 A Abscess imaging, ltd area 0.73 4.11 4.51 NA NA 78805 TC A Abscess imaging, ltd area 0.00 3.87 4.23 NA NA 78805 26 A Abscess imaging, ltd area 0.73 0.24 0.28 0.24 0.28 78806 A Abscess imaging, whole body 0.86 8.01 8.77 NA NA 78806 TC A Abscess imaging, whole body 0.00 7.74 8.45 NA NA 78806 26 A Abscess imaging, whole body 0.86 0.27 0.32 0.27 0.32 78807 A Nuclear localization/abscess 1.09 8.01 8.94 NA NA 78807 TC A Nuclear localization/abscess 0.00 7.71 8.54 NA NA 78807 26 A Nuclear localization/abscess 1.09 0.30 0.40 0.30 0.40 78808 A Iv inj ra drug dx study 0.18 0.85 1.03 NA NA 78811 C Pet image, ltd area 0.00 0.00 0.00 NA NA 78811 TC C Pet image, ltd area 0.00 0.00 0.00 NA NA 78811 26 A Pet image, ltd area 1.54 0.51 0.60 0.51 0.60 78812 C Pet image, skull-thigh 0.00 0.00 0.00 NA NA 78812 TC C Pet image, skull-thigh 0.00 0.00 0.00 NA NA 78812 26 A Pet image, skull-thigh 1.93 0.62 0.75 0.62 0.75 78813 C Pet image, full body 0.00 0.00 0.00 NA NA 78813 TC C Pet image, full body 0.00 0.00 0.00 NA NA 78813 26 A Pet image, full body 2.00 0.67 0.79 0.67 0.79 78814 C Pet image w/ct, lmtd 0.00 0.00 0.00 NA NA 78814 TC C Pet image w/ct, lmtd 0.00 0.00 0.00 NA NA 78814 26 A Pet image w/ct, lmtd 2.20 0.68 0.84 0.68 0.84 
CMS-1503-P 1102

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

78815 C Pet image w/ct, skull-thigh 0.00 0.00 0.00 NA NA 78815 TC C Pet image w/ct, skull-thigh 0.00 0.00 0.00 NA NA 78815 26 A Pet image w/ct, skull-thigh 2.44 0.78 0.94 0.78 0.94 78816 C Pet image w/ct, full body 0.00 0.00 0.00 NA NA 78816 TC C Pet image w/ct, full body 0.00 0.00 0.00 NA NA 78816 26 A Pet image w/ct, full body 2.50 0.75 0.94 0.75 0.94 78999 C Nuclear diagnostic exam 0.00 0.00 0.00 NA NA 78999 TC C Nuclear diagnostic exam 0.00 0.00 0.00 NA NA 78999 26 C Nuclear diagnostic exam 0.00 0.00 0.00 0.00 0.00 79005 A Nuclear rx, oral admin 1.80 1.85 2.27 NA NA 79005 TC A Nuclear rx, oral admin 0.00 1.22 1.57 NA NA 79005 26 A Nuclear rx, oral admin 1.80 0.63 0.70 0.63 0.70 79101 A Nuclear rx, iv admin 1.96 2.21 2.67 NA NA 79101 TC A Nuclear rx, iv admin 0.00 1.32 1.71 NA NA 79101 26 A Nuclear rx, iv admin 1.96 0.89 0.96 0.89 0.96 79200 A Nuclear rx, intracav admin 1.99 2.30 2.73 NA NA 79200 TC A Nuclear rx, intracav admin 0.00 1.59 1.93 NA NA 79200 26 A Nuclear rx, intracav admin 1.99 0.71 0.80 0.71 0.80 79300 C Nuclr rx, interstit colloid 0.00 0.00 0.00 NA NA 79300 TC C Nuclr rx, interstit colloid 0.00 0.00 0.00 NA NA 79300 26 A Nuclr rx, interstit colloid 1.60 0.57 0.63 0.57 0.63 79403 A Hematopoietic nuclear tx 2.25 2.91 3.61 NA NA 79403 TC A Hematopoietic nuclear tx 0.00 2.08 2.67 NA NA 79403 26 A Hematopoietic nuclear tx 2.25 0.83 0.94 0.83 0.94 79440 A Nuclear rx, intra-articular 1.99 2.32 2.53 NA NA 79440 TC A Nuclear rx, intra-articular 0.00 1.42 1.63 NA NA 
CMS-1503-P 1103

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

79440 26 A Nuclear rx, intra-articular 1.99 0.90 0.90 0.90 0.90 79445 C Nuclear rx, intra-arterial 0.00 0.00 0.00 NA NA 79445 TC C Nuclear rx, intra-arterial 0.00 0.00 0.00 NA NA 79445 26 A Nuclear rx, intra-arterial 2.40 0.75 0.92 0.75 0.92 79999 C Nuclear medicine therapy 0.00 0.00 0.00 NA NA 79999 TC C Nuclear medicine therapy 0.00 0.00 0.00 NA NA 79999 26 C Nuclear medicine therapy 0.00 0.00 0.00 0.00 0.00 80500 A Lab pathology consultation 0.37 0.18 0.20 0.12 0.13 80502 A Lab pathology consultation 1.33 0.44 0.47 0.39 0.42 83020 26 A Hemoglobin electrophoresis 0.37 0.17 0.17 0.17 0.17 83912 26 A Genetic examination 0.37 0.15 0.14 0.15 0.14 84165 26 A Protein e-phoresis, serum 0.37 0.17 0.16 0.17 0.16 84166 26 A Protein e-phoresis/urine/csf 0.37 0.17 0.16 0.17 0.16 84181 26 A Western blot test 0.37 0.17 0.16 0.17 0.16 84182 26 A Protein, western blot test 0.37 0.16 0.16 0.16 0.16 85060 A Blood smear interpretation 0.45 0.21 0.20 0.21 0.20 85097 A Bone marrow interpretation 0.94 1.31 1.50 0.38 0.37 85390 26 A Fibrinolysins screen 0.37 0.18 0.17 0.18 0.17 85396 A Clotting assay, whole blood 0.37 NA NA 0.16 0.15 85576 26 A Blood platelet aggregation 0.37 0.17 0.17 0.17 0.17 86077 A Physician blood bank service 0.94 0.52 0.49 0.43 0.41 86078 A Physician blood bank service 0.94 0.53 0.50 0.44 0.41 86079 A Physician blood bank service 0.94 0.52 0.51 0.43 0.41 86255 26 A Fluorescent antibody, screen 0.37 0.17 0.16 0.17 0.16 86256 26 A Fluorescent antibody, titer 0.37 0.17 0.16 0.17 0.16 86320 26 A Serum immunoelectrophoresis 0.37 0.17 0.16 0.17 0.16 
CMS-1503-P 1104

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

86325 26 A Other immunoelectrophoresis 0.37 0.17 0.16 0.17 0.16 86327 26 A Immunoelectrophoresis assay 0.42 0.20 0.19 0.20 0.19 86334 26 A Immunofix e-phoresis, serum 0.37 0.17 0.16 0.17 0.16 86335 26 A Immunfix e-phorsis/urine/csf 0.37 0.17 0.16 0.17 0.16 86485 C Skin test, candida 0.00 0.00 0.00 0.00 0.00 86486 A Skin test, nos antigen 0.00 0.12 0.13 NA NA 86490 A Coccidioidomycosis skin test 0.00 0.16 0.18 NA NA 86510 A Histoplasmosis skin test 0.00 0.16 0.18 NA NA 86580 A TB intradermal test 0.00 0.20 0.21 NA NA 87164 26 A Dark field examination 0.37 0.17 0.16 0.17 0.16 87207 26 A Smear, special stain 0.37 0.18 0.17 0.18 0.17 88104 A Cytopath fl nongyn, smears 0.56 1.31 1.31 NA NA 88104 TC A Cytopath fl nongyn, smears 0.00 1.07 1.08 NA NA 88104 26 A Cytopath fl nongyn, smears 0.56 0.24 0.23 0.24 0.23 88106 A Cytopath fl nongyn, filter 0.56 1.66 1.73 NA NA 88106 TC A Cytopath fl nongyn, filter 0.00 1.43 1.50 NA NA 88106 26 A Cytopath fl nongyn, filter 0.56 0.23 0.23 0.23 0.23 

88107 A Cytopath fl nongyn, sm/fltr 0.76 1.98 2.09 NA NA 88107 TC A Cytopath fl nongyn, sm/fltr 0.00 1.66 1.77 NA NA 88107 26 A Cytopath fl nongyn, sm/fltr 0.76 0.32 0.32 0.32 0.32 88108 A Cytopath, concentrate tech 0.56 1.52 1.59 NA NA 88108 TC A Cytopath, concentrate tech 0.00 1.30 1.37 NA NA 88108 26 A Cytopath, concentrate tech 0.56 0.22 0.22 0.22 0.22 88112 A Cytopath, cell enhance tech 1.18 1.61 1.75 NA NA 88112 TC A Cytopath, cell enhance tech 0.00 1.17 1.32 NA NA 88112 26 A Cytopath, cell enhance tech 1.18 0.44 0.43 0.44 0.43 
CMS-1503-P 1105

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

88125 A Forensic cytopathology 0.26 0.35 0.36 NA NA 88125 TC A Forensic cytopathology 0.00 0.23 0.25 NA NA 88125 26 A Forensic cytopathology 0.26 0.12 0.11 0.12 0.11 88141 A Cytopath, c/v, interpret 0.42 0.40 0.39 0.40 0.39 88160 A Cytopath smear, other source 0.50 1.04 1.05 NA NA 88160 TC A Cytopath smear, other source 0.00 0.83 0.85 NA NA 88160 26 A Cytopath smear, other source 0.50 0.21 0.20 0.21 0.20 88161 A Cytopath smear, other source 0.50 0.97 1.05 NA NA 88161 TC A Cytopath smear, other source 0.00 0.79 0.87 NA NA 88161 26 A Cytopath smear, other source 0.50 0.18 0.18 0.18 0.18 88162 A Cytopath smear, other source 0.76 1.33 1.47 NA NA 88162 TC A Cytopath smear, other source 0.00 1.05 1.18 NA NA 88162 26 A Cytopath smear, other source 0.76 0.28 0.29 0.28 0.29 88172 A Cytopathology eval of fna 0.60 0.98 0.98 NA NA 88172 TC A Cytopathology eval of fna 0.00 0.71 0.72 NA NA 88172 26 A Cytopathology eval of fna 0.60 0.27 0.26 0.27 0.26 88173 A Cytopath eval, fna, report 1.39 2.44 2.54 NA NA 88173 TC A Cytopath eval, fna, report 0.00 1.87 1.98 NA NA 88173 26 A Cytopath eval, fna, report 1.39 0.57 0.56 0.57 0.56 88182 A Cell marker study 0.77 2.00 2.18 NA NA 88182 TC A Cell marker study 0.00 1.80 1.97 NA NA 88182 26 A Cell marker study 0.77 0.20 0.21 0.20 0.21 88184 A Flowcytometry/ tc, 1 marker 0.00 2.24 2.41 NA NA 88185 A Flowcytometry/tc, add-on 0.00 1.36 1.45 NA NA 88187 A Flowcytometry/read, 2-8 1.36 0.56 0.53 0.56 0.53 88188 A Flowcytometry/read, 9-15 1.69 0.72 0.66 0.72 0.66 
CMS-1503-P 1106

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

88189 A Flowcytometry/read, 16 & > 2.23 0.67 0.67 0.67 0.67 88199 C Cytopathology procedure 0.00 0.00 0.00 NA NA 88199 TC C Cytopathology procedure 0.00 0.00 0.00 NA NA 88199 26 C Cytopathology procedure 0.00 0.00 0.00 0.00 0.00 88291 A Cyto/molecular report 0.52 0.29 0.30 0.29 0.30 88299 C Cytogenetic study 0.00 0.00 0.00 0.00 0.00 88300 A Surgical path, gross 0.08 0.62 0.64 NA NA 88300 TC A Surgical path, gross 0.00 0.58 0.60 NA NA 88300 26 A Surgical path, gross 0.08 0.04 0.04 0.04 0.04 88302 A Tissue exam by pathologist 0.13 1.34 1.38 NA NA 88302 TC A Tissue exam by pathologist 0.00 1.28 1.33 NA NA 88302 26 A Tissue exam by pathologist 0.13 0.06 0.05 0.06 0.05 88304 A Tissue exam by pathologist 0.22 1.56 1.66 NA NA 88304 TC A Tissue exam by pathologist 0.00 1.47 1.57 NA NA 88304 26 A Tissue exam by pathologist 0.22 0.09 0.09 0.09 0.09 88305 A Tissue exam by pathologist 0.75 2.16 2.32 NA NA 88305 TC A Tissue exam by pathologist 0.00 1.86 2.02 NA NA 88305 26 A Tissue exam by pathologist 0.75 0.30 0.30 0.30 0.30 88307 A Tissue exam by pathologist 1.59 4.87 4.87 NA NA 88307 TC A Tissue exam by pathologist 0.00 4.16 4.19 NA NA 88307 26 A Tissue exam by pathologist 1.59 0.71 0.68 0.71 0.68 88309 A Tissue exam by pathologist 2.80 7.05 6.98 NA NA 88309 TC A Tissue exam by pathologist 0.00 5.79 5.81 NA NA 88309 26 A Tissue exam by pathologist 2.80 1.26 1.17 1.26 1.17 88311 A Decalcify tissue 0.24 0.28 0.29 NA NA 88311 TC A Decalcify tissue 0.00 0.18 0.19 NA NA 
CMS-1503-P 1107

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

88311 26 A Decalcify tissue 0.24 0.10 0.10 0.10 0.10 88312 A Special stains group 1 0.54 2.44 2.51 NA NA 88312 TC A Special stains group 1 0.00 2.23 2.30 NA NA 88312 26 A Special stains group 1 0.54 0.21 0.21 0.21 0.21 88313 A Special stains group 2 0.24 1.89 1.98 NA NA 88313 TC A Special stains group 2 0.00 1.80 1.89 NA NA 88313 26 A Special stains group 2 0.24 0.09 0.09 0.09 0.09 88314 A Histochemical stain add-on 0.45 1.93 2.12 NA NA 88314 TC A Histochemical stain add-on 0.00 1.73 1.93 NA NA 88314 26 A Histochemical stain add-on 0.45 0.20 0.19 0.20 0.19 88318 A Chemical histochemistry 0.42 3.06 2.90 NA NA 88318 TC A Chemical histochemistry 0.00 2.88 2.73 NA NA 88318 26 A Chemical histochemistry 0.42 0.18 0.17 0.18 0.17 88319 A Enzyme histochemistry 0.53 3.41 3.63 NA NA 88319 TC A Enzyme histochemistry 0.00 3.19 3.42 NA NA 88319 26 A Enzyme histochemistry 0.53 0.22 0.21 0.22 0.21 88321 A Microslide consultation 1.63 0.92 0.91 0.68 0.64 88323 A Microslide consultation 1.83 2.09 2.27 NA NA 88323 TC A Microslide consultation 0.00 1.52 1.69 NA NA 88323 26 A Microslide consultation 1.83 0.57 0.58 0.57 0.58 88325 A Comprehensive review of data 2.50 3.18 3.18 1.23 1.11 88329 A Path consult introp 0.67 0.80 0.80 0.30 0.29 88331 A Path consult intraop, 1 bloc 1.19 1.45 1.44 NA NA 88331 TC A Path consult intraop, 1 bloc 0.00 0.89 0.91 NA NA 88331 26 A Path consult intraop, 1 bloc 1.19 0.56 0.53 0.56 0.53 88332 A Path consult intraop, addl 0.59 0.57 0.56 NA NA 
CMS-1503-P 1108

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

88332 TC A Path consult intraop, addl 0.00 0.30 0.31 NA NA 88332 26 A Path consult intraop, addl 0.59 0.27 0.25 0.27 0.25 88333 A Intraop cyto path consult, 1 1.20 1.53 1.52 NA NA 88333 TC A Intraop cyto path consult, 1 0.00 0.99 1.00 NA NA 88333 26 A Intraop cyto path consult, 1 1.20 0.54 0.52 0.54 0.52 88334 A Intraop cyto path consult, 2 0.73 0.96 0.93 NA NA 88334 TC A Intraop cyto path consult, 2 0.00 0.62 0.62 NA NA 88334 26 A Intraop cyto path consult, 2 0.73 0.34 0.31 0.34 0.31 88342 A Immunohistochemistry 0.85 2.04 2.12 NA NA 88342 TC A Immunohistochemistry 0.00 1.71 1.80 NA NA 88342 26 A Immunohistochemistry 0.85 0.33 0.32 0.33 0.32 88346 A Immunofluorescent study 0.86 1.96 2.07 NA NA 88346 TC A Immunofluorescent study 0.00 1.62 1.74 NA NA 88346 26 A Immunofluorescent study 0.86 0.34 0.33 0.34 0.33 88347 A Immunofluorescent study 0.86 1.23 1.37 NA NA 88347 TC A Immunofluorescent study 0.00 1.00 1.12 NA NA 88347 26 A Immunofluorescent study 0.86 0.23 0.25 0.23 0.25 88348 A Electron microscopy 1.51 17.26 17.95 NA NA 88348 TC A Electron microscopy 0.00 16.68 17.37 NA NA 88348 26 A Electron microscopy 1.51 0.58 0.58 0.58 0.58 88349 A Scanning electron microscopy 0.76 10.10 9.46 NA NA 88349 TC A Scanning electron microscopy 0.00 9.74 9.12 NA NA 88349 26 A Scanning electron microscopy 0.76 0.36 0.34 0.36 0.34 88355 A Analysis, skeletal muscle 1.85 3.13 4.30 NA NA 88355 TC A Analysis, skeletal muscle 0.00 2.61 3.75 NA NA 88355 26 A Analysis, skeletal muscle 1.85 0.52 0.55 0.52 0.55 
CMS-1503-P 1109

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

88356 A Analysis, nerve 3.02 4.37 5.03 NA NA 88356 TC A Analysis, nerve 0.00 3.83 4.35 NA NA 88356 26 A Analysis, nerve 3.02 0.54 0.68 0.54 0.68 88358 A Analysis, tumor 0.95 1.12 1.18 NA NA 88358 TC A Analysis, tumor 0.00 0.89 0.93 NA NA 88358 26 A Analysis, tumor 0.95 0.23 0.25 0.23 0.25 88360 A Tumor immunohistochem/manual 1.10 2.32 2.43 NA NA 88360 TC A Tumor immunohistochem/manual 0.00 1.92 2.03 NA NA 88360 26 A Tumor immunohistochem/manual 1.10 0.40 0.40 0.40 0.40 88361 A Tumor immunohistochem/comput 1.18 2.92 3.16 NA NA 88361 TC A Tumor immunohistochem/comput 0.00 2.50 2.75 NA NA 88361 26 A Tumor immunohistochem/comput 1.18 0.42 0.41 0.42 0.41 88362 A Nerve teasing preparations 2.17 5.84 5.85 NA NA 88362 TC A Nerve teasing preparations 0.00 4.94 4.99 NA NA 88362 26 A Nerve teasing preparations 2.17 0.90 0.86 0.90 0.86 88365 A Insitu hybridization (fish) 1.20 3.44 3.55 NA NA 88365 TC A Insitu hybridization (fish) 0.00 3.00 3.11 NA NA 88365 26 A Insitu hybridization (fish) 1.20 0.44 0.44 0.44 0.44 88367 A Insitu hybridization, auto 1.30 5.90 6.06 NA NA 88367 TC A Insitu hybridization, auto 0.00 5.47 5.63 NA NA 88367 26 A Insitu hybridization, auto 1.30 0.43 0.43 0.43 0.43 88368 A Insitu hybridization, manual 1.40 4.69 4.92 NA NA 88368 TC A Insitu hybridization, manual 0.00 4.35 4.54 NA NA 88368 26 A Insitu hybridization, manual 1.40 0.34 0.38 0.34 0.38 88371 26 A Protein, western blot tissue 0.37 0.17 0.16 0.17 0.16 88372 26 A Protein analysis w/probe 0.37 0.17 0.16 0.17 0.16 
CMS-1503-P 1110

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

88380 A Microdissection, laser 1.56 2.52 3.47 NA NA 88380 TC A Microdissection, laser 0.00 2.09 2.96 NA NA 88380 26 A Microdissection, laser 1.56 0.43 0.51 0.43 0.51 88381 A Microdissection, manual 1.18 2.73 4.13 NA NA 88381 TC A Microdissection, manual 0.00 2.49 3.78 NA NA 88381 26 A Microdissection, manual 1.18 0.24 0.35 0.24 0.35 88384 C Eval molecular probes, 11-50 0.00 0.00 0.00 NA NA 88384 TC C Eval molecular probes, 11-50 0.00 0.00 0.00 NA NA 88384 26 C Eval molecular probes, 11-50 0.00 0.00 0.00 0.00 0.00 88385 A Eval molecul probes, 51-250 1.50 14.78 15.06 NA NA 88385 TC A Eval molecul probes, 51-250 0.00 14.42 14.68 NA NA 88385 26 A Eval molecul probes, 51-250 1.50 0.36 0.38 0.36 0.38 88386 A Eval molecul probes, 251-500 1.88 13.57 16.61 NA NA 88386 TC A Eval molecul probes, 251-500 0.00 13.24 16.01 NA NA 88386 26 A Eval molecul probes, 251-500 1.88 0.33 0.60 0.33 0.60 88387 A Tiss exam molecular study 0.62 0.52 0.52 NA NA 88387 TC A Tiss exam molecular study 0.00 0.24 0.24 NA NA 88387 26 A Tiss exam molecular study 0.62 0.28 0.28 0.28 0.28 88388 A Tiss ex molecul study add-on 0.45 0.20 0.20 NA NA 88388 TC A Tiss ex molecul study add-on 0.00 0.11 0.11 NA NA 88388 26 A Tiss ex molecul study add-on 0.45 0.09 0.09 0.09 0.09 88399 C Surgical pathology procedure 0.00 0.00 0.00 NA NA 88399 TC C Surgical pathology procedure 0.00 0.00 0.00 NA NA 88399 26 C Surgical pathology procedure 0.00 0.00 0.00 0.00 0.00 89049 A Chct for mal hyperthermia 1.40 5.63 5.87 0.38 0.44 89060 26 A Exam,synovial fluid crystals 0.37 0.17 0.16 0.17 0.16 
CMS-1503-P 1111

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

89100 A Sample intestinal contents 0.60 8.90 8.07 0.64 0.59 89105 A Sample intestinal contents 0.50 7.79 7.68 0.51 0.49 89130 A Sample stomach contents 0.45 7.19 6.79 0.46 0.42 89132 A Sample stomach contents 0.19 7.26 7.46 0.34 0.35 89135 A Sample stomach contents 0.79 8.70 8.57 0.71 0.71 89136 A Sample stomach contents 0.21 7.23 6.84 0.35 0.33 89140 A Sample stomach contents 0.94 7.70 7.19 0.67 0.61 89141 A Sample stomach contents 0.85 8.21 7.64 0.67 0.62 89220 A Sputum specimen collection 0.00 0.42 0.45 NA NA 89230 A Collect sweat for test 0.00 0.05 0.08 NA NA 89240 C Pathology lab procedure 0.00 0.00 0.00 0.00 0.00 90281 I Human ig, im 0.00 0.00 0.00 0.00 0.00 90283 I Human ig, iv 0.00 0.00 0.00 0.00 0.00 90284 X Human ig, sc 0.00 0.00 0.00 0.00 0.00 90287 I Botulinum antitoxin 0.00 0.00 0.00 0.00 0.00 90288 I Botulism ig, iv 0.00 0.00 0.00 0.00 0.00 90291 I Cmv ig, iv 0.00 0.00 0.00 0.00 0.00 90296 E Diphtheria antitoxin 0.00 0.00 0.00 0.00 0.00 90371 E Hep b ig, im 0.00 0.00 0.00 0.00 0.00 90375 E Rabies ig, im/sc 0.00 0.00 0.00 0.00 0.00 90376 E Rabies ig, heat treated 0.00 0.00 0.00 0.00 0.00 90378 X Rsv, mab, im, 50mg 0.00 0.00 0.00 0.00 0.00 90384 I Rh ig, full-dose, im 0.00 0.00 0.00 0.00 0.00 90385 E Rh ig, minidose, im 0.00 0.00 0.00 0.00 0.00 90386 I Rh ig, iv 0.00 0.00 0.00 0.00 0.00 90389 I Tetanus ig, im 0.00 0.00 0.00 0.00 0.00 
CMS-1503-P 1112

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

90393 E Vaccina ig, im 0.00 0.00 0.00 0.00 0.00 90396 E Varicella-zoster ig, im 0.00 0.00 0.00 0.00 0.00 90399 I Immune globulin 0.00 0.00 0.00 0.00 0.00 90465 A Immune admin 1 inj, < 8 yrs 0.17 0.49 0.49 NA NA 90466 A Immune admin addl inj, < 8 y 0.15 0.24 0.20 0.07 0.07 90467 R Immune admin o or n, < 8 yrs 0.17 0.49 0.49 NA NA 90468 R Immune admin o/n, addl < 8 y 0.15 0.19 0.18 0.07 0.07 90470 I Immune admin H1N1 im/nasal 0.20 0.39 0.39 NA NA 90471 A Immunization admin 0.17 0.49 0.49 NA NA 90472 A Immunization admin, each add 0.15 0.19 0.18 0.07 0.07 90473 R Immune admin oral/nasal 0.17 0.49 0.49 NA NA 90474 R Immune admin oral/nasal addl 0.15 0.19 0.18 0.07 0.07 90476 E Adenovirus vaccine, type 4 0.00 0.00 0.00 0.00 0.00 90477 E Adenovirus vaccine, type 7 0.00 0.00 0.00 0.00 0.00 90581 E Anthrax vaccine, sc 0.00 0.00 0.00 0.00 0.00 90585 E Bcg vaccine, percut 0.00 0.00 0.00 0.00 0.00 90586 E Bcg vaccine, intravesical 0.00 0.00 0.00 0.00 0.00 90632 E Hep a vaccine, adult im 0.00 0.00 0.00 0.00 0.00 90633 E Hep a vacc, ped/adol, 2 dose 0.00 0.00 0.00 0.00 0.00 90634 E Hep a vacc, ped/adol, 3 dose 0.00 0.00 0.00 0.00 0.00 90636 E Hep a/hep b vacc, adult im 0.00 0.00 0.00 0.00 0.00 90644 X HIB/men/tt vaccine, im 0.00 0.00 0.00 0.00 0.00 90645 E Hib vaccine, hboc, im 0.00 0.00 0.00 0.00 0.00 90646 E Hib vaccine, prp-d, im 0.00 0.00 0.00 0.00 0.00 90647 E Hib vaccine, prp-omp, im 0.00 0.00 0.00 0.00 0.00 90648 E Hib vaccine, prp-t, im 0.00 0.00 0.00 0.00 0.00 
CMS-1503-P 1113

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

90649 E Hpv vaccine 4 valent, im 0.00 0.00 0.00 0.00 0.00 90650 E Hpv vaccine 2 valent, im 0.00 0.00 0.00 0.00 0.00 90655 X Flu vaccine no preserv 6-35m 0.00 0.00 0.00 0.00 0.00 90656 X Flu vaccine no preserv 3 & > 0.00 0.00 0.00 0.00 0.00 90657 X Flu vaccine, 3 yrs, im 0.00 0.00 0.00 0.00 0.00 90658 X Flu vaccine, 3 yrs & >, im 0.00 0.00 0.00 0.00 0.00 90660 X Flu vaccine, nasal 0.00 0.00 0.00 0.00 0.00 90661 X Flu vacc cell cult prsv free 0.00 0.00 0.00 0.00 0.00 90662 X Flu vacc prsv free inc antig 0.00 0.00 0.00 0.00 0.00 90663 X Flu vacc pandemic H1N1 0.00 0.00 0.00 0.00 0.00 90665 E Lyme disease vaccine, im 0.00 0.00 0.00 0.00 0.00 90669 X Pneumococcal vacc, 7 val im 0.00 0.00 0.00 0.00 0.00 90670 X Pneumococcal vacc, 13 val im 0.00 0.00 0.00 0.00 0.00 90675 E Rabies vaccine, im 0.00 0.00 0.00 0.00 0.00 90676 E Rabies vaccine, id 0.00 0.00 0.00 0.00 0.00 90680 E Rotovirus vacc 3 dose, oral 0.00 0.00 0.00 0.00 0.00 90681 E Rotavirus vacc 2 dose oral 0.00 0.00 0.00 0.00 0.00 90690 E Typhoid vaccine, oral 0.00 0.00 0.00 0.00 0.00 90691 E Typhoid vaccine, im 0.00 0.00 0.00 0.00 0.00 90692 E Typhoid vaccine, h-p, sc/id 0.00 0.00 0.00 0.00 0.00 90693 E Typhoid vaccine, akd, sc 0.00 0.00 0.00 0.00 0.00 90696 E Dtap-ipv vacc 4-6 yr im 0.00 0.00 0.00 0.00 0.00 90698 E Dtap-hib-ip vaccine, im 0.00 0.00 0.00 0.00 0.00 90700 E Dtap vaccine, < 7 yrs, im 0.00 0.00 0.00 0.00 0.00 90701 E Dtp vaccine, im 0.00 0.00 0.00 0.00 0.00 90702 E Dt vaccine < 7, im 0.00 0.00 0.00 0.00 0.00 
CMS-1503-P 1114

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

90703 E Tetanus vaccine, im 0.00 0.00 0.00 0.00 0.00 90704 E Mumps vaccine, sc 0.00 0.00 0.00 0.00 0.00 90705 E Measles vaccine, sc 0.00 0.00 0.00 0.00 0.00 90706 E Rubella vaccine, sc 0.00 0.00 0.00 0.00 0.00 90707 E Mmr vaccine, sc 0.00 0.00 0.00 0.00 0.00 90708 E Measles-rubella vaccine, sc 0.00 0.00 0.00 0.00 0.00 90710 E Mmrv vaccine, sc 0.00 0.00 0.00 0.00 0.00 90712 E Oral poliovirus vaccine 0.00 0.00 0.00 0.00 0.00 90713 E Poliovirus, ipv, sc/im 0.00 0.00 0.00 0.00 0.00 90714 E Td vaccine no prsrv >/= 7 im 0.00 0.00 0.00 0.00 0.00 90715 E Tdap vaccine >7 im 0.00 0.00 0.00 0.00 0.00 90716 E Chicken pox vaccine, sc 0.00 0.00 0.00 0.00 0.00 90717 E Yellow fever vaccine, sc 0.00 0.00 0.00 0.00 0.00 90718 E Td vaccine > 7, im 0.00 0.00 0.00 0.00 0.00 90719 E Diphtheria vaccine, im 0.00 0.00 0.00 0.00 0.00 90720 E Dtp/hib vaccine, im 0.00 0.00 0.00 0.00 0.00 90721 E Dtap/hib vaccine, im 0.00 0.00 0.00 0.00 0.00 90723 I Dtap-hep b-ipv vaccine, im 0.00 0.00 0.00 0.00 0.00 90725 E Cholera vaccine, injectable 0.00 0.00 0.00 0.00 0.00 90727 E Plague vaccine, im 0.00 0.00 0.00 0.00 0.00 90732 X Pneumococcal vaccine 0.00 0.00 0.00 0.00 0.00 90733 E Meningococcal vaccine, sc 0.00 0.00 0.00 0.00 0.00 90734 E Meningococcal vaccine, im 0.00 0.00 0.00 0.00 0.00 90735 E Encephalitis vaccine, sc 0.00 0.00 0.00 0.00 0.00 90736 E Zoster vacc, sc 0.00 0.00 0.00 0.00 0.00 90738 I Inactivated je vacc im 0.00 0.00 0.00 0.00 0.00 
CMS-1503-P 1115

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

90740 X Hepb vacc, ill pat 3 dose im 0.00 0.00 0.00 0.00 0.00 90743 X Hep b vacc, adol, 2 dose, im 0.00 0.00 0.00 0.00 0.00 90744 X Hepb vacc ped/adol 3 dose im 0.00 0.00 0.00 0.00 0.00 90746 X Hep b vaccine, adult, im 0.00 0.00 0.00 0.00 0.00 90747 X Hepb vacc, ill pat 4 dose im 0.00 0.00 0.00 0.00 0.00 90748 I Hep b/hib vaccine, im 0.00 0.00 0.00 0.00 0.00 90749 E Vaccine toxoid 0.00 0.00 0.00 0.00 0.00 90801 A Psy dx interview 2.80 1.51 1.59 0.59 0.71 90802 A Intac psy dx interview 3.01 1.78 1.76 0.76 0.83 90804 A Psytx, office, 20-30 min 1.21 0.55 0.59 0.17 0.24 90805 A Psytx, off, 20-30 min w/e&m 1.37 0.68 0.68 0.28 0.31 90806 A Psytx, off, 45-50 min 1.86 0.45 0.57 0.24 0.36 90807 A Psytx, off, 45-50 min w/e&m 2.02 0.81 0.83 0.41 0.46 90808 A Psytx, office, 75-80 min 2.79 0.62 0.78 0.42 0.58 90809 A Psytx, off, 75-80, w/e&m 2.95 1.00 1.04 0.63 0.70 90810 A Intac psytx, off, 20-30 min 1.32 0.47 0.55 0.20 0.27 90811 A Intac psytx, 20-30, w/e&m 1.48 0.84 0.82 0.31 0.35 90812 A Intac psytx, off, 45-50 min 1.97 0.56 0.69 0.26 0.39 90813 A Intac psytx, 45-50 min w/e&m 2.13 0.95 0.96 0.42 0.49 90814 A Intac psytx, off, 75-80 min 2.90 0.73 0.93 0.36 0.60 90815 A Intac psytx, 75-80 w/e&m 3.06 1.32 1.27 0.79 0.79 90816 A Psytx, hosp, 20-30 min 1.25 0.26 0.34 0.26 0.34 90817 A Psytx, hosp, 20-30 min w/e&m 1.41 0.40 0.43 0.40 0.43 90818 A Psytx, hosp, 45-50 min 1.89 0.33 0.47 0.33 0.47 90819 A Psytx, hosp, 45-50 min w/e&m 2.05 0.54 0.58 0.54 0.58 90821 A Psytx, hosp, 75-80 min 2.83 0.47 0.66 0.47 0.66 
CMS-1503-P 1116

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

90822 A Psytx, hosp, 75-80 min w/e&m 2.99 0.72 0.79 0.72 0.79 90823 A Intac psytx, hosp, 20-30 min 1.36 0.28 0.37 0.28 0.37 90824 A Intac psytx, hsp 20-30 w/e&m 1.52 0.42 0.46 0.42 0.46 90826 A Intac psytx, hosp, 45-50 min 2.01 0.37 0.50 0.37 0.50 90827 A Intac psytx, hsp 45-50 w/e&m 2.16 0.55 0.60 0.55 0.60 90828 A Intac psytx, hosp, 75-80 min 2.94 0.50 0.69 0.50 0.69 90829 A Intac psytx, hsp 75-80 w/e&m 3.10 0.73 0.81 0.73 0.81 90845 A Psychoanalysis 1.79 0.42 0.47 0.34 0.41 90846 R Family psytx w/o patient 1.83 0.48 0.57 0.39 0.49 90847 R Family psytx w/patient 2.21 0.68 0.79 0.43 0.55 90849 R Multiple family group psytx 0.59 0.38 0.37 0.22 0.24 90853 A Group psychotherapy 0.59 0.32 0.32 0.24 0.25 90857 A Intac group psytx 0.63 0.43 0.42 0.29 0.28 90862 A Medication management 0.95 0.71 0.69 0.31 0.33 90865 A Narcosynthesis 2.84 1.72 1.66 0.68 0.78 90870 A Electroconvulsive therapy 1.88 2.20 2.22 0.44 0.48 90875 N Psychophysiological therapy 1.20 0.82 0.85 0.52 0.51 90876 N Psychophysiological therapy 1.90 1.11 1.13 0.82 0.81 90880 A Hypnotherapy 2.19 0.51 0.68 0.36 0.47 90882 N Environmental manipulation 0.00 0.00 0.00 0.00 0.00 90885 B Psy evaluation of records 0.97 0.42 0.41 0.42 0.41 90887 B Consultation with family 1.48 0.97 0.97 0.64 0.63 90889 B Preparation of report 0.00 0.00 0.00 0.00 0.00 90899 C Psychiatric service/therapy 0.00 0.00 0.00 0.00 0.00 90901 A Biofeedback train, any meth 0.41 0.68 0.64 0.19 0.17 90911 A Biofeedback peri/uro/rectal 0.89 1.45 1.58 0.37 0.38 
CMS-1503-P 1117

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

90935 A Hemodialysis, one evaluation 1.22 NA NA 0.69 0.70 90937 A Hemodialysis, repeated eval 2.11 NA NA 1.02 1.02 90940 X Hemodialysis access study 0.00 0.00 0.00 0.00 0.00 90945 A Dialysis, one evaluation 1.28 NA NA 0.71 0.71 90947 A Dialysis, repeated eval 2.16 NA NA 1.03 1.03 90951 A Esrd serv, 4 visits p mo, <2 18.46 7.75 8.45 7.75 8.45 90952 C Esrd serv, 2-3 vsts p mo, <2 0.00 0.00 0.00 0.00 0.00 90953 C Esrd serv, 1 visit p mo, <2 0.00 0.00 0.00 0.00 0.00 90954 A Esrd serv, 4 vsts p mo, 2-11 15.98 6.63 6.52 6.63 6.52 90955 A Esrd srv 2-3 vsts p mo, 2-11 8.79 3.90 3.93 3.90 3.93 90956 A Esrd srv, 1 visit p mo, 2-11 5.95 2.85 2.78 2.85 2.78 90957 A Esrd srv, 4 vsts p mo, 12-19 12.52 5.34 5.45 5.34 5.45 90958 A Esrd srv 2-3 vsts p mo 12-19 8.34 3.79 3.84 3.79 3.84 90959 A Esrd serv, 1 vst p mo, 12-19 5.50 2.71 2.62 2.71 2.62 90960 A Esrd srv, 4 visits p mo, 20+ 5.18 2.65 2.81 2.65 2.81 90961 A Esrd srv, 2-3 vsts p mo, 20+ 4.26 2.32 2.30 2.32 2.30 90962 A Esrd serv, 1 visit p mo, 20+ 3.15 1.92 1.74 1.92 1.74 90963 A Esrd home pt, serv p mo, <2 10.56 4.55 4.77 4.55 4.77 90964 A Esrd home pt serv p mo, 2-11 9.14 4.03 3.87 4.03 3.87 90965 A Esrd home pt serv p mo 12-19 8.69 3.87 3.71 3.87 3.71 90966 A Esrd home pt, serv p mo, 20+ 4.26 2.31 2.26 2.31 2.26 90967 A Esrd home pt serv p day, <2 0.35 0.15 0.18 0.15 0.18 90968 A Esrd home pt srv p day, 2-11 0.30 0.13 0.13 0.13 0.13 90969 A Esrd home pt srv p day 12-19 0.29 0.13 0.13 0.13 0.13 90970 A Esrd home pt serv p day, 20+ 0.14 0.08 0.08 0.08 0.08 90989 X Dialysis training, complete 0.00 0.00 0.00 0.00 0.00 
CMS-1503-P 1118

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

90993 X Dialysis training, incompl 0.00 0.00 0.00 0.00 0.00 90997 A Hemoperfusion 1.84 NA NA 0.64 0.66 90999 C Dialysis procedure 0.00 0.00 0.00 0.00 0.00 91000 A Esophageal intubation 0.73 2.25 2.12 NA NA 91000 TC A Esophageal intubation 0.00 1.96 1.83 NA NA 91000 26 A Esophageal intubation 0.73 0.29 0.29 0.29 0.29 91010 A Esophagus motility study 1.25 3.80 4.16 NA NA 

91010 TC A Esophagus motility study 0.00 3.14 3.50 NA NA 

91010 26 A Esophagus motility study 1.25 0.66 0.66 0.66 0.66 

91011 A Esophagus motility study 1.50 5.35 5.82 NA NA 

91011 TC A Esophagus motility study 0.00 4.53 4.99 NA NA 

91011 26 A Esophagus motility study 1.50 0.82 0.83 0.82 0.83 

91012 A Esophagus motility study 1.46 5.42 5.94 NA NA 

91012 TC A Esophagus motility study 0.00 4.63 5.15 NA NA 

91012 26 A Esophagus motility study 1.46 0.79 0.79 0.79 0.79 

91020 A Gastric motility studies 1.44 5.11 5.36 NA NA 91020 TC A Gastric motility studies 0.00 4.34 4.61 NA NA 91020 26 A Gastric motility studies 1.44 0.77 0.75 0.77 0.75 91022 A Duodenal motility study 1.44 3.38 3.83 NA NA 91022 TC A Duodenal motility study 0.00 2.59 3.03 NA NA 91022 26 A Duodenal motility study 1.44 0.79 0.80 0.79 0.80 91030 A Acid perfusion of esophagus 0.91 2.94 3.13 NA NA 91030 TC A Acid perfusion of esophagus 0.00 2.44 2.63 NA NA 91030 26 A Acid perfusion of esophagus 0.91 0.50 0.50 0.50 0.50 91034 A Gastroesophageal reflux test 0.97 4.27 4.71 NA NA 91034 TC A Gastroesophageal reflux test 0.00 3.76 4.21 NA NA 
CMS-1503-P 1119

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

91034 26 A Gastroesophageal reflux test 0.97 0.51 0.50 0.51 0.50 91035 A G-esoph reflx tst w/electrod 1.59 11.71 12.43 NA NA 91035 TC A G-esoph reflx tst w/electrod 0.00 10.87 11.59 NA NA 91035 26 A G-esoph reflx tst w/electrod 1.59 0.84 0.84 0.84 0.84 91037 A Esoph imped function test 0.97 3.50 3.70 NA NA 91037 TC A Esoph imped function test 0.00 2.99 3.18 NA NA 91037 26 A Esoph imped function test 0.97 0.51 0.52 0.51 0.52 91038 A Esoph imped funct test > 1h 1.10 11.69 7.45 NA NA 91038 TC A Esoph imped funct test > 1h 0.00 11.10 6.86 NA NA 91038 26 A Esoph imped funct test > 1h 1.10 0.59 0.59 0.59 0.59 91040 A Esoph balloon distension tst 0.97 6.99 8.98 NA NA 91040 TC A Esoph balloon distension tst 0.00 6.61 8.51 NA NA 91040 26 A Esoph balloon distension tst 0.97 0.38 0.47 0.38 0.47 91052 A Gastric analysis test 0.79 2.96 2.98 NA NA 91052 TC A Gastric analysis test 0.00 2.53 2.58 NA NA 91052 26 A Gastric analysis test 0.79 0.43 0.40 0.43 0.40 91055 A Gastric intubation for smear 0.94 2.80 2.96 NA NA 91055 TC A Gastric intubation for smear 0.00 2.38 2.57 NA NA 91055 26 A Gastric intubation for smear 0.94 0.42 0.39 0.42 0.39 91065 A Breath hydrogen test 0.20 2.30 2.08 NA NA 91065 TC A Breath hydrogen test 0.00 2.19 1.98 NA NA 91065 26 A Breath hydrogen test 0.20 0.11 0.10 0.11 0.10 91105 A Gastric intubation treatment 0.37 2.25 2.17 0.10 0.09 91110 A Gi tract capsule endoscopy 3.64 21.05 22.86 NA NA 91110 TC A Gi tract capsule endoscopy 0.00 19.08 20.89 NA NA 91110 26 A Gi tract capsule endoscopy 3.64 1.97 1.97 1.97 1.97 
CMS-1503-P 1120

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

91111 A Esophageal capsule endoscopy 1.00 18.94 20.25 NA NA 91111 TC A Esophageal capsule endoscopy 0.00 18.40 19.70 NA NA 91111 26 A Esophageal capsule endoscopy 1.00 0.54 0.55 0.54 0.55 91120 A Rectal sensation test 0.97 8.85 10.08 NA NA 91120 TC A Rectal sensation test 0.00 8.42 9.67 NA NA 91120 26 A Rectal sensation test 0.97 0.43 0.41 0.43 0.41 91122 A Anal pressure record 1.77 4.35 4.77 NA NA 91122 TC A Anal pressure record 0.00 3.58 4.01 NA NA 91122 26 A Anal pressure record 1.77 0.77 0.76 0.77 0.76 91123 B Irrigate fecal impaction 0.00 0.00 0.00 0.00 0.00 91132 C Electrogastrography 0.00 0.00 0.00 NA NA 91132 TC C Electrogastrography 0.00 0.00 0.00 NA NA 91132 26 A Electrogastrography 0.52 0.28 0.28 0.28 0.28 91133 C Electrogastrography w/test 0.00 0.00 0.00 NA NA 91133 TC C Electrogastrography w/test 0.00 0.00 0.00 NA NA 91133 26 A Electrogastrography w/test 0.66 0.36 0.37 0.36 0.37 91299 C Gastroenterology procedure 0.00 0.00 0.00 NA NA 91299 TC C Gastroenterology procedure 0.00 0.00 0.00 NA NA 91299 26 C Gastroenterology procedure 0.00 0.00 0.00 0.00 0.00 92002 A Eye exam, new patient 0.88 1.36 1.26 0.49 0.43 92004 A Eye exam, new patient 1.82 2.36 2.17 1.06 0.91 92012 A Eye exam established pat 0.92 1.47 1.35 0.61 0.50 92014 A Eye exam & treatment 1.42 2.06 1.88 0.90 0.75 92015 N Refraction 0.38 0.18 0.38 0.16 0.16 92018 A New eye exam & treatment 2.50 NA NA 1.66 1.42 92019 A Eye exam & treatment 1.31 NA NA 0.67 0.59 
CMS-1503-P 1121

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

92020 A Special eye evaluation 0.37 0.40 0.37 0.24 0.21 92025 A Corneal topography 0.35 0.70 0.64 NA NA 92025 TC A Corneal topography 0.00 0.47 0.45 NA NA 92025 26 A Corneal topography 0.35 0.23 0.19 0.23 0.19 92060 A Special eye evaluation 0.69 1.13 1.03 NA NA 92060 TC A Special eye evaluation 0.00 0.70 0.66 NA NA 92060 26 A Special eye evaluation 0.69 0.43 0.37 0.43 0.37 92065 A Orthoptic/pleoptic training 0.37 1.13 1.03 NA NA 92065 TC A Orthoptic/pleoptic training 0.00 0.97 0.89 NA NA 92065 26 A Orthoptic/pleoptic training 0.37 0.16 0.14 0.16 0.14 92070 A Fitting of contact lens 0.70 1.29 1.22 0.43 0.37 92081 A Visual field examination(s) 0.36 1.29 1.22 NA NA 92081 TC A Visual field examination(s) 0.00 1.08 1.04 NA NA 92081 26 A Visual field examination(s) 0.36 0.21 0.18 0.21 0.18 92082 A Visual field examination(s) 0.44 1.75 1.66 NA NA 92082 TC A Visual field examination(s) 0.00 1.50 1.44 NA NA 92082 26 A Visual field examination(s) 0.44 0.25 0.22 0.25 0.22 92083 A Visual field examination(s) 0.50 2.04 1.93 NA NA 92083 TC A Visual field examination(s) 0.00 1.72 1.65 NA NA 92083 26 A Visual field examination(s) 0.50 0.32 0.28 0.32 0.28 92100 A Serial tonometry exam(s) 0.92 1.81 1.68 0.55 0.47 92120 A Tonography & eye evaluation 0.81 1.40 1.31 0.47 0.41 92130 A Water provocation tonography 0.81 1.65 1.55 0.51 0.44 92135 A Ophth dx imaging post seg 0.35 1.09 1.03 NA NA 92135 TC A Ophth dx imaging post seg 0.00 0.86 0.83 NA NA 92135 26 A Ophth dx imaging post seg 0.35 0.23 0.20 0.23 0.20 
CMS-1503-P 1122

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

92136 A Ophthalmic biometry 0.54 1.94 1.86 NA NA 92136 TC A Ophthalmic biometry 0.00 1.56 1.54 NA NA 92136 26 A Ophthalmic biometry 0.54 0.38 0.32 0.38 0.32 92140 A Glaucoma provocative tests 0.50 1.24 1.18 0.28 0.24 92225 A Special eye exam, initial 0.38 0.39 0.34 0.24 0.21 92226 A Special eye exam, subsequent 0.33 0.38 0.33 0.23 0.19 92230 A Eye exam with photos 0.60 1.00 1.04 0.36 0.31 92235 A Eye exam with photos 0.81 3.07 2.96 NA NA 92235 TC A Eye exam with photos 0.00 2.50 2.47 NA NA 92235 26 A Eye exam with photos 0.81 0.57 0.49 0.57 0.49 92240 A Icg angiography 1.10 5.83 5.81 NA NA 92240 TC A Icg angiography 0.00 5.05 5.15 NA NA 92240 26 A Icg angiography 1.10 0.78 0.66 0.78 0.66 92250 A Eye exam with photos 0.44 1.73 1.68 NA NA 92250 TC A Eye exam with photos 0.00 1.47 1.45 NA NA 92250 26 A Eye exam with photos 0.44 0.26 0.23 0.26 0.23 92260 A Ophthalmoscopy/dynamometry 0.20 0.33 0.31 0.13 0.11 92265 A Eye muscle evaluation 0.81 1.59 1.46 NA NA 92265 TC A Eye muscle evaluation 0.00 1.02 1.02 NA NA 92265 26 A Eye muscle evaluation 0.81 0.57 0.44 0.57 0.44 92270 A Electro-oculography 0.81 1.68 1.68 NA NA 92270 TC A Electro-oculography 0.00 1.30 1.33 NA NA 92270 26 A Electro-oculography 0.81 0.38 0.35 0.38 0.35 92275 A Electroretinography 1.01 3.37 3.08 NA NA 92275 TC A Electroretinography 0.00 2.67 2.49 NA NA 92275 26 A Electroretinography 1.01 0.70 0.59 0.70 0.59 
CMS-1503-P 1123

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

92283 A Color vision examination 0.17 1.31 1.23 NA NA 92283 TC A Color vision examination 0.00 1.22 1.15 NA NA 92283 26 A Color vision examination 0.17 0.09 0.08 0.09 0.08 92284 A Dark adaptation eye exam 0.24 1.39 1.47 NA NA 92284 TC A Dark adaptation eye exam 0.00 1.28 1.37 NA NA 92284 26 A Dark adaptation eye exam 0.24 0.11 0.10 0.11 0.10 92285 A Eye photography 0.20 1.04 1.03 NA NA 92285 TC A Eye photography 0.00 0.92 0.92 NA NA 92285 26 A Eye photography 0.20 0.12 0.11 0.12 0.11 92286 A Internal eye photography 0.66 2.78 2.79 NA NA 92286 TC A Internal eye photography 0.00 2.36 2.43 NA NA 92286 26 A Internal eye photography 0.66 0.42 0.36 0.42 0.36 92287 A Internal eye photography 0.81 2.65 2.55 0.57 0.47 92310 N Contact lens fitting 1.17 1.47 1.47 0.51 0.50 92311 A Contact lens fitting 1.08 1.81 1.66 0.56 0.49 92312 A Contact lens fitting 1.26 2.10 1.89 0.65 0.57 92313 A Contact lens fitting 0.92 1.98 1.79 0.58 0.48 92314 N Prescription of contact lens 0.69 1.49 1.47 0.30 0.29 92315 A Prescription of contact lens 0.45 1.69 1.56 0.22 0.19 92316 A Prescription of contact lens 0.68 2.30 2.02 0.48 0.39 92317 A Prescription of contact lens 0.45 1.66 1.57 0.18 0.17 92325 A Modification of contact lens 0.00 1.06 0.97 NA NA 92326 A Replacement of contact lens 0.00 0.92 1.03 NA NA 92340 N Fitting of spectacles 0.37 0.59 0.63 0.16 0.16 92341 N Fitting of spectacles 0.47 0.64 0.68 0.20 0.20 92342 N Fitting of spectacles 0.53 0.66 0.70 0.23 0.23 
CMS-1503-P 1124

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

92352 B Special spectacles fitting 0.37 0.74 0.77 0.16 0.16 92353 B Special spectacles fitting 0.50 0.80 0.82 0.22 0.21 92354 B Special spectacles fitting 0.00 0.35 1.64 NA NA 92355 B Special spectacles fitting 0.00 0.54 1.14 NA NA 92358 B Eye prosthesis service 0.00 0.29 0.41 NA NA 92370 N Repair & adjust spectacles 0.32 0.52 0.55 0.14 0.14 92371 B Repair & adjust spectacles 0.00 0.30 0.36 NA NA 92499 C Eye service or procedure 0.00 0.00 0.00 NA NA 92499 TC C Eye service or procedure 0.00 0.00 0.00 NA NA 92499 26 C Eye service or procedure 0.00 0.00 0.00 0.00 0.00 92502 A Ear and throat examination 1.51 NA NA 1.33 1.25 92504 A Ear microscopy examination 0.18 0.72 0.71 0.10 0.09 92506 A Speech/hearing evaluation 0.86 3.96 3.90 NA NA 92507 A Speech/hearing therapy 0.52 1.37 1.38 NA NA 92508 A Speech/hearing therapy 0.26 0.67 0.66 NA NA 92511 A Nasopharyngoscopy 0.84 3.74 3.76 0.92 0.88 92512 A Nasal function studies 0.55 1.19 1.21 0.30 0.26 92516 A Facial nerve function test 0.43 1.57 1.51 0.24 0.22 92520 A Laryngeal function studies 0.75 1.35 1.18 0.48 0.41 92526 A Oral function therapy 1.34 0.72 1.32 NA NA 92531 B Spontaneous nystagmus study 0.00 0.00 0.00 0.00 0.00 92532 B Positional nystagmus test 0.00 0.00 0.00 0.00 0.00 92533 B Caloric vestibular test 0.00 0.00 0.00 0.00 0.00 92534 B Optokinetic nystagmus test 0.00 0.00 0.00 0.00 0.00 92540 A Basic vestibular evaluation 1.50 1.28 1.28 NA NA 92540 TC A Basic vestibular evaluation 0.00 0.53 0.53 NA NA 
CMS-1503-P 1125

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

92540 26 A Basic vestibular evaluation 1.50 0.75 0.75 0.75 0.75 92541 A Spontaneous nystagmus test 0.40 0.45 0.90 NA NA 92541 TC A Spontaneous nystagmus test 0.00 0.25 0.72 NA NA 92541 26 A Spontaneous nystagmus test 0.40 0.20 0.18 0.20 0.18 92542 A Positional nystagmus test 0.33 0.41 0.97 NA NA 92542 TC A Positional nystagmus test 0.00 0.24 0.81 NA NA 92542 26 A Positional nystagmus test 0.33 0.17 0.16 0.17 0.16 92543 A Caloric vestibular test 0.10 0.30 0.53 NA NA 92543 TC A Caloric vestibular test 0.00 0.25 0.48 NA NA 92543 26 A Caloric vestibular test 0.10 0.05 0.05 0.05 0.05 92544 A Optokinetic nystagmus test 0.26 0.36 0.80 NA NA 92544 TC A Optokinetic nystagmus test 0.00 0.23 0.68 NA NA 92544 26 A Optokinetic nystagmus test 0.26 0.13 0.12 0.13 0.12 92545 A Oscillating tracking test 0.23 0.34 0.76 NA NA 92545 TC A Oscillating tracking test 0.00 0.23 0.65 NA NA 92545 26 A Oscillating tracking test 0.23 0.11 0.11 0.11 0.11 92546 A Sinusoidal rotational test 0.29 2.53 2.41 NA NA 92546 TC A Sinusoidal rotational test 0.00 2.39 2.28 NA NA 92546 26 A Sinusoidal rotational test 0.29 0.14 0.13 0.14 0.13 92547 A Supplemental electrical test 0.00 0.15 0.13 0.15 0.13 92548 A Posturography 0.50 2.58 2.43 NA NA 92548 TC A Posturography 0.00 2.33 2.20 NA NA 92548 26 A Posturography 0.50 0.25 0.23 0.25 0.23 92550 A Tympanometry & reflex thresh 0.35 0.24 0.24 NA NA 92551 N Pure tone hearing test, air 0.00 0.31 0.32 NA NA 92552 A Pure tone audiometry, air 0.00 0.79 0.73 NA NA 
CMS-1503-P 1126

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

92553 A Audiometry, air & bone 0.00 0.96 0.92 NA NA 92555 A Speech threshold audiometry 0.00 0.57 0.53 NA NA 92556 A Speech audiometry, complete 0.00 0.90 0.82 NA NA 92557 A Comprehensive hearing test 0.60 0.46 0.55 0.32 0.44 92559 N Group audiometric testing 0.00 0.00 0.00 0.00 0.00 92560 N Bekesy audiometry, screen 0.00 0.00 0.00 0.00 0.00 92561 A Bekesy audiometry, diagnosis 0.00 1.01 0.93 NA NA 92562 A Loudness balance test 0.00 1.10 0.90 NA NA 92563 A Tone decay hearing test 0.00 0.78 0.71 NA NA 92564 A Sisi hearing test 0.00 0.68 0.63 NA NA 92565 A Stenger test, pure tone 0.00 0.36 0.37 NA NA 92567 A Tympanometry 0.20 0.20 0.24 0.11 0.16 92568 A Acoustic refl threshold tst 0.29 0.16 0.18 0.16 0.18 92570 A Acoustic immittance testing 0.55 0.35 0.35 0.29 0.29 92571 A Filtered speech hearing test 0.00 0.63 0.56 NA NA 92572 A Staggered spondaic word test 0.00 1.24 0.90 NA NA 92575 A Sensorineural acuity test 0.00 1.69 1.41 NA NA 92576 A Synthetic sentence test 0.00 0.91 0.77 NA NA 92577 A Stenger test, speech 0.00 0.42 0.46 NA NA 92579 A Visual audiometry (vra) 0.70 0.54 0.54 0.40 0.42 92582 A Conditioning play audiometry 0.00 1.65 1.46 NA NA 92583 A Select picture audiometry 0.00 1.03 1.02 NA NA 92584 A Electrocochleography 0.00 1.84 1.91 NA NA 92585 A Auditor evoke potent, compre 0.50 2.98 2.75 NA NA 92585 TC A Auditor evoke potent, compre 0.00 2.72 2.51 NA NA 92585 26 A Auditor evoke potent, compre 0.50 0.26 0.24 0.26 0.24 
CMS-1503-P 1127

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

92586 A Auditor evoke potent, limit 0.00 2.14 2.02 NA NA 92587 A Evoked auditory test 0.13 0.85 0.91 NA NA 92587 TC A Evoked auditory test 0.00 0.78 0.85 NA NA 92587 26 A Evoked auditory test 0.13 0.07 0.06 0.07 0.06 92588 A Evoked auditory test 0.36 1.57 1.53 NA NA 92588 TC A Evoked auditory test 0.00 1.38 1.36 NA NA 92588 26 A Evoked auditory test 0.36 0.19 0.17 0.19 0.17 92590 N Hearing aid exam, one ear 0.00 0.00 0.00 0.00 0.00 92591 N Hearing aid exam, both ears 0.00 0.00 0.00 0.00 0.00 92592 N Hearing aid check, one ear 0.00 0.00 0.00 0.00 0.00 92593 N Hearing aid check, both ears 0.00 0.00 0.00 0.00 0.00 92594 N Electro hearng aid test, one 0.00 0.00 0.00 0.00 0.00 92595 N Electro hearng aid tst, both 0.00 0.00 0.00 0.00 0.00 92596 A Ear protector evaluation 0.00 1.20 1.14 NA NA 92597 A Oral speech device eval 1.26 0.78 1.52 NA NA 92601 A Cochlear implt f/up exam < 7 2.30 1.49 1.85 0.99 1.38 92602 A Reprogram cochlear implt < 7 1.30 1.00 1.26 0.56 0.84 92603 A Cochlear implt f/up exam 7 > 2.25 1.83 1.80 1.19 1.28 92604 A Reprogram cochlear implt 7 > 1.25 1.19 1.16 0.66 0.73 92605 B Eval for nonspeech device rx 0.00 0.00 0.00 0.00 0.00 92606 B Non-speech device service 0.00 0.00 0.00 0.00 0.00 92607 A Ex for speech device rx, 1hr 0.00 5.22 5.09 NA NA 92608 A Ex for speech device rx addl 0.00 1.36 1.14 NA NA 92609 A Use of speech device service 0.00 2.13 2.38 NA NA 92610 A Evaluate swallowing function 1.30 0.89 1.69 0.64 0.64 92611 A Motion fluoroscopy/swallow 1.34 1.05 1.88 NA NA 
CMS-1503-P 1128

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

92612 A Endoscopy swallow tst (fees) 1.27 3.52 3.50 0.70 0.65 92613 A Endoscopy swallow tst (fees) 0.71 0.39 0.37 0.39 0.37 92614 A Laryngoscopic sensory test 1.27 3.02 2.97 0.72 0.66 92615 A Eval laryngoscopy sense tst 0.63 0.36 0.34 0.36 0.34 92616 A Fees w/laryngeal sense test 1.88 3.86 3.86 1.02 0.95 92617 A Interprt fees/laryngeal test 0.79 0.43 0.40 0.43 0.40 92620 A Auditory function, 60 min 1.50 1.15 0.84 0.87 0.70 92621 A Auditory function, + 15 min 0.35 0.27 0.20 0.18 0.15 92625 A Tinnitus assessment 1.15 0.81 0.64 0.61 0.54 92626 A Eval aud rehab status 1.40 1.09 0.99 0.73 0.80 92627 A Eval aud status rehab add-on 0.33 0.29 0.26 0.17 0.20 92630 I Aud rehab pre-ling hear loss 0.00 0.00 0.00 0.00 0.00 92633 I Aud rehab postling hear loss 0.00 0.00 0.00 0.00 0.00 92640 A Aud brainstem implt programg 1.76 1.20 0.76 0.89 0.60 92700 C Ent procedure/service 0.00 0.00 0.00 0.00 0.00 92950 A Heart/lung resuscitation cpr 3.79 4.07 4.10 1.04 1.03 92953 A Temporary external pacing 0.23 NA NA 0.07 0.08 92960 A Cardioversion electric, ext 2.25 3.60 4.65 1.13 1.39 92961 A Cardioversion, electric, int 4.59 NA NA 2.03 2.45 92970 A Cardioassist, internal 3.51 NA NA 1.37 1.51 92971 A Cardioassist, external 1.77 NA NA 0.82 1.04 92973 A Percut coronary thrombectomy 3.28 NA NA 1.29 1.63 92974 A Cath place, cardio brachytx 3.00 NA NA 1.17 1.50 92975 A Dissolve clot, heart vessel 7.24 NA NA 2.88 3.60 92977 A Dissolve clot, heart vessel 0.00 1.42 2.66 NA NA 92978 C Intravasc us, heart add-on 0.00 0.00 0.00 NA NA 
CMS-1503-P 1129

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

92978 TC C Intravasc us, heart add-on 0.00 0.00 0.00 NA NA 92978 26 A Intravasc us, heart add-on 1.80 0.71 0.89 0.71 0.89 92979 C Intravasc us, heart add-on 0.00 0.00 0.00 NA NA 92979 TC C Intravasc us, heart add-on 0.00 0.00 0.00 NA NA 92979 26 A Intravasc us, heart add-on 1.44 0.56 0.72 0.56 0.72 92980 A Insert intracoronary stent 14.82 NA NA 5.99 7.59 92981 A Insert intracoronary stent 4.16 NA NA 1.63 2.07 92982 A Coronary artery dilation 10.96 NA NA 4.48 5.67 92984 A Coronary artery dilation 2.97 NA NA 1.16 1.48 92986 A Revision of aortic valve 22.85 NA NA 11.68 14.46 92987 A Revision of mitral valve 23.63 NA NA 11.91 14.88 92990 A Revision of pulmonary valve 18.27 NA NA 9.74 11.72 92992 C Revision of heart chamber 0.00 0.00 0.00 0.00 0.00 92993 C Revision of heart chamber 0.00 0.00 0.00 0.00 0.00 92995 A Coronary atherectomy 12.07 NA NA 4.91 6.24 92996 A Coronary atherectomy add-on 3.26 NA NA 1.28 1.63 92997 A Pul art balloon repr, percut 11.98 NA NA 4.84 5.58 92998 A Pul art balloon repr, percut 5.99 NA NA 2.33 2.84 93000 A Electrocardiogram, complete 0.17 0.32 0.39 NA NA 93005 A Electrocardiogram, tracing 0.00 0.25 0.31 NA NA 93010 A Electrocardiogram report 0.17 0.07 0.08 0.07 0.08 93012 A Transmission of ecg 0.00 3.87 4.86 NA NA 93014 A Report on transmitted ecg 0.52 0.21 0.24 0.21 0.24 93015 A Cardiovascular stress test 0.75 1.56 1.92 NA NA 93016 A Cardiovascular stress test 0.45 0.18 0.22 0.18 0.22 93017 A Cardiovascular stress test 0.00 1.26 1.56 NA NA 
CMS-1503-P 1130

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

93018 A Cardiovascular stress test 0.30 0.12 0.14 0.12 0.14 93024 A Cardiac drug stress test 1.17 1.88 2.19 NA NA 93024 TC A Cardiac drug stress test 0.00 1.42 1.64 NA NA 93024 26 A Cardiac drug stress test 1.17 0.46 0.55 0.46 0.55 93025 A Microvolt t-wave assess 0.75 3.63 4.83 NA NA 93025 TC A Microvolt t-wave assess 0.00 3.33 4.46 NA NA 93025 26 A Microvolt t-wave assess 0.75 0.30 0.37 0.30 0.37 93040 A Rhythm ECG with report 0.16 0.19 0.21 NA NA 93041 A Rhythm ECG, tracing 0.00 0.14 0.15 NA NA 93042 A Rhythm ECG, report 0.16 0.05 0.06 0.05 0.06 93224 A ECG monitor/report, 24 hrs 0.52 1.95 2.50 NA NA 93225 A ECG monitor/record, 24 hrs 0.00 0.89 0.99 NA NA 93226 A ECG monitor/report, 24 hrs 0.00 0.82 1.24 NA NA 93227 A ECG monitor/review, 24 hrs 0.52 0.24 0.27 0.24 0.27 93228 A Remote 30 day ecg rev/report 0.52 0.21 0.21 0.21 0.21 93229 C Remote 30 day ecg tech supp 0.00 0.00 0.00 0.00 0.00 93230 A ECG monitor/report, 24 hrs 0.52 1.95 2.55 NA NA 93231 A Ecg monitor/record, 24 hrs 0.00 0.78 0.93 NA NA 93232 A ECG monitor/report, 24 hrs 0.00 0.96 1.38 NA NA 93233 A ECG monitor/review, 24 hrs 0.52 0.21 0.24 0.21 0.24 93235 C ECG monitor/report, 24 hrs 0.00 0.00 0.00 0.00 0.00 93236 C ECG monitor/report, 24 hrs 0.00 0.00 0.00 0.00 0.00 93237 A ECG monitor/review, 24 hrs 0.45 0.18 0.22 0.18 0.22 93268 A ECG record/review 0.52 5.52 6.70 NA NA 93270 A ECG recording 0.00 0.23 0.43 NA NA 93271 A Ecg/monitoring and analysis 0.00 5.09 6.04 NA NA 
CMS-1503-P 1131

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

93272 A Ecg/review, interpret only 0.52 0.20 0.23 0.20 0.23 93278 A ECG/signal-averaged 0.25 0.60 0.75 NA NA 93278 TC A ECG/signal-averaged 0.00 0.49 0.64 NA NA 93278 26 A ECG/signal-averaged 0.25 0.11 0.11 0.11 0.11 93279 A Pm device progr eval, sngl 0.65 0.70 0.86 NA NA 93279 TC A Pm device progr eval, sngl 0.00 0.44 0.53 NA NA 93279 26 A Pm device progr eval, sngl 0.65 0.26 0.33 0.26 0.33 93280 A Pm device progr eval, dual 0.77 0.80 1.01 NA NA 93280 TC A Pm device progr eval, dual 0.00 0.50 0.61 NA NA 93280 26 A Pm device progr eval, dual 0.77 0.30 0.40 0.30 0.40 93281 A Pm device progr eval, multi 0.90 0.93 1.17 NA NA 93281 TC A Pm device progr eval, multi 0.00 0.58 0.71 NA NA 93281 26 A Pm device progr eval, multi 0.90 0.35 0.46 0.35 0.46 

93282 A Icd device prog eval, 1 sngl 0.85 0.84 1.06 NA NA 93282 TC A Icd device prog eval, 1 sngl 0.00 0.51 0.63 NA NA 93282 26 A Icd device prog eval, 1 sngl 0.85 0.33 0.43 0.33 0.43 93283 A Icd device progr eval, dual 1.15 1.05 1.29 NA NA 93283 TC A Icd device progr eval, dual 0.00 0.60 0.73 NA NA 93283 26 A Icd device progr eval, dual 1.15 0.45 0.56 0.45 0.56 93284 A Icd device progr eval, mult 1.25 1.17 1.48 NA NA 93284 TC A Icd device progr eval, mult 0.00 0.68 0.83 NA NA 93284 26 A Icd device progr eval, mult 1.25 0.49 0.65 0.49 0.65 93285 A Ilr device eval progr 0.52 0.61 0.76 NA NA 93285 TC A Ilr device eval progr 0.00 0.40 0.49 NA NA 93285 26 A Ilr device eval progr 0.52 0.21 0.27 0.21 0.27 93286 A Pre-op pm device eval 0.30 0.41 0.46 NA NA 
CMS-1503-P 1132

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

93286 TC A Pre-op pm device eval 0.00 0.29 0.34 NA NA 93286 26 A Pre-op pm device eval 0.30 0.12 0.12 0.12 0.12 93287 A Pre-op icd device eval 0.45 0.50 0.55 NA NA 93287 TC A Pre-op icd device eval 0.00 0.32 0.37 NA NA 93287 26 A Pre-op icd device eval 0.45 0.18 0.18 0.18 0.18 93288 A Pm device eval in person 0.43 0.57 0.72 NA NA 93288 TC A Pm device eval in person 0.00 0.40 0.50 NA NA 93288 26 A Pm device eval in person 0.43 0.17 0.22 0.17 0.22 93289 A Icd device interrogate 0.92 0.86 1.04 NA NA 93289 TC A Icd device interrogate 0.00 0.50 0.61 NA NA 93289 26 A Icd device interrogate 0.92 0.36 0.43 0.36 0.43 93290 A Icm device eval 0.43 0.40 0.44 NA NA 93290 TC A Icm device eval 0.00 0.23 0.27 NA NA 93290 26 A Icm device eval 0.43 0.17 0.17 0.17 0.17 93291 A Ilr device interrogate 0.43 0.54 0.67 NA NA 93291 TC A Ilr device interrogate 0.00 0.37 0.45 NA NA 93291 26 A Ilr device interrogate 0.43 0.17 0.22 0.17 0.22 93292 A Wcd device interrogate 0.43 0.45 0.56 NA NA 93292 TC A Wcd device interrogate 0.00 0.28 0.34 NA NA 93292 26 A Wcd device interrogate 0.43 0.17 0.22 0.17 0.22 93293 A Pm phone r-strip device eval 0.32 1.13 1.30 NA NA 93293 TC A Pm phone r-strip device eval 0.00 1.01 1.16 NA NA 93293 26 A Pm phone r-strip device eval 0.32 0.12 0.14 0.12 0.14 93294 A Pm device interrogate remote 0.65 0.26 0.33 0.26 0.33 93295 A Icd device interrogat remote 1.29 0.51 0.63 0.51 0.63 93296 A Pm/icd remote tech serv 0.00 0.69 0.94 NA NA 
CMS-1503-P 1133

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

93297 A Icm device interrogat remote 0.52 0.20 0.20 0.20 0.20 93298 A Ilr device interrogat remote 0.52 0.20 0.27 0.20 0.27 93299 C Icm/ilr remote tech serv 0.00 0.00 0.00 0.00 0.00 93303 A Echo transthoracic 1.30 4.16 4.77 NA NA 93303 TC A Echo transthoracic 0.00 3.64 4.17 NA NA 93303 26 A Echo transthoracic 1.30 0.52 0.60 0.52 0.60 93304 A Echo transthoracic 0.75 2.82 3.11 NA NA 93304 TC A Echo transthoracic 0.00 2.52 2.78 NA NA 93304 26 A Echo transthoracic 0.75 0.30 0.33 0.30 0.33 93306 A Tte w/doppler, complete 1.30 3.97 5.43 NA NA 93306 TC A Tte w/doppler, complete 0.00 3.45 4.78 NA NA 93306 26 A Tte w/doppler, complete 1.30 0.52 0.65 0.52 0.65 93307 A Tte w/o doppler, complete 0.92 2.25 3.36 NA NA 93307 TC A Tte w/o doppler, complete 0.00 1.87 2.91 NA NA 93307 26 A Tte w/o doppler, complete 0.92 0.38 0.45 0.38 0.45 93308 A Tte, f-up or lmtd 0.53 2.14 2.52 NA NA 93308 TC A Tte, f-up or lmtd 0.00 1.93 2.26 NA NA 93308 26 A Tte, f-up or lmtd 0.53 0.21 0.26 0.21 0.26 93312 A Echo transesophageal 2.20 6.49 7.13 NA NA 93312 TC A Echo transesophageal 0.00 5.70 6.17 NA NA 93312 26 A Echo transesophageal 2.20 0.79 0.96 0.79 0.96 93313 A Echo transesophageal 0.95 NA NA 0.22 0.19 93314 A Echo transesophageal 1.25 6.49 6.97 NA NA 93314 TC A Echo transesophageal 0.00 6.03 6.42 NA NA 93314 26 A Echo transesophageal 1.25 0.46 0.55 0.46 0.55 93315 C Echo transesophageal 0.00 0.00 0.00 NA NA 
CMS-1503-P 1134

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

93315 TC C Echo transesophageal 0.00 0.00 0.00 NA NA 93315 26 A Echo transesophageal 2.78 1.04 1.27 1.04 1.27 93316 A Echo transesophageal 0.95 NA NA 0.27 0.29 93317 C Echo transesophageal 0.00 0.00 0.00 NA NA 93317 TC C Echo transesophageal 0.00 0.00 0.00 NA NA 93317 26 A Echo transesophageal 1.83 0.66 0.72 0.66 0.72 93318 C Echo transesophageal intraop 0.00 0.00 0.00 NA NA 93318 TC C Echo transesophageal intraop 0.00 0.00 0.00 NA NA 93318 26 A Echo transesophageal intraop 2.20 0.76 0.86 0.76 0.86 93320 A Doppler echo exam, heart 0.38 0.87 1.43 NA NA 93320 TC A Doppler echo exam, heart 0.00 0.72 1.25 NA NA 93320 26 A Doppler echo exam, heart 0.38 0.15 0.18 0.15 0.18 93321 A Doppler echo exam, heart 0.15 0.50 0.69 NA NA 93321 TC A Doppler echo exam, heart 0.00 0.44 0.62 NA NA 93321 26 A Doppler echo exam, heart 0.15 0.06 0.07 0.06 0.07 93325 A Doppler color flow add-on 0.07 0.47 0.95 NA NA 93325 TC A Doppler color flow add-on 0.00 0.44 0.92 NA NA 93325 26 A Doppler color flow add-on 0.07 0.03 0.03 0.03 0.03 93350 A Stress tte only 1.46 4.14 4.61 NA NA 93350 TC A Stress tte only 0.00 3.56 3.89 NA NA 93350 26 A Stress tte only 1.46 0.58 0.72 0.58 0.72 93351 A Stress tte complete 1.75 4.70 5.40 NA NA 93351 TC A Stress tte complete 0.00 4.01 4.50 NA NA 93351 26 A Stress tte complete 1.75 0.69 0.90 0.69 0.90 93352 A Admin ecg contrast agent 0.19 0.71 0.86 NA NA 93501 A Right heart catheterization 3.02 15.50 18.56 NA NA 
CMS-1503-P 1135

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

93501 TC A Right heart catheterization 0.00 14.32 17.08 NA NA 93501 26 A Right heart catheterization 3.02 1.18 1.48 1.18 1.48 93503 A Insert/place heart catheter 2.91 NA NA 0.77 0.77 93505 A Biopsy of heart lining 4.37 17.19 18.14 NA NA 93505 TC A Biopsy of heart lining 0.00 15.47 16.00 NA NA 93505 26 A Biopsy of heart lining 4.37 1.72 2.14 1.72 2.14 93508 A Cath placement, angiography 4.09 23.65 26.49 NA NA 93508 TC A Cath placement, angiography 0.00 22.05 24.39 NA NA 93508 26 A Cath placement, angiography 4.09 1.60 2.10 1.60 2.10 93510 A Left heart catheterization 4.32 23.12 29.59 NA NA 93510 TC A Left heart catheterization 0.00 21.43 27.38 NA NA 93510 26 A Left heart catheterization 4.32 1.69 2.21 1.69 2.21 93511 C Left heart catheterization 0.00 NA NA NA NA 93511 TC C Left heart catheterization 0.00 NA NA NA NA 93511 26 A Left heart catheterization 5.02 1.96 2.56 1.96 2.56 93514 C Left heart catheterization 0.00 NA NA NA NA 93514 TC C Left heart catheterization 0.00 NA NA NA NA 93514 26 A Left heart catheterization 7.04 2.75 3.46 2.75 3.46 93524 C Left heart catheterization 0.00 NA NA NA NA 93524 TC C Left heart catheterization 0.00 NA NA NA NA 93524 26 A Left heart catheterization 6.94 2.72 3.53 2.72 3.53 93526 A Rt & Lt heart catheters 5.98 28.80 37.22 NA NA 93526 TC A Rt & Lt heart catheters 0.00 26.46 34.18 NA NA 93526 26 A Rt & Lt heart catheters 5.98 2.34 3.04 2.34 3.04 93527 C Rt & Lt heart catheters 0.00 NA NA NA NA 93527 TC C Rt & Lt heart catheters 0.00 NA NA NA NA 
CMS-1503-P 1136

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

93527 26 A Rt & Lt heart catheters 7.27 2.84 3.66 2.84 3.66 93528 C Rt & Lt heart catheters 0.00 NA NA NA NA 93528 TC C Rt & Lt heart catheters 0.00 NA NA NA NA 93528 26 A Rt & Lt heart catheters 8.99 3.51 4.20 3.51 4.20 93529 C Rt, lt heart catheterization 0.00 NA NA NA NA 93529 TC C Rt, lt heart catheterization 0.00 NA NA NA NA 93529 26 A Rt, lt heart catheterization 4.79 1.87 2.44 1.87 2.44 93530 C Rt heart cath, congenital 0.00 NA NA NA NA 93530 TC C Rt heart cath, congenital 0.00 NA NA NA NA 93530 26 A Rt heart cath, congenital 4.22 1.67 2.03 1.67 2.03 93531 C R & l heart cath, congenital 0.00 NA NA NA NA 93531 TC C R & l heart cath, congenital 0.00 NA NA NA NA 93531 26 A R & l heart cath, congenital 8.34 3.26 3.92 3.26 3.92 93532 C R & l heart cath, congenital 0.00 NA NA NA NA 93532 TC C R & l heart cath, congenital 0.00 NA NA NA NA 93532 26 A R & l heart cath, congenital 9.99 3.90 4.60 3.90 4.60 93533 C R & l heart cath, congenital 0.00 NA NA NA NA 93533 TC C R & l heart cath, congenital 0.00 NA NA NA NA 93533 26 A R & l heart cath, congenital 6.69 2.60 3.10 2.60 3.10 93539 A Injection, cardiac cath 0.40 2.03 2.10 0.16 0.20 93540 A Injection, cardiac cath 0.43 3.86 5.64 0.17 0.22 93541 A Injection for lung angiogram 0.29 0.11 0.14 0.11 0.14 93542 A Injection for heart x-rays 0.29 2.37 3.41 0.11 0.14 93543 A Injection for heart x-rays 0.29 2.16 2.23 0.11 0.14 93544 A Injection for aortography 0.25 1.52 1.57 0.10 0.13 93545 A Inject for coronary x-rays 0.40 4.86 4.97 0.16 0.20 
CMS-1503-P 1137

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

93555 A Imaging, cardiac cath 0.81 0.45 1.47 NA NA 93555 TC A Imaging, cardiac cath 0.00 0.13 1.07 NA NA 93555 26 A Imaging, cardiac cath 0.81 0.32 0.40 0.32 0.40 93556 A Imaging, cardiac cath 0.83 0.65 2.24 NA NA 93556 TC A Imaging, cardiac cath 0.00 0.33 1.83 NA NA 93556 26 A Imaging, cardiac cath 0.83 0.32 0.41 0.32 0.41 93561 C Cardiac output measurement 0.00 NA NA NA NA 93561 TC C Cardiac output measurement 0.00 NA NA NA NA 93561 26 A Cardiac output measurement 0.50 0.20 0.18 0.20 0.18 93562 C Cardiac output measurement 0.00 NA NA NA NA 93562 TC C Cardiac output measurement 0.00 NA NA NA NA 93562 26 A Cardiac output measurement 0.16 0.06 0.05 0.06 0.05 93571 C Heart flow reserve measure 0.00 NA NA NA NA 93571 TC C Heart flow reserve measure 0.00 NA NA NA NA 93571 26 A Heart flow reserve measure 1.80 0.71 0.89 0.71 0.89 93572 C Heart flow reserve measure 0.00 NA NA NA NA 93572 TC C Heart flow reserve measure 0.00 NA NA NA NA 93572 26 A Heart flow reserve measure 1.44 0.56 0.69 0.56 0.69 93580 A Transcath closure of asd 17.97 NA NA 7.39 9.12 93581 A Transcath closure of vsd 24.39 NA NA 9.85 11.47 93600 C Bundle of His recording 0.00 0.00 0.00 NA NA 93600 TC C Bundle of His recording 0.00 0.00 0.00 NA NA 93600 26 A Bundle of His recording 2.12 0.84 1.04 0.84 1.04 93602 C Intra-atrial recording 0.00 0.00 0.00 NA NA 93602 TC C Intra-atrial recording 0.00 0.00 0.00 NA NA 93602 26 A Intra-atrial recording 2.12 0.83 1.02 0.83 1.02 
CMS-1503-P 1138

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

93603 C Right ventricular recording 0.00 0.00 0.00 NA NA 93603 TC C Right ventricular recording 0.00 0.00 0.00 NA NA 93603 26 A Right ventricular recording 2.12 0.82 1.02 0.82 1.02 93609 C Map tachycardia, add-on 0.00 0.00 0.00 NA NA 93609 TC C Map tachycardia, add-on 0.00 0.00 0.00 NA NA 93609 26 A Map tachycardia, add-on 4.99 1.96 2.46 1.96 2.46 93610 C Intra-atrial pacing 0.00 0.00 0.00 NA NA 93610 TC C Intra-atrial pacing 0.00 0.00 0.00 NA NA 93610 26 A Intra-atrial pacing 3.02 1.17 1.44 1.17 1.44 93612 C Intraventricular pacing 0.00 0.00 0.00 NA NA 93612 TC C Intraventricular pacing 0.00 0.00 0.00 NA NA 93612 26 A Intraventricular pacing 3.02 1.16 1.42 1.16 1.42 93613 A Electrophys map 3d, add-on 6.99 NA NA 2.74 3.46 93615 C Esophageal recording 0.00 0.00 0.00 NA NA 93615 TC C Esophageal recording 0.00 0.00 0.00 NA NA 93615 26 A Esophageal recording 0.99 0.39 0.48 0.39 0.48 93616 C Esophageal recording 0.00 0.00 0.00 NA NA 93616 TC C Esophageal recording 0.00 0.00 0.00 NA NA 93616 26 A Esophageal recording 1.49 0.33 0.38 0.33 0.38 93618 C Heart rhythm pacing 0.00 0.00 0.00 NA NA 93618 TC C Heart rhythm pacing 0.00 0.00 0.00 NA NA 93618 26 A Heart rhythm pacing 4.25 1.66 2.12 1.66 2.12 93619 C Electrophysiology evaluation 0.00 0.00 0.00 NA NA 93619 TC C Electrophysiology evaluation 0.00 0.00 0.00 NA NA 93619 26 A Electrophysiology evaluation 7.31 2.86 3.68 2.86 3.68 93620 C Electrophysiology evaluation 0.00 0.00 0.00 NA NA 
CMS-1503-P 1139

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

93620 TC C Electrophysiology evaluation 0.00 0.00 0.00 NA NA 93620 26 A Electrophysiology evaluation 11.57 4.54 5.76 4.54 5.76 93621 C Electrophysiology evaluation 0.00 0.00 0.00 NA NA 93621 TC C Electrophysiology evaluation 0.00 0.00 0.00 NA NA 93621 26 A Electrophysiology evaluation 2.10 0.82 1.04 0.82 1.04 93622 C Electrophysiology evaluation 0.00 0.00 0.00 NA NA 93622 TC C Electrophysiology evaluation 0.00 0.00 0.00 NA NA 93622 26 A Electrophysiology evaluation 3.10 1.22 1.50 1.22 1.50 93623 C Stimulation, pacing heart 0.00 0.00 0.00 NA NA 93623 TC C Stimulation, pacing heart 0.00 0.00 0.00 NA NA 93623 26 A Stimulation, pacing heart 2.85 1.12 1.40 1.12 1.40 93624 C Electrophysiologic study 0.00 0.00 0.00 NA NA 93624 TC C Electrophysiologic study 0.00 0.00 0.00 NA NA 93624 26 A Electrophysiologic study 4.80 1.87 2.42 NA NA 93631 C Heart pacing, mapping 0.00 0.00 0.00 NA NA 93631 TC C Heart pacing, mapping 0.00 0.00 0.00 NA NA 93631 26 A Heart pacing, mapping 7.59 2.74 3.03 2.74 3.03 93640 C Evaluation heart device 0.00 0.00 0.00 NA NA 93640 TC C Evaluation heart device 0.00 0.00 0.00 NA NA 93640 26 A Evaluation heart device 3.51 1.38 1.72 1.38 1.72 93641 C Electrophysiology evaluation 0.00 0.00 0.00 NA NA 93641 TC C Electrophysiology evaluation 0.00 0.00 0.00 NA NA 93641 26 A Electrophysiology evaluation 5.92 2.32 2.92 2.32 2.92 93642 A Electrophysiology evaluation 4.88 5.66 7.43 NA NA 93642 TC A Electrophysiology evaluation 0.00 3.74 4.96 NA NA 93642 26 A Electrophysiology evaluation 4.88 1.92 2.47 1.92 2.47 
CMS-1503-P 1140

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

93650 A Ablate heart dysrhythm focus 10.49 NA NA 4.39 5.48 93651 A Ablate heart dysrhythm focus 16.23 NA NA 6.37 8.00 93652 A Ablate heart dysrhythm focus 17.65 NA NA 6.95 8.73 93660 A Tilt table evaluation 1.89 2.34 2.84 NA NA 93660 TC A Tilt table evaluation 0.00 1.59 1.91 NA NA 93660 26 A Tilt table evaluation 1.89 0.75 0.93 0.75 0.93 93662 C Intracardiac ecg (ice) 0.00 0.00 0.00 NA NA 93662 TC C Intracardiac ecg (ice) 0.00 0.00 0.00 NA NA 93662 26 A Intracardiac ecg (ice) 2.80 1.09 1.38 1.09 1.38 93668 N Peripheral vascular rehab 0.00 0.50 0.53 NA NA 93701 A Bioimpedance, cv analysis 0.00 0.64 0.77 NA NA 93720 A Total body plethysmography 0.17 1.19 1.22 NA NA 93721 A Plethysmography tracing 0.00 1.13 1.16 NA NA 93722 A Plethysmography report 0.17 0.06 0.06 0.06 0.06 93724 A Analyze pacemaker system 4.88 2.66 3.73 NA NA 93724 TC A Analyze pacemaker system 0.00 0.71 1.33 NA NA 93724 26 A Analyze pacemaker system 4.88 1.95 2.40 1.95 2.40 93740 B Temperature gradient studies 0.16 0.07 0.08 NA NA 93740 TC B Temperature gradient studies 0.00 0.00 0.02 NA NA 93740 26 B Temperature gradient studies 0.16 0.07 0.06 0.07 0.06 93745 C Set-up cardiovert-defibrill 0.00 0.00 0.00 NA NA 93745 TC C Set-up cardiovert-defibrill 0.00 0.00 0.00 NA NA 93745 26 C Set-up cardiovert-defibrill 0.00 0.00 0.00 0.00 0.00 

93750 A Interrogation vad, in person 0.92 0.54 0.54 0.34 0.34 93770 B Measure venous pressure 0.16 0.07 0.07 NA NA 93770 TC B Measure venous pressure 0.00 0.00 0.01 NA NA 
CMS-1503-P 1141

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

93770 26 B Measure venous pressure 0.16 0.07 0.06 0.07 0.06 93784 A Ambulatory BP monitoring 0.38 1.10 1.39 NA NA 93786 A Ambulatory BP recording 0.00 0.81 0.89 NA NA 93788 A Ambulatory BP analysis 0.00 0.13 0.34 NA NA 93790 A Review/report BP recording 0.38 0.16 0.16 0.16 0.16 93797 A Cardiac rehab 0.18 0.30 0.34 0.08 0.09 93798 A Cardiac rehab/monitor 0.28 0.40 0.46 0.11 0.14 93799 C Cardiovascular procedure 0.00 0.00 0.00 NA NA 93799 TC C Cardiovascular procedure 0.00 0.00 0.00 NA NA 93799 26 C Cardiovascular procedure 0.00 0.00 0.00 0.00 0.00 93875 A Extracranial study 0.22 2.68 2.82 NA NA 93875 TC A Extracranial study 0.00 2.59 2.73 NA NA 93875 26 A Extracranial study 0.22 0.09 0.09 0.09 0.09 93880 A Extracranial study 0.60 6.10 6.60 NA NA 93880 TC A Extracranial study 0.00 5.87 6.35 NA NA 93880 26 A Extracranial study 0.60 0.23 0.25 0.23 0.25 93882 A Extracranial study 0.40 4.49 4.58 NA NA 93882 TC A Extracranial study 0.00 4.34 4.43 NA NA 93882 26 A Extracranial study 0.40 0.15 0.15 0.15 0.15 93886 A Intracranial study 0.94 8.84 8.56 NA NA 93886 TC A Intracranial study 0.00 8.44 8.17 NA NA 93886 26 A Intracranial study 0.94 0.40 0.39 0.40 0.39 93888 A Intracranial study 0.62 5.24 5.45 NA NA 93888 TC A Intracranial study 0.00 4.99 5.19 NA NA 93888 26 A Intracranial study 0.62 0.25 0.26 0.25 0.26 93890 A Tcd, vasoreactivity study 1.00 6.54 6.77 NA NA 
CMS-1503-P 1142

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

93890 TC A Tcd, vasoreactivity study 0.00 6.13 6.37 NA NA 93890 26 A Tcd, vasoreactivity study 1.00 0.41 0.40 0.41 0.40 93892 A Tcd, emboli detect w/o inj 1.15 8.37 8.01 NA NA 93892 TC A Tcd, emboli detect w/o inj 0.00 7.87 7.54 NA NA 93892 26 A Tcd, emboli detect w/o inj 1.15 0.50 0.47 0.50 0.47 93893 A Tcd, emboli detect w/inj 1.15 9.18 8.41 NA NA 93893 TC A Tcd, emboli detect w/inj 0.00 8.67 7.93 NA NA 93893 26 A Tcd, emboli detect w/inj 1.15 0.51 0.48 0.51 0.48 93922 A Extremity study 0.25 3.26 3.41 NA NA 93922 TC A Extremity study 0.00 3.17 3.31 NA NA 93922 26 A Extremity study 0.25 0.09 0.10 0.09 0.10 93923 A Extremity study 0.45 4.84 5.09 NA NA 93923 TC A Extremity study 0.00 4.67 4.92 NA NA 93923 26 A Extremity study 0.45 0.17 0.17 0.17 0.17 93924 A Extremity study 0.50 5.96 6.32 NA NA 93924 TC A Extremity study 0.00 5.77 6.12 NA NA 93924 26 A Extremity study 0.50 0.19 0.20 0.19 0.20 93925 A Lower extremity study 0.58 7.95 8.53 NA NA 93925 TC A Lower extremity study 0.00 7.73 8.30 NA NA 93925 26 A Lower extremity study 0.58 0.22 0.23 0.22 0.23 93926 A Lower extremity study 0.39 5.26 5.52 NA NA 93926 TC A Lower extremity study 0.00 5.12 5.37 NA NA 93926 26 A Lower extremity study 0.39 0.14 0.15 0.14 0.15 93930 A Upper extremity study 0.46 6.33 6.72 NA NA 93930 TC A Upper extremity study 0.00 6.16 6.54 NA NA 93930 26 A Upper extremity study 0.46 0.17 0.18 0.17 0.18 
CMS-1503-P 1143

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

93931 A Upper extremity study 0.31 4.21 4.49 NA NA 93931 TC A Upper extremity study 0.00 4.10 4.37 NA NA 93931 26 A Upper extremity study 0.31 0.11 0.12 0.11 0.12 93965 A Extremity study 0.35 3.05 3.28 NA NA 93965 TC A Extremity study 0.00 2.92 3.14 NA NA 93965 26 A Extremity study 0.35 0.13 0.14 0.13 0.14 93970 A Extremity study 0.68 6.29 6.69 NA NA 93970 TC A Extremity study 0.00 6.05 6.43 NA NA 93970 26 A Extremity study 0.68 0.24 0.26 0.24 0.26 93971 A Extremity study 0.45 4.08 4.40 NA NA 93971 TC A Extremity study 0.00 3.92 4.22 NA NA 93971 26 A Extremity study 0.45 0.16 0.18 0.16 0.18 93975 A Vascular study 1.80 8.33 9.05 NA NA 93975 TC A Vascular study 0.00 7.67 8.33 NA NA 93975 26 A Vascular study 1.80 0.66 0.72 0.66 0.72 93976 A Vascular study 1.21 4.54 4.97 NA NA 93976 TC A Vascular study 0.00 4.11 4.49 NA NA 93976 26 A Vascular study 1.21 0.43 0.48 0.43 0.48 93978 A Vascular study 0.65 5.98 6.32 NA NA 93978 TC A Vascular study 0.00 5.74 6.07 NA NA 93978 26 A Vascular study 0.65 0.24 0.25 0.24 0.25 93979 A Vascular study 0.44 4.15 4.40 NA NA 93979 TC A Vascular study 0.00 3.99 4.23 NA NA 93979 26 A Vascular study 0.44 0.16 0.17 0.16 0.17 93980 A Penile vascular study 1.25 3.48 3.82 NA NA 93980 TC A Penile vascular study 0.00 2.99 3.28 NA NA 
CMS-1503-P 1144

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

93980 26 A Penile vascular study 1.25 0.49 0.54 0.49 0.54 93981 A Penile vascular study 0.44 2.64 3.03 NA NA 93981 TC A Penile vascular study 0.00 2.48 2.85 NA NA 93981 26 A Penile vascular study 0.44 0.16 0.18 0.16 0.18 93982 R Aneurysm pressure sens study 0.30 0.85 0.90 NA NA 93990 A Doppler flow testing 0.25 5.80 5.82 NA NA 93990 TC A Doppler flow testing 0.00 5.71 5.73 NA NA 93990 26 A Doppler flow testing 0.25 0.09 0.09 0.09 0.09 94002 A Vent mgmt inpat, init day 1.99 NA NA 0.58 0.50 94003 A Vent mgmt inpat, subq day 1.37 NA NA 0.48 0.44 94004 A Vent mgmt nf per day 1.00 NA NA 0.34 0.32 94005 B Home vent mgmt supervision 1.50 1.08 1.07 NA NA 94010 A Breathing capacity test 0.17 0.81 0.83 NA NA 94010 TC A Breathing capacity test 0.00 0.74 0.77 NA NA 94010 26 A Breathing capacity test 0.17 0.07 0.06 0.07 0.06 94011 A Up to 2 yrs old, spirometry 2.00 NA NA 0.74 0.74 94012 A = 2 yrs, spiromtry w/dilator 3.10 NA NA 1.12 1.12 94013 A = 2 yrs, lung volumes 0.66 NA NA 0.21 0.21 94014 A Patient recorded spirometry 0.52 0.81 0.88 NA NA 94015 A Patient recorded spirometry 0.00 0.63 0.70 NA NA 94016 A Review patient spirometry 0.52 0.18 0.18 0.18 0.18 94060 A Evaluation of wheezing 0.31 1.39 1.43 NA NA 94060 TC A Evaluation of wheezing 0.00 1.27 1.32 NA NA 94060 26 A Evaluation of wheezing 0.31 0.12 0.11 0.12 0.11 94070 A Evaluation of wheezing 0.60 1.07 1.10 NA NA 94070 TC A Evaluation of wheezing 0.00 0.85 0.89 NA NA 
CMS-1503-P 1145

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

94070 26 A Evaluation of wheezing 0.60 0.22 0.21 0.22 0.21 94150 B Vital capacity test 0.07 0.60 0.61 NA NA 94150 TC B Vital capacity test 0.00 0.57 0.58 NA NA 94150 26 B Vital capacity test 0.07 0.03 0.03 0.03 0.03 94200 A Lung function test (MBC/MVV) 0.11 0.55 0.57 NA NA 94200 TC A Lung function test (MBC/MVV) 0.00 0.51 0.53 NA NA 94200 26 A Lung function test (MBC/MVV) 0.11 0.04 0.04 0.04 0.04 94240 A Residual lung capacity 0.26 0.83 0.88 NA NA 94240 TC A Residual lung capacity 0.00 0.74 0.79 NA NA 94240 26 A Residual lung capacity 0.26 0.09 0.09 0.09 0.09 94250 A Expired gas collection 0.11 0.56 0.61 NA NA 94250 TC A Expired gas collection 0.00 0.52 0.57 NA NA 94250 26 A Expired gas collection 0.11 0.04 0.04 0.04 0.04 94260 A Thoracic gas volume 0.13 0.75 0.79 NA NA 94260 TC A Thoracic gas volume 0.00 0.71 0.75 NA NA 94260 26 A Thoracic gas volume 0.13 0.04 0.04 0.04 0.04 94350 A Lung nitrogen washout curve 0.26 0.66 0.73 NA NA 94350 TC A Lung nitrogen washout curve 0.00 0.57 0.64 NA NA 94350 26 A Lung nitrogen washout curve 0.26 0.09 0.09 0.09 0.09 94360 A Measure airflow resistance 0.26 0.96 1.01 NA NA 94360 TC A Measure airflow resistance 0.00 0.87 0.92 NA NA 94360 26 A Measure airflow resistance 0.26 0.09 0.09 0.09 0.09 94370 A Breath airway closing volume 0.26 0.68 0.71 NA NA 94370 TC A Breath airway closing volume 0.00 0.58 0.62 NA NA 94370 26 A Breath airway closing volume 0.26 0.10 0.09 0.10 0.09 94375 A Respiratory flow volume loop 0.31 0.75 0.78 NA NA 
CMS-1503-P 1146

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

94375 TC A Respiratory flow volume loop 0.00 0.64 0.68 NA NA 94375 26 A Respiratory flow volume loop 0.31 0.11 0.10 0.11 0.10 94400 A CO2 breathing response curve 0.40 1.10 1.14 NA NA 94400 TC A CO2 breathing response curve 0.00 0.96 1.00 NA NA 94400 26 A CO2 breathing response curve 0.40 0.14 0.14 0.14 0.14 94450 A Hypoxia response curve 0.40 1.44 1.29 NA NA 94450 TC A Hypoxia response curve 0.00 1.27 1.15 NA NA 94450 26 A Hypoxia response curve 0.40 0.17 0.14 0.17 0.14 94452 A Hast w/report 0.31 1.25 1.33 NA NA 94452 TC A Hast w/report 0.00 1.14 1.23 NA NA 94452 26 A Hast w/report 0.31 0.11 0.10 0.11 0.10 94453 A Hast w/oxygen titrate 0.40 1.71 1.82 NA NA 94453 TC A Hast w/oxygen titrate 0.00 1.58 1.69 NA NA 94453 26 A Hast w/oxygen titrate 0.40 0.13 0.13 0.13 0.13 94610 A Surfactant admin thru tube 1.16 0.55 0.50 0.55 0.50 94620 A Pulmonary stress test/simple 0.64 0.87 1.16 NA NA 94620 TC A Pulmonary stress test/simple 0.00 0.64 0.94 NA NA 94620 26 A Pulmonary stress test/simple 0.64 0.23 0.22 0.23 0.22 94621 A Pulm stress test/complex 1.42 3.03 3.25 NA NA 94621 TC A Pulm stress test/complex 0.00 2.51 2.71 NA NA 94621 26 A Pulm stress test/complex 1.42 0.52 0.54 0.52 0.54 94640 A Airway inhalation treatment 0.00 0.47 0.45 NA NA 94642 C Aerosol inhalation treatment 0.00 0.00 0.00 0.00 0.00 94644 A Cbt, 1st hour 0.00 1.18 1.15 NA NA 94645 A Cbt, each addl hour 0.00 0.39 0.41 NA NA 94660 A Pos airway pressure, CPAP 0.76 0.93 0.92 0.29 0.27 
CMS-1503-P 1147

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

94662 A Neg press ventilation, cnp 0.76 NA NA 0.25 0.25 94664 A Evaluate pt use of inhaler 0.00 0.46 0.45 NA NA 94667 A Chest wall manipulation 0.00 0.65 0.64 NA NA 94668 A Chest wall manipulation 0.00 0.62 0.62 NA NA 94680 A Exhaled air analysis, o2 0.26 1.32 1.42 NA NA 94680 TC A Exhaled air analysis, o2 0.00 1.21 1.32 NA NA 94680 26 A Exhaled air analysis, o2 0.26 0.11 0.10 0.11 0.10 94681 A Exhaled air analysis, o2/co2 0.20 1.17 1.43 NA NA 94681 TC A Exhaled air analysis, o2/co2 0.00 1.09 1.36 NA NA 94681 26 A Exhaled air analysis, o2/co2 0.20 0.08 0.07 0.08 0.07 94690 A Exhaled air analysis 0.07 1.28 1.41 NA NA 94690 TC A Exhaled air analysis 0.00 1.25 1.38 NA NA 94690 26 A Exhaled air analysis 0.07 0.03 0.03 0.03 0.03 94720 A Monoxide diffusing capacity 0.26 1.15 1.23 NA NA 94720 TC A Monoxide diffusing capacity 0.00 1.06 1.14 NA NA 94720 26 A Monoxide diffusing capacity 0.26 0.09 0.09 0.09 0.09 94725 A Membrane diffusion capacity 0.26 1.14 1.44 NA NA 94725 TC A Membrane diffusion capacity 0.00 1.04 1.35 NA NA 94725 26 A Membrane diffusion capacity 0.26 0.10 0.09 0.10 0.09 94750 A Pulmonary compliance study 0.23 1.99 2.00 NA NA 94750 TC A Pulmonary compliance study 0.00 1.90 1.92 NA NA 94750 26 A Pulmonary compliance study 0.23 0.09 0.08 0.09 0.08 94760 T Measure blood oxygen level 0.00 0.07 0.07 NA NA 94761 T Measure blood oxygen level 0.00 0.12 0.12 NA NA 94762 A Measure blood oxygen level 0.00 0.28 0.57 NA NA 94770 A Exhaled carbon dioxide test 0.15 0.06 0.50 NA NA 
CMS-1503-P 1148

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

94770 TC A Exhaled carbon dioxide test 0.00 0.00 0.44 NA NA 94770 26 A Exhaled carbon dioxide test 0.15 0.06 0.06 0.06 0.06 94772 C Breath recording, infant 0.00 0.00 0.00 NA NA 94772 TC C Breath recording, infant 0.00 0.00 0.00 NA NA 94772 26 C Breath recording, infant 0.00 0.00 0.00 0.00 0.00 94774 C Ped home apnea rec, compl 0.00 0.00 0.00 0.00 0.00 94775 C Ped home apnea rec, hk-up 0.00 0.00 0.00 0.00 0.00 94776 C Ped home apnea rec, downld 0.00 0.00 0.00 0.00 0.00 94777 C Ped home apnea rec, report 0.00 0.00 0.00 0.00 0.00 94799 C Pulmonary service/procedure 0.00 0.00 0.00 NA NA 94799 TC C Pulmonary service/procedure 0.00 0.00 0.00 NA NA 94799 26 C Pulmonary service/procedure 0.00 0.00 0.00 0.00 0.00 95004 A Percut allergy skin tests 0.01 0.16 0.17 NA NA 95010 A Percut allergy titrate test 0.15 0.37 0.37 NA NA 95012 A Exhaled nitric oxide meas 0.00 0.54 0.59 NA NA 95015 A Id allergy titrate-drug/bug 0.15 0.29 0.26 NA NA 95024 A Id allergy test, drug/bug 0.01 0.19 0.19 NA NA 95027 A Id allergy titrate-airborne 0.01 0.11 0.12 NA NA 95028 A Id allergy test-delayed type 0.00 0.37 0.36 NA NA 95044 A Allergy patch tests 0.00 0.15 0.17 NA NA 95052 A Photo patch test 0.00 0.17 0.19 NA NA 95056 A Photosensitivity tests 0.00 1.20 1.17 NA NA 95060 A Eye allergy tests 0.00 0.90 0.82 0.90 0.82 95065 A Nose allergy test 0.00 0.70 0.70 0.70 0.70 95070 A Bronchial allergy tests 0.00 0.78 1.09 NA NA 95071 A Bronchial allergy tests 0.00 1.20 1.47 NA NA 
CMS-1503-P 1149

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

95075 A Ingestion challenge test 0.95 0.89 0.89 0.43 0.41 95115 A Immunotherapy, one injection 0.00 0.25 0.29 NA NA 95117 A Immunotherapy injections 0.00 0.30 0.35 NA NA 95120 I Immunotherapy, one injection 0.00 0.00 0.00 0.00 0.00 95125 I Immunotherapy, many antigens 0.00 0.00 0.00 0.00 0.00 95130 I Immunotherapy, insect venom 0.00 0.00 0.00 0.00 0.00 95131 I Immunotherapy, insect venoms 0.00 0.00 0.00 0.00 0.00 95132 I Immunotherapy, insect venoms 0.00 0.00 0.00 0.00 0.00 95133 I Immunotherapy, insect venoms 0.00 0.00 0.00 0.00 0.00 95134 I Immunotherapy, insect venoms 0.00 0.00 0.00 0.00 0.00 95144 A Antigen therapy services 0.06 0.29 0.30 0.03 0.03 95145 A Antigen therapy services 0.06 0.54 0.48 0.03 0.03 95146 A Antigen therapy services 0.06 1.03 0.89 0.03 0.03 95147 A Antigen therapy services 0.06 0.93 0.83 0.03 0.03 95148 A Antigen therapy services 0.06 1.42 1.24 0.03 0.03 95149 A Antigen therapy services 0.06 1.93 1.67 0.03 0.03 95165 A Antigen therapy services 0.06 0.29 0.30 0.03 0.03 95170 A Antigen therapy services 0.06 0.21 0.21 0.03 0.03 95180 A Rapid desensitization 2.01 1.90 2.03 0.97 1.00 95199 C Allergy immunology services 0.00 0.00 0.00 0.00 0.00 95250 A Glucose monitoring, cont 0.00 4.25 4.26 NA NA 95251 A Gluc monitor, cont, phys i&r 0.85 0.38 0.33 0.38 0.33 95803 A Actigraphy testing 1.00 3.05 3.05 NA NA 95803 TC A Actigraphy testing 0.00 2.58 2.58 NA NA 95803 26 A Actigraphy testing 1.00 0.47 0.47 0.47 0.47 95805 A Multiple sleep latency test 1.88 7.45 9.36 NA NA 
CMS-1503-P 1150

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

95805 TC A Multiple sleep latency test 0.00 6.72 8.66 NA NA 95805 26 A Multiple sleep latency test 1.88 0.73 0.70 0.73 0.70 95806 A Sleep study unatt&resp efft 1.66 4.22 4.36 NA NA 95806 TC A Sleep study unatt&resp efft 0.00 3.58 3.74 NA NA 95806 26 A Sleep study unatt&resp efft 1.66 0.64 0.62 0.64 0.62 95807 A Sleep study, attended 1.66 11.94 12.90 NA NA 95807 TC A Sleep study, attended 0.00 11.35 12.31 NA NA 95807 26 A Sleep study, attended 1.66 0.59 0.59 0.59 0.59 95808 A Polysomnography, 1-3 2.65 18.28 18.00 NA NA 95808 TC A Polysomnography, 1-3 0.00 17.21 16.99 NA NA 95808 26 A Polysomnography, 1-3 2.65 1.07 1.01 1.07 1.01 95810 A Polysomnography, 4 or more 3.52 18.17 19.41 NA NA 95810 TC A Polysomnography, 4 or more 0.00 16.85 18.15 NA NA 95810 26 A Polysomnography, 4 or more 3.52 1.32 1.26 1.32 1.26 95811 A Polysomnography w/cpap 3.79 20.09 21.50 NA NA 95811 TC A Polysomnography w/cpap 0.00 18.68 20.15 NA NA 95811 26 A Polysomnography w/cpap 3.79 1.41 1.35 1.41 1.35 95812 A Eeg, 41-60 minutes 1.08 9.44 7.91 NA NA 95812 TC A Eeg, 41-60 minutes 0.00 8.94 7.45 NA NA 95812 26 A Eeg, 41-60 minutes 1.08 0.50 0.46 0.50 0.46 95813 A Eeg, over 1 hour 1.73 9.39 8.36 NA NA 95813 TC A Eeg, over 1 hour 0.00 8.61 7.64 NA NA 95813 26 A Eeg, over 1 hour 1.73 0.78 0.72 0.78 0.72 95816 A Eeg, awake and drowsy 1.08 8.71 7.22 NA NA 95816 TC A Eeg, awake and drowsy 0.00 8.20 6.76 NA NA 95816 26 A Eeg, awake and drowsy 1.08 0.51 0.46 0.51 0.46 
CMS-1503-P 1151

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

95819 A Eeg, awake and asleep 1.08 10.12 8.20 NA NA 95819 TC A Eeg, awake and asleep 0.00 9.61 7.74 NA NA 95819 26 A Eeg, awake and asleep 1.08 0.51 0.46 0.51 0.46 95822 A Eeg, coma or sleep only 1.08 8.99 7.59 NA NA 95822 TC A Eeg, coma or sleep only 0.00 8.48 7.13 NA NA 95822 26 A Eeg, coma or sleep only 1.08 0.51 0.46 0.51 0.46 95824 C Eeg, cerebral death only 0.00 0.00 0.00 NA NA 95824 TC C Eeg, cerebral death only 0.00 0.00 0.00 NA NA 95824 26 A Eeg, cerebral death only 0.74 0.34 0.32 0.34 0.32 95827 A Eeg, all night recording 1.08 18.67 14.83 NA NA 95827 TC A Eeg, all night recording 0.00 18.16 14.37 NA NA 95827 26 A Eeg, all night recording 1.08 0.51 0.46 0.51 0.46 95829 A Surgery electrocorticogram 6.20 41.25 36.63 NA NA 95829 TC A Surgery electrocorticogram 0.00 38.33 33.96 NA NA 95829 26 A Surgery electrocorticogram 6.20 2.92 2.67 2.92 2.67 95830 A Insert electrodes for EEG 1.70 3.74 3.69 0.72 0.69 95831 A Limb muscle testing, manual 0.28 0.56 0.53 0.14 0.13 95832 A Hand muscle testing, manual 0.29 0.55 0.49 0.16 0.14 95833 A Body muscle testing, manual 0.47 0.60 0.59 0.16 0.18 95834 A Body muscle testing, manual 0.60 0.80 0.71 0.25 0.24 95851 A Range of motion measurements 0.16 0.34 0.34 0.06 0.06 95852 A Range of motion measurements 0.11 0.34 0.31 0.05 0.05 95857 A Tensilon test 0.53 0.90 0.80 0.30 0.26 95860 A Muscle test, one limb 0.96 1.79 1.63 NA NA 95860 TC A Muscle test, one limb 0.00 1.30 1.17 NA NA 95860 26 A Muscle test, one limb 0.96 0.49 0.46 0.49 0.46 
CMS-1503-P 1152

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

95861 A Muscle test, 2 limbs 1.54 2.52 2.21 NA NA 95861 TC A Muscle test, 2 limbs 0.00 1.74 1.48 NA NA 95861 26 A Muscle test, 2 limbs 1.54 0.78 0.73 0.78 0.73 95863 A Muscle test, 3 limbs 1.87 3.07 2.64 NA NA 95863 TC A Muscle test, 3 limbs 0.00 2.16 1.80 NA NA 95863 26 A Muscle test, 3 limbs 1.87 0.91 0.84 0.91 0.84 95864 A Muscle test, 4 limbs 1.99 3.25 2.98 NA NA 95864 TC A Muscle test, 4 limbs 0.00 2.28 2.07 NA NA 95864 26 A Muscle test, 4 limbs 1.99 0.97 0.91 0.97 0.91 95865 A Muscle test, larynx 1.57 2.01 1.86 NA NA 95865 TC A Muscle test, larynx 0.00 1.19 1.09 NA NA 95865 26 A Muscle test, larynx 1.57 0.82 0.77 0.82 0.77 95866 A Muscle test, hemidiaphragm 1.25 1.96 1.70 NA NA 95866 TC A Muscle test, hemidiaphragm 0.00 1.37 1.13 NA NA 95866 26 A Muscle test, hemidiaphragm 1.25 0.59 0.57 0.59 0.57 95867 A Muscle test cran nerv unilat 0.79 1.68 1.50 NA NA 95867 TC A Muscle test cran nerv unilat 0.00 1.28 1.13 NA NA 95867 26 A Muscle test cran nerv unilat 0.79 0.40 0.37 0.40 0.37 95868 A Muscle test cran nerve bilat 1.18 2.19 1.93 NA NA 95868 TC A Muscle test cran nerve bilat 0.00 1.61 1.39 NA NA 95868 26 A Muscle test cran nerve bilat 1.18 0.58 0.54 0.58 0.54 95869 A Muscle test, thor paraspinal 0.37 1.59 1.29 NA NA 95869 TC A Muscle test, thor paraspinal 0.00 1.40 1.12 NA NA 95869 26 A Muscle test, thor paraspinal 0.37 0.19 0.17 0.19 0.17 95870 A Muscle test, nonparaspinal 0.37 1.55 1.26 NA NA 95870 TC A Muscle test, nonparaspinal 0.00 1.37 1.09 NA NA 
CMS-1503-P 1153

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

95870 26 A Muscle test, nonparaspinal 0.37 0.18 0.17 0.18 0.17 95872 A Muscle test, one fiber 2.88 2.50 2.18 NA NA 95872 TC A Muscle test, one fiber 0.00 1.16 1.00 NA NA 95872 26 A Muscle test, one fiber 2.88 1.34 1.18 1.34 1.18 95873 A Guide nerv destr, elec stim 0.37 1.57 1.30 NA NA 95873 TC A Guide nerv destr, elec stim 0.00 1.36 1.10 NA NA 95873 26 A Guide nerv destr, elec stim 0.37 0.21 0.20 0.21 0.20 95874 A Guide nerv destr, needle emg 0.37 1.49 1.22 NA NA 95874 TC A Guide nerv destr, needle emg 0.00 1.30 1.04 NA NA 95874 26 A Guide nerv destr, needle emg 0.37 0.19 0.18 0.19 0.18 95875 A Limb exercise test 1.10 2.14 1.88 NA NA 95875 TC A Limb exercise test 0.00 1.62 1.40 NA NA 95875 26 A Limb exercise test 1.10 0.52 0.48 0.52 0.48 95900 A Motor nerve conduction test 0.42 1.40 1.30 NA NA 95900 TC A Motor nerve conduction test 0.00 1.19 1.10 NA NA 95900 26 A Motor nerve conduction test 0.42 0.21 0.20 0.21 0.20 95903 A Motor nerve conduction test 0.60 1.50 1.38 NA NA 95903 TC A Motor nerve conduction test 0.00 1.21 1.12 NA NA 95903 26 A Motor nerve conduction test 0.60 0.29 0.26 0.29 0.26 95904 A Sense nerve conduction test 0.34 1.25 1.17 NA NA 95904 TC A Sense nerve conduction test 0.00 1.08 1.01 NA NA 95904 26 A Sense nerve conduction test 0.34 0.17 0.16 0.17 0.16 95905 A Motor/sens nrve conduct test 0.05 2.34 2.34 NA NA 95905 TC A Motor/sens nrve conduct test 0.00 2.32 2.32 NA NA 95905 26 A Motor/sens nrve conduct test 0.05 0.02 0.02 0.02 0.02 95920 A Intraop nerve test add-on 2.11 2.62 2.41 NA NA 
CMS-1503-P 1154

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

95920 TC A Intraop nerve test add-on 0.00 1.62 1.48 NA NA 95920 26 A Intraop nerve test add-on 2.11 1.00 0.93 1.00 0.93 95921 A Autonomic nerv function test 0.90 1.49 1.38 NA NA 95921 TC A Autonomic nerv function test 0.00 1.09 1.01 NA NA 95921 26 A Autonomic nerv function test 0.90 0.40 0.37 0.40 0.37 95922 A Autonomic nerv function test 0.96 2.05 1.86 NA NA 95922 TC A Autonomic nerv function test 0.00 1.62 1.46 NA NA 95922 26 A Autonomic nerv function test 0.96 0.43 0.40 0.43 0.40 95923 A Autonomic nerv function test 0.90 3.80 3.22 NA NA 95923 TC A Autonomic nerv function test 0.00 3.37 2.83 NA NA 95923 26 A Autonomic nerv function test 0.90 0.43 0.39 0.43 0.39 95925 A Somatosensory testing 0.54 4.79 3.96 NA NA 95925 TC A Somatosensory testing 0.00 4.54 3.72 NA NA 95925 26 A Somatosensory testing 0.54 0.25 0.24 0.25 0.24 95926 A Somatosensory testing 0.54 4.50 3.78 NA NA 95926 TC A Somatosensory testing 0.00 4.25 3.55 NA NA 95926 26 A Somatosensory testing 0.54 0.25 0.23 0.25 0.23 95927 A Somatosensory testing 0.54 3.94 3.54 NA NA 95927 TC A Somatosensory testing 0.00 3.69 3.30 NA NA 95927 26 A Somatosensory testing 0.54 0.25 0.24 0.25 0.24 95928 A C motor evoked, uppr limbs 1.50 6.06 5.17 NA NA 95928 TC A C motor evoked, uppr limbs 0.00 5.35 4.52 NA NA 95928 26 A C motor evoked, uppr limbs 1.50 0.71 0.65 0.71 0.65 95929 A C motor evoked, lwr limbs 1.50 6.51 5.57 NA NA 95929 TC A C motor evoked, lwr limbs 0.00 5.80 4.91 NA NA 95929 26 A C motor evoked, lwr limbs 1.50 0.71 0.66 0.71 0.66 
CMS-1503-P 1155

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

95930 A Visual evoked potential test 0.35 3.98 3.48 NA NA 95930 TC A Visual evoked potential test 0.00 3.80 3.32 NA NA 95930 26 A Visual evoked potential test 0.35 0.18 0.16 0.18 0.16 95933 A Blink reflex test 0.59 1.73 1.51 NA NA 95933 TC A Blink reflex test 0.00 1.44 1.25 NA NA 95933 26 A Blink reflex test 0.59 0.29 0.26 0.29 0.26 95934 A H-reflex test 0.51 1.27 1.09 NA NA 95934 TC A H-reflex test 0.00 1.02 0.86 NA NA 95934 26 A H-reflex test 0.51 0.25 0.23 0.25 0.23 95936 A H-reflex test 0.55 0.87 0.78 NA NA 95936 TC A H-reflex test 0.00 0.61 0.53 NA NA 95936 26 A H-reflex test 0.55 0.26 0.25 0.26 0.25 95937 A Neuromuscular junction test 0.65 1.36 1.18 NA NA 95937 TC A Neuromuscular junction test 0.00 1.05 0.89 NA NA 95937 26 A Neuromuscular junction test 0.65 0.31 0.29 0.31 0.29 95950 A Ambulatory eeg monitoring 1.51 7.96 6.74 NA NA 95950 TC A Ambulatory eeg monitoring 0.00 7.25 6.09 NA NA 95950 26 A Ambulatory eeg monitoring 1.51 0.71 0.65 0.71 0.65 95951 C EEG monitoring/videorecord 0.00 0.00 0.00 NA NA 95951 TC C EEG monitoring/videorecord 0.00 0.00 0.00 NA NA 95951 26 A EEG monitoring/videorecord 5.99 2.82 2.59 2.82 2.59 95953 A EEG monitoring/computer 3.30 12.06 10.36 NA NA 95953 TC A EEG monitoring/computer 0.00 10.51 8.95 NA NA 95953 26 A EEG monitoring/computer 3.30 1.55 1.41 1.55 1.41 95954 A EEG monitoring/giving drugs 2.45 7.85 6.41 NA NA 95954 TC A EEG monitoring/giving drugs 0.00 6.98 5.64 NA NA 
CMS-1503-P 1156

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

95954 26 A EEG monitoring/giving drugs 2.45 0.87 0.77 0.87 0.77 95955 A EEG during surgery 1.01 4.48 3.78 NA NA 95955 TC A EEG during surgery 0.00 4.01 3.36 NA NA 95955 26 A EEG during surgery 1.01 0.47 0.42 0.47 0.42 95956 A Eeg monitoring, cable/radio 3.08 22.11 20.56 NA NA 95956 TC A Eeg monitoring, cable/radio 0.00 20.74 19.27 NA NA 95956 26 A Eeg monitoring, cable/radio 3.08 1.37 1.29 1.37 1.29 95957 A EEG digital analysis 1.98 9.42 7.67 NA NA 95957 TC A EEG digital analysis 0.00 8.50 6.82 NA NA 95957 26 A EEG digital analysis 1.98 0.92 0.85 0.92 0.85 95958 A EEG monitoring/function test 4.24 10.07 8.61 NA NA 95958 TC A EEG monitoring/function test 0.00 8.17 6.81 NA NA 95958 26 A EEG monitoring/function test 4.24 1.90 1.80 1.90 1.80 95961 A Electrode stimulation, brain 2.97 4.83 4.17 NA NA 95961 TC A Electrode stimulation, brain 0.00 3.40 2.84 NA NA 95961 26 A Electrode stimulation, brain 2.97 1.43 1.33 1.43 1.33 95962 A Electrode stim, brain add-on 3.21 3.65 3.21 NA NA 95962 TC A Electrode stim, brain add-on 0.00 2.12 1.81 NA NA 95962 26 A Electrode stim, brain add-on 3.21 1.53 1.40 1.53 1.40 95965 C Meg, spontaneous 0.00 0.00 0.00 NA NA 95965 TC C Meg, spontaneous 0.00 0.00 0.00 NA NA 95965 26 A Meg, spontaneous 7.99 3.76 3.61 3.76 3.61 95966 C Meg, evoked, single 0.00 0.00 0.00 NA NA 95966 TC C Meg, evoked, single 0.00 0.00 0.00 NA NA 95966 26 A Meg, evoked, single 3.99 1.88 1.81 1.88 1.81 95967 C Meg, evoked, each addl 0.00 0.00 0.00 NA NA 
CMS-1503-P 1157

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

95967 TC C Meg, evoked, each addl 0.00 0.00 0.00 NA NA 95967 26 A Meg, evoked, each addl 3.49 1.64 1.52 1.64 1.52 95970 A Analyze neurostim, no prog 0.45 1.36 1.21 0.21 0.18 95971 A Analyze neurostim, simple 0.78 0.81 0.84 0.34 0.32 95972 A Analyze neurostim, complex 1.50 1.54 1.47 0.70 0.63 95973 A Analyze neurostim, complex 0.92 0.85 0.75 0.46 0.39 95974 A Cranial neurostim, complex 3.00 2.42 2.13 1.37 1.25 95975 A Cranial neurostim, complex 1.70 1.24 1.09 0.80 0.73 95978 A Analyze neurostim brain/1h 3.50 3.01 2.64 1.68 1.52 95979 A Analyz neurostim brain addon 1.64 1.21 1.07 0.78 0.72 95980 A Io anal gast n-stim init 0.80 NA NA 0.43 0.37 95981 A Io anal gast n-stim subsq 0.30 0.59 0.56 0.20 0.17 95982 A Io ga n-stim subsq w/reprog 0.65 0.79 0.69 0.36 0.30 95990 A Spin/brain pump refil & main 0.00 2.45 2.17 NA NA 95991 A Spin/brain pump refil & main 0.77 2.60 2.25 0.36 0.29 95992 A Canalith repositioning proc 0.75 0.45 0.44 0.32 0.31 95999 C Neurological procedure 0.00 0.00 0.00 0.00 0.00 96000 A Motion analysis, video/3d 1.80 NA NA 0.91 0.75 96001 A Motion test w/ft press meas 2.15 NA NA 0.65 0.67 96002 A Dynamic surface emg 0.41 NA NA 0.20 0.18 96003 A Dynamic fine wire emg 0.37 NA NA 0.17 0.15 96004 A Phys review of motion tests 2.14 1.00 0.98 1.00 0.98 96020 C Functional brain mapping 0.00 0.00 0.00 NA NA 96020 TC C Functional brain mapping 0.00 0.00 0.00 NA NA 96020 26 A Functional brain mapping 3.43 1.19 1.39 1.19 1.39 96040 B Genetic counseling, 30 min 0.00 1.20 1.26 NA NA 
CMS-1503-P 1158

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

96101 A Psycho testing by psych/phys 1.86 0.30 0.41 0.28 0.39 96102 A Psycho testing by technician 0.50 1.13 1.12 0.17 0.16 96103 A Psycho testing admin by comp 0.51 1.29 1.10 0.19 0.18 96105 A Assessment of aphasia 0.00 2.42 2.33 NA NA 96110 A Developmental test, lim 0.00 0.23 0.22 NA NA 96111 A Developmental test, extend 2.60 0.82 0.91 0.65 0.78 96116 A Neurobehavioral status exam 1.86 0.69 0.71 0.54 0.55 96118 A Neuropsych tst by psych/phys 1.86 0.68 0.91 0.25 0.37 96119 A Neuropsych testing by tec 0.55 1.36 1.48 0.09 0.12 96120 A Neuropsych tst admin w/comp 0.51 2.03 1.84 0.18 0.17 96125 A Cognitive test by hc pro 1.70 1.02 0.97 NA NA 96150 A Assess hlth/behave, init 0.50 0.07 0.11 0.06 0.10 96151 A Assess hlth/behave, subseq 0.48 0.07 0.11 0.07 0.10 96152 A Intervene hlth/behave, indiv 0.46 0.07 0.10 0.06 0.09 96153 A Intervene hlth/behave, group 0.10 0.02 0.03 0.02 0.02 96154 A Interv hlth/behav, fam w/pt 0.45 0.06 0.10 0.06 0.09 96155 N Interv hlth/behav fam no pt 0.44 0.19 0.19 0.19 0.19 96360 A Hydration iv infusion, init 0.17 1.30 1.45 NA NA 96361 A Hydrate iv infusion, add-on 0.09 0.30 0.35 NA NA 96365 A Ther/proph/diag iv inf, init 0.21 1.66 1.81 NA NA 96366 A Ther/proph/diag iv inf addon 0.18 0.41 0.44 NA NA 96367 A Tx/proph/dg addl seq iv inf 0.19 0.64 0.76 NA NA 96368 A Ther/diag concurrent inf 0.17 0.34 0.39 NA NA 96369 A Sc ther infusion, up to 1 hr 0.21 4.71 4.69 NA NA 96370 A Sc ther infusion, addl hr 0.18 0.25 0.26 NA NA 96371 A Sc ther infusion, reset pump 0.00 2.18 2.30 NA NA 
CMS-1503-P 1159

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

96372 A Ther/proph/diag inj, sc/im 0.17 0.49 0.49 NA NA 96373 A Ther/proph/diag inj, ia 0.17 0.37 0.37 NA NA 96374 A Ther/proph/diag inj, iv push 0.18 1.26 1.40 NA NA 96375 A Tx/pro/dx inj new drug addon 0.10 0.47 0.55 NA NA 96376 X Tx/pro/dx inj new drug adon 0.00 0.00 0.00 0.00 0.00 96379 C Ther/prop/diag inj/inf proc 0.00 0.00 0.00 0.00 0.00 96401 A Chemo, anti-neopl, sq/im 0.21 1.71 1.85 NA NA 96402 A Chemo hormon antineopl sq/im 0.19 0.66 0.82 NA NA 96405 A Chemo intralesional, up to 7 0.52 1.74 1.95 0.36 0.33 96406 A Chemo intralesional over 7 0.80 2.30 2.59 0.49 0.44 96409 A Chemo, iv push, sngl drug 0.24 2.57 2.97 NA NA 96411 A Chemo, iv push, addl drug 0.20 1.38 1.60 NA NA 96413 A Chemo, iv infusion, 1 hr 0.28 3.33 3.91 NA NA 96415 A Chemo, iv infusion, addl hr 0.19 0.60 0.70 NA NA 96416 A Chemo prolong infuse w/pump 0.21 3.75 4.38 NA NA 96417 A Chemo iv infus each addl seq 0.21 1.59 1.85 NA NA 96420 A Chemo, ia, push tecnique 0.17 2.52 2.90 NA NA 96422 A Chemo ia infusion up to 1 hr 0.17 4.14 4.82 NA NA 96423 A Chemo ia infuse each addl hr 0.17 1.84 2.10 NA NA 96425 A Chemotherapy,infusion method 0.17 4.43 4.92 NA NA 96440 A Chemotherapy, intracavitary 2.37 19.36 18.15 1.47 1.42 96445 A Chemotherapy, intracavitary 2.20 5.10 5.90 1.11 1.10 96450 A Chemotherapy, into CNS 1.53 3.26 4.12 0.72 0.85 96521 A Refill/maint, portable pump 0.21 3.26 3.59 NA NA 96522 A Refill/maint pump/resvr syst 0.21 2.63 2.95 NA NA 96523 T Irrig drug delivery device 0.04 0.59 0.69 NA NA 
CMS-1503-P 1160

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

96542 A Chemotherapy injection 0.75 2.31 2.90 0.44 0.49 96549 C Chemotherapy, unspecified 0.00 0.00 0.00 0.00 0.00 96567 A Photodynamic tx, skin 0.00 3.67 3.76 NA NA 96570 A Photodynmc tx, 30 min add-on 1.10 0.43 0.46 0.43 0.46 96571 A Photodynamic tx, addl 15 min 0.55 0.18 0.20 0.18 0.20 96900 A Ultraviolet light therapy 0.00 0.55 0.59 NA NA 96902 B Trichogram 0.41 0.20 0.20 0.18 0.17 96904 R Whole body photography 0.00 1.75 1.94 NA NA 96910 A Photochemotherapy with UV-B 0.00 1.93 1.99 NA NA 96912 A Photochemotherapy with UV-A 0.00 2.49 2.56 NA NA 96913 A Photochemotherapy, UV-A or B 0.00 3.50 3.56 NA NA 96920 A Laser tx, skin < 250 sq cm 1.15 3.72 3.83 0.83 0.77 96921 A Laser tx, skin 250-500 sq cm 1.17 3.84 3.82 0.83 0.75 96922 A Laser tx, skin > 500 sq cm 2.10 4.95 5.07 1.52 1.35 96999 C Dermatological procedure 0.00 0.00 0.00 0.00 0.00 97001 A Pt evaluation 1.20 0.91 0.87 NA NA 97002 A Pt re-evaluation 0.60 0.57 0.54 NA NA 97003 A Ot evaluation 1.20 1.20 1.08 NA NA 97004 A Ot re-evaluation 0.60 0.87 0.78 NA NA 97005 I Athletic train eval 0.00 0.00 0.00 0.00 0.00 97006 I Athletic train reeval 0.00 0.00 0.00 0.00 0.00 97010 B Hot or cold packs therapy 0.06 0.10 0.09 NA NA 97012 A Mechanical traction therapy 0.25 0.20 0.18 NA NA 97014 I Electric stimulation therapy 0.18 0.26 0.24 NA NA 97016 A Vasopneumatic device therapy 0.18 0.35 0.31 NA NA 97018 A Paraffin bath therapy 0.06 0.23 0.20 NA NA 
CMS-1503-P 1161

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

97022 A Whirlpool therapy 0.17 0.47 0.41 NA NA 97024 A Diathermy eg, microwave 0.06 0.11 0.11 NA NA 97026 A Infrared therapy 0.06 0.10 0.09 NA NA 97028 A Ultraviolet therapy 0.08 0.12 0.11 NA NA 97032 A Electrical stimulation 0.25 0.28 0.25 NA NA 97033 A Electric current therapy 0.26 0.63 0.56 NA NA 97034 A Contrast bath therapy 0.21 0.29 0.26 NA NA 97035 A Ultrasound therapy 0.21 0.14 0.13 NA NA 97036 A Hydrotherapy 0.28 0.62 0.56 NA NA 97039 C Physical therapy treatment 0.00 0.00 0.00 0.00 0.00 97110 A Therapeutic exercises 0.45 0.45 0.41 NA NA 97112 A Neuromuscular reeducation 0.45 0.48 0.45 NA NA 97113 A Aquatic therapy/exercises 0.44 0.75 0.68 NA NA 97116 A Gait training therapy 0.40 0.39 0.36 NA NA 97124 A Massage therapy 0.35 0.38 0.35 NA NA 97139 C Physical medicine procedure 0.00 0.00 0.00 0.00 0.00 97140 A Manual therapy 0.43 0.41 0.37 NA NA 97150 A Group therapeutic procedures 0.27 0.30 0.28 NA NA 97530 A Therapeutic activities 0.44 0.53 0.49 NA NA 97532 A Cognitive skills development 0.44 0.31 0.29 NA NA 97533 A Sensory integration 0.44 0.38 0.35 NA NA 97535 A Self care mngment training 0.45 0.53 0.48 NA NA 97537 A Community/work reintegration 0.45 0.39 0.37 NA NA 97542 A Wheelchair mngment training 0.45 0.41 0.38 NA NA 97545 R Work hardening 0.00 0.00 0.00 0.00 0.00 97546 R Work hardening add-on 0.00 0.00 0.00 0.00 0.00 
CMS-1503-P 1162

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

97597 A Active wound care/20 cm or < 0.58 1.56 1.38 0.17 0.24 97598 A Active wound care > 20 cm 0.80 1.80 1.60 0.23 0.31 97602 B Wound(s) care non-selective 0.00 0.00 0.00 0.00 0.00 97605 A Neg press wound tx, < 50 cm 0.55 0.57 0.52 0.16 0.17 97606 A Neg press wound tx, > 50 cm 0.60 0.58 0.53 0.17 0.18 97750 A Physical performance test 0.45 0.47 0.43 NA NA 97755 A Assistive technology assess 0.62 0.38 0.36 NA NA 97760 A Orthotic mgmt and training 0.45 0.60 0.55 NA NA 97761 A Prosthetic training 0.45 0.46 0.42 NA NA 97762 A C/o for orthotic/prosth use 0.25 1.04 0.91 NA NA 97799 C Physical medicine procedure 0.00 0.00 0.00 0.00 0.00 97802 A Medical nutrition, indiv, in 0.53 0.40 0.36 0.35 0.31 97803 A Med nutrition, indiv, subseq 0.45 0.35 0.33 0.30 0.27 97804 A Medical nutrition, group 0.25 0.17 0.15 0.16 0.14 97810 N Acupunct w/o stimul 15 min 0.60 0.41 0.41 0.26 0.26 97811 N Acupunct w/o stimul addl 15m 0.50 0.26 0.26 0.22 0.21 97813 N Acupunct w/stimul 15 min 0.65 0.43 0.43 0.28 0.28 97814 N Acupunct w/stimul addl 15m 0.55 0.31 0.31 0.24 0.23 98925 A Osteopathic manipulation 0.45 0.43 0.40 0.20 0.18 98926 A Osteopathic manipulation 0.65 0.55 0.50 0.27 0.26 98927 A Osteopathic manipulation 0.87 0.69 0.63 0.34 0.32 98928 A Osteopathic manipulation 1.03 0.77 0.71 0.40 0.38 98929 A Osteopathic manipulation 1.19 0.90 0.82 0.47 0.44 98940 A Chiropractic manipulation 0.45 0.29 0.28 0.16 0.15 98941 A Chiropractic manipulation 0.65 0.38 0.36 0.23 0.22 98942 A Chiropractic manipulation 0.87 0.46 0.43 0.30 0.30 
CMS-1503-P 1163

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

98943 N Chiropractic manipulation 0.40 0.27 0.27 0.17 0.17 98960 B Self-mgmt educ & train, 1 pt 0.00 0.71 0.75 NA NA 98961 B Self-mgmt educ/train, 2-4 pt 0.00 0.34 0.36 NA NA 98962 B Self-mgmt educ/train, 5-8 pt 0.00 0.25 0.26 NA NA 98966 N Hc pro phone call 5-10 min 0.25 0.14 0.14 0.11 0.10 98967 N Hc pro phone call 11-20 min 0.50 0.25 0.25 0.22 0.21 98968 N Hc pro phone call 21-30 min 0.75 0.36 0.35 0.32 0.31 98969 N Online service by hc pro 0.00 0.00 0.00 0.00 0.00 99000 B Specimen handling 0.00 0.00 0.00 0.00 0.00 99001 B Specimen handling 0.00 0.00 0.00 0.00 0.00 99002 B Device handling 0.00 0.00 0.00 0.00 0.00 99024 B Postop follow-up visit 0.00 0.00 0.00 0.00 0.00 99026 N In-hospital on call service 0.00 0.00 0.00 0.00 0.00 99027 N Out-of-hosp on call service 0.00 0.00 0.00 0.00 0.00 99050 B Medical services after hrs 0.00 0.00 0.00 0.00 0.00 99051 B Med serv, eve/wkend/holiday 0.00 0.00 0.00 0.00 0.00 99053 B Med serv 10pm-8am, 24 hr fac 0.00 0.00 0.00 0.00 0.00 99056 B Med service out of office 0.00 0.00 0.00 0.00 0.00 99058 B Office emergency care 0.00 0.00 0.00 0.00 0.00 99060 B Out of office emerg med serv 0.00 0.00 0.00 0.00 0.00 99070 B Special supplies 0.00 0.00 0.00 0.00 0.00 99071 B Patient education materials 0.00 0.00 0.00 0.00 0.00 99075 N Medical testimony 0.00 0.00 0.00 0.00 0.00 99078 B Group health education 0.00 0.00 0.00 0.00 0.00 99080 B Special reports or forms 0.00 0.00 0.00 0.00 0.00 99082 C Unusual physician travel 0.00 0.00 0.00 0.00 0.00 
CMS-1503-P 1164

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

99090 B Computer data analysis 0.00 0.00 0.00 0.00 0.00 99091 B Collect/review data from pt 1.10 0.48 0.46 NA NA 99100 B Special anesthesia service 0.00 0.00 0.00 0.00 0.00 99116 B Anesthesia with hypothermia 0.00 0.00 0.00 0.00 0.00 99135 B Special anesthesia procedure 0.00 0.00 0.00 0.00 0.00 99140 B Emergency anesthesia 0.00 0.00 0.00 0.00 0.00 99143 C Mod cs by same phys, < 5 yrs 0.00 0.00 0.00 0.00 0.00 99144 C Mod cs by same phys, 5 yrs + 0.00 0.00 0.00 0.00 0.00 99145 C Mod cs by same phys add-on 0.00 0.00 0.00 0.00 0.00 99148 C Mod cs diff phys < 5 yrs 0.00 0.00 0.00 0.00 0.00 99149 C Mod cs diff phys 5 yrs + 0.00 0.00 0.00 0.00 0.00 99150 C Mod cs diff phys add-on 0.00 0.00 0.00 0.00 0.00 99170 A Anogenital exam, child 1.75 2.13 2.33 0.84 0.89 99172 N Ocular function screen 0.00 0.00 0.00 0.00 0.00 99173 N Visual acuity screen 0.00 0.07 0.07 NA NA 99174 N Ocular photoscreening 0.00 0.76 0.80 NA NA 99175 A Induction of vomiting 0.00 0.64 0.69 NA NA 99183 A Hyperbaric oxygen therapy 2.34 3.60 3.46 0.97 0.87 99190 X Special pump services 0.00 0.00 0.00 0.00 0.00 99191 X Special pump services 0.00 0.00 0.00 0.00 0.00 99192 X Special pump services 0.00 0.00 0.00 0.00 0.00 99195 A Phlebotomy 0.00 2.54 2.43 NA NA 99199 C Special service/proc/report 0.00 0.00 0.00 0.00 0.00 99201 A Office/outpatient visit, new 0.48 0.71 0.68 0.26 0.23 99202 A Office/outpatient visit, new 0.93 1.13 1.07 0.48 0.43 99203 A Office/outpatient visit, new 1.42 1.54 1.44 0.71 0.63 
CMS-1503-P 1165

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

99204 A Office/outpatient visit, new 2.43 2.11 1.97 1.19 1.04 99205 A Office/outpatient visit, new 3.17 2.46 2.32 1.47 1.32 99211 A Office/outpatient visit, est 0.18 0.36 0.38 0.08 0.08 99212 A Office/outpatient visit, est 0.48 0.71 0.69 0.24 0.22 99213 A Office/outpatient visit, est 0.97 1.03 0.97 0.46 0.41 99214 A Office/outpatient visit, est 1.50 1.45 1.38 0.70 0.62 99215 A Office/outpatient visit, est 2.11 1.86 1.76 0.98 0.88 99217 A Observation care discharge 1.28 NA NA 0.72 0.67 99218 A Observation care 1.28 NA NA 0.56 0.52 99219 A Observation care 2.14 NA NA 0.96 0.87 99220 A Observation care 2.99 NA NA 1.31 1.21 99221 A Initial hospital care 1.92 NA NA 0.84 0.75 99222 A Initial hospital care 2.61 NA NA 1.18 1.04 99223 A Initial hospital care 3.86 NA NA 1.73 1.52 99231 A Subsequent hospital care 0.76 NA NA 0.34 0.31 99232 A Subsequent hospital care 1.39 NA NA 0.62 0.56 99233 A Subsequent hospital care 2.00 NA NA 0.88 0.80 99234 A Observ/hosp same date 2.56 NA NA 1.14 1.07 99235 A Observ/hosp same date 3.41 NA NA 1.52 1.40 99236 A Observ/hosp same date 4.26 NA NA 1.86 1.71 99238 A Hospital discharge day 1.28 NA NA 0.72 0.67 99239 A Hospital discharge day 1.90 NA NA 1.06 0.95 99241 I Office consultation 0.64 0.66 0.66 0.24 0.24 99242 I Office consultation 1.34 1.10 1.10 0.51 0.51 99243 I Office consultation 1.88 1.46 1.46 0.71 0.71 99244 I Office consultation 3.02 1.96 1.96 1.14 1.14 
CMS-1503-P 1166

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

99245 I Office consultation 3.77 2.30 2.30 1.38 1.38 99251 I Inpatient consultation 1.00 NA NA 0.32 0.32 99252 I Inpatient consultation 1.50 NA NA 0.52 0.52 99253 I Inpatient consultation 2.27 NA NA 0.84 0.84 99254 I Inpatient consultation 3.29 NA NA 1.23 1.23 99255 I Inpatient consultation 4.00 NA NA 1.44 1.44 99281 A Emergency dept visit 0.45 NA NA 0.14 0.13 99282 A Emergency dept visit 0.88 NA NA 0.26 0.23 99283 A Emergency dept visit 1.34 NA NA 0.38 0.35 99284 A Emergency dept visit 2.56 NA NA 0.65 0.61 99285 A Emergency dept visit 3.80 NA NA 0.88 0.86 99288 B Direct advanced life support 0.00 0.00 0.00 0.00 0.00 99291 A Critical care, first hour 4.50 2.94 2.88 1.62 1.52 99292 A Critical care, addl 30 min 2.25 1.10 1.04 0.82 0.76 99304 A Nursing facility care, init 1.64 0.92 0.80 0.92 0.80 99305 A Nursing facility care, init 2.35 1.25 1.07 1.25 1.07 99306 A Nursing facility care, init 3.06 1.55 1.31 1.55 1.31 99307 A Nursing fac care, subseq 0.76 0.48 0.43 0.48 0.43 99308 A Nursing fac care, subseq 1.16 0.75 0.66 0.75 0.66 99309 A Nursing fac care, subseq 1.55 0.97 0.86 0.97 0.86 99310 A Nursing fac care, subseq 2.35 1.38 1.21 1.38 1.21 99315 A Nursing fac discharge day 1.13 0.68 0.60 0.68 0.60 99316 A Nursing fac discharge day 1.50 0.85 0.75 0.85 0.75 99318 A Annual nursing fac assessmnt 1.71 0.96 0.82 0.96 0.82 99324 A Domicil/r-home visit new pat 1.01 0.54 0.53 NA NA 99325 A Domicil/r-home visit new pat 1.52 0.72 0.71 NA NA 
CMS-1503-P 1167

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

99326 A Domicil/r-home visit new pat 2.63 1.28 1.16 NA NA 99327 A Domicil/r-home visit new pat 3.46 1.70 1.51 NA NA 99328 A Domicil/r-home visit new pat 4.09 1.95 1.73 NA NA 99334 A Domicil/r-home visit est pat 1.07 0.61 0.57 NA NA 99335 A Domicil/r-home visit est pat 1.72 0.92 0.82 NA NA 99336 A Domicil/r-home visit est pat 2.46 1.28 1.12 NA NA 99337 A Domicil/r-home visit est pat 3.58 1.79 1.56 NA NA 99339 B Domicil/r-home care supervis 1.25 0.90 0.89 NA NA 99340 B Domicil/r-home care supervis 1.80 1.21 1.20 NA NA 99341 A Home visit, new patient 1.01 0.52 0.52 NA NA 99342 A Home visit, new patient 1.52 0.69 0.70 NA NA 99343 A Home visit, new patient 2.53 1.13 1.09 NA NA 99344 A Home visit, new patient 3.38 1.71 1.51 NA NA 99345 A Home visit, new patient 4.09 2.00 1.77 NA NA 99347 A Home visit, est patient 1.00 0.54 0.52 NA NA 99348 A Home visit, est patient 1.56 0.79 0.74 NA NA 99349 A Home visit, est patient 2.33 1.23 1.09 NA NA 99350 A Home visit, est patient 3.28 1.66 1.46 NA NA 99354 A Prolonged service, office 1.77 0.98 0.91 0.80 0.74 99355 A Prolonged service, office 1.77 0.94 0.88 0.76 0.71 99356 A Prolonged service, inpatient 1.71 NA NA 0.83 0.74 99357 A Prolonged service, inpatient 1.71 NA NA 0.83 0.75 99358 B Prolong service w/o contact 2.10 0.94 0.92 0.94 0.92 99359 B Prolong serv w/o contact add 1.00 0.47 0.46 0.47 0.46 99360 X Physician standby services 1.20 NA NA 0.52 0.50 99363 B Anticoag mgmt, init 1.65 1.83 1.86 0.71 0.69 
CMS-1503-P 1168

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

99364 B Anticoag mgmt, subseq 0.63 0.56 0.56 0.27 0.26 99366 B Team conf w/pat by hc pro 0.82 0.37 0.36 0.35 0.34 99367 B Team conf w/o pat by phys 1.10 NA NA 0.48 0.46 99368 B Team conf w/o pat by hc pro 0.72 NA NA 0.31 0.30 99374 B Home health care supervision 1.10 0.83 0.83 0.48 0.47 99375 I Home health care supervision 1.73 1.18 1.26 0.75 0.87 99377 B Hospice care supervision 1.10 0.83 0.83 0.48 0.47 99378 I Hospice care supervision 1.73 1.18 1.32 0.75 0.93 99379 B Nursing fac care supervision 1.10 0.83 0.83 0.48 0.47 99380 B Nursing fac care supervision 1.73 1.18 1.17 0.75 0.74 99381 N Init pm e/m, new pat, inf 1.19 1.40 1.46 0.51 0.50 99382 N Init pm e/m, new pat 1-4 yrs 1.36 1.47 1.53 0.59 0.58 99383 N Prev visit, new, age 5-11 1.36 1.46 1.51 0.59 0.58 99384 N Prev visit, new, age 12-17 1.53 1.53 1.58 0.66 0.65 99385 N Prev visit, new, age 18-39 1.53 1.53 1.58 0.66 0.65 99386 N Prev visit, new, age 40-64 1.88 1.68 1.74 0.81 0.80 99387 N Init pm e/m, new pat 65+ yrs 2.06 1.87 1.93 0.89 0.88 99391 N Per pm reeval, est pat, inf 1.02 1.20 1.22 0.44 0.43 99392 N Prev visit, est, age 1-4 1.19 1.28 1.29 0.51 0.50 99393 N Prev visit, est, age 5-11 1.19 1.27 1.28 0.51 0.50 99394 N Prev visit, est, age 12-17 1.36 1.34 1.36 0.59 0.58 99395 N Prev visit, est, age 18-39 1.36 1.35 1.37 0.59 0.58 99396 N Prev visit, est, age 40-64 1.53 1.42 1.44 0.66 0.65 99397 N Per pm reeval est pat 65+ yr 1.71 1.62 1.63 0.74 0.73 99401 N Preventive counseling, indiv 0.48 0.51 0.54 0.21 0.21 99402 N Preventive counseling, indiv 0.98 0.73 0.77 0.42 0.42 
CMS-1503-P 1169

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

99403 N Preventive counseling, indiv 1.46 0.94 0.98 0.63 0.62 99404 N Preventive counseling, indiv 1.95 1.15 1.19 0.84 0.83 99406 A Behav chng smoking 3-10 min 0.24 0.15 0.14 0.10 0.09 99407 A Behav chng smoking > 10 min 0.50 0.27 0.24 0.22 0.20 99408 N Audit/dast, 15-30 min 0.65 0.33 0.32 0.28 0.27 99409 N Audit/dast, over 30 min 1.30 0.61 0.60 0.56 0.55 99411 N Preventive counseling, group 0.15 0.29 0.29 0.06 0.06 99412 N Preventive counseling, group 0.25 0.33 0.34 0.11 0.11 99420 N Health risk assessment test 0.00 0.27 0.29 NA NA 99429 N Unlisted preventive service 0.00 0.00 0.00 0.00 0.00 99441 N Phone e/m by phys 5-10 min 0.25 0.14 0.14 0.11 0.10 99442 N Phone e/m by phys 11-20 min 0.50 0.25 0.25 0.22 0.21 99443 N Phone e/m by phys 21-30 min 0.75 0.36 0.35 0.32 0.31 99444 N Online e/m by phys 0.00 0.00 0.00 0.00 0.00 99450 N Basic life disability exam 0.00 0.00 0.00 0.00 0.00 99455 R Work related disability exam 0.00 0.00 0.00 0.00 0.00 99456 R Disability examination 0.00 0.00 0.00 0.00 0.00 99460 A Init nb em per day, hosp 1.17 NA NA 0.53 0.47 99461 A Init nb em per day, non-fac 1.26 1.42 1.32 0.54 0.53 99462 A Sbsq nb em per day, hosp 0.62 NA NA 0.28 0.26 99463 A Same day nb discharge 1.50 NA NA 0.84 0.74 99464 A Attendance at delivery 1.50 NA NA 0.58 0.53 99465 A Nb resuscitation 2.93 NA NA 0.65 0.91 99466 A Ped crit care transport 4.79 NA NA 2.19 1.94 99467 A Ped crit care transport addl 2.40 NA NA 1.04 0.94 99468 A Neonate crit care, initial 18.46 NA NA 7.15 6.31 
CMS-1503-P 1170

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

99469 A Neonate crit care, subsq 7.99 NA NA 3.46 3.06 99471 A Ped critical care, initial 15.98 NA NA 6.19 5.79 99472 A Ped critical care, subsq 7.99 NA NA 3.16 2.92 99475 A Ped crit care age 2-5, init 11.25 4.37 3.90 4.37 3.90 99476 A Ped crit care age 2-5, subsq 6.75 2.81 2.43 2.81 2.43 99477 A Init day hosp neonate care 7.00 NA NA 3.03 2.75 99478 A Ic, lbw inf < 1500 gm subsq 2.75 NA NA 1.07 1.08 99479 A Ic lbw inf 1500-2500 g subsq 2.50 NA NA 1.19 1.02 99480 A Ic inf pbw 2501-5000 g subsq 2.40 NA NA 0.93 0.88 99499 C Unlisted e&m service 0.00 0.00 0.00 0.00 0.00 99500 I Home visit, prenatal 0.00 0.00 0.00 0.00 0.00 99501 I Home visit, postnatal 0.00 0.00 0.00 0.00 0.00 99502 I Home visit, nb care 0.00 0.00 0.00 0.00 0.00 99503 I Home visit, resp therapy 0.00 0.00 0.00 0.00 0.00 99504 I Home visit mech ventilator 0.00 0.00 0.00 0.00 0.00 99505 I Home visit, stoma care 0.00 0.00 0.00 0.00 0.00 99506 I Home visit, im injection 0.00 0.00 0.00 0.00 0.00 99507 I Home visit, cath maintain 0.00 0.00 0.00 0.00 0.00 99509 I Home visit day life activity 0.00 0.00 0.00 0.00 0.00 99510 I Home visit, sing/m/fam couns 0.00 0.00 0.00 0.00 0.00 99511 I Home visit, fecal/enema mgmt 0.00 0.00 0.00 0.00 0.00 99512 I Home visit for hemodialysis 0.00 0.00 0.00 0.00 0.00 99600 I Home visit nos 0.00 0.00 0.00 0.00 0.00 99601 I Home infusion/visit, 2 hrs 0.00 0.00 0.00 0.00 0.00 99602 I Home infusion, each addtl hr 0.00 0.00 0.00 0.00 0.00 99605 X Mtms by pharm, np, 15 min 0.00 0.00 0.00 0.00 0.00 
CMS-1503-P 1171

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

99606 X Mtms by pharm, est, 15 min 0.00 0.00 0.00 0.00 0.00 99607 X Mtms by pharm, addl 15 min 0.00 0.00 0.00 0.00 0.00 

A4641 C Radiopharm dx agent noc 0.00 0.00 0.00 0.00 0.00 A4642 C In111 satumomab 0.00 0.00 0.00 0.00 0.00 A4890 R Repair/maint cont hemo equip 0.00 0.00 0.00 0.00 0.00 A9500 C Tc99m sestamibi 0.00 0.00 0.00 0.00 0.00 A9501 C Technetium TC-99m teboroxime 0.00 0.00 0.00 0.00 0.00 A9502 C Tc99m tetrofosmin 0.00 0.00 0.00 0.00 0.00 A9503 C Tc99m medronate 0.00 0.00 0.00 0.00 0.00 A9504 C Tc99m apcitide 0.00 0.00 0.00 0.00 0.00 

A9505 C TL201 thallium 0.00 0.00 0.00 0.00 0.00 A9507 C In111 capromab 0.00 0.00 0.00 0.00 0.00 A9508 C I131 iodobenguate, dx 0.00 0.00 0.00 0.00 0.00 A9509 C Iodine I-123 sod iodide mil 0.00 0.00 0.00 0.00 0.00 A9510 C Tc99m disofenin 0.00 0.00 0.00 0.00 0.00 A9512 C Tc99m pertechnetate 0.00 0.00 0.00 0.00 0.00 A9516 C Iodine I-123 sod iodide mic 0.00 0.00 0.00 0.00 0.00 A9517 C I131 iodide cap, rx 0.00 0.00 0.00 0.00 0.00 A9521 C Tc99m exametazime 0.00 0.00 0.00 0.00 0.00 A9524 C I131 serum albumin, dx 0.00 0.00 0.00 0.00 0.00 A9526 C Nitrogen N-13 ammonia 0.00 0.00 0.00 0.00 0.00 A9527 C Iodine I-125 sodium iodide 0.00 0.00 0.00 0.00 0.00 A9528 C Iodine I-131 iodide cap, dx 0.00 0.00 0.00 0.00 0.00 A9529 C I131 iodide sol, dx 0.00 0.00 0.00 0.00 0.00 A9530 C I131 iodide sol, rx 0.00 0.00 0.00 0.00 0.00 A9531 C I131 max 100uCi 0.00 0.00 0.00 0.00 0.00 
CMS-1503-P 1172

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

A9532 C I125 serum albumin, dx 0.00 0.00 0.00 0.00 0.00 A9536 C Tc99m depreotide 0.00 0.00 0.00 0.00 0.00 A9537 C Tc99m mebrofenin 0.00 0.00 0.00 0.00 0.00 A9538 C Tc99m pyrophosphate 0.00 0.00 0.00 0.00 0.00 A9539 C Tc99m pentetate 0.00 0.00 0.00 0.00 0.00 A9540 C Tc99m MAA 0.00 0.00 0.00 0.00 0.00 A9541 C Tc99m sulfur colloid 0.00 0.00 0.00 0.00 0.00 A9542 C In111 ibritumomab, dx 0.00 0.00 0.00 0.00 0.00 A9543 C Y90 ibritumomab, rx 0.00 0.00 0.00 0.00 0.00 A9544 C I131 tositumomab, dx 0.00 0.00 0.00 0.00 0.00 A9545 C I131 tositumomab, rx 0.00 0.00 0.00 0.00 0.00 A9546 C Co57/58 0.00 0.00 0.00 0.00 0.00 A9547 C In111 oxyquinoline 0.00 0.00 0.00 0.00 0.00 A9548 C In111 pentetate 0.00 0.00 0.00 0.00 0.00 A9550 C Tc99m gluceptate 0.00 0.00 0.00 0.00 0.00 A9551 C Tc99m succimer 0.00 0.00 0.00 0.00 0.00 A9552 C F18 fdg 0.00 0.00 0.00 0.00 0.00 A9553 C Cr51 chromate 0.00 0.00 0.00 0.00 0.00 A9554 C I125 iothalamate, dx 0.00 0.00 0.00 0.00 0.00 A9555 C Rb82 rubidium 0.00 0.00 0.00 0.00 0.00 A9556 C Ga67 gallium 0.00 0.00 0.00 0.00 0.00 A9557 C Tc99m bicisate 0.00 0.00 0.00 0.00 0.00 A9558 C Xe133 xenon 10mci 0.00 0.00 0.00 0.00 0.00 A9559 C Co57 cyano 0.00 0.00 0.00 0.00 0.00 A9560 C Tc99m labeled rbc 0.00 0.00 0.00 0.00 0.00 A9561 C Tc99m oxidronate 0.00 0.00 0.00 0.00 0.00 
CMS-1503-P 1173

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

A9562 C Tc99m mertiatide 0.00 0.00 0.00 0.00 0.00 A9563 C P32 Na phosphate 0.00 0.00 0.00 0.00 0.00 A9564 C P32 chromic phosphate 0.00 0.00 0.00 0.00 0.00 A9566 C Tc99m fanolesomab 0.00 0.00 0.00 0.00 0.00 A9567 C Technetium TC-99m aerosol 0.00 0.00 0.00 0.00 0.00 A9568 C Technetium tc99m arcitumomab 0.00 0.00 0.00 0.00 0.00 A9569 C Technetium TC-99m auto WBC 0.00 0.00 0.00 0.00 0.00 A9570 C Indium In-111 auto WBC 0.00 0.00 0.00 0.00 0.00 A9571 C Indium IN-111 auto platelet 0.00 0.00 0.00 0.00 0.00 A9572 C Indium In-111 pentetreotide 0.00 0.00 0.00 0.00 0.00 A9580 C Sodium fluoride F-18 0.00 0.00 0.00 0.00 0.00 A9600 C Sr89 strontium 0.00 0.00 0.00 0.00 0.00 A9699 C Radiopharm rx agent noc 0.00 0.00 0.00 0.00 0.00 G0008 X Admin influenza virus vac 0.00 0.00 0.00 0.00 0.00 G0009 X Admin pneumococcal vaccine 0.00 0.00 0.00 0.00 0.00 G0010 X Admin hepatitis b vaccine 0.00 0.00 0.00 0.00 0.00 G0027 X Semen analysis 0.00 0.00 0.00 0.00 0.00 G0101 A CA screen;pelvic/breast exam 0.45 0.59 0.59 0.31 0.45 G0102 A Prostate ca screening; dre 0.17 0.36 0.38 0.08 0.08 G0103 X PSA screening 0.00 0.00 0.00 0.00 0.00 G0104 A CA screen;flexi sigmoidscope 0.96 2.86 2.89 0.78 0.75 

G0105 A Colorectal scrn; hi risk ind 3.69 6.98 7.24 2.23 2.19 G0105 53 A Colorectal scrn; hi risk ind 0.96 2.86 2.89 0.78 0.75 G0106 A Colon CA screen;barium enema 0.99 4.92 5.07 NA NA G0106 TC A Colon CA screen;barium enema 0.00 4.58 4.68 NA NA G0106 26 A Colon CA screen;barium enema 0.99 0.34 0.39 0.34 0.39 
CMS-1503-P 1174

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

G0108 A Diab manage trn per indiv 0.90 0.56 0.66 NA NA G0109 A Diab manage trn ind/group 0.25 0.15 0.28 NA NA G0117 T Glaucoma scrn hgh risk direc 0.45 1.02 0.96 NA NA G0118 T Glaucoma scrn hgh risk direc 0.17 0.86 0.82 NA NA G0120 A Colon ca scrn; barium enema 0.99 4.92 5.07 NA NA G0120 TC A Colon ca scrn; barium enema 0.00 4.58 4.68 NA NA G0120 26 A Colon ca scrn; barium enema 0.99 0.34 0.39 0.34 0.39 G0121 A Colon ca scrn not hi rsk ind 3.69 6.98 7.24 2.23 2.19 G0121 53 A Colon ca scrn not hi rsk ind 0.96 2.86 2.89 0.78 0.75 G0122 N Colon ca scrn; barium enema 0.99 7.02 6.75 NA NA G0122 TC N Colon ca scrn; barium enema 0.00 6.59 6.33 NA NA G0122 26 N Colon ca scrn; barium enema 0.99 0.43 0.42 0.43 0.42 G0123 X Screen cerv/vag thin layer 0.00 0.00 0.00 0.00 0.00 G0124 A Screen c/v thin layer by MD 0.42 0.40 0.39 0.40 0.39 G0127 R Trim nail(s) 0.17 0.47 0.44 0.05 0.06 G0128 R CORF skilled nursing service 0.08 0.20 0.18 NA NA G0130 A Single energy x-ray study 0.22 0.70 0.73 NA NA G0130 TC A Single energy x-ray study 0.00 0.60 0.64 NA NA G0130 26 A Single energy x-ray study 0.22 0.10 0.09 0.10 0.09 G0141 A Scr c/v cyto,autosys and md 0.42 0.40 0.39 0.40 0.39 G0143 X Scr c/v cyto,thinlayer,rescr 0.00 0.00 0.00 0.00 0.00 G0144 X Scr c/v cyto,thinlayer,rescr 0.00 0.00 0.00 0.00 0.00 G0145 X Scr c/v cyto,thinlayer,rescr 0.00 0.00 0.00 0.00 0.00 G0147 X Scr c/v cyto, automated sys 0.00 0.00 0.00 0.00 0.00 G0148 X Scr c/v cyto, autosys, rescr 0.00 0.00 0.00 0.00 0.00 G0166 A Extrnl counterpulse, per tx 0.07 3.80 4.35 NA NA 
CMS-1503-P 1175

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

G0168 A Wound closure by adhesive 0.45 2.07 2.01 0.30 0.27 G0173 X Linear acc stereo radsur com 0.00 0.00 0.00 0.00 0.00 G0175 X OPPS Service,sched team conf 0.00 0.00 0.00 0.00 0.00 G0176 X OPPS/PHP;activity therapy 0.00 0.00 0.00 0.00 0.00 G0177 X OPPS/PHP; train & educ serv 0.00 0.00 0.00 0.00 0.00 G0179 A MD recertification HHA PT 0.45 0.66 0.70 0.43 0.58 G0180 A MD certification HHA patient 0.67 0.78 0.83 0.55 0.71 G0181 A Home health care supervision 1.73 1.25 1.21 NA NA G0182 A Hospice care supervision 1.73 1.25 1.25 NA NA G0186 C Dstry eye lesn,fdr vssl tech 0.00 0.00 0.00 0.00 0.00 G0202 A Screeningmammographydigital 0.70 3.31 3.34 NA NA G0202 TC A Screeningmammographydigital 0.00 3.03 3.05 NA NA G0202 26 A Screeningmammographydigital 0.70 0.28 0.29 0.28 0.29 G0204 A Diagnosticmammographydigital 0.87 4.01 3.96 NA NA G0204 TC A Diagnosticmammographydigital 0.00 3.66 3.61 NA NA G0204 26 A Diagnosticmammographydigital 0.87 0.35 0.35 0.35 0.35 G0206 A Diagnosticmammographydigital 0.70 3.14 3.12 NA NA G0206 TC A Diagnosticmammographydigital 0.00 2.86 2.83 NA NA G0206 26 A Diagnosticmammographydigital 0.70 0.28 0.29 0.28 0.29 G0219 N PET img wholbod melano nonco 0.00 0.00 0.00 NA NA G0219 TC N PET img wholbod melano nonco 0.00 0.00 0.00 NA NA G0219 26 N PET img wholbod melano nonco 0.00 0.00 0.00 0.00 0.00 G0235 N PET not otherwise specified 0.00 0.00 0.00 NA NA G0235 TC N PET not otherwise specified 0.00 0.00 0.00 NA NA G0235 26 N PET not otherwise specified 0.00 0.00 0.00 0.00 0.00 G0237 A Therapeutic procd strg endur 0.00 0.24 0.28 NA NA 
CMS-1503-P 1176

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

G0238 A Oth resp proc, indiv 0.00 0.25 0.30 NA NA G0239 A Oth resp proc, group 0.00 0.30 0.33 NA NA G0245 R Initial foot exam pt lops 0.88 1.13 1.07 0.48 0.43 G0246 R Followup eval of foot pt lop 0.45 0.71 0.69 0.24 0.22 G0247 R Routine footcare pt w lops 0.50 0.84 0.79 0.20 0.20 G0248 R Demonstrate use home inr mon 0.00 3.17 4.05 NA NA G0249 R Provide INR test mater/equip 0.00 2.96 3.58 NA NA G0250 R MD INR test revie inter mgmt 0.18 0.07 0.08 NA NA G0251 E Linear acc based stero radio 0.00 0.00 0.00 0.00 0.00 G0252 N PET imaging initial dx 0.00 0.00 0.00 NA NA G0252 TC N PET imaging initial dx 0.00 0.00 0.00 NA NA G0252 26 N PET imaging initial dx 1.50 0.65 0.69 0.65 0.69 G0255 N Current percep threshold tst 0.00 0.00 0.00 NA NA G0255 TC N Current percep threshold tst 0.00 0.00 0.00 NA NA G0255 26 N Current percep threshold tst 0.00 0.00 0.00 0.00 0.00 G0257 E Unsched dialysis ESRD pt hos 0.00 0.00 0.00 0.00 0.00 G0259 E Inject for sacroiliac joint 0.00 0.00 0.00 0.00 0.00 G0260 E Inj for sacroiliac jt anesth 0.00 0.00 0.00 0.00 0.00 G0268 A Removal of impacted wax md 0.61 0.89 0.84 0.35 0.31 G0269 B Occlusive device in vein art 0.00 0.00 0.00 0.00 0.00 G0270 A MNT subs tx for change dx 0.45 0.35 0.33 0.30 0.27 G0271 A Group MNT 2 or more 30 mins 0.25 0.17 0.15 0.16 0.14 G0275 A Renal angio, cardiac cath 0.25 NA NA 0.10 0.13 G0278 A Iliac art angio,cardiac cath 0.25 NA NA 0.10 0.13 G0281 A Elec stim unattend for press 0.18 0.20 0.18 NA NA G0282 N Elect stim wound care not pd 0.00 0.00 0.00 0.00 0.00 
CMS-1503-P 1177

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

G0283 A Elec stim other than wound 0.18 0.20 0.18 NA NA G0288 A Recon, CTA for surg plan 0.00 0.98 2.52 NA NA G0289 A Arthro, loose body + chondro 1.48 NA NA 0.86 0.83 G0290 E Drug-eluting stents, single 0.00 0.00 0.00 0.00 0.00 G0291 E Drug-eluting stents,each add 0.00 0.00 0.00 0.00 0.00 G0293 E Non-cov surg proc,clin trial 0.00 0.00 0.00 0.00 0.00 G0294 E Non-cov proc, clinical trial 0.00 0.00 0.00 0.00 0.00 G0295 N Electromagnetic therapy onc 0.00 0.00 0.00 0.00 0.00 G0302 X Pre-op service LVRS complete 0.00 0.00 0.00 0.00 0.00 G0303 X Pre-op service LVRS 10-15dos 0.00 0.00 0.00 0.00 0.00 G0304 X Pre-op service LVRS 1-9 dos 0.00 0.00 0.00 0.00 0.00 G0305 X Post op service LVRS min 6 0.00 0.00 0.00 0.00 0.00 G0306 X CBC/diffwbc w/o platelet 0.00 0.00 0.00 0.00 0.00 G0307 X CBC without platelet 0.00 0.00 0.00 0.00 0.00 G0328 X Fecal blood scrn immunoassay 0.00 0.00 0.00 0.00 0.00 G0329 A Electromagntic tx for ulcers 0.06 0.21 0.19 NA NA G0333 X Dispense fee initial 30 day 0.00 0.00 0.00 0.00 0.00 G0337 X Hospice evaluation preelecti 1.42 0.61 0.61 0.61 0.61 G0339 C Robot lin-radsurg com, first 0.00 0.00 0.00 0.00 0.00 G0340 C Robt lin-radsurg fractx 2-5 0.00 0.00 0.00 0.00 0.00 G0341 A Percutaneous islet celltrans 6.98 51.68 28.38 NA NA G0342 A Laparoscopy islet cell trans 11.92 NA NA 7.73 7.04 G0343 A Laparotomy islet cell transp 19.85 NA NA 13.12 11.91 G0364 A Bone marrow aspirate &biopsy 0.16 0.18 0.19 0.09 0.09 G0365 A Vessel mapping hemo access 0.25 5.80 5.82 NA NA G0365 TC A Vessel mapping hemo access 0.00 5.71 5.73 NA NA 
CMS-1503-P 1178

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

G0365 26 A Vessel mapping hemo access 0.25 0.09 0.09 0.09 0.09 G0372 A MD service required for PMD 0.17 0.08 0.12 0.08 0.07 G0378 X Hospital observation per hr 0.00 0.00 0.00 0.00 0.00 G0379 X Direct refer hospital observ 0.00 0.00 0.00 0.00 0.00 G0389 A Ultrasound exam AAA screen 0.58 2.36 2.61 NA NA G0389 TC A Ultrasound exam AAA screen 0.00 2.15 2.37 NA NA G0389 26 A Ultrasound exam AAA screen 0.58 0.21 0.24 0.21 0.24 G0396 A Alcohol/subs interv 15-30mn 0.65 0.32 0.28 0.26 0.23 G0397 A Alcohol/subs interv >30 min 1.30 0.80 0.61 0.75 0.56 G0398 C Home sleep test/type 2 Porta 0.00 0.00 0.00 NA NA G0398 TC C Home sleep test/type 2 Porta 0.00 0.00 0.00 NA NA G0398 26 C Home sleep test/type 2 Porta 0.00 0.00 0.00 0.00 0.00 G0399 C Home sleep test/type 3 Porta 0.00 0.00 0.00 NA NA G0399 TC C Home sleep test/type 3 Porta 0.00 0.00 0.00 NA NA G0399 26 C Home sleep test/type 3 Porta 0.00 0.00 0.00 0.00 0.00 G0400 C Home sleep test/type 4 Porta 0.00 0.00 0.00 NA NA G0400 TC C Home sleep test/type 4 Porta 0.00 0.00 0.00 NA NA G0400 26 C Home sleep test/type 4 Porta 0.00 0.00 0.00 0.00 0.00 G0402 A Initial preventive exam 2.43 2.14 1.76 NA NA G0403 A EKG for initial prevent exam 0.17 0.32 0.39 0.32 0.40 G0404 A EKG tracing for initial prev 0.00 0.25 0.31 0.25 0.34 G0405 A EKG interpret & report preve 0.17 0.07 0.08 0.07 0.06 G0406 A Telhealth inpt consult 15min 0.76 NA NA 0.34 0.31 G0407 A Telheath inpt consult 25min 1.39 NA NA 0.62 0.56 G0408 A Telhealth inpt consult 35min 2.00 NA NA 0.88 0.80 G0409 A CORF related serv 15 mins ea 0.00 0.29 0.28 NA NA 
CMS-1503-P 1179

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

G0410 X Grp psych partial hosp 45-50 0.00 0.00 0.00 0.00 0.00 G0411 X Inter active grp psych parti 0.00 0.00 0.00 0.00 0.00 G0412 A Open tx iliac spine uni/bil 10.45 NA NA 9.03 8.56 G0413 A Pelvic ring fracture uni/bil 15.73 NA NA 12.41 11.95 G0414 A Pelvic ring fx treat int fix 14.65 NA NA 12.31 11.77 G0415 A Open tx post pelvic fxcture 20.93 NA NA 16.01 15.05 G0416 A Sat biopsy prostate 1-20 spc 3.09 13.96 13.96 NA NA G0416 TC A Sat biopsy prostate 1-20 spc 0.00 12.14 12.14 NA NA G0416 26 A Sat biopsy prostate 1-20 spc 3.09 1.82 1.82 1.82 1.82 G0417 A Sat biopsy prostate 21-40 5.86 27.26 27.26 NA NA G0417 TC A Sat biopsy prostate 21-40 0.00 23.71 23.71 NA NA G0417 26 A Sat biopsy prostate 21-40 5.86 3.55 3.55 3.55 3.55 G0418 A Sat biopsy prostate 41-60 10.30 46.56 46.56 NA NA G0418 TC A Sat biopsy prostate 41-60 0.00 40.50 40.50 NA NA G0418 26 A Sat biopsy prostate 41-60 10.30 6.06 6.06 6.06 6.06 G0419 A Sat biopsy prostate: >60 11.61 55.86 55.86 NA NA G0419 TC A Sat biopsy prostate: >60 0.00 48.60 48.60 NA NA G0419 26 A Sat biopsy prostate: >60 11.61 7.26 7.26 7.26 7.26 G0420 A Ed svc CKD ind per session 2.12 1.01 1.01 NA NA G0421 A Ed svc CKD grp per session 0.50 0.23 0.23 NA NA G0422 A Intens cardiac rehab w/exerc 0.60 0.87 0.88 0.87 0.88 G0423 A Intens cardiac rehab no exer 0.60 0.87 0.88 0.87 0.88 G0424 A Pulmonary rehab w exer 0.28 0.58 0.58 0.12 0.12 G0425 A Inpt telehealth consult 30m 1.92 NA NA 0.84 0.84 G0426 A Inpt telehealth consult 50m 2.61 NA NA 1.18 1.18 G0427 A Inpt telehealth con 70/>m 3.86 NA NA 1.73 1.73 
CMS-1503-P 1180

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

G0430 X Drug screen multi class 0.00 0.00 0.00 0.00 0.00 G0431 X Drug screen single class 0.00 0.00 0.00 0.00 0.00 G0432 X EIA HIV-1/HIV-2 screen 0.00 0.00 0.00 0.00 0.00 G0433 X ELISA HIV-1/HIV-2 screen 0.00 0.00 0.00 0.00 0.00 G0435 X Oral HIV-1/HIV-2 screen 0.00 0.00 0.00 0.00 0.00 G3001 X Admin + supply, tositumomab 0.00 0.00 0.00 0.00 0.00 G9001 X MCCD, initial rate 0.00 0.00 0.00 0.00 0.00 G9002 X MCCD,maintenance rate 0.00 0.00 0.00 0.00 0.00 G9003 X MCCD, risk adj hi, initial 0.00 0.00 0.00 0.00 0.00 G9004 X MCCD, risk adj lo, initial 0.00 0.00 0.00 0.00 0.00 G9005 X MCCD, risk adj, maintenance 0.00 0.00 0.00 0.00 0.00 G9006 X MCCD, Home monitoring 0.00 0.00 0.00 0.00 0.00 G9007 X MCCD, sch team conf 0.00 0.00 0.00 0.00 0.00 G9008 X Mccd,phys coor-care ovrsght 0.00 0.00 0.00 0.00 0.00 G9009 X MCCD, risk adj, level 3 0.00 0.00 0.00 0.00 0.00 G9010 X MCCD, risk adj, level 4 0.00 0.00 0.00 0.00 0.00 G9011 X MCCD, risk adj, level 5 0.00 0.00 0.00 0.00 0.00 G9012 X Other Specified Case Mgmt 0.00 0.00 0.00 0.00 0.00 G9013 N ESRD demo bundle level I 0.00 0.00 0.00 0.00 0.00 G9014 N ESRD demo bundle-level II 0.00 0.00 0.00 0.00 0.00 G9016 N Demo-smoking cessation coun 0.00 0.00 0.00 0.00 0.00 G9017 X Amantadine HCL 100mg oral 0.00 0.00 0.00 0.00 0.00 G9018 X Zanamivir,inhalation pwd 10m 0.00 0.00 0.00 0.00 0.00 G9019 X Oseltamivir phosphate 75mg 0.00 0.00 0.00 0.00 0.00 G9020 X Rimantadine HCL 100mg oral 0.00 0.00 0.00 0.00 0.00 G9033 X Amantadine HCL oral brand 0.00 0.00 0.00 0.00 0.00 
CMS-1503-P 1181

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

G9034 X Zanamivir, inh pwdr, brand 0.00 0.00 0.00 0.00 0.00 G9035 X Oseltamivir phosp, brand 0.00 0.00 0.00 0.00 0.00 G9036 X Rimantadine HCL, brand 0.00 0.00 0.00 0.00 0.00 G9041 A Low vision rehab occupationa 0.69 0.28 0.28 0.28 0.28 G9042 A Low vision rehab orient/mobi 0.25 0.25 0.25 0.25 0.25 G9043 A Low vision lowvision therapi 0.25 0.25 0.25 0.25 0.25 G9044 A Low vision rehabilate teache 0.24 0.19 0.19 0.19 0.19 G9140 X Frontier extended stay demo 0.00 0.00 0.00 0.00 0.00 G9141 X Influenza A H1N1,admin w cou 0.00 0.00 0.00 0.00 0.00 G9142 X Influenza A H1N1, vaccine 0.00 0.00 0.00 0.00 0.00 G9143 X Warfarin respon genetic test 0.00 0.00 0.00 0.00 0.00 G9147 N Outpt IV insulin tx any mea 0.00 0.00 0.00 0.00 0.00 

GXXX1 A Skin/dermal subs init 25or< 2.22 3.10 3.10 1.43 1.43 GXXX2 A Skin/dermal subs each addition 0.50 0.81 0.81 0.19 0.19 

GXXXA A PPPS, initial visit 2.43 2.14 2.14 NA NA 

GXXXB A PPPS, subseq visit 1.50 1.59 1.59 NA NA 

M0064 A Visit for drug monitoring 0.37 1.04 0.97 0.07 0.09 

P3001 A Screening pap smear by phys 0.42 0.40 0.39 0.40 0.39 

Q0035 A Cardiokymography 0.17 0.30 0.35 NA NA Q0035 TC A Cardiokymography 0.00 0.24 0.29 NA NA Q0035 26 A Cardiokymography 0.17 0.06 0.06 0.06 0.06 

Q0091 A Obtaining screen pap smear 0.37 0.85 0.86 0.17 0.15 Q0092 A Set up port xray equipment 0.00 0.69 0.61 0.69 0.61 Q3001 C Brachytherapy Radioelements 0.00 0.00 0.00 0.00 0.00 Q3014 X Telehealth facility fee 0.00 0.00 0.00 0.00 0.00 

R0070 C Transport portable x-ray 0.00 0.00 0.00 0.00 0.00 
CMS-1503-P 1182

CPT1/ 

HCPCS 

Code Mod Status Short Descriptor 

Physician 

Work 

RVUs2,3

Fully 

Implemented 

Nonfacility 

PE 

RVUs2,3

CY 2011

Transitional 

Nonfacility 

PE 

RVUs2,3

Fully 

Implemented 

Facility 

PE 

RVUs2,3

CY 2011

Transitional 

Facility 

PE 

RVUs2,3

R0075 C Transport port x-ray multipl 0.00 0.00 0.00 0.00 0.00 R0076 B Transport portable EKG 0.00 0.00 0.00 0.00 0.00 

V5299 R Hearing service 0.00 0.00 0.00 0.00 0.00 

1 CPT codes and descriptors only are copyright 2010 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply. 2 If values are reflected for codes not payable by Medicare, please note that these values have been established as a courtesy to the general publi

Medicare payment. 3 The budget neutrality reduction from the chiropractic demonstration is not reflected in the RVUs for CPT codes 98940, 98941, and 98942. Thonly 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 Geographic Adjustment Factors (GAFs) 

Contractor Locality Locality Name 2010 

GAF1

2011 

GAF2

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 

GAF1

2011 

GAF2

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-P 1187

ADDENDUM E: Proposed CY 2011 Geographic Practice Cost Indices (GPCIs) by State and Medicare L

Contractor Locality Locality Name 

2010 

Work 

GPCI 1

2010 

PE 

GPCI 2

2010 

MP 

GPCI 

2011 

Work 

GPCI 3

2011 

PE 

GPCI 

2011 

MP 

GPCI 

2012 

Work 

GPCI 3

10102 00 Alabama 1.000 0.927 0.496 0.979 0.937 0.484 0.976 00831 01 Alaska** 1.500 1.090 0.646 1.500 1.086 0.647 1.500 03102 00 Arizona 1.000 0.979 0.822 0.983 0.985 0.913 0.977 00520 13 Arkansas 1.000 0.923 0.446 0.964 0.932 0.444 0.967 01192 26 Anaheim/Santa Ana, CA 1.034 1.269 0.811 1.039 1.232 0.742 1.043 01192 18 Los Angeles, CA 1.041 1.225 0.804 1.039 1.190 0.721 1.036 01102 03 Marin/Napa/Solano, CA 1.034 1.265 0.432 1.042 1.239 0.443 1.050 01102 07 Oakland/Berkley, CA 1.053 1.286 0.425 1.055 1.258 0.469 1.057 01102 05 San Francisco, CA 1.059 1.441 0.414 1.065 1.375 0.464 1.071 01102 06 San Mateo, CA 1.072 1.433 0.394 1.072 1.371 0.454 1.071 01102 09 Santa Clara, CA 1.083 1.294 0.377 1.080 1.279 0.445 1.077 01192 17 Ventura, CA 1.027 1.265 0.766 1.030 1.216 0.683 1.033 01102 99 Rest of California* 1.007 1.058 0.549 1.016 1.067 0.546 1.024 01192 99 Rest of California* 1.007 1.058 0.549 1.016 1.067 0.546 1.024 04102 01 Colorado 1.000 0.996 0.641 0.991 0.999 0.754 0.996 13102 00 Connecticut 1.038 1.185 0.980 1.031 1.151 1.102 1.023 12202 01 DC + MD/VA Suburbs 1.047 1.218 1.032 1.048 1.191 1.081 1.048 12102 01 Delaware 1.011 1.046 0.678 1.012 1.039 0.678 1.012 09102 03 Fort Lauderdale, FL 1.000 1.018 2.250 0.992 1.028 2.112 0.994 09102 04 Miami, FL 1.000 1.069 3.167 0.998 1.057 2.984 0.996 09102 99 Rest of Florida 1.000 0.970 1.724 0.978 0.977 1.634 0.983 10202 01 Atlanta, GA 1.009 1.014 0.836 1.006 1.007 0.891 1.002 10202 99 Rest of Georgia 1.000 0.942 0.829 0.978 0.950 0.876 0.977 01202 01 Hawaii/Guam 1.000 1.161 0.665 0.999 1.162 0.685 1.000 05130 00 Idaho 1.000 0.942 0.546 0.974 0.951 0.572 0.981 00952 16 Chicago, IL 1.025 1.080 1.940 1.028 1.058 2.005 1.030 00952 12 East St. Louis, IL 1.000 0.960 1.793 0.988 0.968 1.851 0.987 
CMS-1503-P 1188

Contractor Locality Locality Name 

2010 

Work 

GPCI 1

2010 

PE 

GPCI 2

2010 

MP 

GPCI 

2011 

Work 

GPCI 3

2011 

PE 

GPCI 

2011 

MP 

GPCI 

2012 

Work 

GPCI 3

00952 15 Suburban Chicago, IL 1.017 1.068 1.629 1.021 1.052 1.664 1.024 00952 99 Rest of Illinois 1.000 0.940 1.219 0.976 0.949 1.275 0.976 00630 00 Indiana 1.000 0.960 0.599 0.978 0.963 0.603 0.969 05102 00 Iowa 1.000 0.935 0.434 0.962 0.943 0.443 0.958 05202 00 Kansas 1.000 0.941 0.557 0.966 0.948 0.746 0.962 00660 00 Kentucky 1.000 0.930 0.652 0.971 0.941 0.701 0.972 00528 01 New Orleans, LA 1.000 1.044 0.956 0.985 1.017 0.933 0.983 00528 99 Rest of Louisiana 1.000 0.939 0.892 0.969 0.943 0.816 0.967 14102 03 Southern Maine 1.000 1.025 0.492 0.982 1.024 0.583 0.984 14102 99 Rest of Maine 1.000 0.947 0.492 0.964 0.954 0.583 0.965 12302 01 Baltimore/Surr. Cntys, MD 1.012 1.057 1.086 1.019 1.073 1.146 1.026 12302 99 Rest of Maryland 1.000 0.991 0.874 1.002 1.008 0.930 1.010 14202 01 Metropolitan Boston 1.029 1.291 0.764 1.021 1.212 0.776 1.013 14202 99 Rest of Massachusetts 1.007 1.106 0.764 1.010 1.090 0.776 1.013 00953 01 Detroit, MI 1.036 1.040 1.906 1.029 1.030 1.855 1.021 00953 99 Rest of Michigan 1.000 0.962 1.083 0.995 0.967 1.075 0.991 00954 00 Minnesota 1.000 0.992 0.245 0.995 0.998 0.262 0.997 00512 00 Mississippi 1.000 0.927 0.808 0.961 0.937 0.782 0.962 05302 02 Metropolitan Kansas City, MO 1.000 0.973 1.188 0.986 0.978 1.204 0.982 05302 01 Metropolitan St Louis, MO 1.000 0.966 1.075 0.992 0.973 1.063 0.990 05302 99 Rest of Missouri 1.000 0.911 0.997 0.953 0.924 1.004 0.956 03202 01 Montana *** 1.000 0.924 0.673 0.948 1.000 0.887 0.946 05402 00 Nebraska 1.000 0.946 0.245 0.964 0.951 0.280 0.968 01302 00 Nevada *** 1.002 1.026 1.083 0.999 1.036 1.149 0.996 14302 40 New Hampshire 1.000 1.039 0.462 0.987 1.038 0.658 0.991 12402 01 Northern NJ 1.057 1.228 1.116 1.051 1.185 1.077 1.044 12402 99 Rest of New Jersey 1.042 1.126 1.116 1.031 1.110 1.077 1.020 04202 05 New Mexico 1.000 0.946 1.096 0.981 0.955 1.053 0.989 13202 01 Manhattan, NY 1.064 1.298 1.010 1.063 1.235 1.137 1.062 
CMS-1503-P 1189

Contractor Locality Locality Name 

2010 

Work 

GPCI 1

2010 

PE 

GPCI 2

2010 

MP 

GPCI 

2011 

Work 

GPCI 3

2011 

PE 

GPCI 

2011 

MP 

GPCI 

2012 

Work 

GPCI 3

13202 02 NYC Suburbs/Long I., NY 1.051 1.289 1.235 1.050 1.242 1.334 1.048 13202 03 Poughkpsie/N NYC Suburbs, NY 1.014 1.077 0.822 1.013 1.064 0.945 1.011 13292 04 Queens, NY 1.032 1.239 1.220 1.047 1.206 1.351 1.062 13282 99 Rest of New York 1.000 0.961 0.425 0.993 0.969 0.493 0.988 05535 00 North Carolina 1.000 0.963 0.634 0.972 0.966 0.664 0.971 03302 01 North Dakota *** 1.000 0.922 0.387 0.957 1.000 0.453 0.966 00883 00 Ohio 1.000 0.964 1.232 0.996 0.968 1.229 0.998 04302 00 Oklahoma 1.000 0.925 0.627 0.960 0.936 0.671 0.955 00835 01 Portland, OR 1.002 1.015 0.472 1.003 1.021 0.542 1.004 00835 99 Rest of Oregon 1.000 0.964 0.472 0.974 0.974 0.542 0.980 12502 01 Metropolitan Philadelphia, PA 1.016 1.097 1.617 1.015 1.077 1.619 1.014 12502 99 Rest of Pennsylvania 1.000 0.963 1.081 0.990 0.964 1.100 0.987 09202 20 Puerto Rico 1.000 0.847 0.250 0.907 0.860 0.249 0.909 14402 01 Rhode Island 1.013 1.088 0.996 1.015 1.067 1.089 1.016 00880 01 South Carolina 1.000 0.954 0.446 0.976 0.959 0.483 0.976 03402 02 South Dakota*** 1.000 0.932 0.420 0.946 1.000 0.424 0.950 10302 35 Tennessee 1.000 0.945 0.608 0.976 0.952 0.566 0.973 04402 31 Austin, TX 1.000 0.992 0.969 0.988 0.995 0.859 0.984 04402 20 Beaumont, TX 1.000 0.938 1.346 0.978 0.944 1.131 0.971 04402 09 Brazoria, TX 1.019 0.961 1.223 1.014 0.973 1.070 1.008 04402 11 Dallas, TX 1.009 1.001 1.110 1.009 1.003 0.970 1.008 04402 28 Fort Worth, TX 1.000 0.977 1.110 0.999 0.984 0.966 0.999 04402 15 Galveston, TX 1.000 0.980 1.223 1.000 0.988 1.100 1.008 04402 18 Houston, TX 1.016 0.994 1.345 1.012 0.995 1.131 1.008 04402 99 Rest of Texas 1.000 0.940 1.065 0.974 0.949 0.936 0.979 03502 09 Utah 1.000 0.954 1.026 0.975 0.959 1.058 0.972 14502 50 Vermont 1.000 0.992 0.489 0.973 1.000 0.523 0.977 00904 00 Virginia 1.000 0.972 0.657 0.988 0.980 0.692 0.993 09202 50 Virgin Islands 1.000 0.990 1.009 0.998 0.995 1.006 0.998 
CMS-1503-P 1190

Contractor Locality Locality Name 

2010 

Work 

GPCI 1

2010 

PE 

GPCI 2

2010 

MP 

GPCI 

2011 

Work 

GPCI 3

2011 

PE 

GPCI 

2011 

MP 

GPCI 

2012 

Work 

GPCI 3

00836 02 Seattle (King Cnty), WA 1.014 1.085 0.706 1.020 1.091 0.786 1.025 00836 99 Rest of Washington 1.000 0.988 0.693 0.991 0.994 0.770 0.994 00884 16 West Virginia 1.000 0.914 1.353 0.968 0.923 1.279 0.963 00951 00 Wisconsin 1.000 0.961 0.409 0.988 0.971 0.477 0.987 03602 21 Wyoming *** 1.000 0.921 0.889 0.964 1.000 1.052 0.972 

1 2010 work GPCI reflects a 1.0 floor required by the Affordable Care Act. 

2 2010 PE GPCI reflects a limited recognition of cost differences for the rent and employee compensation components and application of the hold harmless provision as r3 2011 and 2012 work GPCI does not reflect a 1.0 floor which expires December 31, 2010 as required by the Affordable Care Act. 4 2012 PE GPCI does not reflect a limited recognition of cost differences for the rent and employee compensation components which expires December 31, 2011 as requ

* 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 of 1⁄2 the difference between 2010 PE GPCI and 2012 PE GPCI with limited recognition o

and employee compensation components (as required by the Affordable Care Act) or 1⁄2 the difference between 2010 PE GPCI and 2012 PE GPCI without the limited re

the 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 Myrtle 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 Composite 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 Massachusetts1 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 Jersey1 ----- ------

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 Island1 ----- ----- 

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]